A modern approach to the intensive treatment of patients with severe acute pancreatitis
Abstract
Severe acute pancreatitis (SAP) is an acute inflammatory disorder of the pancreas which is associated with significant morbidity and mortality. The main characteristic of the disease is severe systemic inflammation which can be complicated by multiorgan failure and infection of pancreatic necrosis. Repeated assessment of the severity of SAP, based on clinical signs, intensive care monitoring, blood tests and imaging tools should be performed to determine the optimal way of treatment for each patient. Infectious complications in SAP are considerable problem and have an impact on outcome in patients who survived the first inflammatory hit of the disease. The diagnosis of infected pancreatic necrosis is often challenging. At this moment, the only rational indication for antibiotic treatment is documented infection. If the patient’s condition allows, enteral nutrition should be implemented, otherwise pareneteral or combined nutrition is advised. Surgical treatment of SAP is nowadays delayed and includes minimally invasive techniques. The intensive care of SAP patients is oriented towards supportive treatment and prevention of complications.
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De Waele JJ. Acute pancreatitis. Curr Opin Crit Care. 2014 Apr;20(2):189–95. https://doi.org/10.1097/MCC.0000000000000068 PMID:24553339
Bakker OJ, van Santvoort HC, van Brunschot S, Geskus RB, Besselink MG, Bollen TL, et al.; Dutch Pancreatitis Study Group. Endoscopic transgastric vs surgical necrosectomy for infected necrotizing pancreatitis: a randomized trial. JAMA. 2012 Mar;307(10):1053–61. https://doi.org/10.1001/jama.2012.276 PMID:22416101
Besselink MG, van Santvoort HC, Witteman BJ, Gooszen HG; Dutch Acute Pancreatitis Study Group. Management of severe acute pancreatitis: it’s all about timing. Curr Opin Crit Care. 2007 Apr;13(2):200–6. https://doi.org/10.1097/MCC.0b013e328015b8af PMID:17327743
Lankisch PG. Aetilology of acute pancreatitis. In: Glazer G, Ranson JH, editors. Acute pancreatitis. London: Bailliere Tindall; 1988. pp. 167–81.
Lankisch PG. Pathogenesis of pancreatic inflammation. In: Glazer G, Ranson JH, editors. Acute pancreatitis. London: Bailliere Tindall; 1988. pp. 182–93.
McMahon MJ. Acute pancreatitis. In: Misiewicz JJ, Pounder RE, Venables CW, editors. Diseases of the gut and pancreas. Oxford: Blackwell; 1994. pp. 427–40.
Voga G. Ocena srčne funkcije in stanja cirkulacije pri kritično bolnih. Zdrav Vestn. 2007;76(1):19–27.
Magder S. Invasive hemodynamic monitoring. Crit Care Clin. 2015 Jan;31(1):67–87. https://doi.org/10.1016/j.ccc.2014.08.004 PMID:25435479
Pinsky MR. Functional hemodynamic monitoring. Crit Care Clin. 2015 Jan;31(1):89–111. https://doi.org/10.1016/j.ccc.2014.08.005 PMID:25435480
Cecconi M, De Backer D, Antonelli M, Beale R, Bakker J, Hofer C, et al. Consensus on circulatory shock and hemodynamic monitoring. Task force of the European Society of Intensive Care Medicine. Intensive Care Med. 2014 Dec;40(12):1795–815. https://doi.org/10.1007/s00134-014-3525-z PMID:25392034
Blum T, Maisonneuve P, Lowenfels AB, Lankisch PG. Fatal outcome in acute pancreatitis: its occurrence and early prediction. Pancreatology. 2001;1(3):237–41. https://doi.org/10.1159/000055817 PMID:12120201
Mutinga M, Rosenbluth A, Tenner SM, Odze RR, Sica GT, Banks PA. Does mortality occur early or late in acute pancreatitis? Int J Pancreatol. 2000 Oct;28(2):91–5. https://doi.org/10.1385/IJGC:28:2:091 PMID:11128978
Wu BU. Editorial: fluid resuscitation in acute pancreatitis: striking the right balance. Am J Gastroenterol. 2011 Oct;106(10):1851–2. https://doi.org/10.1038/ajg.2011.241 PMID:21979206
Cherpanath TG, Geerts BF, Lagrand WK, Schultz MJ, Groeneveld AB. Basic concepts of fluid responsiveness. Neth Heart J. 2013 Dec;21(12):530–6. https://doi.org/10.1007/s12471-013-0487-7 PMID:24170232
Grassi P, Lo Nigro L, Berlot G, et al. Pulse pressure variation as a predictor of fluid responsiveness in mechanically ventilated patients with spontaneous breathing activity: a pragmatic observational study. HCR Proc Intensive Care Cardiovasc Anesth. 2013; 5(2): 98–109.
