重症急性胰腺炎的诊断与治疗（英文ppt）

Infection in acute pancreatitis Acute pancreatitis: Interstitial: 80% Necrotizing:20% Infection dependent on - necrosis Extent of necrosis Sterile (n = 155) Infected ( n = 71) 30 - 50% (severe) 21 % 42 % Duration 1 2 weeks 50% 3 weeks 71% Pancreatic abscess 4 weeks Parameters for diagnosing pancreatic necrosis 1. Ransons score 3 10 3. C-reactive protein 120 mg/L 4. Lactate dehydrogenase 270 mg/L 5. Interleukin 6 Poor accuracy in predicting severity 6. CECT Gold standard 48 hours high comparability overall accuracy 95% 120mg/L Ranson 3 APACHE II 8 multiorgan failure British Society of gastroenterology Prophylactic antibiotics early in SAP International Recommendations Cost of antibiotics for 14-day therapy Imipenum cilastatin 1 g 8 hrly Rs. 3000/day Rs.52,000 Ciprofloxacin+ 200mg 12hrly Rs.100/day Metronidazole 500mg 8hrly Rs.45/day Rs.2100 Ofloxacin+ 400mg 12hrly Rs.220/day Metronidazole 500mg 8hrly Rs.45/day Rs.3800 Piperacillin+Tazobac- 4.5gms 8hrly Rs.2400/day Rs. 35,000 tam+Metronidazole 500mg 8hrly Rs.45/day Cefatoxime+ 1gm 8hrly Rs.120/day Metronidazole 500mg 8hrly Rs.45/day Rs. 2310 Ceftazidime+ 2gm 8hrly Rs.2100/day Metronidazole 500mg 8hrly Rs.45/day Rs.30,00 Clindamycin 300mg 8hrly Rs.300/day Rs.4200 Selective decontamination of the digestive tract (SDD) Nonabsorbable antibiotics reduce aerobic gram-ve intestinal flora Decreased total infection rate: 81% to 16% ICU gmve septic complications decreased with SDD Hospitalization - nosocomial gram negative flora SDD reduces intestinal flora improves survival reduces pancreatic infection (experimental animals) AuthorsAnimal Decontamination i inf- imor- Method Start ection tality Persky et al Dog Aureomycin 5-10d Not Yes before AEP studied Lange et al Rat Intestinal lavage Immediately YesYes + kanamycin before AEP Isaji et al Mouse Bacitracin+ M SimultaneouslyNo Yes+ neomycin with AEP Foitzik et al Rat Polymxin B+ 6h after AEP Yes Notobra +ampho Gianotti et al Mouse Various36h after Yes Noantibiotics beginning of CDE diet SDD in acute experimental pancreatitis Randomized controlled clinical trial on SDD Severe acute pancreatitis: Balthazar grade D or E 50/102 treated with colistin sulphate, amphotericin norfloxacin + short term cefotaxime, Overall infected necrosis 38% vs 18% relaparotomy 3.1 vs 0.9 mortality 35% vs 22% Conclusions Indications of antibiotics in pancreatitis infected pancreatic necrosis prophylactic antibiotics