وصف
The management of acute severe pancreatitis (ASP) in the ICU involves a multifaceted approach to stabilize the patient and prevent complications. Initial management focuses on aggressive fluid resuscitation with lactated Ringer's solution, hemodynamic monitoring, and the use of vasopressors if necessary. Respiratory support may include oxygen therapy or mechanical ventilation for cases of acute respiratory distress syndrome (ARDS). Pain control is primarily achieved with opioids, supplemented by non-opioid analgesics. Early enteral nutrition is preferred to maintain gut integrity, while parenteral nutrition is reserved for intolerant patients. Close monitoring for complications such as infected pancreatic necrosis and acute kidney injury is essential, with appropriate interventions as needed. A multidisciplinary team approach ensures comprehensive care and improves patient outcomes.
ملخص
- Acute pancreatitis is a common gastrointestinal disease defined as an inflammatory process in the pancreas, with increasing global incidence and significant mortality. While most cases are mild and resolve within a week, a substantial portion develops into severe pancreatitis, drastically increasing mortality risk. Biliary disease is the primary cause in Asia, while alcohol consumption is more prevalent in Western countries.
- The development of acute pancreatitis from gallstones is explained by three main theories: the common channel theory, duodenal reflux theory, and pancreatic duct obstruction theory. The latter suggests that obstruction leads to autodigestive injury, where enzymes activate prematurely within the pancreas itself, causing damage. Alcohol-induced pancreatitis is typically chronic, often stemming from long-term, heavy alcohol consumption. Drugs like thiazide diuretics, furosemide, valproic acid, tetracycline, and sulfonamides are also definitive causes of acute pancreatitis.
- Clinical presentation typically involves severe epigastric pain radiating to the back, often accompanied by nausea and vomiting. Physical signs may include abdominal distension, guarding, and signs of systemic inflammatory response syndrome (SIRS). Laboratory findings often reveal elevated hematocrit, BUN, creatinine, and amylase or lipase levels. CT scans are not always necessary initially, but are indicated for diagnostic dilemmas and may be deferred to assess the severity later.
- Severity is graded as mild, moderately severe, or severe, based on the presence and duration of organ failure. Organ failure is assessed via modified Marshall scores for respiratory, cardiovascular, and renal systems. Predictive scoring systems like BISAP are valuable in assessing the severity of the disease, which helps in treatment decisions and prognosis.
- Initial management centers on moderate intravenous hydration, preferentially with Ringer's Lactate. The landmark "Waterfall" trial showed aggressive fluid resuscitation could be harmful, leading to fluid overload without improved outcomes. Empiric antibiotics are generally avoided in the first week unless colangitis is present.
- Nutritional support involves early, on-demand enteral feeding with polymeric feeds, and nasogastric administration is often as effective as nasojejunal feeding. Pain management should be addressed with multimodal approaches, including opioid-sparing strategies. Management of local complications like pancreatic pseudocysts and walled-off necrosis depends on the nature and extent of infection and requires intervention for necrosis with air. Vascular complications are addressed with endovascular or surgical means.
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