Novi prognostički parametri u ranom prepoznavanju teških oblika akutnog pankreatitisa

Naumovski-Mihalić, Slavica (2011) Novi prognostički parametri u ranom prepoznavanju teških oblika akutnog pankreatitisa. PhD thesis, Sveučilište u Zagrebu.

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Abstract

OBJECTIVE: The objective of this study was to identify the minimum of prognostic parameters which may in patients with acute pancreatitis within 48 hours upon admission to the hospital be instrumental for the assessment of the course of the disease and early prediction of the adverse clinical outcome. PATIENTS AND METHODS: The study included 60 patients, aged 18-90 years (average age 57.77 years) who had been suffering from acute pancreatitis and had been treated at the Clinical Intensive Care Unit of the Department of Internal Medicine, University Hospital Merkur, Zagreb. The diagnosis of the disease was made based on the presence of acute abdominal pain and levels of serum amylase that were three or more times upper limit of normal. All patients had clinical examinations, central venous pressure and hourly diuresis measurement, and hemodynamic and respiratory status monitoring on a daily basis. In all patients, a number of diverse biochemistry parameters were monitored, and followed-up regularly on admission and at 24, 48 and 72 hours thereafter. Other examinations included ultrasonography (US) of the upper abdomen, contrast enhanced computer tomography (CECT) with establishing disease severity using the Balthazar score, chest radiography and electrocardiography (ECG). On admission, the patients were divided into two groups according to Ranson 's criteria: group consisting of 36 patients with mild acute pancreatitis and group of 24 patients with severe acute pancreatitis. The patients were further divided based on gender and etiology of the disease (biliary, alcoholic, or idiopathic pancreatitis). Statistical processing and analysis of all data collected for the description of the state of acute pancreatitis comprised a detailed definition of all variables used in the investigation. A series of hypotheses on possible influence of these variables on pancreatitis severity, according to the hospital mortality rate, necessity for emergency surgery, the length of treatment in intensive care, and development of complications, were tested. RESULTS: The evaluation performed has determined the minimum of biochemistry parameters, established as early as at the time of the patient's admission to the hospital, which correlate well with the severity of the clinical symptoms. These included: hyperglicemia (glucose > 11 mmol/L), hypertriglyceridemia (cholesterol on admission >3 mmol/L), and base excess in the arterial blood (>-4 mmol/L). The statistical significance of these parameters is at the level of significance of 95%. This study, in addition to the former biochemical parameters, has also yielded the unexpected results, those being some general clinical factors established as the predictors of the severe form of acute pancreatitis. These included: an increased central venous pressure (>12 cm H2O), and a diuresis lower than 500 Naumovski-Mihalić „Novi prognostički parametri u ranom prepoznavanju teških oblika akutnog pankreatitisa“ 107 ml/24 h of admission to the hospital. Moreover, we have found that the male gender accompanied by alcoholism as an aethiological factor is associated with a poorer subsequent clinical course of the disease. The authors termed the combination of general clinical and biochemistry parameters mentioned above „INTENSIVE SCORE“ of the early prediction of the severe form of acute pancreatitis. The APACHE II (Acute Physiology and Chronic Health Evaluation) score >8 at admission is also an indicator of the adverse outcome; however, as it is based on 13 parameters, and the objective of this study was to establish the lowest possible number of predictive factors, this system has not been considered as an indicator reliable enough to be used. In this study, the results of imaging methods in the first 48 hours failed to demonstrate ability to reliably predict the poor outcome. CONCLUSION: Based on the clinical and biochemistry parameters mentioned above and the proposed „INTENSIVE SCORE“, it is possible to detect in a timely manner the forms of severe acute pancreatitis which require treatment and monitoring in the intensive care unit, and in those cases to indicate the early need for a more aggressive medical or surgical treatment.