Working group IAP/APA acute pancreatitis guidelines. IAP/APA evidence-based guidelines for the management of acute pancreatitis. Pancreatology. 2013;13(4):1–15. https://doi.org/10.1016/j.pan.2013.07.063.
Wu BU, Hwang JQ, Gardner TH, Repas K, Delee R, Yu S, et al. Lactated Ringer’s solution reduces systemic inflammation compared with saline in patients with acute pancreatitis. Clin Gastroenterol Hepatol. 2011 Aug;9(8):710–717.e1. https://doi.org/10.1016/j.cgh.2011.04.026 PMID:21645639
Perel P, Roberts I, Ker K. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev. 2013 Feb 28;(2):CD000567. https://doi.org/10.1002/14651858.CD000567.pub6.
Pelosi P, Gama de Abreu M, Rocco PR. New and conventional strategies for lung recruitment in acute respiratory distress syndrome. Crit Care. 2010;14(2):210–6. https://doi.org/10.1186/cc8851 PMID:20236454
Umbrello M, Formenti P, Bolgiaghi L, Chiumello D. Current concepts of ARDS: A narrative review. Int J Mol Sci. 2016 Dec;18(1):1–20. https://doi.org/10.3390/ijms18010064 PMID:28036088
Talmor D, Sarge T, Malhotra A, O’Donnell CR, Ritz R, Lisbon A, et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. N Engl J Med. 2008 Nov;359(20):2095–104. https://doi.org/10.1056/NEJMoa0708638 PMID:19001507
Pelosi P, Vargas M. Mechanical ventilation and intra-abdominal hypertension: ‘Beyond Good and Evil’. Crit Care. 2012 Dec;16(6):187. https://doi.org/10.1186/cc11874 PMID:23256904
Ruiz Ferrón F, Tejero Pedregosa A, Ruiz García M, Ferrezuelo Mata A, Pérez Valenzuela J, Quirós Barrera R, et al. [Intraabdominal and thoracic pressure in critically ill patients with suspected intraabdominal hypertension]. Med Intensiva. 2011 Jun-Jul;35(5):274–9. https://doi.org/10.1016/j.medine.2011.02.001 PMID:21497415
Mirković T. Akutni pankreatitis. In:Pavel-Eržen V, ur. 22.tečaj CEEA. Ljubljna: Slovensko združenje za anesteziologijo in intenzivno medicino, Slovensko zdravniško društvo; 2014. p. 73 –90.
Kirkpatrick AW, Roberts DJ, De Waele J, Jaeschke R, Malbrain ML, De Keulenaer B, et al.; Pediatric Guidelines Sub-Committee for the World Society of the Abdominal Compartment Syndrome. Intra-abdominal hypertension and the abdominal compartment syndrome: updated consensus definitions and clinical practice guidelines from the World Society of the Abdominal Compartment Syndrome. Intensive Care Med. 2013 Jul;39(7):1190–206. https://doi.org/10.1007/s00134-013-2906-z PMID:23673399
Chiumello D, Gallazzi E, Marino A, Berto V, Mietto C, Cesana B, et al. A validation study of a new nasogastric polyfunctional catheter. Intensive Care Med. 2011 May;37(5):791–5. https://doi.org/10.1007/s00134-011-2178-4 PMID:21365314
De Waele JJ, Hoste EA, Malbrain ML. Decompressive laparotomy for abdominal compartment syndrome—a critical analysis. Crit Care. 2006;10(2):R51. https://doi.org/10.1186/cc4870 PMID:16569255
Leppäniemi A, Mentula P, Hienonen P, Kemppainen E. Transverse laparostomy is feasible and effective in the treatment of abdominal compartment syndrome in severe acute pancreatitis. World J Emerg Surg. 2008 Jan;3(1):6. https://doi.org/10.1186/1749-7922-3-6 PMID:18234076
Maher MM, Lucey BC, Gervais DA, Mueller PR. Acute pancreatitis: the role of imaging and interventional radiology. Cardiovasc Intervent Radiol. 2004 May-Jun;27(3):208–25. https://doi.org/10.1007/s00270-003-1907-7 PMID:15024494
Wittau M, Mayer B, Scheele J, Henne-Bruns D, Dellinger EP, Isenmann R. Systematic review and meta-analysis of antibiotic prophylaxis in severe acute pancreatitis. Scand J Gastroenterol. 2011 Mar;46(3):261–70. https://doi.org/10.3109/00365521.2010.531486 PMID:21067283
