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Severe Acute Pancreatitis
14 Plays4 years ago
In this episode of Critical Matters, we discuss the management of severe acute pancreatitis.
Our guest is Dr. Marc G Besselink (@MarcBesselink). He is Professor of pancreatic and hepatobiliary(HPB) surgery, at Amsterdam University Medical Centers in the Netherlands. Dr. Besselink is a member of the Dutch Pancreatitis Study Group and is the senior investigator of the POINTER clinical trial (recently published in the New England Journal of Medicine).
Additional Resources:
Acute Pancreatitis: https://bit.ly/3D6kONK
POINTER Clinical Trial - Immediate Versus Postponed Intervention for Infected Necrotizing Pancreatitis: https://bit.ly/3wxRLQN
PYTHON Clinical Trial - Early Versus On-demand Nasoenteric Tube Feeding in Acute Pancreatitis: https://bit.ly/3km1STK
APEC Clinical Trial - Urgent Versus Conservative ERCP for Acute Pancreatitis: https://bit.ly/3qlVK1I
Books Mentioned in this Episode:
The House of God by Samuel Shem: https://amzn.to/3wy8Lq2
Recommended
Transcript
Introduction to Podcast and Topics
00:00:06
Speaker
Welcome to Critical Matters, a sound podcast covering a broad range of topics related to the practice of intensive care medicine.
00:00:14
Speaker
Sound provides comprehensive critical care programs to hospitals across the country.
00:00:19
Speaker
To learn more about our programs and career opportunities, visit www.soundphysicians.com.
00:00:26
Speaker
And now your host, Dr. Sergio Zanotti.
Management of Severe Acute Pancreatitis
00:00:33
Speaker
Acute pancreatitis is a common gastrointestinal disease requiring acute care in the intensive care unit.
00:00:38
Speaker
The range of severity in acute pancreatitis is wide.
00:00:41
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Patients present with mild cases on one extreme and on the other end of the spectrum, patients can present with severe cases with multiple organ failure and serious local complications require critical care.
00:00:53
Speaker
In today's episode of the podcast, we will focus on current management recommendations for severe acute pancreatitis.
00:00:59
Speaker
Our guest is Dr. Mark Besenling.
Guest Introduction: Dr. Mark Besselink
00:01:01
Speaker
Dr. Besselink is professor of pancreatic and hepatobiliary surgery at Amsterdam University Medical Centers.
00:01:08
Speaker
Dr. Besselink is a member of the Dutch Pancreatitis Study Group, is the senior investigator of the Pointer Clinical Trial, a randomized clinical trial published recently in the New England Journal of Medicine that evaluated immediate versus postponed interventions for infected necrotizing pancreatitis.
00:01:24
Speaker
Mark, welcome to Critical Matters.
00:01:27
Speaker
Thank you very much, and thanks for having me.
00:01:29
Speaker
It's a great honor.
Diagnosis Criteria for Acute Pancreatitis
00:01:31
Speaker
Obviously, we were talking before we started recording that this is a common disease that is full of dogma, especially in the ICU, and old precepts that probably are not aligned with what current evidence is.
00:01:43
Speaker
And I know that you, through your work with the Dutch Pancreatitis, have really advanced our understanding of the surgical management and the interventional management of this disease.
00:01:54
Speaker
So perhaps a good place to start would be just with the basics of how do we diagnose acute pancreatitis?
00:02:02
Speaker
Yeah, so thanks.
00:02:03
Speaker
So basically abdominal pain, amylase or lipase higher than three times the upper limit of normal for your hospital and or CT scan findings compatible with pancreatitis.
00:02:20
Speaker
Now you need only two out of three.
00:02:23
Speaker
So we have a new patient.
00:02:26
Speaker
You can basically only diagnose it with
00:02:28
Speaker
abdominal pain and serum values.
00:02:30
Speaker
You don't necessarily need a scan, but if you want to make a scan, be aware.
00:02:35
Speaker
If you do a scan on admission, you may miss necrotizing pancreatitis and collections, which take a few days to develop.
