How to deal with severe acute pancreatitis in seriously ill patients
PURPOSE OF THE REVIEW:
A review of recent literature on the management of severe acute pancreatitis (SAP) admitted to ICU.
SAP is a devastating disease associated with high morbidity and mortality. Recent data confirm adequate risk assessment and prediction of severity (including monitoring of intra-abdominal pressure), individual fluid administration in favor of balanced crystalloids, refusal of prophylactic antibiotic therapy, and early detection and treatment of extrapancreatic and fungal infections.
Urgent (within 24−48 hours after diagnosis) endoscopic retrograde cholangiopancreatography is indicated when there is a permanent biliary obstruction or cholangitis. Corticosteroid therapy (mainly dexamethasone) can reduce the need for surgical interventions, length of stay in hospital and mortality. Peritoneal lavage can significantly reduce morbidity and mortality. Hemofiltration can be of significant benefit, but more research is needed to prove its effectiveness.
Enteral feeding is recommended using a polymeric formula that is introduced at an early stage through a nasogastric tube, but does not provide any advantages for survival compared with parenteral nutrition. Probiotics may be helpful, but clear recommendations cannot be made.
SAP management is multimodal with an emphasis on monitoring, adequate fluid resuscitation, avoiding the prophylactic use of antibiotics, cause-and-effect procedures or treatment, and organ support. There is a role for early enteral nutrition, including probiotics.
De Waele E, Malbrain MLNG, Spapen HD
CurrOpinCrit Care. 2019 Apr; 25 (2): 150−156