--重症急性胰腺炎的诊断与治疗(英文PPT)

Author
Drug
Patients Pan infection Mortality
Con- case Con- Case Con- case
trol
trol
trol
Pedeiroli et al ’93
Imipenum 33 41 30% 12% 12% 7%
Sainio et al , ‘95 Cefuroxime 30 30 40% 30% 23% 3%
Infection in acute pancreatitis
Acute pancreatitis: Interstitial: 80% Necrotizing: 20%
Infection dependent on - necrosis
Hale Waihona Puke Baidu
Extent of necrosis Sterile (n = 155) Infected ( n = 71)
Delcenserie et al Ceftazidime+ 12 11 58% 0% 25% 9%
’96
M+A
Schwarz et al, Ofloxacin+ M 13 13 53% 61% 15% 0% ‘97
Bassi et al, ’98 Pefloxacin P 30 P 30 I 34% P 10% I 24% 10%
20 – 22G needle Gram stain + culture Avoid colon - oral contrast agent
Influence of pancreatic infection on morbidity and mortality
Morbidity
Pulmonary Renal Cardiocirculatory Mortality
No Necrosis
0% 6%
Necrosis
23% 82%
Air in pancreas/peripancreatic space – infection
Pancreatic Infection
* unresolved organ failure * persisting systemic toxicity – high fever, TLC * low grade fever, < 15000 cells US/CT guided FNA necrosis + fluid collection
Sterile necrosis 56% 28% 13% 11%
Infected necrosis 72% 45% 30% 20%
Bacteriologic findings of infected pancreatitis
E coli
(35%)
Klebsiella pneumoniae (24%)
Imipenum I
PI
Criticisms of antibiotic prophylaxis
Unequal distribution of severity of pancreatitis Mortality significantly reduced with prophylactic antibiotics in high risk patients 10days – 4 weeks
Polymicrobial
42%
Possible pathways for pancreatic infection Colon – bacterial translocation Lymphatics, Hematogenous, Transmural
Antibiotics in pancreatitis
Ranson’s score 3 necrosis 30 two or more fluid collections
Proteus
(8%)
Enterobacter
(7%)
Anaerobes
(6%)
Monomicrobial
58%
Enterococcus
(24%)
Pseudomonas
(11%)
Aerobic streptococcus (7%)
Bacteroides
(6%)
Fungal – antibiotics for long
< 30% (mild)
57 %
35 %
> 30 - < 50% (mod) 22 %
23 %
> 50% (severe) 21 %
42 %
Duration 1 – 2 weeks 50%
3 weeks
71%
Pancreatic abscess > 4 weeks
Parameters for diagnosing pancreatic necrosis
1. Ranson’s score > 3 < 48 hours
2. Apache II illness grading system > 10
3. C-reactive protein > 120 mg/L
4. Lactate dehydrogenase > 270 mg/L
5. Interleukin – 6
▪ Cephalosporins
▪ Quinolones ▪ Carbapenums
Ceftrizoxime 0.76 Ceftriaxone 0.79 Ciprofloxacin 0.86 Imipenum 0.98
Cefotaxime 0.78 Ofloxacin 0.87
Antibiotic prophylaxis in severe acute pancreatitis
Drug concentration pancreas/peripancreatic tissue Efficacy Factor ▪ Aminoglycosides Netilmycin 0.14 Tobramycin 0.12 ▪ Ureidopenicillins Mezlocillin 0.71 Piperacillin 0.72
Poor accuracy in predicting severity
6. CECT –
Gold standard > 48 hours – high comparability overall accuracy – 95% < 50 Hounsfield Unit – Nonperfused
mortality morbidity