重癥急性胰腺炎英文PPTSevereacute-pancreatitis

1、Severe acute pancreatitis S_c7 Academy for Infection Management 2006 (All Rights Reserved) History33-year-old maleAlcohol binge: vodkaAwake and conversantSevere abdominal pain, vomiting, dyspnoeaPhysical and laboratory examinationsTemperature 38.1CPulse 96 bpm, respirations 20/minBlood pressure 110/

2、70 mmHgAbdomen tender, distended, quietAmylase 3500 IU/LLipase 1100 IU/LAST 250 IU/LLDH 350 IU/L WBC count 16 000/mm3 Arterial blood gases:pH 7.30, PaCO2 32, PaO2 58, BE -5Which evaluations would you perform to determine if the patient has severe pancreatitis?C-reactive proteinComputed tomography (C

3、T) scanSeverity scoresRanson scoreGlasgow (Imrie) scoreAPACHE II or III scoreBalthazar scoreInitial tests and treatmentFluid resuscitation Chest radiographyCTCalculation of Ranson score (at 48 hours) The patient has severe pancreatitisby CT criteriaCentral necrosis of the pancreas 30%Peripancreatic

4、oedema and inflammationRanson score: a pancreatitis-specific severity of illness scoreAge 55 years WBC 16 000/mm3 Glucose 200 mg/dL LDH 350 IU/L AST 250 IU/L Haematocrit decrease 10% points BUN increase 5 mg/dL Serum calcium 8 mg/dL PaO2 60 mm Hg Base deficit 6 LPresent on admissionDuring the first

5、48 hours The patient has eight positive Ranson criteriaSGOT 250 IU/LLDH 350 IU/L WBC count 16 000/mm3PaO2 60 mm HgBase deficit 6 LCalcium concentration 0 percentage pointsThe predicted mortality rate for a Ranson score of 8 is 60%Eachempati et al. Arch Surg 2002Figure reproduced with permission from

6、 Arch SurgWould you start prophylactic antibiotics?NoYes, with Ceftriaxone?Gentamicin plus metronidazole?Imipenem/cilastatin or meropenem?Ciprofloxacin plus metronidazole?Other?Yes, plus fluconazolePenetration of pancreatic tissue and pancreatic juice by antimicrobial agentsPoorAminoglycosidesVancom

7、ycinVariablePenicillinsCephalosporinsGoodCarbapenemsMetronidazoleQuinolones FluconazoleBassi et al. Antimicrob Agents Chemother 1994;38:830836What is this patients risk of developing infection?50%Incidence of peripancreatic infection after acute pancreatitisAll episodes 3%7%Any pancreatic necrosis 2

8、0%70%Pancreatic necrosis 30% 15%30%Pancreatic necrosis 50% 40%70%Beger et al. Gastroenterology 1986;91:433438Beger et al. Pancreatology 2003;3:93101Buchler et al. Ann Surg 2000;232:619625Day 14Day 7Day 21Should prophylaxis be given? for the entire at-risk period?Pancreatic infections almost never oc

9、cur before Day 7 The peak incidence is at Day 14Beger et al. Gastroenterology 1986;91:43343899% of data95% of data68% of dataHow long would you administer antibiotic prophylaxis?Would not administer prophylaxis1 week2 weeks3 weeksUntil ICU dischargeShould prophylaxis be administered for the entire r

10、isk period?Prophylactic antibiotics for severe acute pancreatitisFirst double-blind, placebo-controlled trial114 patients enrolled, 76 with necrosisEntry criteriaC-reactive protein 150, orNecrosis on contrast-enhanced CT, and120 mg/dL, orMultiple organ dysfunction score 2 pointsMeropenem 1 g q8h vs

11、placeboPrimary end-pointPancreatic/peripancreatic infection within 42 daysDellinger et al. Ann Surg (in press)Prophylactic antibiotics for severe acute pancreatitis: trial resultsOutcomeMeropenem %Placebo %p-valuePancreatic/peripancreatic infection18120.41Surgical intervention26200.48Mortality20180.

12、80Dellinger et al. Ann Surg (in press)The downside of prolonged antibiotic prophylaxisAllergyExpenseResistanceSuperinfectionProphylactic antibiotics for severe acute pancreatitisRecovery of resistant bacteriap Week 1Sensitivity (%)8897Specificity (%)90100Pos. pred. value (%)83100Neg. pred. value (%)

13、9398Accuracy (%)8998Results of culture and susceptibility testingPatient underwent CT-guided fine-needle aspirationPeripancreatic fluid Proteus mirabilis (pan-sensitive)BloodNo growthUrineNo growthSputumNo growthMicrobiology of infected pancreatic necrosis (%)Fernandez-del Castillo 1998Buchler 2000G

14、ram-positive5546Gram-negative2636Anaerobes 2 4Candida spp.17 6MixedNot reported10Fernandez-del Castillo et al. Ann Surg 1998;228:676684Buchler et al. Ann Surg 2000;232:619626TherapyFormal operative debridement and drainageOnly one operation requiredMeropenem x 14 daysChoice based on tissue penetrati

15、on Dosage reduction for creatinine clearance 35 mL/minOutcomeFever and leukocytosis resolveOrgan dysfunction resolvesRenal function improvesCreatinine stabilises at 2.0 mg/dLPatient recoversKey learning pointsMost patients (85%) with acute pancreatitis do not develop severe diseaseDetermination of s

16、everity of illness provides prognostic information and can guide therapyAntimicrobial prophylaxis does not prevent secondary infection in severe acute pancreatitis, but does increase risk of resistant pathogens if infection does occurAntibiotics may be withheld until needed for therapy AIM core principlesSelect the most appropriate antibiotic depending on the patient, risk factors, suspecte