SEMICYUC 2012. Recommendations for intensive care management of acute pancreatitis. Med Intensiva. 2013;37:163-179. [PMID: 23541063 DOI: 10.1016/j.medin.2013.01.007]

Update on the strategy for intravenous fluid treatment in acute pancreatitis

Fluid therapy/resuscitation is mandatory in acute pancreatitis due to the pathophysiology of fluid loss as a consequence of the inflammatory process. For many years, without clear evidence, early and aggressive fluid resuscitation with crystalloid solutions (normal saline solution or Ringer lactate solution) was recommended. Recently, many randomized control trials and meta-analyses on fluid therapy have revealed that high fluid rate infusion is associated with increased mortality and severe adverse events compared to those resulting from moderate fluid rates, and this has triggered a paradigm shift in fluid management strategies. Meanwhile, there is evidence to show that Ringer lactate solution is superior to normal saline solutions in this context. The purpose of this review is to provide an update on the strategies for intravenous fluid treatment in acute pancreatitis, including the type, optimal amount, rate of infusion, and monitoring guides. Recommendations from recent guidelines are critically evaluated for this review in order to reach the authors' recommendations based on the available evidence.

Intravenous fluid therapy in patients with severe acute pancreatitis admitted to the intensive care unit: a narrative review

Patients with acute pancreatitis (AP) often require ICU admission, especially when signs of multiorgan failure are present, a condition that defines AP as severe. This disease is characterized by a massive pancreatic release of pro-inflammatory cytokines that causes a systemic inflammatory response syndrome and a profound intravascular fluid loss. This leads to a mixed hypovolemic and distributive shock and ultimately to multiorgan failure. Aggressive fluid resuscitation is traditionally considered the mainstay treatment of AP. In fact, all available guidelines underline the importance of fluid therapy, particularly in the first 24–48 h after disease onset. However, there is currently no consensus neither about the type, nor about the optimal fluid rate, total volume, or goal of fluid administration. In general, a starting fluid rate of 5–10 ml/kg/h of Ringer’s lactate solution for the first 24 h has been recommended. Fluid administration should be aggressive in the first hours, and continued only for the appropriate time frame, being usually discontinued, or significantly reduced after the first 24–48 h after admission. Close clinical and hemodynamic monitoring along with the definition of clear resuscitation goals are fundamental. Generally accepted targets are urinary output, reversal of tachycardia and hypotension, and improvement of laboratory markers. However, the usefulness of different endpoints to guide fluid therapy is highly debated. The importance of close monitoring of fluid infusion and balance is acknowledged by most available guidelines to avoid the deleterious effect of fluid overload. Fluid therapy should be carefully tailored in patients with severe AP, as for other conditions frequently managed in the ICU requiring large fluid amounts, such as septic shock and burn injury. A combination of both noninvasive clinical and invasive hemodynamic parameters, and laboratory markers should guide clinicians in the early phase of severe AP to meet organ perfusion requirements with the proper administration of fluids while avoiding fluid overload. In this narrative review the most recent evidence about fluid therapy in severe AP is discussed and an operative algorithm for fluid administration based on an individualized approach is proposed.

Factors Affecting the Circulating Levels of Oxyntomodulin in Health and After Acute Pancreatitis

OBJECTIVES

To investigate the factors associated with the circulating levels of oxyntomodulin in healthy individuals and individuals after an episode of acute pancreatitis (AP).

METHODS

Blood samples were collected from all participants after an overnight fast and analyzed for 28 biomarkers. Participants also underwent comprehensive body composition analysis on a 3-T magnetic resonance imaging scanner. Regression analyses were done to investigate the associations between oxyntomodulin and the studied factors.

RESULTS

The study included 105 individuals who had a primary diagnosis of AP and 58 healthy individuals. Peptide YY (B coefficient, 0.094; 95% confidence interval [95% CI], 0.164-0.123), pancreatic polypeptide (0.048; 95% CI, 0.030-0.066), and leptin (0.394; 95% CI, 0.128-0.661) had significant associations with oxyntomodulin in healthy individuals. Peptide YY was the most prominent factor associated with oxyntomodulin, explaining 60% of its variance in health. Cholecystokinin (0.014; 95% CI, 0.010-0.018), amylin (-0.107; 95% CI, -0.192 to -0.021), and glycated hemoglobin (-0.761; 95% CI, -1.249 to -0.273) had significant associations with oxyntomodulin in individuals after AP. Cholecystokinin was the most prominent factor associated with oxyntomodulin, explaining 44% of its variance after AP.

CONCLUSIONS

Factors affecting the circulating levels of oxyntomodulin are different in health and after AP. These insights will enable the determination of populations that benefit from oxyntomodulin therapeutics in the future.

Glucose variability during the early course of acute pancreatitis predicts two‐year probability of new‐onset diabetes: A prospective longitudinal cohort study

Background

Acute pancreatitis (AP) is the largest contributor to diabetes of the exocrine pancreas. However, there is no accurate predictor at the time of hospitalisation for AP to identify individuals at high risk for new‐onset diabetes.

Objective

To investigate the accuracy of indices of glucose variability (GV) during the early course of AP in predicting the glycated haemoglobin (HbA1c) trajectories during follow‐up.

Methods

This was a prospective longitudinal cohort study of patients without diabetes at the time of hospitalisation for AP. Fasting blood glucose was regularly measured over the first 72 h of hospital admission. The study endpoint was the HbA1c trajectories ‐ high‐increasing, moderate‐stable, normal‐stable ‐ over two years of follow‐up. Multinomial logistic regression analyses were conducted to investigate the associations between several common GV indices and the HbA1c trajectories, adjusting for covariates (age, sex, and body mass index). A sensitivity analysis constrained to patients with non‐necrotising AP was conducted.

Results

A total of 120 consecutive patients were studied. All patients in the high‐increasing HbA1c trajectory group had new‐onset diabetes at 18 and 24 months of follow‐up. Glycaemic lability index had the strongest significant direct association (adjusted odds ratio = 13.69; p = 0.040) with the high‐increasing HbA1c trajectory. High admission blood glucose, standard deviation of blood glucose, and average real variability significantly increased the patients' odds of taking the high‐increasing HbA1c trajectory by at least two‐times. Admission blood glucose, but not the other GV indices, had a significant direct association (adjusted odds ratio = 1.46; p = 0.034) with the moderate‐stable HbA1c trajectory. The above findings did not change materially in patients with non‐necrotising AP alone.

Conclusions

High GV during the early course of AP gives a prescient warning of worsening HbA1c pattern and new‐onset diabetes after hospital discharge. Determining GV during hospitalisation could be a relatively straightforward approach to early identification of individuals at high risk for new‐onset diabetes after AP.

