INFECCION EN PANCREATITIS AGUDA. Julio Pontet 2016

INFECCION EN PANCREATITIS AGUDA Julio Pontet 2016

PARTES DE ESTE TEMA 1. IMPORTANCIA Y GENERALIDADES. CONCEPTOS PREVIOS NECESARIOS 2. DIAGNOSTICO/DETECCION DE INFECCION 3. PROFILAXIS 4. TRATAMIENTO 1. INTERVENCIONISTA 2. ATB

Pancreatitis aguda severa 2 Fases fase 1 Fase 2 Semanas 1-2 SIRS- citoquinas Semanas 2-3 en adelante Infeccion de necrosis DOM 72

IMPORTANCIA DEL PROBLEMA LA COMPLICACION INFECCIOSA Modifica el pronostico Modifica el tratamiento Médico- ATB Procedimientos quirúrgicos Prolonga estadía y aumenta costos 73

Septic multiple organ systemic failure is the cause in 80% of all deaths from this disease. Muller C et al. Gut 2000;46:233 238)

CLASIFICACIÓN DE BALTHAZAR: VALORACIÓN MORFOLÓGICA DE LAS PANCREATITIS AGUDAS SEGÚN LA TAC Balthazar EJ, Robinson DL, Megibow AJ, Ranson JHC. Acute pancreatitis: value of CT in establishing prognosis. Radiology. 1990; 174: 331-336. Grado A Grado B Grado C Grado D Grado E Páncreas normal Aumento del páncreas, normal y difuso, que incluye: -irregularidades de la glándula -dilatación del ducto pancreático -colecciones líquidas pequeñas sin evidencia de enfermedad peripancreática Alteraciones pancreáticas intrínsecas asociadas con cambios inflamatorios en la grasa peripancreática Colección líquida o flemón único bien definido Dos o más colecciones mal definidas o presencia de gas en o cerca del páncreas

Otra clasificación.(2013)

Infeccion en pancreatitis Tasa global 10% pero NECROSIS INCREMENTA tasa de infección hasta 40-80% El tratamiento quirúrgico disminuye la mortalidad de PAN infectada (Worl J Surg 1997; 21: 155).

NECROSIS PANCREATICA ES LA PRINCIPAL Y MAS DEVASTADORA COMPLICACIÓN DE LA P.A.G. INFECTADA 84

Sospechando.

PENSAMOS EN INFECCION.. EXTRAPANCREATICA? PANCREATICA? Pancreatica? = PAF

NECROSIS PANCREATICA INFECTADA DIAGNOSTICO PUNCION ECOGUIADA CON AGUJA FINA O guia por TC BACTERIOLOGICO POSITIVO TAC GAS RETROPERITONEAL CLINICA : DOLOR sisirs 86

Currently, guided fine needle aspiration is the only invasive means for an early and accurate diagnosis of infected necrosis and the standard new techniques have to compete with it. Rau B. et al. Gut 1997; 41: 832 840) CTI Hospital de Clínicas- Cátedra de Medicina Intensiva 2007. 90

NECROSIS PANCREATICA INFECTADA CUANDO HACER PUNCION PERCUTANEA GUIADA? EMPEORA LA CLINICA * FIEBRE >38 * LEUCOCITOS>12000 O < 4000 * TAQUICARDIA POLIPNEA PERSISTENCIA S.I.R.S. > DE 10 DIAS CUADRO CLINICO INDISTINGUIBLE N.P.E. Y N.P.I. PUNCION BACTRIOLOGIA + SE OPERA - SE ESPERA 87

An accurate and readily available biochemical parameter for identifying patients who are at risk of developing infected necrosis would contribute to an easier, less invasive, and less cost intensive diagnosis. PCT IL-8- citoquina activadora neutrofilos. G-CSF Estimulante de colonias de granulocitos-macrófagos IL-6 PCR TNF alfa

CTI Hospital de Clínicas- Cátedra de Medicina Intensiva 2007. 94

Rau B. et al. Gut 1997; 41: 832 840 95

median PCT peaks in infected necrosis with MODS 28.8 ng/ml, (3.1 186.2) versus infected necrosis without MODS 3.8 ng/ml, (1.7 5.8), with sterile necrosis did not cause a relevant increase in PCT sterile necrosis with MODS 1.0, (0.6 1.7). Rau B. et al. Gut 1997; 41: 832 840 CTI Hospital de Clínicas- Cátedra de Medicina Intensiva 2007. 96

Rau B. et al. Int Care Med 2000; 26: 159-164. CTI Hospital de Clínicas- Cátedra de Medicina Intensiva 2007. 101

CTI Hospital de Clínicas- Cátedra de Medicina Intensiva 2007. 104

Inflammatory cytokines, C reactive protein, and procalcitonin as early predictors of necrosis infection in acute necrotizing pancreatitis Riche F. Surgery. 133(3):257-262, March 2003. To better target patients in whom antibiotic prophylaxis could be beneficial, IL-6, TNF-[alpha], CRP, and PCT were measured during the first 3 days after admission 106

PCT (P < 0.003) and IL-6 (p < 0.04) were higher in the serum of patients who eventually developed infection of necrosis No difference was noted between the 2 groups for TNF- [alpha] and CRP. The combination of IL-6 < 400 pg/l and PCT < 2 ng/l best identified patients who were not at risk for necrosis infection. 107

PROFILAXIS ATB?

