Page 47 - GTM-3-2

Global Translational Medicine Prognostic indicators and management of SAP

3. Treatment Caloric intake is provided parenterally during the algic
phase, but as soon as the pain subsides (especially after food
3.1. Goals ingestion), progressive enteral feeding can be introduced.
Once the severity of the condition has been diagnosed The aims of early enteral feeding are to modulate the systemic
and the patient has been appropriately referred, the aims inflammatory response and reduce bacterial translocation
of treatment are to control pain and shock and to restore and pancreatic infection by maintaining normal digestive
electrolyte and metabolic balance. Surgery is required flora and stimulating intestinal peristalsis by inserting
for the majority of septic complications and for some a naso-jejunal tube. A recent meta-analysis of seven
complications of sterile necrosis. All curable etiologies randomized trials concluded that enteral nutrition in AP is
must be properly managed to avoid recurrence. correlated with a reduction in infection, morbidity, visceral
failure, and length of hospitalization. Several studies have
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3.2. Resources reported that enteral nutrition reduces the rate of pancreatic
3.2.1. Medical infection and multi-visceral failure. Furthermore, enteral
The management of pain in pancreatitis typically involves feeding is correlated with a lower cost and a lower risk of
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the administration of analgesics in successive stages nosocomial infections. Finally, mortality in SAP does not
with potent options (morphine) such as Dilaudid tablets differ between parenteral and enteral feeding.
(hydromorphone hydrochloride), often being necessary Over 80% of deaths in AP are caused by septic
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due to the severity of the pain. Utilizing a morphine complications due to the bacterial infection of pancreatic
pump makes a definite contribution and allows optimal, necrosis. Patients with retro-pancreatic necrosis
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more personalized pain management with a grade 1C are more prone to bacterial infection. Logically,
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recommendation. If there is no response, multi-modal antibiotic therapy should only be administered in the
analgesia may be used, including the use of an epidural. event of superinfection of the necrosis documented by
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However, in cases of biliary pancreatitis, pethidine is bacteriological sampling (either by blood culture or by
preferred over morphine due to its lower propensity for fine needle puncture of the abscessed collection with a
causing ODDI sphincter spasm. 47 specificity of 100% and a sensitivity over 90%), and it
Intensive care represents the cornerstone of treatment. should be adapted to the germ according to the results
Aggressive crystalloid resuscitation must be used to of the antibiogram. Where appropriate and when the
correct hydroelectrolyte disorders. Central catheterization bacteriological proof is unavailable, probabilistic antibiotic
is strongly recommended, to monitor central venous therapy with carbapenems is recommended when signs
pressure on the one hand and to adjust filling to avoid any of superinfection are present (fever, hyperleukocytosis,
overload on the other hand. hemodynamic instability, gas on imaging, associated
angiocholitis, or extra-pancreatic infection confirmed
In cardiac patients, a Swann-Ganz or pulmonary artery by fine needle aspiration). 53,55,56 Three published meta-
catheter is strongly recommended. Yan et al. exhibited in analyses have compared the administration of antibiotic
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their study of SAP patients that CAP-guided hydroelectrolytic prophylaxis to control groups. 55,57,58 Each study reported a
resuscitation reduced the length of stay in the intensive reduction in the severity of the condition and in mortality
medical care unit. In the same group of patients, there was a following the use of antibiotics. The Cochrane Foundation
decreased need for renal dialysis and a lower rate of MVFS. recently published the results of five studies involving
However, there was no significant difference in mortality. 294 patients, who also support a mortality reduction
In cases of refractory shock, vasoactive drugs should be following the use of antibiotic prophylaxis in PAS.
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employed, while strict monitoring and maintenance of Despite a lack of consensus, due to its potential to improve
respiratory and renal functions are essential. certain septic states, we recommend the use of antibiotic

A bladder catheter is utilized in conjunction with prophylaxis in suspected or confirmed necrosis, regardless
IAP monitoring. Insulin therapy should be introduced of infected status. However, in 30% of cases, untimely
early in cases of impaired glycemic regulation because antibiotic therapy leads to superinfection of the necrosis by
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when it prevents blood glucose levels from exceeding Candida albicans, complicating treatment and prognosis.
110 mg/dL, mortality is reduced by 3 – 4%. Stress-induced Antibiotic therapy should not exceed 14 days. If infectious
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gastrointestinal hemorrhage can occur, especially when signs persist beyond this period, empirical anti-fungal
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the pH of the gastric aspiration fluid is below three. This therapy should be introduced. He et al. demonstrated a
condition should be prevented through the administration reduction in colonization after antifungal agent use in a
of proton pump inhibitors. In addition; preventive study involving 70 patients, though no mortality reduction
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heparin therapy should be instituted. was observed.

Volume 3 Issue 2 (2024) 6 doi: 10.36922/gtm.2480