00:02:46
Speaker
Yeah.
00:02:47
Speaker
And I think it's an important point also in terms of what you require, because we tend to forget that we can make diagnoses such as acute pancreatitis with simple labs and a good clinical
00:02:57
Speaker
history and exam and not necessarily have to get like a thousand things for every patient that we suspect abdominal pain in, right?
00:03:05
Speaker
Correct, correct.
00:03:06
Speaker
The only reason, the only indication basically for a scan on admission for acute pancreatitis, that is if you are unsure about the diagnosis that, for instance, a patient has peritonitis, you should not have peritonitis, meaning abdominal guarding or pain or when releasing the abdominal wall.
00:03:25
Speaker
You should not have that with pancreatitis, which is a retroperitoneal organ.
00:03:29
Speaker
So you should have a lot of pain, but no physical signs of peritonitis.
00:03:35
Speaker
Absolutely.
Causes and Etiology of Acute Pancreatitis
00:03:36
Speaker
And in terms of etiology for acute pancreatitis, what are the things that you think our clinicians and listeners should be aware of?
00:03:44
Speaker
Yeah, so the vast majority is gallstones.
00:03:47
Speaker
Even if you don't see the gallstones, even in those patients, more than half, it's still gallstones or biliary sludge or biliary cause.
00:03:55
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And then alcohol, so probably, so biliary nowadays, they're 60%, six zero, alcohol another 20, and then you have another 10 in which we cannot find a cause first.
00:04:08
Speaker
And then the rest is just a long, a long range of causes.
00:04:13
Speaker
In terms of, you mentioned how we make a diagnosis, some of the important causes.
00:04:17
Speaker
I presume that part of our initial workup really focuses obviously in A, making the diagnosis, B, evaluating the etiology,
00:04:25
Speaker
and C, perhaps trying to evaluate how severe the presentation is.
00:04:30
Speaker
But what would you recommend, Mark, as an initial diagnostic workup in terms of the basic things that we should be looking at as clinicians that were suspecting acute pancreatitis?
Fluid Management in Pancreatitis
00:04:39
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Well, in the older days, there was a lot of emphasis on doing predictive scores, predicting how severe the pancreatitis would be.
00:04:49
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But in essence, that's no longer relevant because at the moment, A,
00:04:55
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There is no intervention or treatment that you will start on a basis of high risk and B, there is probably not a single ICU in the world anymore that will admit the patient who may become sick in the future.
00:05:06
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So I think the early management, basically you as intensivists need to train us as surgeons and internal medicine or gastroenterology doctors how to assess vital functions in the first one and two days, meaning
00:05:23
Speaker
giving sufficient fluids and probably a lot of fluids, but monitor carefully and slow down.
00:05:29
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We found the amount of fluids administered once there is sufficient urinary output and we see blood pressure and heart rate stabilizing.
00:05:39
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And those things is what go wrong in many, many places.
00:05:44
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Patients are not treated with sufficient fluids initially.
00:05:50
Speaker
And then later on, they I mean,
00:05:53
Speaker
Many hospitals, I don't know what it's like in the U.S., but in the Netherlands, you may just get three or four liters of saline infusion for four days in a row without anyone thinking after 20 hours, we need to tune this down a bit.
00:06:04
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Yeah, absolutely.
00:06:06
Speaker
And we'll definitely dig into that a little
Risk Scores for Severity Assessment
00:06:08
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bit more.
00:06:08
Speaker
But you did mention severity.
00:06:10
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And I wanted to ask you your perspective as a clinician.
00:06:13
Speaker
So obviously, there's a lot of risk scores that have been published around pancreatitis, Apache 2, Ransom's criteria, modified Glasgow acute pancreatitis.
00:06:25
Speaker
are those really useful at the bedside or are they more for studies?
00:06:29
Speaker
Pure for studies.
00:06:29
Speaker
So what they are used for in studies is, so you can include the 50% of patients who are high risk, the 5-0, 50%.
00:06:37
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And among those, half of them will actually get sick.