Villatoro E, Mulla M, Larvin M. Antibiotic therapy for prophylaxis against infection of pancreatic necrosis in acute pancreatitis. Cochrane Database Syst Rev. 2010 May;12(5):CD002941. https://doi.org/10.1002/14651858.CD002941.pub3 PMID:20464721
Jiang K, Huang W, Yang XN, Xia Q. Present and future of prophylactic antibiotics for severe acute pancreatitis. World J Gastroenterol. 2012 Jan;18(3):279–84. https://doi.org/10.3748/wjg.v18.i3.279 PMID:22294832
Maraví-Poma E, Gener J, Alvarez-Lerma F, Olaechea P, Blanco A, Domínguez-Muñoz JE; Spanish Group for the Study of Septic Complications in Severe Acute Pancreatitis. Early antibiotic treatment (prophylaxis) of septic complications in severe acute necrotizing pancreatitis: a prospective, randomized, multicenter study comparing two regimens with imipenem-cilastatin. Intensive Care Med. 2003 Nov;29(11):1974–80. https://doi.org/10.1007/s00134-003-1956-z PMID:14551680
Greenberg JA, Hsu J, Bawazeer M, Marshall J, Friedrich JO, Nathens A, et al. Clinical practice guideline: management of acute pancreatitis. Can J Surg. 2016 Apr;59(2):128–40. https://doi.org/10.1503/cjs.015015 PMID:27007094
Brattström C, Malmborg AS, Tydén G. Penetration of imipenem into human pancreatic juice following single intravenous dose administration. Chemotherapy. 1989;35(2):83–7. https://doi.org/10.1159/000238652 PMID:2758871
Wittau M, Wagner E, Kaever V, Koal T, Henne-Bruns D, Isenmann R. Intraabdominal tissue concentration of ertapenem. J Antimicrob Chemother. 2006 Feb;57(2):312–6. https://doi.org/10.1093/jac/dki459 PMID:16396920
Wacke R, Förster S, Adam U, Mundkowski RG, Klar E, Hopt UT, et al. Penetration of moxifloxacin into the human pancreas following a single intravenous or oral dose. J Antimicrob Chemother. 2006 Nov;58(5):994–9. https://doi.org/10.1093/jac/dkl353 PMID:16956903
Schubert S, Dalhoff A. Activity of moxifloxacin, imipenem, and ertapenem against Escherichia coli, Enterobacter cloacae, Enterococcus faecalis, and Bacteroides fragilis in monocultures and mixed cultures in an in vitro pharmacokinetic/pharmacodynamic model simulating concentrations in the human pancreas. Antimicrob Agents Chemother. 2012 Dec;56(12):6434–6. https://doi.org/10.1128/AAC.00872-12 PMID:23070164
Whitcomb DC. Clinical practice. Acute pancreatitis. N Engl J Med. 2006 May;354(20):2142–50. https://doi.org/10.1056/NEJMcp054958 PMID:16707751
Gloor B, Müller CA, Worni M, Martignoni ME, Uhl W, Büchler MW. Late mortality in patients with severe acute pancreatitis. Br J Surg. 2001 Jul;88(7):975–9. https://doi.org/10.1046/j.0007-1323.2001.01813.x PMID:11442530
van Santvoort HC, Besselink MG, Bakker OJ, Hofker HS, Boermeester MA, Dejong CH, et al.; Dutch Pancreatitis Study Group. A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med. 2010 Apr;362(16):1491–502. https://doi.org/10.1056/NEJMoa0908821 PMID:20410514
Behrman SW, Bahr MH, Dickson PV, Zarzaur BL. The microbiology of secondary and postoperative pancreatic infections: implications for antimicrobial management. Arch Surg. 2011 May;146(5):613–9. https://doi.org/10.1001/archsurg.2011.85 PMID:21576614
Klein S, Kinney J, Jeejeebhoy K, Alpers D, Hellerstein M, Murray M, et al. Nutrition support in clinical practice: review of published data and recommendations for future research directions. National Institutes of Health, American Society for Parenteral and Enteral Nutrition, and American Society for Clinical Nutrition. JPEN J Parenter Enteral Nutr. 1997 May-Jun;21(3):133–56. https://doi.org/10.1177/0148607197021003133 PMID:9168367
