重症急性胰腺炎（英文ppt）severe acute pancreatitis课件

Severeacutepancreatitis S c7 AcademyforInfectionManagement2006 AllRightsReserved History 33 year oldmaleAlcoholbinge vodkaAwakeandconversantSevereabdominalpain vomiting dyspnoea Physicalandlaboratoryexaminations Temperature38 1 CPulse96bpm respirations20 minBloodpressure110 70mmHgAbdomentender distended quietAmylase3500IU LLipase1100IU LAST 250IU LLDH 350IU LWBCcount16000 mm3Arterialbloodgases pH7 30 PaCO232 PaO258 BE 5 Whichevaluationswouldyouperformtodetermineifthepatienthasseverepancreatitis C reactiveproteinComputedtomography CT scanSeverityscoresRansonscoreGlasgow Imrie scoreAPACHEIIorIIIscoreBalthazarscore Initialtestsandtreatment FluidresuscitationChestradiographyCTCalculationofRansonscore at48hours ThepatienthasseverepancreatitisbyCTcriteria Centralnecrosisofthepancreas 30 Peripancreaticoedemaandinflammation Ransonscore apancreatitis specificseverityofillnessscore Age 55yearsWBC 16000 mm3Glucose 200mg dLLDH 350IU LAST 250IU L Haematocritdecrease 10 pointsBUNincrease 5mg dLSerumcalcium6L Presentonadmission Duringthefirst48hours ThepatienthaseightpositiveRansoncriteria SGOT 250IU LLDH 350IU LWBCcount 16000 m m3PaO26LCalciumconcentration0percentagepoints ThepredictedmortalityrateforaRansonscoreof8is60 Eachempatietal ArchSurg2002 FigurereproducedwithpermissionfromArchSurg Wouldyoustartprophylacticantibiotics NoYes with Ceftriaxone Gentamicinplusmetronidazole Imipenem cilastatinormeropenem Ciprofloxacinplusmetronidazole Other Yes plusfluconazole Penetrationofpancreatictissueandpancreaticjuicebyantimicrobialagents PoorAminoglycosidesVancomycinVariablePenicillinsCephalosporinsGoodCarbapenemsMetronidazoleQuinolonesFluconazole Bassietal AntimicrobAgentsChemother1994 38 830 836 Whatisthispatient sriskofdevelopinginfection 50 Incidenceofperipancreaticinfectionafteracutepancreatitis Allepisodes3 7 Anypancreaticnecrosis20 70 Pancreaticnecrosis 30 15 30 Pancreaticnecrosis 50 40 70 Begeretal Gastroenterology1986 91 433 438Begeretal Pancreatology2003 3 93 101Buchleretal AnnSurg2000 232 619 625 Day14 Day7 Day21 Shouldprophylaxisbegiven fortheentireat riskperiod PancreaticinfectionsalmostneveroccurbeforeDay7ThepeakincidenceisatDay14 Begeretal Gastroenterology1986 91 433 438 99 ofdata 95 ofdata 68 ofdata Howlongwouldyouadministerantibioticprophylaxis Wouldnotadministerprophylaxis1week2weeks3weeksUntilICUdischarge Shouldprophylaxisbeadministeredfortheentireriskperiod ProphylacticantibioticsforsevereacutepancreatitisFirstdouble blind placebo controlledtrial 114patientsenrolled 76withnecrosisEntrycriteriaC reactiveprotein 150 orNecrosisoncontrast enhancedCT and 72hoursfromonsetofpainCiprofloxacinplusmetronidazolevsplaceboAllpatientstreated14 21daysunlessconvertedtoopen label therapeutic use Isenmannetal Gastroenterology2004 126 997 Results intention to treatanalysis n 114 Prophylacticantibioticsforsevereacutepancreatitis double blind placebo controlledtrial 100patientswithsevereacutepancreatitisContrast enhancedCTmultipleperipancreaticfluidcollectionsbynon contrastCT plusC reactiveprotein 120mg dL orMultipleorgandysfunctionscore 2pointsMeropenem1gq8hvsplaceboPrimaryend pointPancreatic peripancreaticinfectionwithin42days Dellingeretal AnnSurg inpress Prophylacticantibioticsforsevereacutepancreatitis trialresults Dellingeretal AnnSurg inpress Thedownsideofprolongedantibioticprophylaxis AllergyExpenseResistanceSuperinfection Prophylacticantibioticsforsevereacutepancreatitis Recoveryofresistantbacteria p 0 0001 Isenmannetal Gastroenterology2004 126 997 Whatantibioticregimenwasprescribedinitially ThispatientwasNOTstartedonantibioticprophylaxis Thepatient sconditionimproves ResolutionofleukocytosisResolutionofpainOralintakeresumed Thepatientdevelopsmultipleorgandysfunctionsyndrome Day16NewfeverandleukocytosisIncreasedabdominaldistentionARDSLowVTventilationPEEPRenaldysfunctionWhatdoyoudonow RepeatCTscanshowsalargeperipancreaticfluidcollection Smallamountofstill perfusedpancreas Whataction s shouldbetakennow ContinuetoobserveMicrobiologicalsamplingRepeatCTscanwithfine needleaspirationOperate Whatspecimen s wouldyoucollect NoneBloodSputumPeripancreaticfluid fine needleaspiration Incidenceofinfectedpancreatitiswhensoughtbyfine needleaspiration Resultsofcultureandsusceptibilitytesting PatientunderwentCT guidedfine needleaspirationPeripancreaticfluidProteusmirabilis pan sensitive BloodNogrowthUrineNogrowthSputumNogrowth Microbiologyofinfectedpancreaticnecrosis Fernandez delCastilloetal AnnSurg1998 228 676 684Buchleretal AnnSurg2000 232 619 626 Therapy FormaloperativedebridementanddrainageOnlyoneoperationrequiredMeropenemx14daysChoicebasedontissuepenetrationDosagereductionforcreatinineclearance35mL min Outcome FeverandleukocytosisresolveOrgandysfunctionresolvesRenalfunctionimprovesCreatininestabilisesat 2 0mg dLPatientrecovers Keylearningpoints Mostpatients 85 withacutepancreatitisdonotdevelopseverediseaseDeterminationofseverityofillnessprovidesprognosticinformationandcanguidetherapyAntimicrobialprophylaxisdoesnotpreventsecondaryinfectioninsevereacutepancreatitis butdoesincreaseriskofresistantpathogensifinfectiondoesoccurAntibioticsmaybewithhelduntilneededfortherapy AIMcoreprinciples Selectthemostappropriateantibio