00:06:41
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So you have a higher risk ratio in your clinical trials.
00:06:44
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But basically outside clinical trials, and I hope I don't offend anyone, but basically there's no clinical use for these scores at the present time.
00:06:53
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And probably as we talk about the definition, ultimately what it really matters is assessing the patient and trying to identify where their local complications and acute organ dysfunction, correct?
00:07:05
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Yeah.
00:07:05
Speaker
So, so one, uh, simple technique is looking at CRP for instance.
00:07:10
Speaker
So if CRP remains high after three, four days, doesn't come down.
00:07:17
Speaker
The vast majority of these patients have necrotizing pancreatitis, but I expect
00:07:22
Speaker
as an intensivist, you would not see these patients because they are typically on the ward.
00:07:26
Speaker
The most challenging patients are of course the ones who present with organ failure and remain in organ failure throughout the first one.
00:07:34
Speaker
Absolutely.
00:07:35
Speaker
And Mark, let me ask you, in terms of classifications or definitions for a severe acute pancreatitis, I understand that today we kind of go either with the Atlanta classification or what's called the determinant base classification.
00:07:50
Speaker
Could you comment on that a little bit more?
00:07:54
Speaker
Yeah, so the Atlanta, revised Atlanta classification is what I use, but there is a determinant-based classification.
00:08:04
Speaker
They use the same variables, which are collections with necrosis in our around the pancreas and then organ failure.
00:08:18
Speaker
I think in the end, it does not really make that much difference.
00:08:21
Speaker
What you need to be on the lookout for is organ failure and collections in and around the pancreas.
00:08:26
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So if you have a collection which is non-infected, that does not require treatment.
00:08:32
Speaker
In fact, if you treat that, it will become infected and you will worsen the prognosis.
00:08:37
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So a lot of it is just straightforward, state-of-the-art organ failure
Classification Systems in Pancreatitis
00:08:42
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management.
00:08:42
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So if you have organ failure, clearly it's severe.
00:08:45
Speaker
And the other is if you have a collection
00:08:46
Speaker
but you do not have organ failure, but you also do not have fever or signs of infection, then basically it's still, it is called severe pancreatitis, but the outcome is clearly a lot better than once you have.
00:08:57
Speaker
Yeah.
00:09:00
Speaker
So clearly, like you mentioned, Mark, organ failure should be within the purvey of what we do in the intensive care unit.
00:09:06
Speaker
and there's nothing specific for acute pancreatitis.
00:09:09
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We support the organs like we do in any other multi-system disease.
00:09:12
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And then the other part of this is understanding fluid collections and that distinction that we'll dive in a little bit deeper in a little bit of where it's infected or not.
00:09:21
Speaker
But before we go there, what I would like to do is just touch on some of the management issues at the initial phase.
00:09:28
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We did talk a little bit about fluids, and I just want to kind of cap the fluid discussion with what you said earlier, right?
00:09:35
Speaker
It's kind of either we have an error of omission or of commission.
00:09:41
Speaker
So either we don't give enough fluids or we give too much fluids and both obviously are dangerous for these patients.
00:09:47
Speaker
So really trying to provide the adequate amount of fluids.
00:09:51
Speaker
Is there any comments that you have or any preferences based on the literature and what type of fluid we should be using?
00:09:58
Speaker
No, I mean, you'd be surprised in Europe how many hospitals still give high amounts of regular saline.
00:10:05
Speaker
To these patients, which which I guess, but I mean, intensivists are my view, the specialists on this.
00:10:12
Speaker
But there are two randomized
Fluid Management Strategies
00:10:14
Speaker
trials from China where they intervened in fluid management and tried to get and based on a metric just did a maximum aggressive resuscitation.
00:10:27
Speaker
And in those studies, mortality was worse by by maximizing aggressive resuscitation.
00:10:34
Speaker
So I guess it's just common sense and basically tailoring it to a urinary output, cardiovascular science.
00:10:43
Speaker
But I mean, that's what you guys and girls are much better than we as non-intensivists.
00:10:49
Speaker
Is there any value?