Abstract in Croatian

CILJ RADA: Cilj ovog rada bio je u bolesnika s akutnim pankreatitisom utvrditi najmanji broj prognostičkih parametara kojima bi se u roku od 48 sati po prijemu bolesnika na Kliniku, mogao utvrditi tijek bolesti i pravovremeno prepoznati loš ishod bolesti. PACIJENTI I METODE: Ovim je radom obuhvaćena grupa od 60 bolesnika u dobi od 18-90 godina (prosječna dob bila je 57,77 godina), koji su bolovali od akutnog pankreatitisa i bili liječeni u Kliničkoj Jedinici za intenzivnu medicinu Interne Klinike KB Merkur u Zagrebu. Dijagnoza bolesti postavljena je temeljem akutne boli u abdomenu te povišenjem amilaze u serumu 3x više od normalnih vrijednosti. Kod svih liječenih bolesnika, svakodnevno se je uz klinički pregled mjerio centralni venski tlak, satna diureza te vršio hemodinamski i respiratorni nadzor. U svih bolesnika pratili su se brojni biokemijski parametri, koji su redovito kontrolirani pri prijemu, nakon 24, 48 i 72 sata. Od ostalih pretraga kontrolirani su UZV gornjeg abdomena, CT s kontrastom s određivanjem Balthazar bodovnog skora, RTG pluća i srca i EKG. Bolesnici su pri prijemu prema Ransonovim parametrima podijeljeni u dvije grupe: grupu od 36 bolesnika s lakim akutnim pankreatitisom i grupom od 24 bolesnika s teškim akutnim pankreatitisom. Nadalje, podijeljeni su po spolu i etiologiji bolesti (bilijarni pankreatitis, alkoholni pankreatitis i idiopatski ). Statistička obrada i analiza svih prikupljenih podataka za opis statusa akutnog pankreatitisa sastojala se je od temeljnog opisa svih u istraživanju korištenih varijabli. Testirano je niz hipoteza o mogućem utjecaju tih varijabli na težinu pankreatitisa, prema stopi bolničke smrtnosti, potrebi za hitnim kirurškim liječenjem, dužini liječenja u JIL-u i razvoju komplikacija. REZULTATI: učinjenom obradom utvrđen je najmanji broj biokemijskih parametara, utvrđenih već pri prijemu bolesnika, a koji dobro koreliraju s težinom kliničke slike. To su bili: hipeglikemija (GUK>11mmol/L, hipertrigliceridemija (kolesterol pri prijemu >3mmol/L) te višak baza u arterijskoj krvi (> - 4 mmol/L). Statistička značajnost ovih prametara je na razini signifikantnosti od 95%. Uz navedene biokemijske parametre, ova studija pokazala je i neočekivane rezultate a to su utvrđeni neki opći klinički pokazatelji kao prediktori teškog oblika akutnog pankreatitisa. To su bili: visoki CVT pri prijemu (>12cmH20) te diureza manja od 500 ml 24 sati po prijemu bolesnika na Kliniku. Također smo ustanovili da je muški spol udružen s alkoholizmom kao etiološkim čimbenikom imao kasniji lošiji tijek bolesti. Kombinaciju navedenih općih kliničkih i biokemijskih parametara nazvali smo „INTENZIVNIM SKOROM“ rane predikcije teškog oblika akutnog pankreatitisa. Naumovski-Mihalić „Novi prognostički parametri u ranom prepoznavanju teških oblika akutnog pankreatitisa“ 104 Apache II skor >8 bodova pri prijemu je također prediktor lošeg ishoda, ali kako se on sastoji od 13 parametara, a cilj ove studije bio je utvrđivanje što manjeg broja pokazatelja, to nije razmatran kao dovoljno pouzdan pokazatelj. U ovoj studiji nalazi slikovnih metoda u prvih 48 sati nisu bili pouzdani rani prediktori lošeg ishoda. ZAKLJUČAK: Na osnovi iznijetih kliničkih i biokemijskih parametara i predloženog „INTENZIVNOG SKORA“, moguće je pravovremeno otkriti one teške oblike akutnog pankratitisa koje je potrebno liječiti i pratiti u jedinicama intenzivne skrbi, te u njih pravovremeno odrediti potrebu za agresivnijim internističkim ili kirurškim liječenjem.

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