Relationship between intra-abdominal hypertension, outcome and the revised Atlanta and determinant-based classifications in acute pancreatitis

[Management of acute pancreatitis in the emergency department and the intensive care unit]

Acute pancreatitis is a gastrointestinal emergency where diagnosis is based on typical symptoms, increased serum lipase concentration, and abdominal imaging. Local complications and organ failure in severe acute pancreatitis regularly necessitate treatment in the intensive care unit and are associated with increased mortality rates. Only optimal interdisciplinary treatment can improve the prognosis of patients with severe acute pancreatitis. This article gives guidance on the initial diagnostic and etiological examinations as well as on the evaluation of organ failure and the severity assessment according to common classification systems. Furthermore, the endoscopic management of biliary pancreatitis and infected necrosis is discussed and the basics of targeted volume therapy, nutrition, and indications for antibiotic treatment are reviewed.

[Management of acute pancreatitis in the emergency department and the intensive care unit]

Acute pancreatitis is a gastrointestinal emergency where diagnosis is based on typical symptoms, increased serum lipase concentration, and abdominal imaging. Local complications and organ failure in severe acute pancreatitis regularly necessitate treatment in the intensive care unit and are associated with increased mortality rates. Only optimal interdisciplinary treatment can improve the prognosis of patients with severe acute pancreatitis. This article gives guidance on the initial diagnostic and etiological examinations as well as on the evaluation of organ failure and the severity assessment according to common classification systems. Furthermore, the endoscopic management of biliary pancreatitis and infected necrosis is discussed and the basics of targeted volume therapy, nutrition, and indications for antibiotic treatment are reviewed.

ESPEN practical guideline on clinical nutrition in acute and chronic pancreatitis

Both acute and chronic pancreatitis are frequent diseases of the pancreas, which, despite being of benign nature, are related to a significant risk of malnutrition and may require nutritional support. Acute necrotizing pancreatitis is encountered in 20 % of patients with acute pancreatitis, is associated with increased morbidity and mortality, and may require artificial nutrition by enteral or parenteral route, as well as additional endoscopic, radiological or surgical interventions. Chronic pancreatitis represents a chronic inflammation of the pancreatic gland with development of fibrosis. Abdominal pain leading to decreased oral intake, as well as exocrine and endocrine failure are frequent complications of the disease. All of the above represent risk factors related to malnutrition. Therefore, patients with chronic pancreatitis should be considered at risk, screened and supplemented accordingly. Moreover, osteoporosis and increased facture risk should be acknowledged in patients with chronic pancreatitis, and preventive measures should be considered.

Abdominal compartment syndrome in critically ill patients

Intra-abdominal hypertension can have severe consequences, including abdominal compartment syndrome, which can contribute to multi-organ failure. An increase in intra-abdominal hypertension is influenced by factors such as diminished abdominal wall compliance, increased intraluminal content, and certain systemic conditions. Regular measurement of intra-abdominal pressure is essential, and particular attention must be paid to patient positioning. Nonsurgical treatments, such as decompression of intraluminal content using a nasogastric tube, percutaneous drainage, and fluid balance optimization, play crucial roles. Additionally, point-of-care ultrasonography aids in the diagnosis and treatment of intra-abdominal hypertension. Emphasizing the importance of regular measurements, timely decompressive laparotomy is a definitive, but complex, treatment option. Balancing the urgency of surgical intervention against potential postoperative complications is challenging.

Optimising the measurement of intra-bladder pressure in patients with predicted severe acute pancreatitis

BACKGROUND

Measuring intra-abdominal pressure (IAP) is important for management of patients with severe acute pancreatitis (SAP). Intra-bladder pressure (IBP) is an indirect index that reflects IAP, but measuring techniques vary. We sought to optimise IBP measuring techniques in predicted SAP patients.