00:10:50
Speaker
I know there's some studies that suggest that perhaps a ringer's lactate might have some benefits, but that obviously has never been demonstrated in a clinical trial.
00:10:58
Speaker
But is there, I mean, there's other reasons why probably isotonic, um,
00:11:03
Speaker
and fluids are valuable in critical care.
00:11:07
Speaker
Is that something that you think about a lot?
00:11:09
Speaker
Yeah, I do.
00:11:10
Speaker
I do.
00:11:10
Speaker
And I do think it makes more sense.
00:11:13
Speaker
In smaller randomized trials, it seems a bit better, but more on, not on the hard endpoints like mortality.
00:11:21
Speaker
So those studies have not been done, but everybody thinks that, yeah, it would make sense.
00:11:25
Speaker
Probably if you would do a very, very large study, most people would predict that it would really be a benefit, but so far there's not been shown.
00:11:34
Speaker
So in terms of kind of where we stand today, obviously, is appropriate judicial fluid management early on without overdoing it, perhaps some advantages to use ringers lactate as your to-go fluid.
00:11:47
Speaker
And when you talked about higher mortality, one of the concerns, obviously, that we have with acute pancreatitis is intra-abdominal compartment syndrome.
00:11:54
Speaker
Is that something that should always be in the back of our mind and maybe something that we don't think about so much as medical intensivists, but definitely that you and the surgical world see all the time?
Use of Antibiotics and ERCP
00:12:05
Speaker
Absolutely.
00:12:06
Speaker
So, so in my view, those are, I think the two main issues show an intra-abdominal catastrophe that you may miss, which is either abdominal compartment syndrome or bowel ischemia, chronic necrosis, something like that.
00:12:21
Speaker
That's, that's, that's one.
00:12:23
Speaker
And then the other is, um, of course, bleeding, maybe the second and then the third, in fact, the necrosis.
00:12:29
Speaker
And the, the problem comes when you have a patient who has been sick from the beginning,
00:12:35
Speaker
and has a collection and everybody starts towards the source control reflex, which makes sense.
00:12:44
Speaker
But in essence, the first one, two weeks of pancreatitis are like a major trauma, major burn patient.
00:12:52
Speaker
It is inflammation, it's not infection.
00:12:56
Speaker
Excellent.
00:12:57
Speaker
And the second aspect that I think has a lot of misconceptions still is nutritional support in the early phases.
00:13:04
Speaker
So historically, people have talked about strict MPOs.
00:13:09
Speaker
Then people started pushing for post-eugenial tube feeds.
00:13:15
Speaker
There's people, obviously, who have always pushed.
00:13:17
Speaker
And now we learn that parental nutrition is probably not a good idea.
00:13:22
Speaker
What's the summary of what we should be doing for these patients from a nutritional standpoint?
00:13:27
Speaker
Yeah.
Nutritional Strategies in Pancreatitis
00:13:28
Speaker
So actually, in a bigger step, but we did with it, multiple randomized trials showing in anything you want to do in pancreatitis more aggressive or earlier or sooner or bigger, it's always worse.
00:13:39
Speaker
So the same is for the nutrition.
00:13:41
Speaker
You can hold off safely for a couple of days if a patient is still on a ventilator or not on a ventilator, but not able to get sufficient calories, then you can start naso enteral tube feeding or probably the ICU setting, nasogastric feeding.
00:13:57
Speaker
You don't need to feed aggressively in the first couple of days.
00:14:00
Speaker
It's basically like a post-op patient.
00:14:02
Speaker
They need some nutrition, but there's no clinical benefit from an aggressive nutritional management within 24 hours.
00:14:09
Speaker
That was the Python trial that was published in the New England Journal of Medicine.
00:14:15
Speaker
And in terms of if you start enteral feeding in somebody who, let's say, is intubated, and is there any value in having a post-piloric tube?
00:14:25
Speaker
or should you just do an orogastric and that's okay?
00:14:28
Speaker
Yeah, so there are three, I think there are three relatively small randomized trials, also in the ward, the clinical ward setting.