Mazaki, T.; Ishii, Y.; Takayama, T. Division of Digestive Surgery, Department of Surgery, Nihon University School of Medicine, Tokyo, Japan Meta-analysis of prophylactic antibiotic use in acute necrotizing pancreatitis British Journal of Surgery. 93(6):674-684, June 2006. Background: Thassesses whether intravenous prophylactic antibiotic use reduces infected necrosis and death in acute necrotizing pancreatitis. Methods: A meta-analysis of randomized controlled trials.

Results: Six of 328 studies assessed were included in data extraction. Primary outcome measures were infected necrosis and death. Secondary outcome measures were non-pancreatic infections, surgical intervention and length of hospital stay. Prophylactic antibiotic use was not associated with a statistically significant reduction in infected necrosis (RR 0.77); (P = 0.173), mortality (RR 0.78) (P = 0.404), non-pancreatic infections (RR 0.71, P = 0.402) and surgical intervention (RR 0.78 ; P = 0.167). It was, however, associated with a statistically significant reduction in hospital stay (P = 0.040). Conclusion: Prophylactic antibiotics do not prevent infected necrosis or death in acute necrotizing pancreatitis. 111

Controversia GUIAS IAP-APA 2013 GUIAS ACG 2013 No ATB profiláctico GUIAS JPN 2015 ATB en fase temprana (72 h) en PA severa Opinión mayoritaria: NO ATB

The lowest incidence of use of antibiotic prophylaxis was 41% and the highest 88%. Basado en encuestas mas de 2300 médicos

Sincerarnos, discutir entre nosotros y con los cirujanos. Luego decidir Hacer ATB NO hacer ATB Quizás beneficio en algunos pacientes seleccionados Tranquiliza al cirujano!! Y a algunos intensivistas Lo que tiene más evidencia Exige monitoreo apropiado en búsqueda de la infección Paciente no seleccionado en su flora por ATB Quizás Menos MO MR

TRATAMIENTO EN LA PANCREATITIS INFECTADA

Minimally Invasive Step-up Approach 1. The first step was percutaneous or endoscopic transgastric drainage. The preferred route was through the left retroperitoneum, thereby facilitating minimally invasive retroperitoneal necrosectomy at a later stage, if necessary. 2. If there was no clinical improvement after 72 hours and if the position of the drain (or drains) was inadequate or other fluid collections could be drained, a second drainage procedure was performed. 3. If this was not possible, or if there was no clinical improvement after an additional 72 hours, the second step, videoassisted retroperitoneal debridement (VARD) with postoperative lavage, was performed. 4. (Otra opción: necrosectomia transgástrica)

NECROSIS PANCREATICA INFECTADA TRATAMIENTO QUIRURGICO NECROSECTOMIA MANEJO DEL PANCREAS REMANENTE = TEMA DE DISCUSION. 116

NECROSIS PANCREATICA INFECTADA TRATAMIENTO QUIRURGICO TARDIA NO ANTES DE LA 3º SEMANA CONSOLIDE Y LIMITE LA NECROSIS METODOS : ABIERTOS R.PROG. CERRADOS CIERRE Y LAVADOS ABORDAJE POSTERIOR 117

TRATAMIENTO QUIRURGICO METODO CERRADO 119

NECROSIS PANCREATICA INFECTADA TRATAMIENTO QUIRURGICO MARSUPIALIZACION LAPAROSTOMIA DRENAJE AMPLIO DE LA LOGIA CURACIONES PROGRAMADAS DEBRIDAMIENTO REPETIDO MENOS ABSCESOS INTRA ABDOMINALES RECURRENTES 120

NECROSIS PANCREATICA INFECTADA DRENAJE ABIERTO (BRADLEY) NECROSECTOMIA EN ETAPAS MANIOBRAS DIGITALES SUAVES ROMAS RELLENO DE LA LOGIA CON GASAS VASELINADAS 124

MARSUPIALIZACIÓN (OPEN PACKING) ABORDAJE RETROPERITONEAL 12ª COSTILLA 130

NECROSIS PANCREATICA INFECTADA DRENAJE ABIERTO (BRADLEY) YEYUNOSTOMIA DE ALIMENTACION AISLAMIENTO DEL COLON Y ASAS YEYUNALES LAVADO PROFUSO CON VARIOS LITROS DE S. FISIOLOGICO REEXPLORAR CADA 48 o 72 Hrs. 125

NECROSIS PANCREATICA INFECTADA DRENAJE ABIERTO (BRADLEY) CIERRE PARIETAL ABIERTO CON SUTURA DEL ESTOMAGO A LA PARED VACUM PACK 126

MENSAJE FINAL: nuevo paradigma menos es más m Uso racional de ATB- no profilaxis Administración racional-acotada de fluídos Evitar grandes cirugías- intervencionismo menor posible