Relationship between Energy Balance and Circulating Levels of Hepcidin and Ferritin in the Fasted and Postprandial States

Markers of iron metabolism are altered in new-onset diabetes, but their relationship with metabolic signals involved in the maintenance of energy balance is poorly understood. The primary aim was to explore the associations between markers of iron metabolism (hepcidin and ferritin) and markers of energy balance (leptin, ghrelin, and the leptin/ghrelin ratio) in both the fasted and postprandial states. These associations were also studied in the sub-groups stratified by diabetes status. This was a cross-sectional study of individuals without disorders of iron metabolism who were investigated after an overnight fast and, in addition, some of these individuals underwent a mixed meal test to determine postprandial responses of metabolic signals. The associations between hepcidin, ferritin, and leptin, ghrelin, leptin/ghrelin ratio were studied using several multiple linear regression models. A total of 76 individuals in the fasted state and 34 individuals in the postprandial state were included. In the overall cohort, hepcidin was significantly inversely associated with leptin (in the most adjusted model, the β coefficient ± SE was -883.45 ± 400.94; p = 0.031) and the leptin/ghrelin ratio (in the most adjusted model, the β coefficient ± SE was -148.26 ± 61.20; p = 0.018) in the fasted state. The same associations were not statistically significant in the postprandial state. In individuals with new-onset prediabetes or diabetes (but not in those with normoglycaemia or longstanding prediabetes or diabetes), hepcidin was significantly inversely associated with leptin (in the most adjusted model, the β coefficient ± SE was -806.09 ± 395.44; p = 0.050) and the leptin/ghrelin ratio (in the most adjusted model, the β coefficient ± SE was -129.40 ± 59.14; p = 0.037). Leptin appears to be a mediator in the link between iron metabolism and new-onset diabetes mellitus. These findings add to the growing understanding of mechanisms underlying the derangements of glucose metabolism.

Association between Habitual Dietary Iron Intake and Glucose Metabolism in Individuals after Acute Pancreatitis

Dietary intake of iron is known to be associated with impaired glucose metabolism. However, its involvement in derangements of glucose metabolism after acute pancreatitis (AP) is not completely understood. The aim was to investigate the association between dietary iron intake and markers of glucose metabolism in individuals after an attack of AP. Fasting blood samples were collected to analyse markers of glucose metabolism (fasting plasma glucose (FPG) and haemoglobin A1c (HbA1c)). The EPIC-Norfolk food frequency questionnaire was used to determine the habitual intake of dietary iron (total, haem, and non-haem). Multivariable linear regression analyses were conducted and six statistical models were built to adjust for covariates. A total of 109 individuals after AP were studied in a cross-sectional fashion. Total iron (β (95% confidence interval) = -0.19 (-0.35, -0.05); p = 0.01 in the most adjusted model) and non-haem iron (β (95% confidence interval) = -0.19 (-0.33, -0.04); p = 0.03 in the most adjusted model) were significantly associated with FPG, consistently in all adjusted model. Total iron and non-haem iron did not have consistent significant associations with HbA1c. Dietary haem iron intake was not associated with either FPG or HbA1c. Habitual intake of dietary iron is inversely associated with FPG in individuals after an attack of AP and may be involved in the pathogenesis of new-onset diabetes after pancreatitis. Prospective longitudinal studies are now warranted to unveil the specific mechanism underlying the involvement of dietary iron.

Trajectories of glycaemia following acute pancreatitis: a prospective longitudinal cohort study with 24 months follow-up

BACKGROUND

New-onset diabetes is the most common sequela of acute pancreatitis (AP). Yet, prospective changes in glycaemia over time have never been investigated comprehensively in this study population. The primary aim was to determine the cumulative incidence of new-onset prediabetes and new-onset diabetes after AP over 24 months of follow-up in a prospective cohort study. The secondary aim was to identify trajectories of glycaemia during follow-up and their predictors at the time of hospitalisation.

METHODS

Patients with a prospective diagnosis of AP and no diabetes based on the American Diabetes Association criteria were followed up every 6 months up to 24 months after hospital discharge. Incidence of new-onset prediabetes/diabetes over each follow-up period was calculated. Group-based trajectory modelling was used to identify common changes in glycaemia. Multinomial regression analyses were conducted to investigate the associations between a wide array of routinely available demographic, anthropometric, laboratory, imaging, and clinical factors and membership in the trajectory groups.

RESULTS

A total of 152 patients without diabetes were followed up. The cumulative incidence of new-onset prediabetes and diabetes was 20% at 6 months after hospitalisation and 43% over 24 months of follow-up (p trend < 0.001). Three discrete trajectories of glycaemia were identified: normal-stable glycaemia (32%), moderate-stable glycaemia (60%), and high-increasing glycaemia (8%). Waist circumference was a significant predictor of moderate-stable glycaemia. None of the studied predictors were significantly associated with high-increasing glycaemia.

CONCLUSIONS

This first prospective cohort study of changes in glycaemia (determined at structured time points in unselected AP patients) showed that at least one out of five patients develops new-onset prediabetes or diabetes at 6 months of follow-up and more than four out of ten-in the first 2 years. Changes in glycaemia after AP follow three discrete trajectories. This may inform prevention or early detection of critical changes in blood glucose metabolism following an attack of AP and, hence, reduce the burden of new-onset diabetes after acute pancreatitis.

Serum lipid profile as a biomarker of intra-pancreatic fat deposition: A nested cross-sectional study

BACKGROUND AND AIMS

The relationship between intra-pancreatic fat deposition (IPFD) and lipid profile has been investigated in individuals with obesity and/or type 2 diabetes, but not in healthy non-obese individuals and those after acute pancreatitis. The aim of the study was to investigate the association between serum lipid profile and IPFD in the latter individuals and to determine the effect of abdominal fat distribution and other covariates.

METHODS AND RESULTS

A total of 90 individuals with a history of acute pancreatitis as well as 23 healthy non-obese individuals participated in the study. Magnetic resonance imaging was used to quantify IPFD and visceral-to-subcutaneous fat volume ratio, followed by fasting state measurement of high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), total cholesterol (TC), TC/HDL-C ratio, and triglycerides. In healthy non-obese individuals, IPFD was not significantly associated with any of the studied markers. In individuals after acute pancreatitis, IPFD was significantly associated with triglycerides in both unadjusted (β = 0.360; 95% CI, 0.090-0.629; p = 0.009) and adjusted models, with a β-coefficient of 0.280 [(95% CI, 0.016-0.545); p = 0.038] in the most adjusted model. Also, IPFD was significantly associated with TC/HDL-C ratio in both unadjusted (β = 0.336; 95% CI, 0.045-0.626; p = 0.024) and adjusted models, with a β-coefficient of 0.375 [(95% CI, 0.090-0.660); p = 0.010] in the most adjusted model. Multiple regression yielded triglycerides, but not TC/HDL-C ratio, as a significant marker of IPFD in individuals after acute pancreatitis.

CONCLUSIONS

Serum lipid profile is not associated with IPFD in healthy non-obese. Triglycerides, but not other components of lipid profile, is a promising biomarker for IPFD in individuals following acute pancreatitis.

