Patients with severe acute pancreatitis should be more often treated in an Intensive Care Department

Abstract

Background: Acute pancreatitis (AP) is a serious disease with a frustrating mortality rate, but with a very good quality of life reported among survivors, that justifies an optimised allocation of therapy intensity.

Purpose: To audit monitoring and treatment of severe AP in our Intensive Care Department based upon Atlanta severity classification and following recommendations.

Methods: Retrospective study of all AP admitted to our ICU between 1st January, 1993 and 31st December, 1999 in a tertiary University Hospital in Northern Portugal.

Results: Our sample (n = 44) represents less than 1% of all patients observed in our ICU and approximately 3% of all patients with AP admitted to our Hospital between 1993 and 1999. All cases fulfilled at least one Atlanta criteria of severe AP. Mean length of stay was 11.6 days. Diagnosis of AP was established in less than 48 hours in 86% of cases: amylasemia and lypasemia were determined in 84 and 7%, respectively and 64% of cases were submitted to ultrasonography. The median time between diagnosis and ICU admission was 2 days. Biliary calculus was responsible for 38% of cases and ethanol for 14%: Thirty-six per cent were considered idiopathic (in none was ERCP performed). Concerning local complications, necrosis was diagnosed in 56% and pseudocysts or abscesses in 23%. Infection was diagnosed by US/CT guided punction or by the presence of gas in CT (performed in 83% during the first ten days of disease) in 18% of the cases. 68% were put on parenteral nutrition (beginning on the 2nd day after admission to ICU in 50% of patients); and 51% had enteric feeding (median day of start = 8.5 days). Antibiotics were prescribed in 91%. Forty-five per cent of patients were submitted to surgery (median day of surgery was 6 days). No statistically significant differences were found concerning local or systemic complications according to different therapies. Mortality rate in our ICU was 36%, mostly during first and second weeks. Patients admitted to ICU later than the second day after diagnosis seem to die earlier (P < 0.005). Outcome (death) was statistically related with organ dysfunction criteria, namely Atlanta criteria (renal failure), SOFA and proportion of days with organ dysfunction.

Conclusions: In our Institution (a tertiary hospital) AP diagnosis is quickly made, local and systemic complications are clearly diagnosed and monitored, but at least 50% of patient waited for 2 days until ICU admission, representing those who die earlier.