METHODS

Predicted SAP patients consecutively admitted between June 2018 and January 2020 were scrutinised. Eligible patients had their IBP monitored for the first 72 h at 6-h intervals, and were then sequentially allocated into three research scenarios: (1) in the supine position along with head of bed elevation(HoBE)of 0, 15 and 30° at various points including the iliac crest the midaxillary line, pubic symphysis, and right atrium level, instilled with 25 mL normal saline (NS) at room temperature (RT); (2) NS instillation volume from 0, 10, 25, 40-50 mL at the iliac crest with HoBE15 at RT; and (3) NS instillation (25 mL) at either RT or 37 °C with HoBE15.

RESULTS

The dynamic IBP values measured at the pubic symphysis and iliac crest were fairly similar between HoBE0 and HoBE15 (all P > 0.05), but greatly increased at HoBE30 (all P < 0.01). IBP was significantly increased with escalating instillation volumes of NS (all P < 0.01 versus 0 mL NS), while there was no significant difference between 25 mL and 10 mL (P = 0.055). IBP was similar between NS at RT and under 37 °C (P = 0.643).

CONCLUSION

In predicted SAP patients, measuring IBP at the iliac crest with HoBE15 after instilling 10 mL of NS seems to be appropriate for monitoring IAP.

Intra-Abdominal Hypertension: A Systemic Complication of Severe Acute Pancreatitis

Patients with severe acute pancreatitis (SAP) present complications and organ failure, which require treatment in critical care units. These extrapancreatic complications determine the clinical outcome of the disease. Intra-abdominal hypertension (IAH) deteriorates the prognosis of SAP. In this paper, relevant recent literature was reviewed, as well as the authors’ own experiences, concerning the clinical importance of IAH and its treatment in SAP. The principal observations confirmed that IAH is a frequent consequence of SAP but is practically absent in mild disease. Common manifestations of AP such as pain, abdominal distension, and paralytic ileus contribute to increased abdominal pressure, as well as fluid loss in third space and aggressive fluid replacement therapy. A severe increase in IAP can evolve to abdominal compartment syndrome and new onset organ failure. Conservative measures are useful, but invasive interventions are necessary in several cases. Percutaneous drainage of major collections is preferred when possible, but open decompressive laparotomy is the final possibility in some cases in order to definitively reduce abdominal pressure. Intra-abdominal pressure should be measured in all SAP cases that worsen despite adequate treatment in critical care units. Conservative measures must be introduced to treat IAH, including negative fluid balance, digestive decompression by gastric–rectal tube, and prokinetics, including neostigmine. In the case of insufficient responses to these measures, minimally invasive interventions should be preferred.

Role of intra-abdominal pressure measurement in patients with acute abdomen requiring exploratory laparotomy

<b>Introduction:</b> Acute abdomen is one of the most common surgical emergencies faced by a surgeon. Monitoring Intra-Abdominal Pressure (IAP) in patients with acute abdomen referred for exploratory laparotomy may help guide the need for early intervention. </br></br> <b>Aim:</b> This study was performed to determine whether preoperative IAP had any significant association with organ failure as assessed using SOFA score. Furthermore, effect of IAP on patient outcome in terms of hospital stay, mortality was also evaluated. </br></br> <b>Materials and methods:</b> 60 patients above 18 years of age presenting with acute abdomen requiring exploratory laparotomy were included in this prospective observational study from November 2013 until March 2015. IAP and SOFA scores were calculated at the time of admission. The outcome of patients was assessed in terms of hospital stay, morbidity and mortality. The correlation between IAP and SOFA scores was also assessed to determine the risk of organ failure. The inferences were drawn with the use of SPSS v22.0 statistical software. ANOVA, Chi-square and Student’s t-test were used in the analysis. </br></br> <b> Results:</b> There was a positive correlation between SOFA score and IAP; and this correlation was found to be statistically significant with Pearson’s correlation coefficient being 0.6247 and significance levels being <0.0001. Both hospital stay and mortality positively correlated with the degree of IAP. </br></br> <b> Conclusions:</b> IAP should be routinely measured in patients with acute abdomen requiring exploratory laparotomy. Patients with preoperatively raised IAP should be referred for emergency surgery as soon as possible for better outcome.

