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DOI: 10.1055/s-2002-35761
© Georg Thieme Verlag Stuttgart · New York
Die Bedeutung eines klinischen Protokolls bei der Behandlung der schweren akuten Pankreatitis
Importance of a Clinical Protocol in the Treatment of Severe Acute PancreatitisPublikationsverlauf
Publikationsdatum:
11. Dezember 2002 (online)
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Zusammenfassung
Zielsetzung: Die Auswahl der optimalen Therapiestrategie bei Patienten mit schwerer akuter Pankreatitis (SAP) stellt eine klinische Herausforderung dar aufgrund der schwierigen Differenzialdiagnose im frühen Stadium der Erkrankung. Anhand der vorliegenden retrospektiven Untersuchung sollen unsere ersten Erfahrungen bei der Behandlung von Patienten mit (früher) SAP mit einem festen klinischen Protokoll (CP) dargestellt werden.
Methodik: 210 Patienten, die die Atlanta-Kriterien einer SAP erfüllten, wurden in diese Studie aufgenommen. Die Patienten wurden in zwei Gruppen entsprechend der diagnostischen und therapeutischen Strategie unterteilt. Die erste Gruppe (Nicht-Protokoll-Gruppe, NP) umfasste 154 Patienten, bei denen die Behandlung auf der subjektiven Entscheidung des Dienst-habenden Arztes und der bisherigen Klinikroutine beruhte. 56 Patienten wurden nach einem neuen Protokoll (CP) behandelt, das folgende Parameter einschloss:
- frühe Bestimmung des Schweregrades der Erkrankung (APACHE II Score, Bestimmung eines systemischen inflammatorischen Responsesyndroms (SIRS) und/oder der Organdysfunktion).
- Sofortige Überwachung auf der Intensivstation mit routinemäßiger Messung des intraabdominellen Drucks.
- Konservative Therapie, die eine frühe enterale Ernährung, die Gabe von Kolloiden, eine antibakterielle Prophylaxe und eine frühe kontinuierliche veno-venöse Hämofiltration (CVVHF) beinhaltete, falls indiziert.
- Chirurgische Behandlung, falls die konservative Therapie versagte (definiert als Fortschreiten der Organdysfunktion) oder wenn Hinweise auf eine Infektion bestanden.
Es wurden die Länge des Hospital- und Intensivstationaufenthaltes sowie der Krankheitsverlauf analysiert.
Ergebnisse: Altersstruktur und Schwergrad der Erkrankung waren in beiden Gruppen ähnlich, das Alter betrug 51,3 (15,6) vs. 46,8 (15,2) Jahre, der APACHE II-Score 9,7 (5,1) vs. 9,8 (4,4) Punkte in den Gruppen NP und CP. Das Geschlechtsverhältnis Männer zu Frauen war 2 : 1, Alkohol war die hauptsächliche Ursache der Erkrankung in beiden Gruppen (55 %). Eine frühe SAP wurde in 33 % bzw. 46 % der Patienten diagnostiziert, entsprechend dem SOFA-Score. Die Ergebnisse der konservativen Therapie besserten sich nach Einführung des festen Protokolls erheblich, die chirurgische Intervention war bei 46 bzw. 52 % der Patienten notwendig. Ein multiples Organversagen war die Haupttodesursache in beiden Gruppen. Es wurde eine erhebliche Abnahme der Frühsterblichkeit (innerhalb der ersten Woche nach Krankenhauseinweisung) beobachtet mit 1,8 % in der CP-Gruppe verglichen mit 22,1 % bei den Nicht-Protokoll-Patienten (p < 0,01). Die Letalität der frühen SAP wurde durch die Protokoll- Behandlung deutlich reduziert (3,8 % verglichen mit 33 % bei den NP-Patienten, p < 0,01). Auch die postoperative Letalität ging beträchtlich zurück, mit 10,3 % in der CP-Gruppe verglichen mit 32,7 % in der NP- Gruppe (p < 0,05). Die Gesamtletalität betrug in der CP-Gruppe 5 vs. 34 % in der NP-Gruppe (p < 0,01). Da ein beträchtlicher Anteil der Patienten in der NP-Gruppe früh verstarb, verlängerte sich in der CP-Gruppe statistisch signifikant die Aufenthaltsdauer auf der Intensivstation und im Krankenhaus, mit 14,1 (14,1) vs. 9,6 (15,2) Tagen bzw. 37,9 (26,7) vs. 23,4 (21,8) Tagen (p < 0.01).
