Nathens Avery B, Curtis J Randall, Beale Richard J, Cook Deborah J, Moreno Rui P, Romand Jacques-Andre, Skerrett Shawn J, Stapleton Renee D, Ware Lorraine B, Waldmann Carl S
University of Washington, Seattle, WA, USA.
Crit Care Med. 2004 Dec;32(12):2524-36. doi: 10.1097/01.ccm.0000148222.09869.92.
Acute pancreatitis represents a spectrum of disease ranging from a mild, self-limited course requiring only brief hospitalization to a rapidly progressive, fulminant illness resulting in the multiple organ dysfunction syndrome (MODS), with or without accompanying sepsis. The goal of this consensus statement is to provide recommendations regarding the management of the critically ill patient with severe acute pancreatitis (SAP).
An international consensus conference was held in April 2004 to develop recommendations for the management of the critically ill patient with SAP. Evidence-based recommendations were developed by a jury of ten persons representing surgery, internal medicine, and critical care after conferring with experts and reviewing the pertinent literature to address specific questions concerning the management of patients with severe acute pancreatitis.
There were a total of 23 recommendations developed to provide guidance to critical care clinicians caring for the patient with SAP. Topics addressed were as follows. 1) When should the patient admitted with acute pancreatitis be monitored in an ICU or stepdown unit? 2) Should patients with severe acute pancreatitis receive prophylactic antibiotics? 3) What is the optimal mode and timing of nutritional support for the patient with SAP? 4) What are the indications for surgery in acute pancreatitis, what is the optimal timing for intervention, and what are the roles for less invasive approaches including percutaneous drainage and laparoscopy? 5) Under what circumstances should patients with gallstone pancreatitis undergo interventions for clearance of the bile duct? 6) Is there a role for therapy targeting the inflammatory response in the patient with SAP? Some of the recommendations included a recommendation against the routine use of prophylactic systemic antibacterial or antifungal agents in patients with necrotizing pancreatitis. The jury also recommended against pancreatic debridement or drainage for sterile necrosis, limiting debridement or drainage to those with infected pancreatic necrosis and/or abscess confirmed by radiologic evidence of gas or results or fine needle aspirate. Furthermore, the jury recommended that whenever possible, operative necrosectomy and/or drainage be delayed at least 2-3 wk to allow for demarcation of the necrotic pancreas.
This consensus statement provides 23 different recommendations concerning the management of patients with SAP. These recommendations differ in several ways from previous recommendations because of the release of recent data concerning the management of these patients and also because of the focus on the critically ill patient. There are a number of important questions that could not be answered using an evidence-based approach, and areas in need of further research were identified.
急性胰腺炎是一种疾病谱，范围从仅需短暂住院治疗的轻度自限性病程到迅速进展的暴发性疾病，可导致多器官功能障碍综合征（MODS），伴或不伴有脓毒症。本共识声明的目的是提供关于重症急性胰腺炎（SAP）危重患者管理的建议。
2004年4月召开了一次国际共识会议，以制定SAP危重患者管理的建议。由代表外科、内科和重症监护的10人评审团在与专家协商并查阅相关文献后，针对重症急性胰腺炎患者管理的具体问题制定了基于证据的建议。
共制定了23条建议，为护理SAP患者的重症监护临床医生提供指导。涉及的主题如下。1）急性胰腺炎入院患者何时应在重症监护病房（ICU）或降级病房进行监测？2）重症急性胰腺炎患者是否应接受预防性抗生素治疗？3）SAP患者营养支持的最佳方式和时机是什么？4）急性胰腺炎手术的指征是什么，最佳干预时机是什么，包括经皮引流和腹腔镜检查在内的微创方法的作用是什么？5）在何种情况下胆石性胰腺炎患者应接受胆管清除干预？6）针对SAP患者的炎症反应进行治疗是否有作用？一些建议包括反对在坏死性胰腺炎患者中常规使用预防性全身抗菌或抗真菌药物。评审团还建议对于无菌性坏死不进行胰周清创或引流，仅对经气体影像学证据或细针穿刺结果证实有感染性胰腺坏死和/或脓肿的患者进行清创或引流。此外，评审团建议只要有可能，手术清创和/或引流应至少推迟2 - 3周，以便坏死胰腺分界。
本共识声明提供了23条关于SAP患者管理的不同建议。由于有关这些患者管理的最新数据发布，以及对危重患者的关注，这些建议在几个方面与以前的建议不同。有许多重要问题无法通过基于证据的方法回答，并且确定了需要进一步研究的领域。
