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Jabaudon M, Genevrier A, Jaber S, Windisch O, Bulyez S, Laterre PF, Escudier E, Sossou A, Guerci P, Bertrand PM, Danin PE, Bonnassieux M, Bühler L, Heidegger CP, Chabanne R, Godet T, Roszyk L, Sapin V, Futier E, Pereira B, Constantin JM. Thoracic epidural analgesia in intensive care unit patients with acute pancreatitis: the EPIPAN multicenter randomized controlled trial. Crit Care 2023; 27:213. [PMID: 37259157 DOI: 10.1186/s13054-023-04502-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 05/20/2023] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND Findings from preclinical studies and one pilot clinical trial suggest potential benefits of epidural analgesia in acute pancreatitis. We aimed to assess the efficacy of thoracic epidural analgesia, in addition to usual care, in improving clinical outcomes of intensive care unit patients with acute pancreatitis. METHODS A multicenter, open-label, randomized, controlled trial including adult patients with a clinical diagnosis of acute pancreatitis upon admission to the intensive care unit. Participants were randomly assigned (1:1) to a strategy combining thoracic epidural analgesia and usual care (intervention group) or a strategy of usual care alone (control group). The primary outcome was the number of ventilator-free days from randomization until day 30. RESULTS Between June 2014 and January 2019, 148 patients were enrolled, and 135 patients were included in the intention-to-treat analysis, with 65 patients randomly assigned to the intervention group and 70 to the control group. The number of ventilator-free days did not differ significantly between the intervention and control groups (median [interquartile range], 30 days [15-30] and 30 days [18-30], respectively; median absolute difference of - 0.0 days, 95% CI - 3.3 to 3.3; p = 0.59). Epidural analgesia was significantly associated with longer duration of invasive ventilation (median [interquartile range], 14 days [5-28] versus 6 days [2-13], p = 0.02). CONCLUSIONS In a population of intensive care unit adults with acute pancreatitis and low requirement for intubation, this first multicenter randomized trial did not show the hypothesized benefit of epidural analgesia in addition to usual care. Safety of epidural analgesia in this setting requires further investigation. TRIAL REGISTRATION ClinicalTrials.gov registration number NCT02126332 , April 30, 2014.
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Affiliation(s)
- Matthieu Jabaudon
- Department of Perioperative Medicine, CHU Clermont-Ferrand, 58 Rue Montalembert, 63000, Clermont-Ferrand, France.
- iGReD, CNRS, INSERM, Université Clermont Auvergne, Clermont-Ferrand, France.
| | - Alexandra Genevrier
- Department of Perioperative Medicine, CHU Clermont-Ferrand, 58 Rue Montalembert, 63000, Clermont-Ferrand, France
| | - Samir Jaber
- Saint Eloi Intensive Care Unit, CHU Montpellier, Montpellier, France
- PhyMedExp, Université de Montpellier, INSERM, CNRS, Montpellier, France
| | - Olivier Windisch
- Department of Surgery, Geneva University Hospitals, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Division of Intensive Care, Department of Acute Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Stéphanie Bulyez
- Division of Intensive Care, Department of Acute Medicine, Geneva University Hospitals, Geneva, Switzerland
- Service de Recherche Clinique en Soins Critiques, Pôle Anesthésie Douleur Urgences Réanimation, CHU Nîmes, Université de Montpellier, Nîmes, France
| | - Pierre-François Laterre
- Department of Critical Care Medicine, Saint Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium
| | - Etienne Escudier
- Department of Emergency Medicine and Intensive Care, Annecy Genevois General Hospital, Annecy, France
| | - Achille Sossou
- Department of Intensive Care Medicine, Emile-Roux General Hospital, Le Puy-en-Velay, France
| | - Philippe Guerci
- Department of Anesthesiology and Critical Care Medicine, CHU Nancy-Brabois, Nancy, France
- Institut Lorrain du Coeur Et Des Vaisseaux and INSERM U1116, Institut Lorrain du Coeur et des Vaisseaux, University of Lorraine, Nancy, France
| | | | - Pierre-Eric Danin
- Department of Intensive Care Medicine, CHU Nice, Nice, France
- INSERM U1065, Team 8, C3M, CHU de Nice, Nice, France
| | - Martin Bonnassieux
