Pancreatitis aguda. Su manejo en Cuidados Intensivos
Contenido principal del artículo
Resumen
En los últimos años se han producido grandes cambios en el manejo de la pancreatitis aguda. Las razones son múltiples: conocemos en detalle la fisiopatología, existen más y mejores herramientas para tratar a los pacientes críticos en forma general, hay avances en cuanto al soporte nutricional, mayor conocimiento sobre la prevención y tratamiento de las infecciones pancreáticas, y sin dudas un cambio radical en las diferentes técnicas quirúrgicas.
El objetivo de este artículo es revisar dichas recomendaciones y actualizarlas, unificar criterios para el manejo integral de la pancreatitis aguda potencialmente grave que ingresa a los cuidados intensivos.
Han participado de la confección de este texto, médicos intensivistas y cirujanos expertos en el manejo de esta patología. Posteriormente dicho documento se ha discutido y consensuado en el grupo de Patologías digestivas Críticas de la Sociedad Argentina de Terapia Intensiva.
Detalles del artículo
La revista no retiene los derechos de reproducción (copyright) por lo que los autores pueden volver a publicar sus trabajos con la sola mención a la fuente original de publicación.
Citas
1. Cappell MS. Acute pancreatitis: etiology, clinical presentation, diagnosis, and therapy. Med Clin North Am. Jul 2008;92(4):889-923.
2. Van Woerkom RC, Adler DG. Acute pancreatitis: Contemporary Diagnosis and Management. J Clin Outcomes Manag. Jan 2012;19(1):13-26.
3. Cruz-Santamaria DM, Taxonera C, Giner M. Update on pathogenesis and clinical management of acute pancreatitis. World J Gastrointest Pathophysiol. Jun 15 2012;3(3):60-70.
4. Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus. Gut. Jan 2013;62(1):102-111.
5. Dellinger EP, Forsmark CE, Layer P, et al. Determinant-based classification of acute pancreatitis severity: an international multidisciplinary consultation. Ann Surg. Dec 2012;256(6):875-880.
6. De Waele JJ. Acute pancreatitis. Curr Opin Crit Care. Apr 2014;20(2):189-195.
7. Otsuki M, Takeda K, Matsuno S, et al. Criteria for the diagnosis and severity stratification of acute pancreatitis. World J Gastroenterol. Sep 21 2013;19(35):5798-5805.
8. Wu BU, Johannes RS, Sun X, Tabak Y, Conwell DL, Banks PA. The early prediction of mortality in acute pancreatitis: a large population-based study. Gut. Dec 2008;57(12):1698-1703.
9. Isenmann R, Rau B, Beger HG. Early severe acute pancreatitis: characteristics of a new subgroup. Pancreas. Apr 2001;22(3):274-278.
10. Ranson JH, Rifkind KM, Roses DF, Fink SD, Eng K, Localio SA. Objective early identification of severe acute pancreatitis. Am J Gastroenterol. Jun 1974;61(6):443-451.
11. Ranson JH, Rifkind KM, Roses DF, Fink SD, Eng K, Spencer FC. Prognostic signs and the role of operative management in acute pancreatitis. Surg Gynecol Obstet. Jul 1974;139(1):69-81.
12. Imrie CW, Benjamin IS, Ferguson JC, et al. A single-centre double-blind trial of Trasylol therapy in primary acute pancreatitis. Br J Surg. May 1978;65(5):337-341.
13. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med. Oct 1985;13(10):818-829.
14. Larvin M, McMahon MJ. APACHE-II score for assessment and monitoring of acute pancreatitis. Lancet. Jul 22 1989;2(8656):201-205.
15. Marshall JC, Cook DJ, Christou NV, Bernard GR, Sprung CL, Sibbald WJ. Multiple organ dysfunction score: a reliable descriptor of a complex clinical outcome. Crit Care Med. Oct 1995;23(10):1638-1652.
16. Vincent JL, Moreno R, Takala J, et al. The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. Intensive Care Med. Jul 1996;22(7):707-710.
17. Balthazar EJ, Ranson JH, Naidich DP, Megibow AJ, Caccavale R, Cooper MM. Acute pancreatitis: prognostic value of CT. Radiology. Sep 1985;156(3):767-772.
18. Mortele KJ, Wiesner W, Intriere L, et al. A modified CT severity index for evaluating acute pancreatitis: improved correlation with patient outcome. AJR Am J Roentgenol. Nov 2004;183(5):1261-1265.
19. Bollen TL, Singh VK, Maurer R, et al. A comparative evaluation of radiologic and clinical scoring systems in the early prediction of severity in acute pancreatitis. Am J Gastroenterol. Apr 2011;107(4):612-619.
20. Warndorf MG, Kurtzman JT, Bartel MJ, et al. Early fluid resuscitation reduces morbidity among patients with acute pancreatitis. Clin Gastroenterol Hepatol. Aug 2011;9(8):705-709.
21. de-Madaria E, Soler-Sala G, Sanchez-Paya J, et al. Influence of fluid therapy on the prognosis of acute pancreatitis: a prospective cohort study. Am J Gastroenterol. Oct 2011;106(10):1843-1850.
