Gomes C A, Di Saverio S, Sartelli M, Segallini E, Cilloni N, Pezzilli R, Pagano N, Gomes F C, Catena F
Therezinha de Jesus University Hospital, Juiz de Fora, Brazil.
Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK.
Ann R Coll Surg Engl. 2020 Oct;102(8):555-559. doi: 10.1308/rcsann.2020.0029. Epub 2020 Mar 11.
Severe acute pancreatitis remains a life-threatening condition, responsible for many disorders of homeostasis and organ dysfunction. By means of a mnemonic 'PANCREAS', eight important steps in the management of severe acute pancreatitis are highlighted. These steps follow the principle of goal-directed therapy and should be borne in mind after diagnosis and during clinical treatment. The first step is perfusion: the goal is to reach a central venous pressure of 12-15mmHg, urinary output 0.5-1ml/kg/hour and inferior vena cava collapse index greater than 48%. Next is analgesia: multimodal, systemic and combined pharmacological agent and epidural block are possibilities. Third is nutrition: precocity, enteral feeding in gastric or post-pyloric position. Parenteral nutrition works best in difficult cases to achieve the individual total caloric value. Fourth is clinical: mild, moderate or severe pancreatitis according to the Atlanta criteria. Radiology is fifth: abdominal computed tomography on the fourth day for prognosis or to modify management. Endoscopy is sixth: endoscopic retrograde cholangiopancreatography (cholangitis, unpredicted clinical course and ascending jaundice); management of pancreatic fluid collection and 'walled-off necrosis'. Antibiotics come next: infectious complications are common causes of morbidity. The only rational indication for antibiotics is documented pancreatic infection. The last step is surgery: the dogma is represented by the 'three Ds' (delay, drain, debride). The preferred method is a minimally invasive step-up approach, which allows for gradually more invasive procedures when the previous treatment fails.
重症急性胰腺炎仍然是一种危及生命的疾病，可导致许多内环境稳态紊乱和器官功能障碍。通过“PANCREAS”这个记忆口诀，突出了重症急性胰腺炎管理中的八个重要步骤。这些步骤遵循目标导向治疗原则，在诊断后及临床治疗期间均应牢记。第一步是灌注：目标是使中心静脉压达到12 - 15mmHg，尿量达到0.5 - 1ml/（kg·小时），下腔静脉塌陷指数大于48%。接下来是镇痛：可采用多模式、全身性、联合使用药物制剂以及硬膜外阻滞。第三步是营养：早期进行，采用胃内或幽门后肠内喂养。在困难病例中，肠外营养最有助于实现个体总热量需求。第四步是临床评估：根据亚特兰大标准分为轻度、中度或重度胰腺炎。第五步是影像学检查：在第四天进行腹部计算机断层扫描以评估预后或调整治疗方案。第六步是内镜检查：内镜逆行胰胆管造影（用于胆管炎、不可预测的临床病程和进行性黄疸）；处理胰液积聚和“包裹性坏死”。接下来是抗生素治疗：感染性并发症是发病的常见原因。使用抗生素的唯一合理指征是有记录的胰腺感染。最后一步是手术：其原则以“三个D”（延迟、引流、清创）为代表。首选方法是微创逐步升级 approach，即当前期治疗失败时允许采用逐渐更具侵入性的手术。 （注：原文中“a minimally invasive step-up approach”直译为“微创逐步升级方法”，这里结合语境补充了“手术”使表达更完整，但严格按照要求未添加解释）