- Department of Intensive Care Medicine, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Leo Bühler
- Department of Surgery, Geneva University Hospitals, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Claudia Paula Heidegger
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Division of Intensive Care, Department of Acute Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Russell Chabanne
- Department of Perioperative Medicine, CHU Clermont-Ferrand, 58 Rue Montalembert, 63000, Clermont-Ferrand, France
| | - Thomas Godet
- Department of Perioperative Medicine, CHU Clermont-Ferrand, 58 Rue Montalembert, 63000, Clermont-Ferrand, France
| | - Laurence Roszyk
- iGReD, CNRS, INSERM, Université Clermont Auvergne, Clermont-Ferrand, France
- Department of Biochemistry and Molecular Genetics, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Vincent Sapin
- iGReD, CNRS, INSERM, Université Clermont Auvergne, Clermont-Ferrand, France
- Department of Biochemistry and Molecular Genetics, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Emmanuel Futier
- Department of Perioperative Medicine, CHU Clermont-Ferrand, 58 Rue Montalembert, 63000, Clermont-Ferrand, France
- iGReD, CNRS, INSERM, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Bruno Pereira
- Biostatistics and Data Management Unit, Department of Clinical Research and Innovation, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Jean-Michel Constantin
- Department of Anesthesiology and Critical Care, GRC 29, DMU DREAM, Pitié-Salpêtrière Hospital, Sorbonne University, Assistance Publique-Hôpitaux de Paris, Paris, France
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Chaigneau T, Morello R, Vannier E, Musikas M, Piquet MA, Dupont B. Impact of sarcopenic obesity on predicting the severity of acute pancreatitis. Dig Liver Dis 2023:S1590-8658(23)00217-7. [PMID: 36849286 DOI: 10.1016/j.dld.2023.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 02/04/2023] [Accepted: 02/09/2023] [Indexed: 03/01/2023]
Abstract
BACKGROUND AND AIMS This work aimed to evaluate the impact of sarcopenia and sarcopenic obesity on the occurrence of severe pancreatitis and to study the performance of anthropometric indices to predict severe forms. METHODS We conducted a single-center retrospective study at Caen University Hospital between 2014 and 2017. Sarcopenia was assessed by measuring the psoas area on an abdominal scan. The psoas area /body mass index ratio reflected sarcopenic obesity. By normalizing the value to the body surface, we obtained an index called sarcopancreatic index, avoiding sex differences in measurements. RESULTS Among 467 included patients, 65 (13.9%) developed severe pancreatitis. The sarcopancreatic index was independently associated with the occurrence of severe pancreatitis (1.455 95% CI [1.028-2.061]; p = 0.035), as was the Visual Analog Scale, creatinine or albumin. The complication rate was not different depending on sarcopancreatic index value. Based on variables independently associated with the occurrence of severe pancreatitis, we constructed a score called Sarcopenia Severity Index. This score presented an area under the receiver operating characteristics curve of 0.84, comparable to the Ranson score (0.87) and superior to body mass index or the sarcopancreatic index to predict a severe form of acute pancreatitis. CONCLUSIONS Sarcopenic obesity seems to be associated with severe acute pancreatitis.
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Affiliation(s)
- Thomas Chaigneau
- Département d'Hepato-Gastroenterologie et Nutrition, Normandie Univ, UNICAEN, CHU de Caen Normandie, Avenue Côte de Nacre, 14033 CAEN, France
| | - Remy Morello
- Plateforme de Méthodologie, Normandie Univ, UNICAEN, CHU de Caen Normandie, 14000 CAEN, France
| | - Elise Vannier
- Département d'Hepato-Gastroenterologie et Nutrition, Normandie Univ, UNICAEN, CHU de Caen Normandie, Avenue Côte de Nacre, 14033 CAEN, France
| | - Marietta Musikas
- Département d'Hepato-Gastroenterologie et Nutrition, Normandie Univ, UNICAEN, CHU de Caen Normandie, Avenue Côte de Nacre, 14033 CAEN, France
| | - Marie-Astrid Piquet
- Département d'Hepato-Gastroenterologie et Nutrition, Normandie Univ, UNICAEN, CHU de Caen Normandie, Avenue Côte de Nacre, 14033 CAEN, France
| | - Benoît Dupont
- Département d'Hepato-Gastroenterologie et Nutrition, Normandie Univ, UNICAEN, CHU de Caen Normandie, Avenue Côte de Nacre, 14033 CAEN, France.
