Page 1495 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

1034 PART 9: Gastrointestinal Disorders

should be utilized (see Chap. 34 on “Judging the Adequacy of Fluid not been shown to be beneficial. In patients who cannot tolerate gastric
Resuscitation”) and fluid resuscitation should begin early in the course feeding due to large fluid collections causing gastric compression or
of management. A large single center retrospective study showed that duodenal obstruction, nasojejunal tube placement is usually needed.
(receiving more than one-third of total 72-hour fluid volume within first ■ ROLE OF PROPHYLACTIC ANTIBIOTICS
those patients with acute pancreatitis who received early resuscitation
24 hours of presentation) had significantly lower incidence of SIRS, organ Approximately one-fourth of patients with acute pancreatitis develop
failure, admission to intensive care unit, and a reduced length of stay infectious complications and those with severe acute pancreatitis are at
compared to those with late resuscitation (receiving less than one-third particularly high risk. Patients with infected pancreatic necrosis have a
of total 72 hours fluid volume within first 24 hours). 29 mortality of around 30% (Fig. 108-3). The use of prophylactic antibiot-
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A general approach is to start with a 1000- to 2000-mL crystalloid ics was common in the early 2000s in patients with severe acute pancre-
fluid bolus followed by fluid resuscitation at a rate of 250 to 300 mL/h for atitis. Multiple studies and a recently published Cochrane meta-analysis
1000 to 3000 mL, to target a urine output of at least 0.5 mL/kg per hour. have shown that the use of prophylactic antibiotics is not associated
However, one should utilize the tools outlined in Chap. 34 to judge the with decreased incidence of infected pancreatic necrosis, mortality, or
adequacy of fluid resuscitation rather than following an exact recipe. Some need for surgical interventions, 37-39 even though a decreased incidence
patients with cardiopulmonary disease, particularly those with ARDS, of infection in pancreatic necrosis and a trend toward lower mortality
may progress to respiratory failure and require endotracheal intubation. were noted in patients receiving imipenem. However, all patients with
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■ NUTRITION IN ACUTE PANCREATITIS severe acute pancreatitis requiring critical care should be monitored
closely for development of any signs of sepsis or infection, since delay
The nutritional therapy in acute pancreatitis has significantly evolved in starting antibiotic therapy has been shown to be associated with
from the concept of “pancreas rest” to efforts directed at early resump- declining survival. Hence, recent guidelines from American College of
tion of enteral nutrition with an aim to maintain the gut integrity and Gastroenterology published in 2013 suggest that when an infection is
prevent bacterial translocation and associated complications. Enteral suspected, it is justifiable to start empiric antibiotics covering both gram,
nutrition should be initiated as soon as possible. It is safe in patients with negative and gram-positive organisms; antibiotics should be discontin-
acute pancreatitis and it has been shown to be associated with lower rates ued if cultures are negative and no definite source is identified. 33
Until recently, the general practice was to
of systemic infections, multiorgan failure, and mortality in comparison ■
to parenteral nutrition. 30,31 ROLE OF ERCP IN ACUTE PANCREATITIS
avoid oral intake until resolution of abdominal pain; however, patients The role of endoscopic retrograde cholangiopancreatography in ERCP
with mild acute pancreatitis can be fed as soon as they are hungry, with- in management of acute pancreatitis is limited to patients with acute
out any restriction on the consistency of food. A low fat solid diet seems gallstone pancreatitis with cholangitis and those with pancreatic
to be as safe as clear liquid diet. Nutritional support is often needed in duct disruption. Patients with acute pancreatitis and biliary sepsis
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patients with moderately severe and severe acute pancreatitis and should (cholangitis) should have ERCP performed within 24 hours of admis-
be started within 24 to 48 hours of initial presentation, especially when it sion since it has been shown to be associated with decreased morbidity
is likely that the patient will be unable to start oral intake within the next and mortality. 41,42 The beneficial role of ERCP in patients with gallstone
5 to 7 days. As noted above, enteral nutrition is preferred over parenteral pancreatitis without cholangitis is not clear. A large multicenter study
nutrition. Multiple studies and meta-analyses have shown that parental and a recent meta-analysis involving 717 patients have both shown that
nutrition is associated with vascular catheter-related complications and there is no beneficial role for early ERCP in acute pancreatitis patients
infections, while enteral nutrition appears to help maintain gut mucosal with severe acute biliary pancreatitis without biliary sepsis. 43,44
integrity and hence decrease bacterial translocation; 30,31,33 it is associated When acute pancreatitis is mild interstitial, and biliary in origin, it
with decreases in infections, organ failure, and length of stay. There has is favorable to proceed with cholecystectomy prior to discharging the
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been significant debate regarding nasogastric versus nasojejunal feeding patient home. With moderate or severe biliary pancreatitis, it is favored
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in these patients but no data are currently available to strongly favor any to wait and re-image a month after the episode to assure that no fluid
one approach over the other. Though traditionally nasojejunal feedings collections are present; if so, the gallbladder can be removed and the
have been preferred in patients with acute pancreatitis, nasogastric tube fluid collection treated, both during the same surgery. ERCP with bili-
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feeding has been shown to as safe as the jejunal feeding. 31,35,36 Aspiration ary sphincterotomy should be performed to protect the pancreas against
precautions, including elevation of head end of bed, should be applied another attack of pancreatitis while waiting for the cholecystectomy or
in all patients. Checking gastric residuals to guide gastric feeding has in those patients who are poor candidates for cholecystectomy. 47

Liver Liver
Stomach Stomach

FIGURE 108-3. A 34-year-old man with a history biliary pancreatitis with epigastric abdominal pain and new onset of fever and chills 48 hours prior to admission. CT Scan reveals walled
off necrosis (WON) in the tail of the pancreas area with air (white arrow). This finding and associated symptoms are diagnostic of infected WON.

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