Thursday March 9, 2006
Evidence-based recommendations for Severe Acute Pancreatitis (SAP)
An international consensus conference was held in April 2004 to develop guidelines for the management of the critically ill patient with SAP and published in December 2004 issue of Critical Care Medicine. 23 evidence-based recommendations were developed by a jury of ten persons representing surgery, internal medicine, and critical care after conferring with experts and reviewing the pertinent literature. We are pening here few most important recommendations but full article can be pulled from reference below.
* Critically ill patients with pancreatitis be cared for by an intensivist-led multidisciplinary team with ready access to physicians skilled in endoscopy, endoscopic retrograde cholangiopancreatography (ERCP), surgery, and interventional radiology.
* Followup CT to identify local complications be delayed for 48-72 hrs when possible, as necrosis might not be visualized earlier.
* Recommendation against the routine use of prophylactic systemic antibacterial or antifungal agents in patients with necrotizing pancreatitis.
* Enteral nutrition should be initiated after initial resuscitation. The jejunal route should be used if possible and parenteral nutrition only be used when attempts at enteral nutrition have failed after a 5- to 7-day trial and when used, parenteral nutrition should be enriched with glutamine.
* Sonographic- or CT-guided FNA with Gram stain and culture of pancreatic or peripancreatic tissue to discriminate between sterile and infected necrosis in patients with radiological evidence of pancreatic necrosis and clinical features consistent with infection and recommendation against debridement and/or drainage in patients with sterile necrosis.
* Pancreatic debridement or drainage in patients with infected pancreatic necrosis and/or abscess confirmed by radiological evidence of gas or results of FNA. The gold standard for achieving this goal is open operative debridement. If possible, operative necrosectomy and/or drainage be delayed at least 2-3 wks to allow for demarcation of the necrotic pancreas.
* In acute pancreatitis due to suspected or confirmed gallstones, urgent ERCP should be performed within 72 hrs of onset of symptoms.
* Use of early volume resuscitation and lung-protective ventilation strategies for patients with acute lung injury.
* In SAP with severe sepsis careful consideration be used before the administration of rh-APC based on the theoretical but unproven concern of retroperitoneal hemorrhage.
Reference:
Management of the critically ill patient with severe acute pancreatitis - Critical Care Medicine: Volume 32(12) December 2004 pp 2524-2536 . Sponsored by the American Thoracic (ATS), the European Respiratory Society (ERS), the European Society of Intensive Care Medicine (ESICM), the Society of Critical Care Medicine (SCCM) and the Société de Réanimation de Langue Française (SRLF).
