重症急性胰腺炎(英文PPT)Severe acute pancreatitis

Eachempati et al. Arch Surg 2002
Figure reproduced with permission from Arch Surg
Would you start prophylactic antibiotics?
1. No 2. Yes, with …
a. Ceftriaxone? b. Gentamicin plus metronidazole? c. Imipenem/cilastatin or meropenem? d. Ciprofloxacin plus metronidazole? e. Other?
3%–7% 20%–70% 15%–30% 40%–70%
Beger et al. Gastroenterology 1986;91:433–438 Beger et al. Pancreatology 2003;3:93–101 Buchler et al. Ann Surg 2000;232:619–625
Initial tests and treatment
• Fluid resuscitation • Chest radiography • CT • Calculation of Ranson score (at 48 hours)
The patient has severe pancreatitis by CT criteria
1. <10% 2. 10%–30% 3. 30%–50% 4. >50%
Incidence of peripancreatic infection after acute pancreatitis
All episodes Any pancreatic necrosis Pancreatic necrosis >30% Pancreatic necrosis >50%
99% of data
Day 14
Day 21
Beger et al. Gastroenterology 1986;91:433–438
1. C-reactive protein 2. Computed tomography (CT) scan 3. Severity scores
a. Ranson score b. Glasgow (Imrie) score c. APACHE II or III score d. Balthazar score
• Age >55 years • WBC >16 000/mm3 • Glucose >200 mg/dL • LDH >350 IU/L • AST >250 IU/L
During the first 48 hours
• Haematocrit decrease >10% points
• BUN increase >5 mg/dL • Serum calcium <8 mg/dL • PaO2 <60 mm Hg • Base deficit <-4 mEq/L • Fluid sequestration >6 L
Pancreatic infections almost never occur before Day 7
The peak incidence is at Day 14
Should prophylaxis be given? for the entire at-risk period?
Day 7
68% of data 95% of data
3. Yes, plus fluconazole
Penetration of pancreatic tissue and pancreatic juice by antimicrobial agents
• Poor
– Aminoglycosides – Vancomycin
• Variable
– Penicillins – Cephalosporins
• Good
– Carbapenems – Metronidazole – Quinolones – Fluconazole
Bassi et al. Antimicrob Agents Chemother 1994;38:830–836
What is this patient’s risk of developing infection?
S_c7
Severe acute pancreatitis
© Academy for Infection Management 2006 (All Rights Reserved)
Which evaluations would you perform to determine if the patient has severe pancreatitis?
The patient has eight positive Ranson criteria
• SGOT >250 IU/L
100
• LDH >350 IU/L
90
பைடு நூலகம்
• WBC count >16 000/m m3 80
Mortality (%)
70
• PaO2 <60 mm Hg
60
• Base deficit <-4 mEq/L
50
40
• Net fluid sequestration >6 L 30
• Calcium concentration
20
10
• <8 mg/dL
0
• Haematocrit decrease • >0 percentage points
1–2
3–4
5–6
7–8
>8
Ranson score
The predicted mortality rate for a Ranson score of 8 is 60%
Central necrosis of the pancreas >30% Peripancreatic oedema and inflammation
Ranson score: a pancreatitisspecific severity of illness score
Present on admission