Improved Outcome of Severe Acute Pancreatitis in the Intensive Care Unit

Hindawi Publishing Corporation Critical Care Research and Practice Volume 2013, Article ID 897107, 5 pages http://dx.doi.org/10.1155/2013/897107 Research Article Improved Outcome of Severe Acute Pancreatitis in the Intensive Care Unit Polychronis Pavlidis,1 Siobhan Crichton,2 Joanna Lemmich Smith,1 David Morrison,3 Simon Atkinson,3 Duncan Wyncoll,1 and Marlies Ostermann1 1 Department of Critical Care, Guy’s and St. Thomas’ NHS Foundation Trust, King’s College London, London SE1 7EH, UK Division of Health and Social Care Research, King’s College London, London SE1 3QD, UK 3 Department of Abdominal Surgery, Guy’s and St. Thomas’ NHS Foundation Trust, King’s College London, London SE1 7EH, UK 2 Correspondence should be addressed to Marlies Ostermann; Received 1 November 2012; Accepted 28 January 2013 Academic Editor: Stephen M. Pastores Copyright © 2013 Polychronis Pavlidis et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background. Severe acute pancreatitis (SAP) is associated with serious morbidity and mortality. Our objective was to describe the case mix, management, and outcome of patients with SAP receiving modern critical care in the Intensive Care Unit (ICU). Methods. Retrospective analysis of patients with SAP admitted to the ICU in a single tertiary care centre in the UK between January 2005 and December 2010. Results. Fifty SAP patients were admitted to ICU (62% male, mean age 51.7 (SD 14.8)). The most common aetiologies were alcohol (40%) and gallstones (30%). On admission to ICU, the median Acute Physiology and Chronic Health Evaluation (APACHE) II score was 17, the pancreatitis outcome prediction score was 8, and the median Computed Tomography Severity Index (CTSI) was 4. Forty patients (80%) tolerated enteral nutrition, and 46% received antibiotics for non-SAP reasons. Acute kidney injury was significantly more common among hospital nonsurvivors compared to survivors (100% versus 42%, 𝑃 = 0.0001). ICU mortality and hospital mortality were 16% and 20%, respectively, and median lengths of stay in ICU and hospital were 13.5 and 30 days, respectively. Among hospital survivors, 27.5% developed diabetes mellitus and 5% needed long-term renal replacement therapy. Conclusions. The outcome of patients with SAP in ICU was better than previously reported but associated with a resource demanding hospital stay and long-term morbidity. 1. Introduction Acute pancreatitis affects 22.4 people per 100 000 of the general UK population per annum [1]. The incidence has risen by 46% over the last three decades with an epidemiological trend towards younger, female patients and alcohol as the main aetiology. Approximately 25% of patients with acute pancreatitis develop severe disease with associated organ dysfunction and require admission to the Intensive Care Unit (ICU) [2]. Although the mortality rate for the mild form of the disease is as low as 1%, severe acute pancreatitis (SAP) is still associated with high mortality and a prolonged stay in the ICU [3]. According to the Intensive Care National Audit & Research Centre (ICNARC), between 1995 and 2003 in the UK, 2677 patients with SAP were admitted to an ICU, and ICU mortality and hospital mortality were 31% and 42%, respectively [4]. There are several different scoring systems aimed at identifying patients with a high risk of a more complicated course. The Ranson and Glasgow (Imrie) criteria are the most commonly used [5, 6]. The Computed Tomography Severity Index (CTSI) is another score that has been shown to have good predictive value [7]. The Acute Physiology and Chronic Health Evaluation (APACHE) II and the Sequential Organ Failure Assessment (SOFA) scores are general severity of illness scoring systems that have also been shown to have good prognostic value in SAP [8, 9]. In 2007, Harrison et al. described the pancreatitis outcome prediction (POP) score which was derived from data in the ICNARC cohort and is based on arterial pH, age, serum urea, mean arterial pressure, pO2 /FiO2 ratio, and total serum calcium (in order of 2 Critical Care Research and Practice decreasing impact) [10]. Although the original paper showed superiority over the aforementioned models, it has not yet been validated in other patient cohorts. The objectives of our paper were to describe the case mix, current management, and outcome of patients with SAP in a large ICU in a tertiary care centre with a dedicated surgical pancreatitis team. In addition, we aimed to identify risk factors for mortality and to test the prognostic accuracy of commonly used scoring systems and the recently proposed POP score. continuous variables, and the Chi-squared or Fisher’s exact test, as appropriate, for categorical variables. The relationship between the number of computed tomography (CT) scans and CTSI was evaluated using Pearson’s correlation. The correlation between APACHE II, SOFA, CTSI and POP scores and hospital outcome was assessed by receiver operating characteristic curve (ROC) analysis. 2. Materials and Methods 3.1. Demographics. Between January 2005 and December 2010, 50 patients (31 male) were admitted to the ICU with SAP (Table 1). The mean age was 51.7 years (SD 14.8; range 16–85). Twenty patients (40%) had a previous episode of pancreatitis, and 8 patients (16%) were known to have gallstone disease, of whom 4 had previously undergone a cholecystectomy. The most common aetiologies of SAP were alcohol (40%) and gallstone disease (30%). On admission to the ICU, the median APACHE II score was 17 (IQR 12–19); median SOFA score, 5 (IQR 3–5); median POP score, 8 (IQR 5–12); and median CTSI 4 (IQR 2–7.5). 2.1. Setting. Guy’s and St Thomas’ NHS Foundation Trust is a tertiary referral centre for specialist services with 53 ICU beds and a dedicated surgical pancreatitis team. 2.2. Study Design. We retrospectively analysed available data between January 2005 and December 2010. In the absence of a consensus definition for SAP, we pragmatically included all patients with pancreatitis who were admitted to the ICU. Patients with chronic pancreatitis and patients who were transferred from other ICUs if their previous ICU stay was more than 48 hours were excluded. Clinical, laboratory, and imaging data were retrieved from the medical notes and electronic record system. We documented 6 conditions from the past medical history: history of pancreatitis, gallstones, diabetes mellitus, transplantation, chronic kidney disease, and liver cirrhosis. Detailed data regarding associated organ failure, need for organ support, type of nutrition, antibiotic use, complications, and radiological and surgical interventions throughout the whole stay in ICU were recorded. The criteria by the American-European Consensus Conference on ARDS were used to define Acute Lung Injury (ALI) and Acute Respiratory (...truncated)