hồi sức

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 !