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Dupont B, Dejardin O, Bouvier V, Piquet MA, Alves A. Systematic Review: Impact of Social Determinants of Health on the Management and Prognosis of Gallstone Disease. Health Equity 2022; 6:819-835. [PMID: 36338799 PMCID: PMC9629913 DOI: 10.1089/heq.2022.0063] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2022] [Indexed: 11/06/2022] Open
Abstract
Background: Due to its prevalence, gallstone disease is a major public health issue. It affects diverse patient populations across various socioeconomic levels. Socioeconomic and geographic deprivation may impact both morbidity and mortality associated with digestive diseases, such as biliary tract disease. Aim: The aim of this systematic review was to review the available data on the impact of socioeconomic determinants and geographic factors on gallstone disease and its complications. Methods: This systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The MEDLINE and Web of Science databases were searched by two investigators to retrieve studies about the impact of income, insurance status, hospital status, education level, living areas, and deprivation indices on gallstone disease. Thirty-seven studies were selected for this review. Results: Socially disadvantaged populations appear to be more frequently affected by complicated or severe forms of gallstone disease. The prognosis of biliary tract disease is poor in these populations regardless of patient status, and increased morbidity and mortality were observed for acute cholangitis or subsequent cholecystectomy. Limited or delayed access and low-quality therapeutic interventions could be among the potential causes for this poor prognosis. Conclusions: This systematic review suggests that socioeconomic determinants impact the management of gallstone disease. Enhanced knowledge of these parameters could contribute to improved public health policies to manage these diseases.
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Affiliation(s)
- Benoît Dupont
- Departement d'Hepato-Gastroenterologie et Nutrition, UNICAEN, CHU de Caen Normandie, Normandie Univ, Caen, France
- “Anticipe” U1086 INSERM-UCBN, “Cancers & Preventions,” Team Labelled “League Against Cancer,” UNICAEN, Normandie Univ, CAEN, France
| | - Olivier Dejardin
- “Anticipe” U1086 INSERM-UCBN, “Cancers & Preventions,” Team Labelled “League Against Cancer,” UNICAEN, Normandie Univ, CAEN, France
- Registre des Tumeurs Digestives du Calvados, “Anticipe” U1086 INSERM-UCBN, UNICAEN, Normandie Univ, Caen, France
| | - Véronique Bouvier
- “Anticipe” U1086 INSERM-UCBN, “Cancers & Preventions,” Team Labelled “League Against Cancer,” UNICAEN, Normandie Univ, CAEN, France
- Registre des Tumeurs Digestives du Calvados, “Anticipe” U1086 INSERM-UCBN, UNICAEN, Normandie Univ, Caen, France
| | - Marie-Astrid Piquet
- Departement d'Hepato-Gastroenterologie et Nutrition, UNICAEN, CHU de Caen Normandie, Normandie Univ, Caen, France
| | - Arnaud Alves
- “Anticipe” U1086 INSERM-UCBN, “Cancers & Preventions,” Team Labelled “League Against Cancer,” UNICAEN, Normandie Univ, CAEN, France
- Service de Chirurgie Digestive, UNICAEN, CHU de Caen Normandie, Normandie Univ, Caen, France
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Bulyez S, Pereira B, Caumon E, Imhoff E, Roszyk L, Bernard L, Bühler L, Heidegger C, Jaber S, Lefrant JY, Chabanne R, Bertrand PM, Laterre PF, Guerci P, Danin PE, Escudier E, Sossou A, Morand D, Sapin V, Constantin JM, Jabaudon M. Epidural analgesia in critically ill patients with acute pancreatitis: the multicentre randomised controlled EPIPAN study protocol. BMJ Open 2017; 7:e015280. [PMID: 28554928 PMCID: PMC5730003 DOI: 10.1136/bmjopen-2016-015280] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Acute pancreatitis (AP) is associated with high morbidity and mortality in its most severe forms. Most patients with severe AP require intubation and invasive mechanical ventilation, frequently for more than 7 days, which is associated with the worst outcome. Recent increasing evidence from preclinical and clinical studies support the beneficial effects of epidural analgesia (EA) in AP, such as increased gut barrier function and splanchnic, pancreatic and renal perfusion, decreased liver damage and inflammatory response, and reduced mortality. Because