Buffered solutions versus 0.9% saline for resuscitation in critically ill adults and children

BACKGROUND

Fluid therapy is one of the main interventions provided for critically ill patients, although there is no general consensus regarding the type of solution. Among crystalloid solutions, 0.9% saline is the most commonly administered. Buffered solutions may offer some theoretical advantages (less metabolic acidosis, less electrolyte disturbance), but the clinical relevance of these remains unknown.

OBJECTIVES

To assess the effects of buffered solutions versus 0.9% saline for resuscitation in critically ill adults and children.

SEARCH METHODS

We searched the following databases to July 2018: CENTRAL, MEDLINE, Embase, CINAHL, and four trials registers. We checked references, conducted backward and forward citation searching of relevant articles, and contacted study authors to identify additional studies. We imposed no language restrictions.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) with parallel or cross-over design examining buffered solutions versus intravenous 0.9% saline in a critical care setting (resuscitation or maintenance). We included studies on participants with critical illness (including trauma and burns) or undergoing emergency surgery during critical illness who required intravenous fluid therapy. We included studies of adults and children. We included studies with more than two arms if they fulfilled all of our inclusion criteria. We excluded studies performed in persons undergoing elective surgery and studies with multiple interventions in the same arm.

DATA COLLECTION AND ANALYSIS

We used Cochrane's standard methodological procedures. We assessed our intervention effects using random-effects models, but when one or two trials contributed to 75% of randomized participants, we used fixed-effect models. We reported outcomes with 95% confidence intervals (CIs).

MAIN RESULTS

We included 21 RCTs (20,213 participants) and identified three ongoing studies. Three RCTs contributed 19,054 participants (94.2%). Four RCTs (402 participants) were conducted among children with severe dehydration and dengue shock syndrome. Fourteen trials reported results on mortality, and nine reported on acute renal injury. Sixteen included trials were conducted in adults, four in the paediatric population, and one trial limited neither minimum or maximum age as an inclusion criterion. Eight studies involving 19,218 participants were rated as high methodological quality (trials with overall low risk of bias according to the domains: allocation concealment, blinding of participants/assessors, incomplete outcome data, and selective reporting), and in the remaining trials, some form of bias was introduced or could not be ruled out.We found no evidence of an effect of buffered solutions on in-hospital mortality (odds ratio (OR) 0.91, 95% CI 0.83 to 1.01; 19,664 participants; 14 studies; high-certainty evidence). Based on a mortality rate of 119 per 1000, buffered solutions could reduce mortality by 21 per 1000 or could increase mortality by 1 per 1000. Similarly, we found no evidence of an effect of buffered solutions on acute renal injury (OR 0.92, 95% CI 0.84 to 1.00; 18,701 participants; 9 studies; low-certainty evidence). Based on a rate of 121 per 1000, buffered solutions could reduce the rate of acute renal injury by 19 per 1000, or result in no difference in the rate of acute renal injury. Buffered solutions did not show an effect on organ system dysfunction (OR 0.80, 95% CI 0.40 to 1.61; 266 participants; 5 studies; very low-certainty evidence). Evidence on the effects of buffered solutions on electrolyte disturbances varied: potassium (mean difference (MD) 0.09, 95% CI -0.10 to 0.27; 158 participants; 4 studies; very low-certainty evidence); chloride (MD -3.02, 95% CI -5.24 to -0.80; 351 participants; 7 studies; very low-certainty evidence); pH (MD 0.04, 95% CI 0.02 to 0.06; 200 participants; 3 studies; very low-certainty evidence); and bicarbonate (MD 2.26, 95% CI 1.25 to 3.27; 344 participants; 6 studies; very low-certainty evidence).

AUTHORS' CONCLUSIONS

We found no effect of buffered solutions on preventing in-hospital mortality compared to 0.9% saline solutions in critically ill patients. The certainty of evidence for this finding was high, indicating that further research would detect little or no difference in mortality. The effects of buffered solutions and 0.9% saline solutions on preventing acute kidney injury were similar in this setting. The certainty of evidence for this finding was low, and further research could change this conclusion. Patients treated with buffered solutions showed lower chloride levels, higher levels of bicarbonate, and higher pH. The certainty of evidence for these findings was very low. Future research should further examine patient-centred outcomes such as quality of life. The three ongoing studies once published and assessed may alter the conclusions of the review.

Intrapancreatic fat deposition and visceral fat volume are associated with the presence of diabetes after acute pancreatitis

Ectopic fat and abdominal adiposity phenotypes have never been studied holistically in individuals after acute pancreatitis (AP). The aim of the study was to investigate phenotypical differences in ectopic fat and abdominal fat between individuals after AP (with and without diabetes) and to determine the role of pancreatitis-related factors. Eighty-four individuals were studied cross-sectionally after a median of 21.5 mo since last episode of AP and were categorized into "diabetes" and "no diabetes" groups. Twenty-eight healthy volunteers were also recruited. With the use of magnetic resonance imaging, intrapancreatic fat percentage, liver fat percentage, visceral fat volume (VFV), subcutaneous fat volume, and visceral-to-subcutaneous (V/S) fat volume ratio were quantified. Analysis of variance was used to investigate the differences in these phenotypes between the groups. All analyses were adjusted for age and sex. Linear regression analysis was used to investigate the association between pancreatitis-related factors and the studied phenotypes. Intrapancreatic fat percentage was significantly higher in the diabetes group (10.2 ± 1.2%) compared with the no diabetes (9.2 ± 1.7%) and healthy volunteers (7.9 ± 1.9%) groups (P < 0.001). VFV was significantly higher in the diabetes (2,715.3 ±1,077.6 cm³) compared with no diabetes (1,983.2 ± 1,092.4 cm³) and healthy volunteer (1,126.2 ± 740.4 cm³) groups (P < 0.001). V/S fat volume ratio was significantly higher in the diabetes (0.97 ± 0.27) compared with no diabetes (0.68 ± 0.42) and healthy volunteer (0.52 ± 0.34) groups (P = 0.001). Biliary AP was associated with significantly higher intrapancreatic fat percentage (β = 0.67; 95% CI, 0.01, 1.33; P = 0.047). C-reactive protein levels during hospitalization for AP were associated with significantly higher VFV (β = 3.32; 95% CI, 1.68, 4.96; P < 0.001). In conclusion, individuals with diabetes after AP have higher intrapancreatic fat percentage, VFV, and V/S fat volume ratio. Levels of C-reactive protein during AP are significantly associated with VFV, whereas biliary AP is significantly associated with intrapancreatic fat percentage. NEW & NOTEWORTHY Individuals with diabetes after acute pancreatitis have significantly higher intrapancreatic fat percentage and visceral fat volume compared with individuals without diabetes after acute pancreatitis and healthy controls. C-reactive protein levels during hospitalization for acute pancreatitis and biliary etiology of acute pancreatitis are associated with significantly larger visceral fat and pancreatic fat depots, respectively.

