hospital course? Is there anything different we could have ... and... · Discussion • Morbidity and Mortality of Pancreatitis • Abdominal Compartment Syndrome • Could we have

DiscussionDiscussion

•• Morbidity and Mortality of PancreatitisMorbidity and Mortality of Pancreatitis•• Abdominal Compartment SyndromeAbdominal Compartment Syndrome•• Could we have predicted the patients Could we have predicted the patients

hospital course?hospital course?•• Is there anything different we could have Is there anything different we could have

done ?done ?•• Were do we go from here?Were do we go from here?

Abdominal Compartment SyndromeAbdominal Compartment Syndrome

•• Organ dysfunction caused by Organ dysfunction caused by Intraabdominal HypertensionIntraabdominal Hypertension

•• Intraabdominal Htn = sustained Intraabdominal Htn = sustained intraabdominal pressue >12intraabdominal pressue >12

•• Abdominal Compartment syndrome = Abdominal Compartment syndrome = sustained IAP >20 and organ dysfunctionsustained IAP >20 and organ dysfunction


•• CausesCauses–– PrimaryPrimary

•• TraumaTrauma•• Liver transplantionLiver transplantion•• Acute PancreatitisAcute Pancreatitis•• Intraperitoneal bleeding, massive ascitesIntraperitoneal bleeding, massive ascites•• Bowel distentionBowel distention

–– SecondarySecondary•• Sepsis, burns, capillary leaks Sepsis, burns, capillary leaks –– extensive IVFextensive IVF


•• EffectsEffects•• CV CV –– Decreased CO and venous returnDecreased CO and venous return•• Pulm Pulm –– Hypoxemia, hypercarbiaHypoxemia, hypercarbia•• Renal Renal –– Renal failureRenal failure•• GI GI –– hypoperfusion, bowel ischemia, lactic hypoperfusion, bowel ischemia, lactic

acidosisacidosis•• CNS CNS –– increased ICP can lead to ischemiaincreased ICP can lead to ischemia


•• Measuring abdominal pressureMeasuring abdominal pressure–– BladderBladder–– IntracolonicIntracolonic–– IntragastricIntragastric–– IVCIVC


•• ManagementManagement–– SupportiveSupportive

•• Mechanical Ventilation Mechanical Ventilation •• Aggressive volume administrationAggressive volume administration

–– Surgical DecompressionSurgical Decompression•• Indicated for Abdominal compartment syndrome Indicated for Abdominal compartment syndrome

when: 15when: 15--25 or greater or based on APP25 or greater or based on APP

Mortality of Acute PancreatitisMortality of Acute Pancreatitis

•• Overall mortality 2Overall mortality 2--3%3%•• Mortality for Severe Necrotizing 15%Mortality for Severe Necrotizing 15%

–– ½½ of deaths in first week from multi organ of deaths in first week from multi organ failurefailure

–– After 1After 1stst week from organ failure and also week from organ failure and also infection of necrotic tissueinfection of necrotic tissue

Severe PancreatitisSevere Pancreatitis

•• Atlanta CriteriaAtlanta Criteria•• Presence of organ failure and/or local Presence of organ failure and/or local

pancreatic complications, complemented pancreatic complications, complemented by the presence of unfavorable prognostic by the presence of unfavorable prognostic signs (Apache II or Ransons)signs (Apache II or Ransons)

Morbidity of PancreatitisMorbidity of Pancreatitis

•• Pleural EffusionPleural Effusion•• Necrosis / Infection of necrotic tissueNecrosis / Infection of necrotic tissue•• SIRS / Organ FailureSIRS / Organ Failure•• PseudocystPseudocyst•• AbscessAbscess•• Abdominal compartment syndromeAbdominal compartment syndrome•• Splenic Vein thrombosisSplenic Vein thrombosis•• IlleusIlleus

Morbidity of PancreatitisMorbidity of Pancreatitis

•• How can we predict who will develop How can we predict who will develop severe pancreatitissevere pancreatitis