22. Gardner TB, Vege SS, Pearson RK, Chari ST. Fluid resuscitation in acute pancreatitis. Clin Gastroenterol Hepatol. Oct 2008;6(10):1070-1076.
23. Mao EQ, Fei J, Peng YB, Huang J, Tang YQ, Zhang SD. Rapid hemodilution is associated with increased sepsis and mortality among patients with severe acute pancreatitis. Chin Med J (Engl). Jul 2010;123(13):1639-1644.
24. IAP/APA evidence-based guidelines for the management of acute pancreatitis. Pancreatology. Jul-Aug 2013;13(4 Suppl 2):e1-15.
25. Petrov MS PR, Emelyanov NV. Systematic review: nutritional support in acute pacnreatitis. Alim Pharmacol Ther. 2008(28):704-712.
26. Gianotti L, Meier R, Lobo DN, et al. ESPEN Guidelines on Parenteral Nutrition: pancreas. Clin Nutr. Aug 2009;28(4):428-435.
27. McClave SA, Taylor BE, Martindale RG, et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr. Feb 2016;40(2):159-211.
28. Yi F GL, Zhao J e t al. Meta-analysis: total parenteral nutrition versus total enteral nutrition in predicted severe acute pancreatitis . Intern Med. 2012(51):523-530.
29. Li JY YT, Chen YH, Yuan YH, Zhong W, Zhao LN, Chen QK. Enteral nutrition within 48hs of admission imporves clinical outcomes of acute pacnretitis by reducing complicaction: a meta-analysis. PLOS one. 2013;8(6):1-12.
30. Sun JK MX, Li WQ, Tong ZH, Li J, Zheng SY. Effects of early enteral nutrition on immune function of severe acute pancreatitis patients. Gastroenterology. 2013;19:917-922.
31. O´keefe SJ LR, Li J, et al. Trypsin secretion and turnover in patients with acute pancreatitis. Am J Physiol Gastrointest Liver Physiol. 2005;289:G181-G187.
32. Chang YS FH, Xiao YM, Liu JC. Nasogastric or nasojejunal feeding in predicted severe acute pancreatitis: a meta-analysis. Critical Care. 2013;17(3):118-127.
33. Petrov MS LB, Pylypchuk RD, McIlroy K, Phillips AR, Windsor JA. Systematic review and meta-analysis of enteral nutrition formulations in acute pancreatitis. Br J Surg. 2009;96:1243-1242.
34. Mirtallo JM FA, McClave SA, Jensen GL, Waitzberg DL, Davies AR. International consensus guidelines for nutrition therapy in pancreatitis. JPEN J Parenter Enetral Nutr. 2012;36:284-291.
35. De Waele JJ. Use of antibiotics in severe acute pancreatitis. Expert Rev Anti Infect Ther. Mar 2010;8(3):317-324.
36. De Waele JJ. Rational use of antimicrobials in patients with severe acute pancreatitis. Semin Respir Crit Care Med. Apr 2011;32(2):174-180.
37. Tenner S, Baillie J, DeWitt J, Vege SS. American College of Gastroenterology guideline: management of acute pancreatitis. Am J Gastroenterol. Sep 2013;108(9):1400-1415; 1416.
38. De Waele JJ, Rello J, Anzueto A, et al. Infections and use of antibiotics in patients admitted for severe acute pancreatitis: data from the EPIC II study. Surg Infect (Larchmt). Aug 2014;15(4):394-398.
39. Cacopardo B, Pinzone M, Berretta S, et al. Localized and systemic bacterial infections in necrotizing pancreatitis submitted to surgical necrosectomy or percutaneous drainage of necrotic secretions. BMC Surg. 2013;13 Suppl 2:S50.
40. Xue P, Deng LH, Zhang ZD, et al. Effect of antibiotic prophylaxis on acute necrotizing pancreatitis: results of a randomized controlled trial. J Gastroenterol Hepatol. May 2009;24(5):736-742.
41. Tse F, Yuan Y, Leontiadis GI. The role of endoscopic retrograde cholangiopancreatography in acute pancreatitis. Am J Gastroenterol. Mar 2014;109(3):443-444.
42. Folsch UR, Nitsche R, Ludtke R, Hilgers RA, Creutzfeldt W. Early ERCP and papillotomy compared with conservative treatment for acute biliary pancreatitis. The German Study Group on Acute Biliary Pancreatitis. N Engl J Med. Jan 23 1997;336(4):237-242.
43. Neoptolemos JP, Carr-Locke DL, London NJ, Bailey IA, James D, Fossard DP. Controlled trial of urgent endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy versus conservative treatment for acute pancreatitis due to gallstones. Lancet. Oct 29 1988;2(8618):979-983.
44. Tse F, Yuan Y. Early routine endoscopic retrograde cholangiopancreatography strategy versus early conservative management strategy in acute gallstone pancreatitis. Cochrane Database Syst Rev. 2012;5:CD009779.
45. Petrov MS, Shanbhag S, Chakraborty M, Phillips AR, Windsor JA. Organ failure and infection of pancreatic necrosis as determinants of mortality in patients with acute pancreatitis. Gastroenterology. Sep 2010;139(3):813-820.
46. van Santvoort HC, Besselink MG, Bakker OJ, et al. A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med. Apr 22 2010;362(16):1491-1502.