Effect of continuous hemofiltration on severe acute pancreatitis with different intra-abdominal pressure: A cohort study

BACKGROUND

The clinical efficacy and timing of continuous veno-venous hemofiltration (CVVH) in the treatment of severe acute pancreatitis (SAP) remain uncertain. In this prospective cohort study, patients with SAP were classified according to intra-abdominal pressure (IAP).

METHODS

Seventy-four patients with SAP admitted to the intensive care unit were randomly divided into group A (IAP ≥20 mm Hg) and group B (with IAP ≤20 mm Hg). Then, according to whether CVVH was administered or not, groups A and B were divided into 4 subgroups: group A1 and B1 (non-CVVH treatment), group A2 and B2 (CVVH treatment). Changes in clinical and laboratory indicators were recorded before and on the seventh day after treatment, and clinical outcomes were analyzed.

RESULTS

Before treatment, there was no significant difference in general conditions between subgroups A1 and A2, and between subgroups B1 and B2. After CVVH treatment, the indicators recorded in group A2 were significantly improved compared to those in group A1 (P < .05). In group A2, the 28 day operation rate was lower (P < .05), as mechanical ventilation, gastric decompression, and intensive care unit treatment time were shorter (P < .05). However, there was no statistically significant difference in any of the above indicators between subgroups B (P > .05). Groups A2 and B2 had more days of negative fluid balance within 1 week of admission than groups A1 and B1 (P < .05).

CONCLUSIONS

For SAP, patients with IAP ≥20 mm Hg can benefit from treatment with CVVH, but for patients with IAP ≤20 mm Hg, the efficacy is not clear, and monitoring IAP may be an indicator to decide whether or when to initiate CVVH. Negative fluid balance caused by CVVH treatment may be one of the reasons for the benefit of this group of patients.

Intra-abdominal hypertension and abdominal compartment syndrome: a current review

PURPOSE OF REVIEW

Intra-abdominal hypertension (IAH) and its deleterious effects are present in at least one-third of ICU patients. Increased recognition of IAH has led to significant reduction in the incidence of abdominal compartment syndrome (ACS). Many questions remain regarding what therapeutic interventions truly reduce morbidity and mortality associated with IAH/ACS. Recent research sheds new light on the effects of IAH in individual organ systems and unique disease states. This paper will review recent research in IAH/ACS recognition, treatment, and management.

RECENT FINDINGS

Recent research on IAH/ACS includes an improved understanding of the prevalence of IAH/ACS and confirmation of its independent association with organ failure. Specifically, new research adds clarity to the effects of IAH/ACS on individual organ systems and specific disease states. These results combine to improve the clinical ability to diagnose, monitor, and treat IAH/ACS.

SUMMARY

There is significant research on the broad impact of IAH/ACS in the ICU setting. Focus on IAH/ACS has gone beyond the purview of intensivists and surgeons to include outstanding work by specialists in multiple sub-specialties. These advances have generated improvements in current treatment algorithms. We review recent IAH/ACS literature and have categorized the most pertinent results into organ system-specific contributions.

Management of Severe Acute Pancreatitis

Purpose of review

There have been significant advancements in different aspects of management of severe acute pancreatitis (SAP). Our review of the most recent literature focuses on severity prediction, fluid resuscitation, analgesic administration, nutrition, and endoscopic intervention for SAP and its extra-pancreatic complications.

Recent findings

Recent studies on serum cytokines for the prediction of SAP have shown superior prognostic performance when compared with conventional laboratory tests and clinical scoring systems. In patients with established SAP and vascular leak syndrome, intravenous fluids should be administered with caution to prevent intra-abdominal hypertension and volume overload. Endoscopic retrograde cholangiopancreatography improves outcomes only in AP patients with suspected cholangitis. Early enteral tube-feeding does not appear to be superior to on-demand oral feeding. Abdominal compartment syndrome is a highly lethal complication of SAP that requires percutaneous drainage or decompressive laparotomy. Endoscopic transmural drainage followed by necrosectomy (i.e., “step-up approach”) is the treatment strategy of choice in patients with symptomatic or infected walled-off pancreatic necrosis.