00:14:37
Speaker
There's no downside to nasogastric feeding.
00:14:40
Speaker
So if you are used in the ICU to do nasogastric feeding, you can do that in these pancreatitis patients as well safely.
00:14:49
Speaker
So the summary here would be if somebody's not intubated, maybe even outside of the ICU,
00:14:55
Speaker
start enteral, I mean, regular nutrition or once they tolerate it based on their symptoms without necessarily going to be too aggressive and starting something immediately.
00:15:06
Speaker
And then those who are a little bit sicker, once they're hemodynamically compensated and stable, start some sort of enteral nutrition and see how they tolerate.
00:15:13
Speaker
Yeah, well, that, yeah, exactly.
00:15:15
Speaker
So you mentioned, yeah, hemodynamically stable patient.
00:15:17
Speaker
That is an odd thing that happened in our probiotics trial where we did, we intervened
00:15:24
Speaker
Within the first 72 hours of pangotitis of nasal enteral probiotics combined with fiber rich tube feeding, those patients had a significant worse mortality, mostly used to probably, although we are not sure, probably a non-inclusive mesenteric ischemia, a thing that intensivists recognize from, say, post-op patients getting bowel ischemia from the from the exact spot
00:15:53
Speaker
where tube feeding enters the bowel.
00:15:56
Speaker
And that is a poorly understood phenomenon, but it's probably related to flow.
00:16:02
Speaker
So that's actually another argument to withhold exactly as you summarized tube feeding in the first couple of days.
00:16:09
Speaker
Excellent.
00:16:10
Speaker
Another area that I think we've always been back and forth and still unclear for a lot of clinicians is antibiotics.
00:16:19
Speaker
So from giving everybody antibiotics to getting a CT in everybody and you see anything that you suspected necrosis giving antibiotics to probably a more current evidence aligned recommendation of not giving antibiotics in the early days.
00:16:33
Speaker
Could you just tell us, Mark, your take on antibiotics?
00:16:38
Speaker
Yeah.
00:16:39
Speaker
So it's become quite clear from several randomized trials that the hypothesis that if you sterilize
00:16:48
Speaker
the guts or just give systemic antibiotics improves outcome.
00:16:52
Speaker
That's not true.
00:16:53
Speaker
So prophylactic antibiotics, no role for in pancreatitis.
00:16:56
Speaker
The one thing that is that has become very clear from the point of trial last month in New England, that once you have documented or highly suspicion, high suspicion of infected necrotizing pancreatitis, then one in three or more than one in three of the patients will be treated successfully with only antibiotics.
00:17:15
Speaker
But that is a treatment
00:17:17
Speaker
not a prophylaxis.
Infection vs. Inflammation in Pancreatitis
00:17:20
Speaker
So really we should remember that in the early phases these patients might present with systemic inflammatory response syndrome similar to sepsis, but it's likely not due to infection, so there's no rush to give them infections.
00:17:33
Speaker
And we should only give them antibiotics early on if we have a documented infection, either cholangitis, we can sometimes present with pancreatitis or some other infection.
00:17:42
Speaker
And then, like you said, once we have a documented or high suspicion
00:17:46
Speaker
or a fluid collection that is necrotic and infected, obviously antibiotics not only are treatment, but they can avoid, as we'll talk a little bit, more interventions down the road.
00:17:56
Speaker
I think that's important because I still see that a lot of people, as a knee-jerk reflection, will basically start antibiotics in very sick pancreatitis patients in the ICU on day one.
00:18:09
Speaker
Yeah, and moreover, so if you're treating a very, very sick patient,
00:18:14
Speaker
and you see fluid in the abdomen.
00:18:17
Speaker
The reflex we have as intensivists, probably also in surgeons, the urge to drain that is very strong.
00:18:24
Speaker
I mean, for many years, I had sort of an on-page, I was on call with my pager for including patients in these trials we did.
00:18:32
Speaker
And I spoke to so many intensivists, it's really difficult to withhold intervention.
00:18:36
Speaker
And I feel your pain, but please hold off.
