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• Interrogate large national ICU pt data base collected from UK ICUs to examine outcomes in pt admitted with severe acute pancreatitis • See if improved prognostic scoring system can be developed based on physiologic/biochemical variables collected within 24hr of ICU admission
Prognostic scoring systems
• • • • Atlanta classification Ranson Score Glasgow Score Modified Glascow
Atlanta Classification
• • ACUTE PANCREATITIS Acute pancreatitis is an acute inflammatory process of the pancreas, with variable involvement of other regional tissues or remote organ systems. SEVERE ACUTE PANCREATITIS Severe acute pancreatitis is associated with organ failure and/or local complications such as necrosis (with infection), pseudocyst or abscess. Most often this is an expression of the development of pancreatic necrosis, although patients with oedematous pancreatitis may manifest clinical features of a severe attack. MILD ACUTE PANCREATITIS Mild acute pancreatitis is associated with minimal organ dysfunction and an uneventful recovery. The predominant pathological feature is interstitial oedema of the gland. ACUTE FLUID COLLECTIONS Acute fluid collections occur early in the course of acute pancreatitis, are located in or near the pancreas, and always lack a wall of granulation of fibrous tissue. PANCREATIC NECROSIS AND INFECTED NECROSIS Pancreatic necrosis is a diffuse or focal area(s) of non-viable pancreatic parenchyma, which is typically associated with peripancreatic fat necrosis. The onset of infection results in infected necrosis, which is associated with a trebling of the mortality risk. ACUTE PSEUDOCYST An acute pseudocyst is a collection of pancreatic juice enclosed in a wall of fibrous or granulation tissue that arises following an attack of acute pancreatitis. Formation of a pseudocyst requires four or more weeks from the onset of acute pancreatitis. PANCREATIC ABSCESS A pancreatic abscess is a circumscribed intra-abdominal collection of pus, usually in proximity to the pancreas, containing little or no pancreatic necrosis, which arises as a consequence of acute pancreatitis. SPECIALIST UNIT A specialist unit is one in which multidisciplinary expertise is available on-site. Full intensive care facilities are mandatory, together with recourse to ERCP at any stage on an emergency basis. Expert radiological input for dynamic scanning, percutaneous procedures and angiography is essential. A surgeon with pancreatico-biliary expertise should supervise management.
The Pancreatitis Outcome Prediction (POP) Score: A New Prognostic index for patients with severe acute pancreatitis
Harrison, David A, D’Amico, Giovanna, Singer, Mervyn. “Critical Care Med 2007 Vol.35 No. 7” Presenter: 郭妍伶 August 13, 2007
Modified Glasgow Score
• • • • • • • • Age >55 years pO2 <60mmHg WCC >15x109/litre Ca2+ (uncorr.) <2.0 mmol/L LDH >600 IU glucose >10 mmol/L urea >16 mmol/L Minimum score: 0 albumin <3.2g/L Maximum 用之照片之版權仍屬於原期刊 公開使用時, 須獲得原期刊之同意授權
Introduction
• Pancreatitis severity ranges from mild to MOF with sepsis and necrotizing or hemorrhagic forms • Overall mortality: 10-15% • Biphasic time to death
• Admissions selected if primary reason:
– Acute pancreatitis – Chronic pancreatitis with severe AE – Infective pancreatitis
• Exclusions:
– Same pt readmission within same H. stay – Transfer from other ICU – Pt age<16 yrs – Missing OP status/outcome(mortality)
If score<3: severe pancreatitis unlikely If score>=3:severe pancreatitis likely
Ranson’s Criteria
Ranson's Criteria on Admission : • age greater than 55 years Score 0-2: 2% mortality • a white blood cell count of > 16,000/µL Score 3-4: 15% mortality Score 5-6: 40% mortality • blood glucose > 11 mmol/L (>200 mg/dL) Score 7-8: 100% mortality • serum LDH > 350 IU/L • serum AST >250 IU/L Ranson's Criteria after 48 hours of admission : • fall in hematocrit by more than 10 percent • fluid sequestration of > 6 L • hypocalcemia (serum calcium < 2.0 mmol/L (<8.0 mg/dL)) • hypoxemia (PO2 < 60 mmHg) • increase in BUN to >1.98 mmol/L (>5 mg/dL) after IV fluid hydration • base deficit of >4 mmol/L
Materials and Methods
• Intensive Care National Audit and Research Centre Case Mix Programme Database(CMPD) contains info on case mix, outcome, activity for all admissions to adult, general critical care units participating in CMP (national comparative audit in England, Wales, North Ireland since 1995) • 159 ICUs from Dec.1995-June 2003