Severe acute pancreatitis: diagnosis and intensive resuscitation treatment

2021-07-31 09:49 PM

Acute pancreatitis, the clinical picture is quite diverse, mild, requiring only a short hospital stay, few complications, severe degree, complicated course, many complications

About 15 to 25 percent of all patients with acute pancreatitis develop severe pancreatitis. The mortality rate from acute pancreatitis fell from 12% to 2%, according to a large epidemiological study from the United States. However, the mortality rate is still much higher in the critically ill patient groups. Its ability to predict severity could help identify patients at higher risk of morbidity and mortality, thereby supporting early treatment for intensive care units and patient selection for intervention. specific card.

A multitude of predictive models has been developed to predict the severity of acute pancreatitis based on clinical, laboratory, and radiological risk factors, different severity grading systems, and serum markers. Some of these may be performed on admission to aid in patient triage, while others may be obtained only after the first 48 to 72 hours or later.

However, these prediction models have low specificity (that is, a high false-positive rate), which, when combined with a low incidence of severe acute pancreatitis (15 to 25%), leads to values of low positive prognosis. Future prediction models will need to incorporate additional factors (e.g., biomarkers, genetic polymorphisms and mutations, and protein and metabolic models) and analytical methods.

Acute pancreatitis is an acute inflammatory process of the pancreas, the clinical picture is quite diverse, manifesting at different levels: mild, requiring only a short hospital stay, few complications, severe severity, and progressive disease. complicated complications, many complications, the high mortality rate of 20-50% in the context of multi-organ failure, infection.

The pathogenesis of acute pancreatitis is increasingly elucidated, recent studies have shown that in acute pancreatitis, there is an increased concentration of cytokines in the blood, an increase in the response of white blood cells and endothelial cells. Blood clots are the main cause of multi-organ failure in acute pancreatitis. On the other hand, recent studies from the late 90s of European and American authors have shown that increased intra-abdominal pressure (ALOB) is proportional to the severity of acute pancreatitis and is also a consequence of acute pancreatitis. Increased cytokines, inflammatory factors in acute pancreatitis create a pathological spiral leading to severe multi-organ failure in severe acute pancreatitis.

These new insights have helped researchers and clinicians change their views on the treatment of acute pancreatitis according to the pathogenesis.

Clinical presentation of acute pancreatitis

Functions

Abdominal pain above the navel.

Nausea, vomiting.

Liquid stools

Physical signs

Abdomen distended.

Painful back ribs.

Abdominal wall reaction.

Peritoneal induction.

Ascites.

Bruising under the skin.

Navel tension mass.

Pleural effusion.

Skin rainbow.

Intra-abdominal pressure.

Subclinical acute pancreatitis

Biochemical

Blood amylase increased > 3 times normal (increased after 1-2 hours of pain, increased after 24 hours, and normalized after 2-3 days).

Increased lipase is more diagnostic than elevated amylase.

LDH increased.

Increased CRP has prognostic significance.

Hematology

WBC increased, neutrophils increased, hematocrit increased due to blood concentration.

Coagulation disorders in critically ill patients.

Image analyzation

Abdominal X-ray:

The abdomen is bloated, loops of the intestine near the pancreas are dilated.

Pleural effusion.

Supersonic

Edema body.

Necrotic body.

Exploration of biliary tract obstruction, pancreatic duct.

Computed tomography (CT) scan

This is the standard for diagnosis.

Diagnosis of severity is based on one of the following scales:

Based on APACHE-II

> 8 points are heavy.

According to the Ranson scale

> 3 heavy factors.

Upon admission to the hospital:

Age > 55.

B L > 16000.

LDH > 350U/I.

AST > 250U/I.

Glucose > 11 mmol/l.

Within 48 hours:

HP reduction > 10%.

Ure > 1,8mmol/l.

Calcium <1.9mmol / l.

PaO2 < 60mmHg.

Dehydration > 6000ml.

Central venous pressure decreased by more than 4 mmHg.

Follow Imrie

Based on the assessment on admission, including 8 factors:

WBC >15000.

Blood calcium < 2mmol/l.

Blood Glucose  > 10mmol/l.

Albumin < 32g/l.

PaO2 < 60mmHg.

AST/ALT > 200U/I.

If > 3/8 factors are severe.

Based on diagnostic imaging Balthazar Score (CT Score)

Degree of pancreatitis:

Normal pancreas: 0.

Acute pancreatitis with edema: 1.

Peri pancreatitis: 2.

A peripancreatic outbreak: 3.

> 2 peripancreatic outbreaks: 4.

Total score = score for inflammation + score for necrosis.

1-2 points: no serious complications.

Degree of necrosis:

No necrosis: 0.

Necrosis of one-third of the pancreas: 2.

Necrosis 1/3 -1/2: 4.

Necrosis > 1/2: 6.

3-6: Unknown complications.

> 7-10: severe, high mortality.

Differential diagnosis

Inflammation, gallstones, gastric perforation, aortic dissection, myocardial infarction, ...

Treatment

Active resuscitation measures

Respiratory resuscitation:

Indications: when the patient has clinical respiratory failure and blood gas testing, chest X-ray.

Methods: oxygen glasses, mask, non-invasive breathing -» if severe lung damage, ARDS => mechanical ventilation according to ARDS Net.

Circulatory Resuscitation:

The patient was placed with a central venous catheter.

Fluid replacement: isotonic saline, high molecular weight fluid, fresh human plasma albumin to ensure central venous pressure 10-15cm of water.

Vasoactive drugs, heart support when enough fluid is rehydrated: noradrenaline, dopamine, dobutamine.

Electrolyte replenishment, acid-base balance.

Decreased pancreatic secretion:

Stilamin, Sandostatin.

Pain relief:

Common pain relievers (paracetamol), opiates.

Antibiotic:

Blood culture, urine culture, pleural fluid, peritoneal fluid, and necrotic pancreatic tissue (collect specimens during surgery or aspiration under ultrasound, CT).

Antibiotics according to the recommended regimen: 3rd generation cephalosporins or imipenem + fluoroquinolone and/or antibiotics active against anaerobic bacteria (metronidazole, clindamycin).

Feed, take care:

The intravenous route in the first stage (glucid, lipid, amino acid) ensures 40 - 60 calories/kg body weight, early oral feeding immediately after pain relief and no symptoms of intestinal obstruction and gradually increasing quantity.

Common measures to reduce intra-abdominal pressure:

Gastric suction, anal enema.

Drainage of abdominal fluid, peripancreatic fluid:

Drain with a small 12-16F catheter under ultrasound or CT guidance.

Continuous hemodialysis (CVVH)

Determination:

Early indications immediately after admission is assessed for severe acute pancreatitis with the aim of eliminating cytokines and incorporating symptomatic treatment.

Contraindications:

Severe heart failure, low blood pressure (systolic blood pressure < 60 mmHg) that cannot be corrected, heavy bleeding - contraindications are relative.

Monitoring

Clinical.

Abdominal pressure every 8 hours.

Progression of organ failure according to SOFA scale.

Complications of acute pancreatitis.

Complications of continuous dialysis.

Indications for surgical treatment

Acute pancreatitis caused by gallstones, pancreatic duct stones, pancreatic abscess, infectious necrosis, pancreatic pseudocyst > 6 cm, and lasting > 6 weeks (percutaneous drainage).

Prevention

Eliminate favorable causes of acute pancreatitis.

Endoscopic treatment, surgery to remove bile duct stones, pancreatic stones.

Alcohol withdrawal, treatment of hyperlipidemia.