Summary

SAP is a complex clinical syndrome associated with a high mortality rate. Early prediction of SAP remains challenging due to the limited accuracy of the available prediction tools. Early fluid resuscitation, organ support, enteral nutrition, and prevention of/or prompt recognition of abdominal compartment syndrome remain cornerstones of its management. A step-up, minimally invasive drainage/debridement is the preferred approach for patients with infected pancreatic necrosis.

Gastrointestinal Failure Is a Predictor of Poor Outcome in Patients with Acute Pancreatitis

OBJECTIVE

Although gastrointestinal dysfunction is common in patients with acute pancreatitis, its impact on the outcome of disease has not been adequately studied. The present study was conducted to study the frequency of gastrointestinal failure (GIF) as well as its effect on outcome in patients with acute pancreatitis.

METHODS

Patients with acute pancreatitis admitted in our unit were prospectively studied. Gastrointestinal dysfunction and intra-abdominal pressures were measured daily till their resolution, and gastrointestinal failure score was calculated. Baseline parameters including various severity scores were noted. The patients were followed till clinical recovery or death.

RESULTS

Sixty-four patients (mean age 41.52 ± 16.28 years; 45 (70.3%) males) were prospectively studied. Forty-five (70.3%) patients had severe disease, and 18 (28.1%) patients succumbed to illness. GIF was present in 31 (48.4%) patients. The median duration of GIF was 5 (range 1-20) days. The presence of GIF was significantly associated with mortality (p value < 0.05). On multivariate analysis, the presence of GIF [OR 10.6 (95% CI 1.97-57.04)] and duration of ICU stay [OR 1.08 (95% CI 1.015-1.15)] were found to be independent predictors of mortality.

CONCLUSION

Gastrointestinal failure is an important organ failure in patients with acute pancreatitis and is an independent predictor of mortality. Incorporation of gastrointestinal failure scores in dynamic assessment of patients with acute pancreatitis could help us in better stratifying severity of patients and predicting outcome.

Results of the modification of an acute pancreatitis management protocol in Intensive Care medicine

OBJECTIVE

To determine whether the implementation of a protocol for the management of patients with acute pancreatitis (AP) in an Intensive Care Unit (ICU) improves the clinical outcomes.

DESIGN

A retrospective, before-after observational case series study was carried out.

STUDY PERIOD

1 January 2001 to 31 December 2016, divided in 2 periods (pre-protocol 2001-2007, post-protocol 2008-2016).

SCOPE

An ICU with 48 beds and a recruitment population of 700,000 inhabitants.

PARTICIPANTS

AP patients admitted to the ICU, with no exclusion criteria.

INTERVENTIONS

The recommendations proposed in the 7th Consensus Conference of the SEMICYUC on AP (5 September 2007) were applied in the second period.

MAIN VARIABLES OF INTEREST

Patient age, sex, APACHE II, SOFA, study period, pre-ICU hospital stay, nutrition, surgery, antibiotic prophylaxis, hospital mortality, ICU length of stay, hospital length of stay, determinant-based classification.

RESULTS

The study comprised 286 patients (94 in the pre-protocol period, 192 in the post-protocol period), with a global in-hospital mortality rate of 23.1% (n=66). Application of the protocol decreased the pre-ICU hospital stay and the use of antibiotic prophylaxis, and increased the use of enteral nutrition. Hospital mortality decreased in the second period (35.1 vs. 17.18%; P=.001), with no significant changes in ICU and hospital stays. In the multivariate logistic regression analysis, the variable period of treatment remained as a variable of statistical significance in terms of hospital mortality (OR 0.34 for the period 2008-2016, 95% CI 0.15-0.74).

CONCLUSIONS

The implementation of a protocol could result in decreased mortality among AP patients admitted to the ICU.