This document summarizes a retrospective study of 85 patients with severe acute pancreatitis treated with continuous venovenous hemofiltration (CVVH) and drainage of necrosis fluid under imaging guidance. The study found that intra-abdominal pressure (IAP) directly correlated with organ failure, mortality, and treatment duration and costs. Patients with higher IAP grades had longer CVVH duration, more filter changes, and longer drainage times. IAP values correlated with Sequential Organ Failure Assessment (SOFA) scores and mortality rates. The combination of CVVH and drainage reduced mortality significantly compared to previous studies using early surgery alone.

1. Experience in Treatment for
Severe Acute Pancreatitis
Dao Xuan Co, MD,PHD
ICU, Bach Mai hospital
Hanoi, Vietnam

2. Background
 Acute pancreatitis (AP) is a common cause
for hospitalization, with severe cases
requiring ICU level monitoring and resulting in
a substantial mortality.
 Acute necrotizing pancreatitis accounts for
10-15% of all cases of AP. It is frequently
accompanied by a SIRS and MOFS and
occasion ally by infected necrosis.

3. Background
 The mainstay of treatment of patients with
acute necrotizing pancreatitis traditionally has
been surgical débridement (VIETNAM).
 Mortality among patients undergoing early
surgery is high, varying between 21% and
42% (VN 52 %).

4. Am J Respir Crit Care Med,
http://www.atsjournals.org/doi/abs/10.1164/ajrccm.164.1.2008026
Pathophysiology of acute pancreatitis

5. Background
 Intra-abdominal pressures (IAP) has been studied by many
researchers and physicians and noted to have correlation with
acute pancreatitis.
 Studies have shown a direct correlation between elevated IAP
and higher rates of complications, mortality, duration of
treatment and cost of hospital stay in acute pancreatitis.
 Early CVVH can improve vascular permeability through
elimination of cytokines such as TNF-α, and thereby decrease
interstitial edema to lower IAP and should be applied in the
early stages of ACS.
 Intensivist-performed bedside drainage of free intraperitoneal
fluid or blood (percutaneous catheter decompression [PCD])
has been advocated as a less-invasive alternative to open
abdominal decompression (OAD for………… ).

6. Subjects and Methods
 Retrospective study conducted in 85 severe acute
pancreatitis patients in ICU of Bach Mai Hospital.
(APACHE II score is 13±3.85):
 A total of 85 SAP patients were treated with conventional
protocol combinned with CVVH and drainged necrosis
fluid under ECHO or CT guide:
 CVVH was started 35 ± 25.5 hours after onset of the
disease, AN69 hemofilter was changed every 12-24
hours. The ultrafiltration rate during HVHF was 45ml /kg,
blood flow rate was 200-250 ml/min and the substitute
fluid was infused with 50% pre-dilution. Low molecular
weight heparin was used for anticoagulation.

7. RESULT

8. index  SD (n = 85) Min Max
Age 43,5  16,5 23 75
SIRS 2,8  0,8 2 4
Ranson 6,5  2,5 3 11
APACHEII 13±3.85 8 28
Imrie 4,5  2,8 3 8
CTSI 7,5  3,7 7 11
SOFA 8,2  4,5 5 20
Number of failed organ 2,8  2,5 1 6
IAP(cmH2O) 23,2  4,8 17 38
X
Nguyễn Quang Hải, De Waele
Clinical parameters of patients

9. IAP Classifications based on World Society
of the Abdominal Compartment Syndrome
Grade (n) Rate %
I 15 17,6
II 30 35,3
III 30 35,3
IV 10 11,8
Total 85 100

10. Amount of fluid tranfusion for patient during first 24 hour
(CVP 12-16 cm H2O and/ urine amount ≥ 0,5ml/kg/h)
Amount of fluid
IAP grade
X  SD (ml)
I (16 – 20 cm H2O)
n = 15
3.125 ± 756
II (21 – 27 cm H2O)
n = 30
3.950 ± 785
III (28 -34 cm H2O)
n = 30
5.450 ± 2.475
IV (> 35 cm H2O)
n = 10
5.850 ± 2.355
Balogh (2003), Malbrain (2005), Paugherty (2007), Vidal (2008)

11. Ventilation
Mode
IAP grade
Noninvasive
(n, %)
Invasive
(n, %) (%)
I
(n=15)
1
6,6
0
0
6,6
II
(n=30)
4
13,3
1
3,3
16,6
III
(n=30)
10
33,3
5
16,6
50
IV
(n=10)
1
10,0
9
90,0
100
Bùi Văn Khích (71%)

12. Time of total enteral nutrition related to IAP Grade
IAP Grade
Time of total enteral
nutrition X  SD (hour)
I (n=15) 30,6 ± 16,4
II (n=30) 36,6 ± 17,8
III (n=30) 52,5 ± 15,7
IV (n=10) 65,5 ± 24,5
Bùi Văn Khích 2004 (5-10 ngày)

13. CVVH
IAP Grade
Duration of CVVH
(X  SD) (hour)
Number of
membrane filter
(X  SD)
I (n=15) 28 ± 14,5 1,5 ± 0,5
II (n=30) 45 ± 18,6 2,4 ± 1,2
III (n=30) 45 ± 28,5 3,5 ± 1,4
IV (n=10) 96 ± 38,5 5,5 ± 2,5
Vũ Đức Định, De Waele, Nguyễn Gia Bình
Characteristics of CVVH related to IAP Grade

14. Characteristics of free fluid drained
IAP Grade
Volume of
fluid drained
per catheter
(X  SD) (ml)
Positive fluid
culture (n, %)
Catheterization
( X SD) (days)
I
(n=5)
653±352
2
02 Ecoli
3,5 ± 2,3
II
(n=20)
865±656
5
3 Ecoli
2 Enterococcus
5,2 ± 3,5
III
(n=30)
2.553±755
5
3 Ecoli
2 Enterococcus
10,5 ± 3,8
IV
(n=10)
2.853±456
4
3 Ecoli
1 Enterococcus
12,3 ± 8,5
overoll 1.564±583
19
(32,8)
8,2 ± 6,7

15. IAP values in survived vs non-survived
patients

16. SOFA scores in survived vs non-survived
patients

17. Correlection between IAP and SOFA score
y = 1,04x + 13,58 ; r = 0,81 ; p = 0,001
0
5
10
15
20
25
30
35
0 5 10 15 20
SOFA
ALOB(cmH2O)
Paivi Keskinen
IAP

18. Survived vs non-survived patients between WSACS
grading classifications
0
10
20
30
40
50
60
70
80
90
100
Grade I (n=15) Grade II (n=30) Grade III (n=30) Grade IV (n=10)
100 100
90
50
0 0
10
50
%
Surived Non- suriverd

19. Mortality rate
Mortality rate
Number of organ failure
(n), (%)
1 organ failure (n =41 ) 0
2 organ failure (n = 23) 1(4,3%)
3 - 4 organ failure (n = 17) 2 (11,8%)
5 - 6 organ failure (n = 8) 4(62,5%)
Overall mortality
(n = 85)
8 (14,5%)
Paivi Keskinen, De Waele, Sun ZX, Nguyễn Quang Hải

20. Clinical case
32cmH2O

24. Conclutions
 Combine CVVH + tapping and draining the
fluid collection: Reduce significant mortality.
 IAP values when recorded throughout
hospitalization during the first 7 days
correlate with SOFA scores and mortality
rates and can be used as a marker to
guideline for treament, monitor the course of
illness in acute pancreatitis.

25. Thank you !