2. Acute Severe Pancreatitis Treatment in the second millenium Up to date Martin Albert M.D. Critical Care Fellow October 2000

3. PLAN Definition Antibioprophylaxis ERCP Surgery Nutrition

4. PLAN Other modalities lexipafant octreotide... Conclusion

5. DEFINITION 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

6. DEFINITION 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

7. 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

8. DEFINITION 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

9. Definition APACHE 2  8

10. 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

11. CT-SCAN

13. Relationship between mortality/morbidity and imaging

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

15. TREATMENT General approach Antibioprophylaxis Nutrition Surgery ERCP Octreotide and lexipafant...

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

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

18. 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

19. 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

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

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

22. ANTIBIOPROPHYLAXIS

23. Multicenter,randomized study 6 centers in Italy 74 patients with necrotizing pancreatitis »37 biliary »24 roh

24. 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

25. 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

26. ANTIBIOPROPHYLAXIS

27. 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

28. 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

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

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