Darvas Katalin, Futó Judit, Okrös Ilona, Gondos Tibor, Csomós Akos, Kupcsulik Péter
Semmelweis Egyetem, Altalános Orvostudományi Kar I. Sebészeti Klinika, Budapest.
Orv Hetil. 2008 Nov 23;149(47):2211-20. doi: 10.1556/OH.2008.28482.
Acute pancreatitis is a dynamic, often progressive disease; 14-20% require intensive care in its severe form due to multiorgan dysfunction and/or failure. This review was created using systematic literature review of articles published on this subject in the last 5 years. The outcome of severe acute pancreatitis is determined by the inflammatory response and multiorgan dysfunction - the prognostic scores (Acute Physiology and Chronic Health Evaluation, Glasgow Prognostic Index, Sepsis-related Organ Failure Assessment, Multi Organ Dysfunction Syndrome Scale, Ranson Scale) can be used to determine outcome. Clinical signs (age, coexisting diseases, confusion, obesity) and biochemistry values (serum amylase, lipase, C-reactive protein, procalcitonin, creatinine, urea, calcium) have important prognostic roles as well. Early organ failure increases the risk of late abdominal complications and mortality. Intensive care can provide appropriate multi-function patient monitoring which helps in early recognition of complications and appropriate target-controlled treatment. Treatment of severe acute pancreatitis aims at reducing systemic inflammatory response and multiorgan dysfunction and, on the other side, at increasing the anti-inflammatory response. Oral starvation for 24-48 hours is effective in reducing the exocrine activity of the pancreas; the efficacy of protease inhibitors is questionable. Early intravascular volume resuscitation and stable haemodynamics improve microcirculation. Early oxygen therapy and mechanical ventilation provide adequate oxygenation. Electrolyte and acid-base control can be as important as tight glucose control. Adequate pain relief can be achieved by thoracic epidural catheterization. Early enteral nutrition with immunonutrition should be used. There is evidence that affecting the coagulation cascade by activated protein C can play a role in reducing the inflammatory response. The complex therapy of acute pancreatitis includes appropriate antibiotics, thrombo-embolic prophylaxis and in certain cases plasmapheresis and/or haemofiltration. Reducing intraabdominal pressure may be necessary in the acute phase. Intensive care multidisciplinary teamwork can reduce the mortality of severe acute pancreatitis from 30% to 10%.
急性胰腺炎是一种动态的、通常呈进行性发展的疾病；14% - 20%的重症患者由于多器官功能障碍和/或衰竭需要重症监护。本综述通过对过去5年发表的关于该主题的文章进行系统文献回顾而撰写。重症急性胰腺炎的预后取决于炎症反应和多器官功能障碍，预后评分（急性生理与慢性健康状况评估、格拉斯哥预后指数、脓毒症相关器官功能衰竭评估、多器官功能障碍综合征量表、兰森评分）可用于判断预后。临床体征（年龄、并存疾病、意识障碍、肥胖）和生化指标（血清淀粉酶、脂肪酶、C反应蛋白、降钙素原、肌酐、尿素、钙）也具有重要的预后作用。早期器官功能衰竭会增加后期腹部并发症和死亡风险。重症监护可提供适当的多功能患者监测，有助于早期识别并发症并进行适当的目标导向治疗。重症急性胰腺炎的治疗旨在减轻全身炎症反应和多器官功能障碍，另一方面增强抗炎反应。禁食24 - 48小时可有效降低胰腺外分泌活动；蛋白酶抑制剂的疗效存疑。早期血管内容量复苏和稳定的血流动力学可改善微循环。早期氧疗和机械通气可提供充足的氧合。电解质和酸碱平衡控制与严格的血糖控制同样重要。通过胸段硬膜外导管置入可实现充分的疼痛缓解。应采用早期肠内营养并添加免疫营养。有证据表明，活化蛋白C影响凝血级联反应可能在减轻炎症反应中发挥作用。急性胰腺炎的综合治疗包括使用适当的抗生素、血栓栓塞预防，在某些情况下还包括血浆置换和/或血液滤过。急性期可能需要降低腹内压。重症监护多学科团队协作可将重症急性胰腺炎的死亡率从30%降至10%。