Glucose Counter-regulation After Acute Pancreatitis

OBJECTIVES

Persistent hyperglycemia is a common sequela of acute pancreatitis (AP). The role of counter-regulatory hormones in maintaining glucose homeostasis has been largely studied during the course of AP, but not after clinical resolution of the disease. The objectives of this study were to investigate the associations between circulating levels of glucagon, cortisol, and human growth hormone and glucose homeostasis after AP as well as their associations with a comprehensive panel of pancreatic hormones, gut peptides, and proinflammatory cytokines.

METHODS

Participants with no history of pre-existing prediabetes or diabetes were categorized into hyperglycemia and normoglycemia after AP groups. Binary logistic regression and linear regression analyses were conducted.

RESULTS

Eighty-three individuals were included, of whom 19 had hyperglycemia. Glucagon, cortisol, and human growth hormone did not differ significantly between the groups. Glucagon explained up to 86% of the variance in glucagon-like peptide 1, whereas cortisol explained up to 89% of the variance in interleukin 6 in hyperglycemia after AP.

CONCLUSIONS

Counter-regulatory hormones do not appear to play a direct role in the mechanisms underlying hyperglycemia after AP. However, significant associations between glucagon and glucagon-like peptide 1, as well as between cortisol and interleukin 6, suggest that that these hormones may be involved indirectly in the pathophysiology of hyperglycemia after AP.

Comprehensive analysis of body composition and insulin traits associated with intra-pancreatic fat deposition in healthy individuals and people with new-onset prediabetes/diabetes after acute pancreatitis

Current knowledge of biomarkers of intra-pancreatic fat deposition (IFD) is limited. We aimed to analyse comprehensively body composition and insulin traits as biomarkers of IFD in healthy normoglycaemic individuals as well as in individuals with new-onset prediabetes or diabetes after acute pancreatitis (NODAP). A total of 29 healthy individuals and 34 individuals with NODAP took part in this cross-sectional study. The studied biomarkers belonged to the following domains: body composition (anthropometric and MRI-derived variables); indices of insulin secretion; indices of insulin sensitivity; incretins and related peptides; and pancreatitis-related factors. All MRI-derived variables (including IFD) were measured using ImageJ software. Univariate and step-wise regression analyses were conducted to determine variables that best explained variance in IFD. Visceral fat volume and oxyntomodulin were the best biomarkers of IFD in normoglycaemic healthy individuals, contributing to 64% variance. The Raynaud index was the best biomarker of IFD in individuals with NODAP, contributing to 20% variance. Longitudinal studies are warranted to investigate the cause and effect relationship between oxyntomodulin and IFD in healthy individuals, as well as insulin sensitivity and IFD in individuals with NODAP.

Pro-inflammatory cytokine-induced lipolysis after an episode of acute pancreatitis

CONTEXT

Pro-inflammatory cytokine-stimulated lipolysis is one of the mechanisms underlying the pathogenesis of type 2 diabetes. However, whether it plays a role in the pathogenesis of post-pancreatitis diabetes mellitus (PPDM) remains unknown.

OBJECTIVE

To investigate the associations between markers of lipid metabolism and pro-inflammatory cytokines in individuals after acute pancreatitis (AP) in general, and in individuals with abnormal glucose metabolism (AGM) following AP in particular.

METHODS

Fasting blood samples were collected to measure markers of lipid metabolism (apolipoprotein-B, cholesterol, free fatty acids (FFA), glycerol, high and low-density lipoproteins, triglycerides) and cytokines (interleukin (IL)-6, monocyte chemoattractant protein (MCP)-1, and tumour necrosis factor (TNF) α). Linear regression analysis was conducted. Four statistical models were used to adjust for patient- and pancreatitis-related characteristics.

RESULTS

A total of 83 patients were recruited. IL-6 was significantly associated with glycerol in all models (p < .05), with glycerol levels increasing by 106% in individuals with AGM after AP (p <.05) compared to a 30.3% increase in individuals with normal glucose metabolism (NGM) (p >.05). TNFα was significantly associated with FFA (p = .015) in individuals with AGM after AP in the most adjusted model, with FFA levels increasing by 314% in these individuals compared to a 162% decrease in individuals with NGM after AP (p >.05).

CONCLUSIONS

Lipolysis appears to be an important pathogenetic mechanism in glucose derangements after diseases of the exocrine pancreas. IL-6 and TNFα are the driving forces behind lipolysis in individuals with AGM after AP. Modulation of lipolysis may be a promising therapeutic modality.

Quality of critical care clinical practice guidelines: Assessment with AGREE II instrument

STUDY OBJECTIVE

Clinical practice guidelines (CPGs) are cornerstones for the management of critically ill patients. Numerous CPGs have been generated in critical care medicine, but their qualities have never been systematically appraised. The aim of the present study was to systematically assess the quality of critical care CPGs.

DESIGN

A systematic electronic search was performed in PubMed and Scopus. All critical care CPGs were included for analysis.

SETTING

Not applicable.

PATIENTS

Not applicable.

INTERVENTION

None.

MEASUREMENTS

The Appraisal of guidelines for research & evaluation II (AGREE II) instrument was employed to appraise the quality. CPGs were assessed independently by three raters and intraclass correlation coefficient to represent the agreement among raters.

MAIN RESULTS

A total of 89 CPGs were included for quantitative analysis. The results showed that domain 1 (scope and purpose) had the highest scores (0.93, IQR: 0.89-0.98) and domain 2 (stakeholder involvement) had the lowest scores (0.37, IQR: 0.30-0.46). The overall score was 0.83 (IQR: 0.67-0.83). Publication year was not associated with scaled scores in each domain. Domain 2 (stakeholder involvement) was significantly associated with the number of societies (coefficient: 0.702, p = 0.033). Also, greater number of societies were associated with higher scaled scores of domain 3 (coefficient: 0.768, p = 0.027), 4 (coefficient: 0.730, p = 0.029) and 5 (coefficient: 0.995, p = 0.023).

CONCLUSIONS

The study showed that the reporting quality of critical care CPGs were suboptimal. The reporting quality varied across the six domains, with the highest quality in domain 1 and lowest quality in domain 2. Strenuous efforts need to be made to improve the reporting of critical care CPGs.

Abdominal obesity and insulin resistance after an episode of acute pancreatitis

BACKGROUND

Emerging evidence indicates that individuals after an episode of acute pancreatitis (AP) are at an increased risk of developing metabolic derangements. While the link between general obesity and insulin resistance (IR) is well established, only a few studies have investigated the association between abdominal obesity and IR. The aim of this study was to investigate the associations between abdominal obesity and several indices of IR in individuals after an episode of AP.

METHODS

Patients were eligible for this cross-sectional study if they were previously admitted with a primary diagnosis of AP based on the recent international guidelines. Fasting venous bloods were collected to measure glucose, insulin, free fatty acids, glycerol, adiponectin (AD), omentin (OM), and vaspin (VAS). The IR indices - HOMA-IR, Adipo-IR, insulin*glycerol (IG) index, HOMA-AD, HOMA-OM, and HOMA-VAS were calculated. Modified Poisson regression was conducted, with statistical model adjusting for patient-, metabolic-, and pancreatitis-related risk factors. Areas under ROC curve were calculated and Bland-Altman plots were created.