Singh VK, Moran RA, Afghani E, de-Madaria E. Treating acute pancreatitis: what’s new? Expert Rev Gastroenterol Hepatol. 2015 Jul;9(7):901–11. https://doi.org/10.1586/17474124.2015.1048225 PMID:25982517
Janisch NH, Gardner TB. Advances in management of acute pancreatitis. Gastroenterol Clin North Am. 2016 Mar;45(1):1–8. https://doi.org/10.1016/j.gtc.2015.10.004 PMID:26895677
Fritz S, Hackert T, Hartwig W, Rossmanith F, Strobel O, Schneider L, et al. Bacterial translocation and infected pancreatic necrosis in acute necrotizing pancreatitis derives from small bowel rather than from colon. Am J Surg. 2010 Jul;200(1):111–7. https://doi.org/10.1016/j.amjsurg.2009.08.019 PMID:20637344
Petrov MS, van Santvoort HC, Besselink MG, van der Heijden GJ, Windsor JA, Gooszen HG. Enteral nutrition and the risk of mortality and infectious complications in patients with severe acute pancreatitis: a meta-analysis of randomized trials. Arch Surg. 2008 Nov;143(11):1111–7. https://doi.org/10.1001/archsurg.143.11.1111 PMID:19015471
Jacobson BC, Vander Vliet MB, Hughes MD, Maurer R, McManus K, Banks PA. Nutrition in acute pancreatitis: a critical review Jacobson BC, Vander Vliet MB, Hughes MD, Maurer R, McManus K, Banks PA. A prospective, randomized trial of clear liquids versus low-fat solid diet as the initial meal in mild acute pancreatitis. Clin Gastroenterol Hepatol. 2007;5(8):946–51. https://doi.org/10.1016/j.cgh.2007.04.012.
Muftuoglu MA, Isikgor S, Tosun S, Saglam A. Effects of probiotics on the severity of experimental acute pancreatitis. Eur J Clin Nutr. 2006 Apr;60(4):464–8. https://doi.org/10.1038/sj.ejcn.1602338 PMID:16340953
Barraud D, Bollaert PE, Gibot S. Impact of the administration of probiotics on mortality in critically ill adult patients: a meta-analysis of randomized controlled trials. Chest. 2013 Mar;143(3):646–55. https://doi.org/10.1378/chest.12-1745 PMID:23460153
Lei QC, Wang XY, Xia XF, Zheng HZ, Bi JC, Tian F, et al. The role of omega-3 fatty acids in acute pancreatitis: a meta-analysis of randomized controlled trials. Nutrients. 2015 Mar;7(4):2261–73. https://doi.org/10.3390/nu7042261 PMID:25835048
Jafari T, Feizi A, Askari G, Fallah AA. Parenteral immunonutrition in patients with acute pancreatitis: a systematic review and meta-analysis. Clin Nutr. 2015 Feb;34(1):35–43. https://doi.org/10.1016/j.clnu.2014.05.008 PMID:24931755
Pérez S, Pereda J, Sabater L, Sastre J. Redox signaling in acute pancreatitis. Redox Biol. 2015 Aug;5:1–14. https://doi.org/10.1016/j.redox.2015.01.014 PMID:25778551
Yao H, He C, Deng L, Liao G. Enteral versus parenteral nutrition in critically ill patients with severe pancreatitis: a meta-analysis. Eur J Clin Nutr. 2018 Jan;72(1):66–8. https://doi.org/10.1038/ejcn.2017.139 PMID:28901335
Pan LL, Li J, Shamoon M, Bhatia M, Sun J. Recent Advances on Nutrition in Treatment of Acute Pancreatitis. Front Immunol. 2017 Jun;8:762. https://doi.org/10.3389/fimmu.2017.00762 PMID:28713382
Feng P, He C, Liao G, Chen Y. Early enteral nutrition versus delayed enteral nutrition in acute pancreatitis A PRISMA-compliant systematic review and meta-analysis. Medicine 2017; 96:46 (e8648)
Meier R, Beglinger C, Layer P, Gullo L, Keim V, Laugier R, et al.; ESPEN Consensus Group; European Society of Parenteral and Enteral Nutrition. ESPEN guidelines on nutrition in acute pancreatitis. Clin Nutr. 2002 Apr;21(2):173–83. https://doi.org/10.1054/clnu.2002.0543 PMID:12056792
Jakobs R, Adamek MU, von Bubnoff AC, Riemann JF; R. Jakobs, M. U. Adamek, A. C. Von. Buprenorphine or procaine for pain relief in acute pancreatitis. A prospective randomized study. Scand J Gastroenterol. 2000 Dec;35(12):1319–23. https://doi.org/10.1080/003655200453692 PMID:11199374