recent studies suggest that EA might be a safe procedure in the critically ill, we sought to determine whether EA reduced AP-associated respiratory failure and other major clinical outcomes in patients with AP. METHODS AND ANALYSIS The Epidural Analgesia for Pancreatitis (EPIPAN) trial is an investigator-initiated, prospective, multicentre, randomised controlled two-arm trial with assessor-blinded outcome assessment. The EPIPAN trial will randomise 148 patients with AP requiring admission to an intensive care unit (ICU) to receive EA (with patient-controlled epidural administration of ropivacaine and sufentanil) combined with standard care based on current recommendations on the treatment of AP (interventional group), or standard care alone (reference group). The primary outcome is the number of ventilator-free days at day 30. Secondary outcomes include main complications of AP (eg, organ failure and mortality, among others), levels of biological markers of systemic inflammation, epithelial lung injury, renal failure, and healthcare-associated costs. ETHICS AND DISSEMINATION The study was approved by the appropriate ethics committee (CPP Sud-Est VI). Informed consent is required. If the combined application of EA and standard care proves superior to standard care alone in patients with AP in the ICU, the use of EA may become standard practice in experienced centres, thereby decreasing potential complications related to AP and its burden in critically ill patients. The results will be disseminated in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT02126332.
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Affiliation(s)
- Stéphanie Bulyez
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Bruno Pereira
- Department of Clinical Research and Innovation (DRCI), CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Elodie Caumon
- Department of Clinical Research and Innovation (DRCI), CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Etienne Imhoff
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Laurence Roszyk
- Department of Medical Biochemistry and Molecular Biology, CHU Clermont-Ferrand, Clermont-Ferrand, France
- Université Clermont Auvergne, CNRS UMR 6293, INSERM U1103, GReD, Clermont-Ferrand, France
| | - Lise Bernard
- Department of Pharmacy, CHU Clermont-Ferrand, Clermont-Ferrand, France
- Université Clermont Auvergne, Clermont-Ferrand, France
| | - Leo Bühler
- Department of Surgery, Geneva university hospitals, Geneva, Switzerland
| | - Claudia Heidegger
- Division of Intensive Care, Geneva university hospitals, Geneva, Switzerland
| | - Samir Jaber
- Department of Anesthesiology and Critical Care Medicine B (DAR B), Saint-Eloi teaching hospital, Montpellier university hospital, Montpellier, France
| | - Jean-Yves Lefrant
- Division of Anesthesiology, Critical Care, Pain and Emergency Medicine, Nîmes university hospital and EA 2992, Université Montpellier, Nîmes, France
| | - Russell Chabanne
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | | | - Pierre-François Laterre
- Department of Critical Care Medicine, Saint Luc university hospital, Université Catholique de Louvain, Brussels, Belgium
| | - Philippe Guerci
- Department of Anesthesiology and Intensive Care Medicine, Nancy university hospital, Nancy, France
| | - Pierre-Eric Danin
- Anesthesia and Surgical Intensive Care, Nice Archet 2 university hospital and INSERM U1065, team 8, Nice, France
| | - Etienne Escudier
- Intensive Care Unit, Annecy Genevois general hospital, Annecy, France
| | - Achille Sossou
- Department of Anesthesiology and Critical Care Medicine, Emile-Roux general hospital, Le Puy-en-Velay, France
| | - Dominique Morand
- Department of Clinical Research and Innovation (DRCI), CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Vincent Sapin
- Department of Medical Biochemistry and Molecular Biology, CHU Clermont-Ferrand, Clermont-Ferrand, France
- Université Clermont Auvergne, CNRS UMR 6293, INSERM U1103, GReD, Clermont-Ferrand, France
| | - Jean-Michel Constantin
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
- Université Clermont Auvergne, CNRS UMR 6293, INSERM U1103, GReD, Clermont-Ferrand, France
| | - Matthieu Jabaudon
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
- Université Clermont Auvergne, CNRS UMR 6293, INSERM U1103, GReD, Clermont-Ferrand, France