RESULTS

Of the 92 individuals recruited, 41 had abdominal obesity. HOMA-IR, IG index, HOMA-OM, and HOMA-VAS were significantly associated with abdominal obesity, both in unadjusted and adjusted models. Area under ROC curves for HOMA-IR, IG index, HOMA-OM, and HOMA-VAS were 0.698, 0.695, 0.756, and 0.735, respectively. There was a good agreement between observed HOMA-IR values and values obtained from HOMA-OM (P = 0.733) and HOMA-VAS (P = 0.595).

CONCLUSION

Individuals with abdominal obesity after AP have a significantly higher IR, independent of diabetes and other covariates. Visceral adipose tissue specific adipokines, omentin and vaspin, hold promise for future clinical investigation of tissue-specific IR.

Early Predictors of Abdominal Hemorrhage Among Critically Ill Patients With Pancreatitis: A Prospective Cohort Study

OBJECTIVE

To establish incidence, risk factors, and prognostic implications of abdominal hemorrhage (AH) among critically ill patients with acute pancreatitis (AP).

METHODS

Prospective cohort study in 46 intensive care units aimed at describing the characteristics of critically ill patients with AP (Epidemiología de la Pancreatitis Aguda en Medicina Intensiva Study). Adult patients with AP and at least 1 organ failure were included. The presence of AH was established either by using computed tomography, magnetic resonance imaging, or by direct visualization during surgery. Statistical analyses were carried out using multivariate logistic regression.

RESULTS

Three hundred seventy-four patients were studied. Most were men (62.6%), with a mean (standard deviation) age of 60.4 (15.6) years. Most episodes (56.4%) of AP were severe, and 28.9% died during their hospital stay. Thirty-eight patients (10.2%; 95% confidence interval, 7.3%-13.7%) developed AH. The odds of presenting AH was influenced by age, the underlying cause of pancreatitis, and the presence of shock or respiratory failure on admission.

CONCLUSIONS

Abdominal hemorrhages were common among critically ill patients with pancreatitis. These early predictors may be of use in detecting patients at risk of developing them.

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.

Iron: a Strong Element in the Pathogenesis of Chronic Hyperglycaemia After Acute Pancreatitis

Evidence shows an association between markers of iron metabolism and glucose metabolism in type 2 diabetes mellitus. Acute pancreatitis is the largest contributor to diabetes of the exocrine pancreas. However, the pathogenesis of new-onset pre-diabetes or diabetes after pancreatitis remains unclear. This study aimed to investigate associations between markers of iron metabolism and glucose metabolism following acute pancreatitis. Fasting blood samples were collected to analyse markers of glucose metabolism (haemoglobin A1c) and iron metabolism (hepcidin, ferritin, and soluble transferrin receptor). Participants were categorised into two groups: normoglycaemia after acute pancreatitis and chronic hyperglycaemia after acute pancreatitis. Binary logistic and linear regression analyses were conducted, and potential confounders were adjusted for in multivariable analyses. A total of 83 individuals following an episode of acute pancreatitis were included, of whom 19 developed chronic hyperglycaemia. Hepcidin was significantly increased in individuals with chronic hyperglycaemia after acute pancreatitis in two adjusted models (p = 0.045 and p = 0.048). Ferritin was significantly decreased in individuals with chronic hyperglycaemia after acute pancreatitis in three adjusted models (p = 0.016, p = 0.009, and p = 0.011). Soluble transferrin receptor was not significantly associated with chronic hyperglycaemia after acute pancreatitis. These findings suggest that iron metabolism is significantly altered in individuals with chronic hyperglycaemia after acute pancreatitis and may provide better insights into the pathogenesis of new-onset diabetes after pancreatitis.

Development and validation of a multivariate prediction model for patients with acute pancreatitis in Intensive Care Medicine

BACKGROUND/OBJECTIVES

Development and validation of a multivariate prediction model for patients with acute pancreatitis (AP) admitted in Intensive Care Units (ICU).

METHODS

A prospective multicenter observational study, in 1 year period, in 46 international ICUs (EPAMI study).

PATIENTS

adults admitted to an ICU with AP and at least one organ failure.

INTERVENTIONS

Development of a multivariate prediction model, using the worst data of the stay in ICU, based in multivariate analysis, simple imputation in a development cohort. The model was validated in another cohort.

RESULTS

374 patients were included (mortality of 28.9%). Variables with statistical significance in multivariate analysis were age, no alcoholic and no biliary etiology, development of shock, development of respiratory failure, need of continuous renal replacement therapy, and intra-abdominal pressure. The model created with these variables presented an AUC of ROC curve of 0.90 (CI 95% 0.81-0.94) in the validation cohort. We developed a multivariable prediction model, and AP cases could be classified as low mortality risk (between 2 and 9.5 points, mortality of 1.35%), moderate mortality risk (between 10 and 12.5 points, 28.92% of mortality), and high mortality risk (13 points of more, mortality of 88.37%). Our model presented better AUC of ROC curve than APACHE II (0.91 vs 0.80) and SOFA in the first 24 h (0.91 vs 0.79).

CONCLUSIONS

We developed and validated a multivariate prediction model, which can be applied in any moment of the stay in ICU, with better discriminatory power than APACHE II and SOFA in the first 24 h.

Profile of Gut Hormones, Pancreatic Hormones and Pro-inflammatory Cytokines in New Zealand Maori

Background

Maori, indigenous people of New Zealand, have at least two times higher prevalence of obesity and diabetes in comparison with the general population in the country. Gut and pancreatic hormone profile differences as well as pro-inflammatory milieu may contribute to this disparity. The aim was to investigate the differences in gut hormones, pancreatic hormones and pro-inflammatory cytokines between Maori and non-Maori individuals.

Methods

This was a cross-sectional study. Fasting blood samples were collected to measure cholecystokinin, ghrelin, gastric inhibitory peptide, glicentin, glucagon-like peptide-1 and -2, oxyntomodulin, secretin, amylin, C-peptide, glucagon, insulin, pancreatic polypeptide, somatostatin, interleukin-6, monocyte chemoattractant protein-1 and tumour necrosis factor-α. Binary logistic regression analysis was conducted in one unadjusted and four adjusted statistical models adjusting for patient-, metabolic- and pancreatitis-related factors.

Results

A total of 8 Maori and 85 non-Maori individuals were included. Circulating levels of ghrelin, pancreatic polypeptide and interleukin-6 levels were significantly higher in Maori (P = 0.005, P = 0.003 and P = 0.011, respectively) in both unadjusted and all the four adjusted analyses. Other signaling molecules did not show consistently significant associations with ethnicity.

Conclusion

Profile of gut hormones, pancreatic hormones and pro-inflammatory cytokines appears to differ between Maori and non-Maori individuals, independent of obesity, diabetes and other covariates. This may go some way to explain the increased propensity to obesity and diabetes in the Maori population.