00:18:41
Speaker
The action bias, right?
00:18:42
Speaker
We always want to do more.
00:18:44
Speaker
And we're learning that sometimes more is worse.
00:18:46
Speaker
Absolutely.
00:18:47
Speaker
Exactly.
00:18:47
Speaker
And especially in pancreatitis, which I think is a one off disease.
00:18:52
Speaker
It doesn't compare.
00:18:53
Speaker
It's very, it is challenging.
00:18:54
Speaker
It's the only disease that I know that you just hold off antibiotics, wait, wait, wait.
00:18:58
Speaker
And that's really, it doesn't feel natural to us.
00:19:01
Speaker
Yeah.
00:19:02
Speaker
What about the role of ERCP?
00:19:07
Speaker
Same story.
00:19:07
Speaker
Do less, less is more.
00:19:09
Speaker
So,
00:19:10
Speaker
We did APEC, APEC randomized trial published in Lancet.
00:19:14
Speaker
Again, aggressive within 24 hours.
00:19:16
Speaker
ERCP, everyone with biliary pancreatitis predicted high risk.
00:19:20
Speaker
So the high risk score versus just wait and see.
00:19:23
Speaker
And again, no benefit for early ERCP, maybe even a bit worse.
00:19:29
Speaker
So again, also there, just wait.
00:19:31
Speaker
Look at the cholestasis parameters.
00:19:33
Speaker
Clearly, if bilirubin or whatever goes up,
00:19:37
Speaker
and you get gallingitis, 39 degree higher fever and spiking chills and a bilirubin of 100.
00:19:42
Speaker
Of course, then you need to do an ERCP, but actually that's super rare.
00:19:45
Speaker
So in the vast majority of patients, the stones will just pass, claustasis lab will improve and you do not need an ERCP, one.
00:19:52
Speaker
And two, if in doubt, most big centers nowadays will have availability of EOS, endoscopic ultrasound, to check first what's going on inside the bowel, because don't forget mortality of ERCP is 0.5.
00:20:06
Speaker
to 0.5% mortality.
00:20:10
Speaker
Yeah, so definitely, I mean, I think, like you said, in terms of our approach, more conservative.
00:20:16
Speaker
And would cholangitis be a situation where you actually would give not only antibiotics but also do an ERCP earlier?
00:20:24
Speaker
Absolutely, yeah.
00:20:25
Speaker
That's an indication for an urgent ERCP, yes.
00:20:29
Speaker
Okay, perfect.
00:20:30
Speaker
And then I wanted to dive into, obviously we did mention the POINTER trial, but ultimately the management of local complications.
00:20:38
Speaker
Could we start, Marc, just by a very brief overview of what are the types of local complications that we talk about in acute pancreatitis?
00:20:46
Speaker
Yeah, so we have two things.
00:20:47
Speaker
So you have necrosis of the parenchyma or the fatty tissue around the pancreas.
00:20:52
Speaker
So necrotizing pancreatitis is a term which summarizes
00:20:58
Speaker
any form of necrosis in and around the pancreas.
00:21:01
Speaker
That's one then, too.
00:21:02
Speaker
You have an acute necrotic collection, meaning like basically anything around the bankers that sort of starts to to wall off to look like a little bit of world off thing.
00:21:16
Speaker
And once it's fully walled off, you have a wall fully encircling it, then you call it walled off necrosis and the letter, the walled off necrosis, the one
00:21:25
Speaker
is what most gastroenterologists would like to see because that clearly, then there's a clear demarcation between dead and alive stuff, which makes any intervention a lot safer.
00:21:38
Speaker
And obviously the main factor to get there is time.
00:21:42
Speaker
Absolutely.
00:21:43
Speaker
And another aspect that I believe is important, and you mentioned it earlier, is that it is not uncommon to have just edema or some fluid around the pancreas and acute pancreatitis.
00:21:55
Speaker
And I think a lot of clinicians might confuse that with these more complicated and necrotizing collections.
00:22:03
Speaker
And like you said, have that impulse to think that a needle should be stuck there.
