Intensive Care Management of Acute Pancreatitis

Abstract

Despite progress in recent years in the diagnostics, surgical treatment and intensive care therapy, severe acute pancreatitis remains a major challenge to the medical profession and a serious threat to the patients. In its most severe form, acute pancreatitis is characterised by a profound inflammatory process in the pancreas leading to partial or total necrosis of the parenchyma. Acute pancreatitis also frequently causes dysfunction of remote organs as well as local complications (pancreatic infection, haemorrhage and pseudocysts). The majority of the attacks of acute pancreatitis (85-90%) are, however, mild and can be dealt with by simple routine treatment. It is essential to identify at an early stage those patients who will develop a severe form of the disease, to allow timely vital organ system monitoring and support in an intensive care unit. Early intervention may have a significant influence on the course of the disease. As soon as the pancreatic inflammation has progressed to necrosis, anti-enzyme or anti-inflammatory therapy and/or treatment which may enhance the pancreatic microcirculation is not likely to change the course of the disease and leaves the treating physician with symptomatic measures only. On arrival to the ICU the patients are frequently hypovolaemic, have diminished blood flow to the abdominal organs, resulting not only in more severe local disease, but also frequently causing failure of remote organs such as the lungs (adult respiratory distress syndrome), kidneys, liver and the intestine (possibly encouraging translocation of enteral bacteria). The aim of therapy in severe pancreatitis is obviously to halt the progress of the local disease and to prevent remote organ failure. So far, very limited experimental and clinical research has been performed on the effects of different modes of intensive care therapy on pancreatic blood flow or on the progress of the panceatic necrosis. Based on clinical experience and available research data, the following procedures are currently recommended in the ICU management of severe pancreatitis. (l)Use invasive monitoring. (2) Optimise oxygen transport by maintaining hyperdynamic circulation (at least during the first 3 days), for example by using isovolaemic or hypervolaemic haemodilution, administration of low dose dopexamine and if necessary other cardio-inotropic drugs. (3) Indications for assisted ventilation should be liberal in order to guarantee high blood oxygen content and to decrease energy expenditure. (4) Start nutrition early to minimise negative nitrogen balance, but avoid overfeeding. (5) Use crystalloids for replacement of insensible fluid loss only and synthetic colloids such as pentastarch for plasma substitution. (6) Provide effective pain relief, for example, by continuous epidural or coeliac block. (7) In cases of extensive necrosis, prophylactic antibiotic therapy (imipenem) should be considered. (8) Follow the clinical course of the patient very closely and monitor the degree of necrosis and possible pancreas infection for tim...

Acute pancreatitis: the substantial human and financial costs

“…27 Death from local complications is more common after the first week, especially if infection supervenes 1546 Pancreatic necrosis by itself is not particularly predictive of mortality, but if multiple organ failure is present also, mortality is higher 27…”

“…Patients with severe acute pancreatitis on the intensive care unit are among the most resource demanding in intensive care medicine 15. The mainstay of management is intensive monitoring and organ support, including (as required) intravenous fluid replacement, oxygen therapy and artificial ventilation, use of inotropes, prevention of stress ulceration, renal support by haemoperfusion and haemofiltration, pain relief, and nutritional support.…”

“…The initial improvement occurred principally because of better definition of the natural history of the disease,12 13 refined imaging techniques for identifying complications at an earlier stage during its pathogenesis,12 14 advances in critical care support,1 15 and avoidance of major surgery where it could increase morbidity and mortality 59 16 17Failure to even entertain, and hence make, the diagnosis of acute pancreatitis in patients admitted to medical and surgical wards has formerly, and may still, contribute to a higher mortality rate 3…”

Blutreinigungsmaßnahmen bei Patienten mit Organversagen bei schwerer Pankreatitis*

“…Zu den Eckpfeilern der Diagnostik gehören die Klassifikation der akuten Pankreatitis nach entsprechenden Empfehlungen der Atlanta Konsensus-Konferenz [10], die Durchführung eines kontrastverstärkten CT©s, um das Ausmaû der Nekrosen zu erkennen und die CT-gestützte Feinnadelaspiration, um Infektionen nachzuweisen. Die therapeutische Strategie besteht in der Antibiotikaprophylaxe [3 ± 6, 13, 23], einer frühen aggressiven Kreislaufstabilisierung durch isovolämische Hämodilution mit Dextranen, einem Monitoring der Lungen-und Nierenfunktion mit assistierter Beatmung, wenn notwendig [12,25], und einer frühen enteralen Ernährung [16]. Die Chirurgie ist erst in einer späteren Behandlungsphase allgemein akzeptiert, etwa ab der dritten Woche oder wenn Zeichen der Infektion vorliegen [7,9].…”

Akute nekrotisierende Pankreatitis

“…Bei Verdacht auf das Vorliegen einer schweren Pankreatitis muß diese unter intensivmedizinischen Bedingungen in einem mit diesem Krankheitsbild erfahrenen Krankenhaus durchgeführt werden.Beim Vorliegen einer schweren akuten Pankreatitis haben sich frühzeitig operative Vorgehensweisen nicht bewährt, so daß heute allgemein akzeptiert ist, daß die konservativ, intensivmedizinische Betreuung dieser Patienten die wichtigste initiale Behandlungmaßnahme darstellt [Übersichten siehe: 4, 5, 7, 10,15,25,28,31,42,52,55,60,61]. Jeder Patient mit Verdacht auf eine akute Pankreatitis muß umgehend zur weiteren Diagnostik und Beobachtung in ein Krankenhaus eingewiesen werden.…”