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

BACKGROUND

The aim of this study was to analyse the relationship between intra-abdominal hypertension (IAH) and severity of acute pancreatitis (AP) measured by the revised Atlanta classification (RAC) and determinant-based classification (DBC). Secondary objectives were to assess IAH as a predictor of morbidity and mortality in the ICU.

METHODS

This prospective international observational study included patients admitted to the ICU with AP and at least one organ failure. Information was collected on demographics, severity scores at admission using RAC and DBC, organ failure, mechanical ventilation, continuous renal replacement therapy (CRRT), surgery and mortality. Maximum intra-abdominal pressure (IAP) during ICU stay was used for analysis.

RESULTS

Some 374 patients were included. The hospital mortality rate was 28·9 per cent. IAP was measured in 301 patients (80·5 per cent), of whom 274 (91·0 per cent) had IAH and 103 (34·2 per cent) acute compartment syndrome. A higher IAH grade was more likely in patients with severe AP (42 per cent for grade I versus 84 per cent for grade IV) and acute critical pancreatitis (9 versus 25 per cent; P = 0·001). Compared with grade I IAH, patients with grade IV had more infected necrosis (16 versus 28 per cent; P = 0·005), need for surgery (27 versus 50 per cent; P = 0·006), mechanical ventilation (53 versus 84 per cent; P = 0·007) and requirement for CRRT (22 versus 66 per cent; P < 0·001). IAH predicted shock (area under receiver operating characteristic (ROC) curve (AUC) 0·79, 95 per cent c.i. 0·73 to 0·84), respiratory failure (AUC 0·82, 0·77 to 0·87), renal failure (AUC 0·93, 0·89 to 0·96) and mortality (AUC 0·89, 0·86 to 0·93).

CONCLUSION

IAH was associated with severity of AP classified according to both RAC and DBC systems. IAP grade can predict outcome of AP during ICU stay.

Lipid metabolism in patients with chronic hyperglycemia after an episode of acute pancreatitis

BACKGROUND

The importance of dyslipidemia is well recognized in the context of both risk factor for acute pancreatitis and prognostic factor for its in-hospital outcomes. With a growing appreciation of post-pancreatitis diabetes mellitus, there is a need to catalogue changes in lipid metabolism after hospitalization due to an acute pancreatitis attack and their associations with glucose metabolism.

OBJECTIVE

To investigate lipid metabolism in patients with impaired glucose homeostasis following acute pancreatitis.

METHODS

There were two study groups: newly diagnosed chronic hyperglycemia or normoglycemia after acute pancreatitis. During the fasting state, venous blood samples were collected to analyse markers of lipid metabolism (triglycerides, glycerol, low density lipoprotein, high density lipoprotein, total cholesterol, free fatty acids, and apolipoprotein-B) and glucose metabolism (HbA1c, insulin, index of adipose tissue insulin resistance (Adipo-IR), and HOMA-IR). Binary logistic and linear regression analyses were conducted, and potential confounders were adjusted for in multivariate analyses.

RESULTS

The study included 64 patients with normoglycemia and 19 - with chronic hyperglycemia. Glycerol was significantly associated with the development of chronic hyperglycemia in both unadjusted (p=0.02) and adjusted (p=0.006) models. Triglycerides were significantly associated with the development of chronic hyperglycemia in adjusted (p=0.019) model. Other markers of lipid metabolism did not differ significantly between the two groups. None of the markers of lipid metabolism was significantly associated with Adipo-IR or HOMA-IR.

CONCLUSION

Overall, patients with chronic hyperglycemia after acute pancreatitis appear to have a lipid profile indicative of an up-regulation of lipolysis, which is not significantly affected by either general or adipose tissue-specific insulin resistance.

Derivation and validation of the prediabetes self-assessment screening score after acute pancreatitis (PERSEUS)

BACKGROUND AND AIM

Approximately 40% of patients develop abnormal glucose metabolism after a single episode of acute pancreatitis. This study aimed to develop and validate a prediabetes self-assessment screening score for patients after acute pancreatitis.

METHODS

Data from non-overlapping training (n=82) and validation (n=80) cohorts were analysed. Univariate logistic and linear regression identified variables associated with prediabetes after acute pancreatitis. Multivariate logistic regression developed the score, ranging from 0 to 215. The area under the receiver-operating characteristic curve (AUROC), Hosmer-Lemeshow χ² statistic, and calibration plots were used to assess model discrimination and calibration. The developed score was validated using data from the validation cohort.

RESULTS

The score had an AUROC of 0.88 (95% CI, 0.80-0.97) and Hosmer-Lemeshow χ² statistic of 5.75 (p=0.676). Patients with a score of ≥75 had a 94.1% probability of having prediabetes, and were 29 times more likely to have prediabetes than those with a score of <75. The AUROC in the validation cohort was 0.81 (95% CI, 0.70-0.92) and the Hosmer-Lemeshow χ² statistic was 5.50 (p=0.599). Model calibration of the score showed good calibration in both cohorts.

CONCLUSION

The developed and validated score, called PERSEUS, is the first instrument to identify individuals who are at high risk of developing abnormal glucose metabolism following an episode of acute pancreatitis.

The optimal timing of enteral nutrition and its effect on the prognosis of acute pancreatitis: A propensity score matched cohort study

BACKGROUND

Early enteral nutrition (EN) can improve the prognosis of acute pancreatitis (AP), but the optimal initiation time is unknown. In this study, the optimal time of early EN was analyzed to disclose the application of early EN in AP.

METHODS

Data of 104 patients with AP were prospectively collected. With secondary infection (infected pancreatic necrosis and extrapancreatic infection) as the primary outcome variable, receiver operating characteristic (ROC) curve was used to calculate the optimal cut-off time of early EN. Propensity score matching was used to adjust for covariates. Secondary outcomes include acute gastrointestinal injury (AGI) grades, serum albumin level, and EN-related complications.

RESULTS

The ROC curve analysis showed that the third day after hospital admission was the best cut-off time of early EN (with the area under the curve of 0.744). After PS matching, the proportion of secondary infection in the early EN group was significantly lower than the late EN group (8.6% vs. 36.5%, P < 0.05). Regression analysis showed that early EN was a protective factor against secondary infection (OR 0.161, 95%CI 0.036-0.718, P < 0.05). The AGI grades and serum albumin levels were better improved in the early EN group (AGI F = 4.468, P < 0.05; serum albumin F = 3.794, P < 0.05).The proportion of EN-related abdominal distension in the early EN group was significantly lower (8.8% vs. 38.5%, P < 0.05).

CONCLUSIONS

Early EN initiated within three days could reduce the risk of secondary infection and improve the nutritional status of patients with acute pancreatitis, with a better tolerance.

Effect of Intravenous Fluids and Analgesia on Dysmotility in Patients With Acute Pancreatitis: A Prospective Cohort Study

OBJECTIVES

Analgesia and intravenous fluid resuscitation are cornerstones of initial patient management in acute pancreatitis (AP). The aim was to investigate the effect of intravenous fluids and analgesia on gastrointestinal motility in the early course of AP.