Stevens M, Esler R, Asher G. Transdermal fentanyl for the management of acute pancreatitis pain. Appl Nurs Res. 2002 May;15(2):102–10. https://doi.org/10.1053/apnr.2002.29532 PMID:11994827
Kahl S, Zimmermann S, Pross M, Schulz HU, Schmidt U, Malfertheiner P. Procaine hydrochloride fails to relieve pain in patients with acute pancreatitis. Digestion. 2004;69(1):5–9. https://doi.org/10.1159/000076541 PMID:14755147
Mennecier D, Ceppa F, Sinayoko L, Corberand D, Harnois F, Thiolet C, et al. [Acute pancreatitis after treatment by celecoxib]. Gastroenterol Clin Biol. 2007 Aug-Sep;31(8-9 Pt 1):668–9. https://doi.org/10.1016/S0399-8320(07)91915-6 PMID:17925765
Heluwaert F, Pofelski J, Germain E, Roblin X. [Piroxicam and acute pancreatitis]. Gastroenterol Clin Biol. 2006 Apr;30(4):635–6. https://doi.org/10.1016/S0399-8320(06)73248-1 PMID:16733395
Mété D, Milon A, Belon G, Gatina JH. [Acute pancreatitis and ketoprofen]. Gastroenterol Clin Biol. 2001 Jun-Jul;25(6-7):721–2. PMID:11673744
Aygencel G, Akbuga B, Keles A. Acute pancreatitis following naproxen intake. Eur J Emerg Med. 2006 Dec;13(6):372. https://doi.org/10.1097/01.mej.0000224428.51623.b2 PMID:17091064
Murray B, Carter R, Imrie C, Evans S, O’Suilleabhain C. Diclofenac reduces the incidence of acute pancreatitis after endoscopic retrograde cholangiopancreatography. Gastroenterology. 2003 Jun;124(7):1786–91. https://doi.org/10.1016/S0016-5085(03)00384-6 PMID:12806612
Pezzilli R, Morselli-Labate AM, Corinaldesi R. NSAIDs and Acute Pancreatitis: A Systematic Review. Pharmaceuticals (Basel). 2010 Mar;3(3):558–71. https://doi.org/10.3390/ph3030558 PMID:27713268
Basurto Ona X, Rigau Comas D, Urrútia G. Opioids for acute pancreatitis pain. Cochrane Database Syst Rev. 2013 Jul;(7):CD009179. PMID:23888429
Takeda K, Takada T, Kawarada Y, Hirata K, Mayumi T, Yoshida M, et al.; JPN. JPN Guidelines for the management of acute pancreatitis: medical management of acute pancreatitis. J Hepatobiliary Pancreat Surg. 2006;13(1):42–7. https://doi.org/10.1007/s00534-005-1050-8 PMID:16463210
Bernhardt A, Kortgen A, Niesel HC, Goertz A. [Using epidural anesthesia in patients with acute pancreatitis—prospective study of 121 patients]. Anaesthesiol Reanim. 2002;27(1):16–22. PMID:11908096
Sielenkämper AW, Eicker K, Van Aken H. Thoracic epidural anesthesia increases mucosal perfusion in ileum of rats. Anesthesiology. 2000 Sep;93(3):844–51. https://doi.org/10.1097/00000542-200009000-00036 PMID:10969320
Freise H, Anthonsen S, Fischer LG, Van Aken HK, Sielenkämper AW. Continuous thoracic epidural anesthesia induces segmental sympathetic block in the awake rat. Anesth Analg. 2005 Jan;100(1):255–62. https://doi.org/10.1213/01.ANE.0000140253.65577.1C PMID:15616087
Sadowski SM, Andres A, Morel P, Schiffer E, Frossard JL, Platon A, et al. Epidural anesthesia improves pancreatic perfusion and decreases the severity of acute pancreatitis. World J Gastroenterol. 2015 Nov;21(43):12448–56. https://doi.org/10.3748/wjg.v21.i43.12448 PMID:26604652
Banks PA, Freeman ML; Practice Parameters Committee of the American College of Gastroenterology. Practice guidelines in acute pancreatitis. Am J Gastroenterol. 2006 Oct;101(10):2379–400. https://doi.org/10.1111/j.1572-0241.2006.00856.x PMID:17032204
Fong ZV, Fagenholz PJ. Minimally Invasive Debridement for Infected Pancreatic Necrosis. J Gastrointest Surg. 2019 Jan;23(1):185–91. PMID:30097963
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