[Principles of intensive care in severe acute pancreatitis in 2008].
Acute pancreatitis is a dynamic, often progressive disease; 14-20% require intensive care in its severe form due to multiorgan dysfunction and/or failure. This review was created using systematic literature review of articles published on this subject in the last 5 years. The outcome of severe acute pancreatitis is determined by the inflammatory response and multiorgan dysfunction - the prognostic scores (Acute Physiology and Chronic Health Evaluation, Glasgow Prognostic Index, Sepsis-related Organ Failure Assessment, Multi Organ Dysfunction Syndrome Scale, Ranson Scale) can be used to determine outcome. Clinical signs (age, coexisting diseases, confusion, obesity) and biochemistry values (serum amylase, lipase, C-reactive protein, procalcitonin, creatinine, urea, calcium) have important prognostic roles as well. Early organ failure increases the risk of late abdominal complications and mortality. Intensive care can provide appropriate multi-function patient monitoring which helps in early recognition of complications and appropriate target-controlled treatment. Treatment of severe acute pancreatitis aims at reducing systemic inflammatory response and multiorgan dysfunction and, on the other side, at increasing the anti-inflammatory response. Oral starvation for 24-48 hours is effective in reducing the exocrine activity of the pancreas; the efficacy of protease inhibitors is questionable. Early intravascular volume resuscitation and stable haemodynamics improve microcirculation. Early oxygen therapy and mechanical ventilation provide adequate oxygenation. Electrolyte and acid-base control can be as important as tight glucose control. Adequate pain relief can be achieved by thoracic epidural catheterization. Early enteral nutrition with immunonutrition should be used. There is evidence that affecting the coagulation cascade by activated protein C can play a role in reducing the inflammatory response. The complex therapy of acute pancreatitis includes appropriate antibiotics, thrombo-embolic prophylaxis and in certain cases plasmapheresis and/or haemofiltration. Reducing intraabdominal pressure may be necessary in the acute phase. Intensive care multidisciplinary teamwork can reduce the mortality of severe acute pancreatitis from 30% to 10%.
Darvas
Katalin
K
Semmelweis Egyetem, Altalános Orvostudományi Kar I. Sebészeti Klinika, Budapest. dk@seb1.sote.hu
Futó
Judit
J
Okrös
Ilona
I
Gondos
Tibor
T
Csomós
Akos
A
Kupcsulik
Péter
P
D000137:Acid-Base Imbalance / Q000628:therapy; D015360:Analgesia, Epidural; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D000925:Anticoagulants / Q000627:therapeutic use; D015415:Biomarkers / Q000097:blood; D001786:Blood Glucose / Q000378:metabolism; D001810:Blood Volume; D003422:Critical Care / Q000379:methods*; D004750:Enteral Nutrition; D019317:Evidence-Based Medicine; D005104:Expert Testimony; D006439:Hemodynamics; D006440:Hemofiltration; D006801:Humans; D009102:Multiple Organ Failure / Q000175:diagnosis / Q000209:etiology / Q000517:prevention & control*; D010100:Oxygen / Q000008:administration & dosage; D010146:Pain / Q000209:etiology; D059408:Pain Management; D019283:Pancreatitis, Acute Necrotizing / Q000097:blood / Q000150:complications / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D010956:Plasmapheresis; D011379:Prognosis; D012720:Severity of Illness Index; D018746:Systemic Inflammatory Response Syndrome / Q000209:etiology / Q000628:therapy*
D000900:Anti-Bacterial Agents; D000925:Anticoagulants; D015415:Biomarkers; D001786:Blood Glucose; D010100:Oxygen