METHODS

Gastrointestinal dysmotility was assessed using the Gastroparesis Cardinal Symptom Index (GCSI). One-way analysis of variance and analysis of covariance were conducted, adjusting for age, sex, body mass index, severity of AP, preexisting diabetes mellitus, and time from first symptom onset to hospital admission.

RESULTS

A total of 108 patients with AP were prospectively enrolled. Opioid analgesia, when compared with nonopioid analgesia, was significantly associated with increase in total GCSI score in both unadjusted and adjusted analyses. There was no significant difference between aggressive and nonaggressive fluid resuscitation in both unadjusted and adjusted analyses. A combination of opioids and any intravenous fluids was associated with a significantly increased total GCSI score compared with opioids and no intravenous fluids in both unadjusted and adjusted analyses. Duration of symptoms was the confounder that significantly affected 6 of 9 studied associations.

CONCLUSIONS

Intravenous fluids and analgesia significantly affect motility independent of severity and other covariates. Guidelines on prudent use of opioids and fluids in AP need to be developed, particularly taking into account duration of symptoms from onset to hospitalization.

The Role of Gut-brain Axis in Regulating Glucose Metabolism After Acute Pancreatitis

Objectives:

Diabetes has become an epidemic in developed and developing countries alike, with an increased demand for new efficacious treatments. A large body of pre-clinical evidence suggests that the gut–brain axis may be exploited as a potential therapeutic target for defective glucose homeostasis. This clinical study aimed to investigate a comprehensive panel of glucoregulatory peptides, released by both the gut and brain, in individuals after acute pancreatitis.

Methods:

Fasting levels of glucagon-like peptide-1 (GLP-1), glicentin, oxyntomodulin, peptide YY, ghrelin, cholecystokinin, vasoactive intestinal peptide (VIP), and secretin were studied. Modified Poisson and multivariable linear regression analyses were conducted. Pre-determined concentration ranges were used to categorize each peptide into quartiles.

Results:

A total of 83 individuals were included, of who 30 (36%) developed abnormal glucose metabolism (AGM) after acute pancreatitis. In individuals with AGM, the highest quartile of oxyntomodulin differed most significantly from the lowest quartile with a prevalence ratio (PR; 95% confidence interval) of 0.50 (0.21, 1.20; P=0.005); of glicentin with a PR of 0.26 (0.13, 0.54; P<0.001); and of VIP with a PR of 0.34 (0.13, 0.89; P=0.043). Peptide YY, GLP-1, cholecystokinin, ghrelin, and secretin were not significantly associated with AGM.

Conclusions:

Fasting circulating oxyntomodulin, glicentin, and VIP levels are significantly decreased in patients with defective glucose homeostasis after acute pancreatitis. Oxyntomodulin appears to be a promising therapeutic target for future clinical studies on diabetes associated with diseases of the exocrine pancreas.

Relationship between circulating levels of pancreatic proteolytic enzymes and pancreatic hormones

BACKGROUND

While the close morphological relationship between the exocrine and endocrine pancreas is well established, their functional interaction remains poorly understood. The aim of this study was to investigate the associations between circulating levels of pancreatic proteolytic enzymes and insulin, as well as other pancreatic hormones.

METHODS

Fasting venous blood samples were collected and analyzed for trypsin, chymotrypsin, insulin, glucagon, somatostatin, and pancreatic polypeptide. Linear regression analysis was used in unadjusted and two adjusted (accounting for prediabetes/diabetes, body mass index, smoking, and other covariates) statistical models.

RESULTS

A total of 93 individuals with a history of acute pancreatitis were included in this cross-sectional study. Chymotrypsin was significantly associated with insulin in the two adjusted models (p = 0.005; p = 0.003) and just missed statistical significance in the unadjusted model (p = 0.066). Chymotrypsin was significantly associated with glucagon in both unadjusted (p = 0.025) and adjusted models (p = 0.014; p = 0.015); as well as with somatostatin - in both unadjusted (p = 0.001) and adjusted models (p = 0.001; p = 0.002). Trypsin was not significantly associated with insulin in any of the models but was significantly associated with glucagon in both unadjusted (p < 0.001) and adjusted models (p < 0.001), and pancreatic polypeptide in both unadjusted (p < 0.001) and adjusted (p < 0.001) models.

CONCLUSION

The state of hyperinsulinemia is characterized by a dysfunction of the exocrine pancreas. In particular, chymotrypsin is increased in the state of hyperinsulinemia and trypsin is significantly associated with glucagon and pancreatic polypeptide.

Comparison Between Revised Atlanta Classification and Determinant-Based Classification for Acute Pancreatitis in Intensive Care Medicine. Why Do Not Use a Modified Determinant-Based Classification?

OBJECTIVE

To compare the classification performance of the Revised Atlanta Classification, the Determinant-Based Classification, and a new modified Determinant-Based Classification according to observed mortality and morbidity.

DESIGN

A prospective multicenter observational study conducted in 1-year period.

SETTING

Forty-six international ICUs (Epidemiology of Acute Pancreatitis in Intensive Care Medicine study).

PATIENTS

Admitted to an ICU with acute pancreatitis and at least one organ failure.

INTERVENTIONS

Modified Determinant-Based Classification included four categories: In group 1, patients with transient organ failure and without local complications; in group 2, patients with transient organ failure and local complications; in group 3, patients with persistent organ failure and without local complications; and in group 4, patients with persistent organ failure and local complications.

MEASUREMENTS AND MAIN RESULTS

A total of 374 patients were included (mortality rate of 28.9%). When modified Determinant-Based Classification was applied, patients in group 1 presented low mortality (2.26%) and morbidity (5.38%), patients in group 2 presented low mortality (6.67%) and high morbidity (60.71%), patients in group 3 presented high mortality (41.46%) and low morbidity (8.33%), and patients in group 4 presented high mortality (59.09%) and morbidity (88.89%). The area under the receiver operator characteristics curve of modified Determinant-Based Classification for mortality was 0.81 (95% CI, 0.77-0.85), with significant differences in comparison to Revised Atlanta Classification (0.77; 95% CI, 0.73-0.81; p < 0.01), and Determinant-Based Classification (0.77; 95% CI, 0.72-0.81; p < 0.01). For morbidity, the area under the curve of modified Determinant-Based Classification was 0.80 (95% CI, 0.73-0.86), with significant differences in comparison to Revised Atlanta Classification (0.63, 95% CI, 0.57-0.70; p < 0.01), but not in comparison to Determinant-Based Classification (0.81, 95% CI, 0.74-0.88; nonsignificant).

CONCLUSION

Modified Determinant-Based Classification identified four groups with different clinical presentation in patients with acute pancreatitis in ICU, with better discriminatory power in comparison to Determinant-Based Classification and Revised Atlanta Classification.