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van den Heever M, Mittal A, Haydock M, Windsor J. The use of intelligent database systems in acute pancreatitis--a systematic review. Pancreatology 2013; 14:9-16. [PMID: 24555973 DOI: 10.1016/j.pan.2013.11.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Revised: 10/15/2013] [Accepted: 11/18/2013] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Acute pancreatitis (AP) is a complex disease with multiple aetiological factors, wide ranging severity, and multiple challenges to effective triage and management. Databases, data mining and machine learning algorithms (MLAs), including artificial neural networks (ANNs), may assist by storing and interpreting data from multiple sources, potentially improving clinical decision-making. AIMS 1) Identify database technologies used to store AP data, 2) collate and categorise variables stored in AP databases, 3) identify the MLA technologies, including ANNs, used to analyse AP data, and 4) identify clinical and non-clinical benefits and obstacles in establishing a national or international AP database. METHODS Comprehensive systematic search of online reference databases. The predetermined inclusion criteria were all papers discussing 1) databases, 2) data mining or 3) MLAs, pertaining to AP, independently assessed by two reviewers with conflicts resolved by a third author. RESULTS Forty-three papers were included. Three data mining technologies and five ANN methodologies were reported in the literature. There were 187 collected variables identified. ANNs increase accuracy of severity prediction, one study showed ANNs had a sensitivity of 0.89 and specificity of 0.96 six hours after admission--compare APACHE II (cutoff score ≥8) with 0.80 and 0.85 respectively. Problems with databases were incomplete data, lack of clinical data, diagnostic reliability and missing clinical data. CONCLUSION This is the first systematic review examining the use of databases, MLAs and ANNs in the management of AP. The clinical benefits these technologies have over current systems and other advantages to adopting them are identified.
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Affiliation(s)
| | - Anubhav Mittal
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Matthew Haydock
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - John Windsor
- Department of Surgery, University of Auckland, Auckland, New Zealand.
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Degardin J, Pons B, Ardisson F, Gallego JP, Thiery G. [Multiple organ failure complicating a severe acute necrotising pancreatitis secondary of a severe hypertriglyceridemia: a case report]. ACTA ACUST UNITED AC 2013; 32:611-4. [PMID: 23948029 DOI: 10.1016/j.annfar.2013.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Accepted: 05/20/2013] [Indexed: 10/26/2022]
Abstract
We report the case of a 42-year-old man admitted for a multi-organ failure with a coma, a hemodynamic instability, a respiratory distress syndrome, an acute renal failure and a thrombocytopenia. The blood samples highlighted a milky serum and allowed to diagnose an acute pancreatitis associated with a major dyslipidemia: hypertriglyceridemia 11,800 mg/dL and hypercholesterolemia 1195 mg/dL. The CT-scans do not reveal any cerebral abnormalities but highlighted pancreatic lesions without biliary obstruction. A multi-organ failure complicating a severe acute pancreatitis secondary of a major hypertriglyceridemia was mentioned. Despite the absence of clear guidelines, a session of plasma exchange was started in emergency. Symptomatic treatment with protective ventilation, vasopressors, continuous heparin and insulin was continued. The clinical and biological course was good in parallel of the normalization of lipid abnormalities. The patient was discharged at day 17 with a lipid-lowering therapy. We discuss the various treatments available for the management of acute pancreatitis complicating a severe hypertriglyceridemia and their actual relevance in the absence of clear recommendations.
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Affiliation(s)
- J Degardin
- Service de réanimation et grands brûlés, CHU de Pointe-à-Pitre-Guadeloupe, route de Chauvel, 97159 Pointe-à-Pitre cedex, France
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