Folgerungen: Eine frühe Erkennung der Erkrankung und standardisierte Therapiestrategie, die das Monitoring auf der Intensivstation, die Gabe von Kolloiden, eine antibakterielle Prophylaxe, frühe enterale Ernährung und CVVHF einschließt, sind bei diesen Patienten äußerst wirksam. Die Einführung eines speziellen Therapieprotokolls verbesserte den Patientenverlauf signifikant und half, die Zahl der Todesfälle nach chirurgischen Eingriffen und bei früher SAP zu reduzieren.
Abstract
Background: Selection of the optimal treatment strategy in severe acute pancreatitis (SAP) is a serious clinical challenge largely due to difficult differential diagnosis of patients with early SAP. The aim of this study is a retrospective evaluation of the first experiences in the treatment of patients with SAP and early SAP according to a new complex clinical protocol (CCP).
Methods: A total of 210 patients complied with Atlanta recommendations for SAP and were included in the retrospective study. Patients were stratified into two groups according to the diagnostic and treatment strategy. Non-protocol (NP) group comprised 154 patients who had received their treatment based on previous clinical routine and subjective decision of physicians in charge. 56 patients who were managed according to the new CCP developed for SAP comprised the CCP group. CCP included:
- Early assessment of the severity of acute pancreatitis (APACHE II score, presence of SIRS and/or organ dysfunction);
- Immediate ICU monitoring including routine measurement of the intraabdominal pressure;
- Conservative treatment including early enteral nutrition, colloids, antibacterial prophylaxis and early continuous venovenous hemofiltration (CVVHF) when indicated;
- Surgical treatment when conservative treatment was not effective (progression of the organ dysfunction) or presence of infection was evident.
Hospital, ICU stays and outcomes were analysed. Statistical comparison was done by Mann-Whitney U-test and Chi-square test.
Results: The age structure and severity of the disease were similar in both groups with mean of 51.3 (15.6) vs. 46.8 (15.2) years and 9.7 (5.1) vs. 9.8 (4.4) APACHE II points in groups NP and CCP, respectively. Male/female ratio was 2 : 1, and alcohol was the main etiologic factor in about 55 % of cases in both groups. Early SAP was diagnosed in 33 % to 46 % of patients according to the results of the SOFA scoring. The results of the conservative therapy considerably improved after implementation of the CCP treatment. Surgical intervention was done in 46-52 % of patients. MODS was the main cause of death in both groups. Remarkable decrease in early mortality (within the first week from admission) was a real advantage of CCP treatment comprising 1.8 % vs. 22.1 % in NP patients, p < 0.01. Mortality from early SAP was reduced by CCP treatment to 3.8 % compared to 33 % in NP group, p < 0.01. There was a considerable reduction in postoperative mortality with CCP treatment comprising 10.3 % vs. 32.7 % in patients who did not receive CCP treatment, p < 0.05. Overall mortality associated with CCP treatment ranged to 5 %, compared to 34 % mortality in the NP treatment group, p < 0.01. Due to the considerable number of early deaths among NP patients, there was statistically longer ICU and hospital stay in CP group with mean of 14.1 (14.1) vs. 9.6 (15.2) days and 37.9 (26.7) vs. 23.4 (21.8) days, compared to NP group, p < 0.01.
Conclusions: Timely recognition and complex therapy of SAP including ICU monitoring, colloids, antibacterial prophylaxis, early enteral nutrition, and CVVHF is the most effective way how to manage this category of patients. Implementation of a specialised treatment protocol considerably improves outcome and reduces the number of deaths associated with surgery and early SAP.
Schlüsselwörter
Akute Pankreatitits - standardisiertes Behandlungsprotokoll - Ergebnisse
Key words
Severe acute pancreatititis - clinical protocol - results
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Dr. G. Pupelis
Department of Surgery
Clinical Hospital „Gailezers”
Medical Academy of Latvia
Riga
Latvia
eMail: pupelis@gailes.lv