Independent VariablesIndependent Variables

•• AgeAge•• Comorbid ConditionsComorbid Conditions•• ObesityObesity•• Hct >44% at admit without a decrease at Hct >44% at admit without a decrease at

24 hours24 hours•• CRP >150 at 48 hours (Europe) CRP >150 at 48 hours (Europe) •• SIRSSIRS

Predicting SeverityPredicting Severity

•• Ransons CriteriaRansons Criteria•• Apache IIApache II•• CT severity indexCT severity index•• Glasgow CriteriaGlasgow Criteria•• BanksBanks•• Clinical JudgmentClinical Judgment

RansonRanson’’s Criterias Criteria

•• Severe likely to develop if >3Severe likely to develop if >3•• At AdmissionAt Admission

–– Age >55 (70)Age >55 (70)–– WBC >16000 (18,000)WBC >16000 (18,000)–– BS >200 (220)BS >200 (220)–– LDH >350 (>400)LDH >350 (>400)–– AST >250AST >250

RansonRanson’’s Criterias Criteria

•• At 48 hoursAt 48 hours–– Decrease Hct >10%Decrease Hct >10%–– BUN increase >5 despite fluidsBUN increase >5 despite fluids–– CA <8CA <8–– PO2 <60PO2 <60–– Base deficit >4 ( >6)Base deficit >4 ( >6)–– Fluid sequestration >6 L (>4L)Fluid sequestration >6 L (>4L)

Apache IIApache II

•• Approximately 12 parametersApproximately 12 parameters•• Temp, MAP, HR, RR, AA grad, HC03, pH, Temp, MAP, HR, RR, AA grad, HC03, pH,

Na, K, Cr, Hct, WBC, GCS, AgeNa, K, Cr, Hct, WBC, GCS, Age•• Apache II score >8Apache II score >8

Comparing Scoring SystemsComparing Scoring Systems

•• RansonRanson’’s Criterias Criteria–– Meta Analysis (1307 patients total) of Meta Analysis (1307 patients total) of

RansonRanson’’s criterias criteria•• Sensitivity = 75%Sensitivity = 75%•• Specificity = 77%Specificity = 77%•• PPV = 49%PPV = 49%•• NPV = 91%NPV = 91%

Comparing Scoring SystemsComparing Scoring Systems

•• Apache II score > 7Apache II score > 7–– Sensitivity = 76%Sensitivity = 76%–– Specificity = 84%Specificity = 84%–– PPV = 54%PPV = 54%–– NPV = 93%NPV = 93%

Comparing scoring systemsComparing scoring systems

•• Studies show varying results in comparing Studies show varying results in comparing scoring systemsscoring systems

AGAAGA

•• The prediction of severe disease, before The prediction of severe disease, before its onset, is best achieved by careful its onset, is best achieved by careful ongoing clinical assessment coupled with ongoing clinical assessment coupled with the use of a multiple factor scoring system the use of a multiple factor scoring system and imaging studies. The APACHE II and imaging studies. The APACHE II system is preferred, utilizing a cutoff of system is preferred, utilizing a cutoff of >8. Those with predicted or actual severe >8. Those with predicted or actual severe disease and those with other severe disease and those with other severe comorbid medical conditionscomorbid medical conditions

The caseThe case

•• RansonRanson’’s at admits at admit–– WBC WBC –– >18>18–– AST AST -- 850850

•• RansonRanson’’s at 48 hourss at 48 hours–– Hct decrease >10%Hct decrease >10%–– BUN > 10 BUN > 10 -- 25 to 3525 to 35–– Ca <8 (7.4)Ca <8 (7.4)–– Fluid sequestrationFluid sequestration

The CaseThe Case

•• Apache II at admitApache II at admit

88

•• Apache II at 48 hoursApache II at 48 hours

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hospital course? Is there anything different we could have ... and... · Discussion • Morbidity and Mortality of Pancreatitis • Abdominal Compartment Syndrome • Could we have