Interleukin-6 is associated with chronic hyperglycemia and insulin resistance in patients after acute pancreatitis

BACKGROUND

Diabetes is a pervasive disease, with a mounting prevalence and burden on health care systems. Under this collective term of diabetes falls diabetes after diseases of the exocrine pancreas, a condition which was previously under-recognised and often mislabeled as type 2 diabetes mellitus and is now increasingly acknowledged as a stand-alone entity. However, there is a paucity of clinical studies investigating the underlying pathophysiology of diabetes after acute pancreatitis, the most frequent disease of the pancreas. This study aimed to investigate the role of adipocytokines in glucose metabolism after acute pancreatitis.

METHODS

This was a cross-sectional follow-up study of a patient cohort diagnosed with acute pancreatitis. Fasting venous blood samples were collected to analyse markers of glucose metabolism (fasting blood glucose, haemoglobin A1c, homeostasis model assessment (HOMA-IR) as a measure of insulin resistance) and adypocytokines (adiponectin, interleukin-6, leptin, monocyte chemoattractant protein-1, retinol binding protein-4, resistin, and tumor necrosis factor-α). Participants were categorized into two groups: normoglycemia after acute pancreatitis and chronic hyperglycemia after acute pancreatitis (CHAP). Binary logistic regression and linear regression analyses were used to investigate the association between each of the adipocytokines and markers of glucose metabolism. Potential confounders were adjusted for in multivariate analyses.

RESULTS

A total of 83 patients with acute pancreatitis were included, of whom 19 developed CHAP. Interleukin-6 was significantly associated with CHAP in both unadjusted and adjusted models (p = 0.030 and p = 0.018, respectively). Further, it was also significantly associated with HOMA-IR in both unadjusted and adjusted models (p = 0.029 and p = 0.037, respectively). Other adipocytokines were not significantly associated with markers of glucose metabolism.

CONCLUSION

Interleukin-6 appears to be implicated in the development of chronic hyperglycemia and insulin resistance in patients after acute pancreatitis. It may become a potential target in the prevention and early treatment of diabetes after diseases of the exocrine pancreas.

New Atlanta Classification of acute pancreatitis in intensive care unit: Complications and prognosis

BACKGROUND

The updated Atlanta Classification of acute pancreatitis (AP) in adults defined three levels of severity according to the presence of local and/or systemic complications and presence and length of organ failure. No study focused on complications and mortality of patients with moderately severe AP admitted to intensive care unit (ICU). The main aim of this study is to describe the complications developed and outcomes of these patients and compare them to those with severe AP.

METHODS

Prospective, observational study. We included patients with acute moderately severe or severe AP admitted in a medical-surgical ICU during 5years. We collected demographic data, admission criteria, pancreatitis etiology, severity of illness, presence of organ failure, local and systemic complications, ICU length of stay, and mortality.

RESULTS

Fifty-six patients were included: 12 with moderately severe AP and 44 with severe. All patients developed some kind of complications without differences on complications rate between moderately severe or severe AP. All the patients present non-infectious systemic complications, mainly acute respiratory failure and hemodynamic failure. 82.1% had an infectious complication, mainly non-pancreatic infection (66.7% on moderately severe AP vs. 79.5% on severe, p=0.0443). None of the patients with moderately severe AP died during their intensive care unit stay vs. 29.5% with severe AP (p=0.049).

CONCLUSIONS

Moderately severe AP has a high rate of complications with similar rates to patients with severe AP admitted to ICU. However, their ICU mortality remains very low, which supports the existence of this new group of pancreatitis according to their severity.

Fluid resuscitation in acute pancreatitis

Acute pancreatitis remains a clinical challenge, despite an exponential increase in our knowledge of its complex pathophysiological changes. Early fluid therapy is the cornerstone of treatment and is universally recommended; however, there is a lack of consensus regarding the type, rate, amount and end points of fluid replacement. Further confusion is added with the newer studies reporting better results with controlled fluid therapy. This review focuses on the pathophysiology of fluid depletion in acute pancreatitis, as well as the rationale for fluid replacement, the type, optimal amount, rate of infusion and monitoring of such patients. The basic goal of fluid epletion should be to prevent or minimize the systemic response to inflammatory markers. For this review, various studies and reviews were critically evaluated, along with authors’ recommendations, for predicted severe or severe pancreatitis based on the available evidence.

Study on acute recent stage pancreatitis

Acute pancreatitis (AP) is an inflammatory disease of the pancreas which involves the pancreas and surrounding tissue, and systemic inflammation with a characteristic systemic increase of vascular permeability and increased risk of multiple organ dysfunction. Currently, the pathogenesis of AP is fuzzy, and the diagnosis and treatment need to be standardized. Nevertheless, increased knowledge of AP may achieve more thorough understanding of the pathogenesis. The use of further advanced diagnostic tools and superior treatment, potentially will help clinicians to manage AP at an appropriate stage. However, in view of the multi factorial disease and the complex clinical manifestations, the management of patients with AP is also remaining areas for improvement.

Evolution and results of the surgical management of 143 cases of severe acute pancreatitis in a referral centre

INTRODUCTION

Surgery is the accepted treatment for infected acute pancreatitis, although mortality remains high. As an alternative, a staged management has been proposed to improve results. Initial percutaneous drainage could allow surgery to be postponed, and improve postoperative results. Few centres in Spain have published their results of surgery for acute pancreatitis.

OBJECTIVE

To review the results obtained after surgical treatment of acute pancreatitis during a period of 12 years, focusing on postoperative mortality.

MATERIAL AND METHODS

We have reviewed the experience in the surgical treatment of severe acute pancreatitis (SAP) at Bellvitge University Hospital from 1999 to 2011. To analyse the results, 2 periods were considered, before and after 2005. A descriptive and analytical study of risk factors for postoperative mortality was performed

RESULTS

A total of 143 patients were operated on for SAP, and necrosectomy or debridement of pancreatic and/or peripancreatic necrosis was performed, or exploratory laparotomy in cases of massive intestinal ischemia. Postoperative mortality was 25%. Risk factors were advanced age (over 65 years), the presence of organ failure, sterility of the intraoperative simple, and early surgery (< 7 days). The only risk factor for mortality in the multivariant analysis was the time from the start of symptoms to surgery of<7 days; furthermore, 50% of these patients presented infection in one of the intraoperative cultures.

CONCLUSIONS

Pancreatic infection can appear at any moment in the evolution of the disease, even in early stages. Surgery for SAP has a high mortality rate, and its delay is a factor to be considered in order to improve results.

Moving beyond the 'pancreatic rest' in severe and critical acute pancreatitis

Nasojejunal tube feeding is considered the current standard of care in patients with severe and critical acute pancreatitis. However, it is not known whether enteral nutrition is best delivered into the jejunum. This Commentary discusses recent clinical studies that have shown that tube feeding into the stomach is safe and well tolerated in the vast majority of patients with acute pancreatitis, thus overthrowing the notion of putting the pancreas at rest. Development of a new conceptual framework is warranted to further advance nutritional management of patients with acute pancreatitis.