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PLAN

Acute Severe Pancreatitis Treatment in the second millenium Up to date Martin Albert M.D. Critical Care Fellow October 2000. PLAN. Definition Antibioprophylaxis ERCP Surgery Nutrition. PLAN. Other modalities lexipafant octreotide... Conclusion. Ranson  3 ( Gallstone ) Age > 70

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PLAN

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  1. Acute Severe PancreatitisTreatment in the second milleniumUp to dateMartin Albert M.D.Critical Care FellowOctober 2000

  2. PLAN • Definition • Antibioprophylaxis • ERCP • Surgery • Nutrition

  3. PLAN • Other modalities • lexipafant • octreotide... • Conclusion

  4. Ranson  3 ( Gallstone ) Age > 70 WBC > 18000 Glucose >220 mg/dl LDH > 400 AST >250 Decrease > 10% Ht Increase in BUN > 2mg/dl Calcium < 8 mg/dl Base deficit > 5 Fluid deficit > 4L DEFINITION

  5. Ranson  3 ( other causes ) Age > 55 WBC > 16000 Glucose >200 mg/dl LDH > 350 AST >250 Decrease > 10% Ht Increase in BUN > 5mg/dl Calcium < 8 mg/dl PaO2 < 60 mmHg Base deficit > 4 Fluid deficit > 6L DEFINITION

  6. DEFINITION • 10 % AP patients have severe disease • IF Ranson ’s criteria < 3 • mortality less than 1% • IF Ranson ’s criteria > 3 • 34% of septic complications • IF Ranson ’s criteria > 8 • 90% mortality

  7. IMRIE > 3 Imrie and al Br Jour Sur 65,337, 1978 Age over 55 WBC > 15000 Glucose > 10 BUN >16 PaO2 < 60 Calcium < 2 LDH > 600 AST > 32 ALBUMIN <32 g/l DEFINITION

  8. Definition • APACHE 2  8

  9. Definition • Balthazar’s scale • A) Normal CT-SCAN • B) Focal or diffuse enlargment • C) Pancreatic gland abdnormalities • haziness • streaky densities • D) Acute fluid collection • E) 2 or more collections and/or gaz • Balthazar and al Radiology 1990:174:331-336

  10. CT-SCAN

  11. CT-SCAN

  12. Relationship between mortality/morbidity and imaging CT-SCAN

  13. Relationship between mortality/morbidity and degree of necrosis CT-SCAN

  14. TREATMENT • General approach • Antibioprophylaxis • Nutrition • Surgery • ERCP • Octreotide and lexipafant...

  15. TREATMENT ( General approach ) • ABC ’s • Stratification • Control of pain ( Demerol..) • Fluid ressuscitation

  16. TREATMENT ( General approach ) • Metabolic correction • hyperglycemia • hypocalcemia • hypomagnesemia • acidosis...

  17. ANTIBIOPROPHYLAXIS • 20% of all acute pancreatitis = necrotizing • Up to 70% of infection in N.Pancreatitis • Bradley III EL and al Arch Surg 128:586,1993 • 50% of all infections in the first 2 weeks • 80% mortality of AP = infections • Mortality: • Infected NP = 25% • Sterile NP = 13% • Beger and al World J Surg 9:972-979,1985

  18. ANTIBIOPROPHYLAXIS • ATB could be a good choice to • Reduce necrosis infection? • Decrease the need in surgery? • Decrease mortality?... • ATB should: • Have a broad spectrum • Good pancreas penetration

  19. Ratschko and al Gastro Clinics N A,28;3,641 1999

  20. ANTIBIOPROPHYLAXIS • Ratschko and al Gastro Clinics N A,28;3,641 1999

  21. ANTIBIOPROPHYLAXIS

  22. ANTIBIOPROPHYLAXIS • Multicenter,randomized study • 6 centers in Italy • 74 patients with necrotizing pancreatitis • 37 biliary • 24 roh

  23. ANTIBIOPROPHYLAXIS • Inclusion criteria • admission within 48 hrs • no previous pancreatic disease • no clinical evidence of sepsis • no previous antibiotic treatment • Ct-Scan within 72 hrs • presence of necrosis

  24. ANTIBIOPROPHYLAXIS • Group 1 control • Group 2 imipenem 500mg QID for 2 weeks • Fine needle aspiration PRN for pancreas sepsis suspicion • Group 1 treated with ampicilin or an aminoglycosid for urinary or pulm. infections

  25. ANTIBIOPROPHYLAXIS

  26. ANTIBIOPROPHYLAXIS • Discussion • ATB decrease the number of pancreatic and extra-pancreatic infection • The power of that study was not enough to demonstrate any difference in mortality

  27. ANTIBIOPROPHYLAXIS • But many problems • Unblind study • Criteria for infection??? • Use of TPN and antiprotease ( reproducibility ) • Standardisation of treatment? • Indication of surgery??? • Use of ampi + genta

  28. ANTIBIOPROPHYLAXIS • Ratschko and al Gastro Clinics N A,28;3,641 1999

  29. ANTIBIOPROPHYLAXIS • Selective gut decontamination • Ratschko and al Gastro Clinics N A,28;3,641 1999

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