00:22:07
Speaker
Can you talk about that a little bit?
00:22:10
Speaker
Yeah, so basically the size of the collection doesn't so much matter.
00:22:15
Speaker
It can be five by 10 or 30 by 30.
00:22:20
Speaker
If the patient has no clinical signs of infection,
00:22:24
Speaker
then that can be left alone.
00:22:26
Speaker
You'd be surprised what you see in a scan six months later.
00:22:29
Speaker
So either if there are infected gas bubbles within the collection, so these little black dots and you see them typically spread out through the collection, which will tell you, listen, this is not a fluid collection.
00:22:42
Speaker
This is thick stuff, necrosis, because the gas is infected inside it.
00:22:48
Speaker
Otherwise you would see an air fluid level, right?
00:22:50
Speaker
That's one.
00:22:51
Speaker
And two, if you're in doubt,
00:22:53
Speaker
patient is very sick.
00:22:54
Speaker
Half of the patients, only half of those who have infection in the collection have gas bubbles.
00:23:00
Speaker
The other half you cannot see on the CT scan.
00:23:03
Speaker
So those may require a sterile aspiration to detect any bacteria in the collection.
00:23:10
Speaker
So that's the key point if they're infected or not.
00:23:13
Speaker
If not infected, leave it alone.
00:23:15
Speaker
It's not the source of your patient being sick.
00:23:19
Speaker
Excellent.
00:23:20
Speaker
And just to
00:23:20
Speaker
To dive a little bit deeper on this, I think it's important that there are a lot of clinical signs that can give you a good indication of potential infection of these necrotic fluid collections.
00:23:32
Speaker
You mentioned the CT appearance.
00:23:35
Speaker
I presume that also you could get biomarkers such as procalcitonin, and if that is very low, it'd be very unlikely that it's an infection, right?
00:23:44
Speaker
You can also look at other markers as well.
00:23:46
Speaker
And that in a lot of cases, like you said,
00:23:48
Speaker
The clinical diagnosis can be made and we can avoid a needle insertion to document infection.
00:23:54
Speaker
But in some cases, if you're not sure, you might have to put that needle in, right?
00:24:01
Speaker
Yeah.
00:24:01
Speaker
So I think in the first two weeks of pancreatitis in a sick patient, the ICU patient is basically impossible to differentiate between inflammation and infection.
00:24:13
Speaker
So luckily, that's also not the major issue because it's very rare to have infection of a collection in the first two weeks.
00:24:19
Speaker
And if it were so, it can still be treated only with antibiotics.
00:24:23
Speaker
So I think in the first two weeks, there's definitely no no point to stick in anything there around the pancreas.
00:24:30
Speaker
After two weeks, then that may help you.
00:24:35
Speaker
Maybe it'll help you to tailor antibiotic treatment, although strangely enough.
00:24:40
Speaker
because it's impacted because it's necrosis is not an abscess.
00:24:45
Speaker
It's not a fluid collection.
00:24:46
Speaker
So you may have one bacteria on the left side of the collection.
00:24:48
Speaker
You can have another bacteria on the right side of the collection.
00:24:51
Speaker
So it's not 100% guaranteed that if you culture something into tailor your antibiotics to that, that the patient will improve.
00:24:58
Speaker
So that makes it a bit more complicated.
00:24:59
Speaker
But if you're three, four weeks out and in doubt, I would stick a needle in with a nice sterile approach.
00:25:07
Speaker
We would do the fire intervention radiology
00:25:09
Speaker
that may then really help you.
00:25:13
Speaker
Excellent.
00:25:14
Speaker
And in terms of managing this, obviously, as a surgeon, you mentioned that your first impulse is always to perform surgery.
POINTER Trial on Drainage Timing
00:25:23
Speaker
But in pancreatitis, it's a very individualized case where perhaps waiting and not intervening is the best mode.
00:25:30
Speaker
And we've learned that through the years.
00:25:32
Speaker
But I also think that we went from surgery to delaying surgery to stage interventions.
00:25:38
Speaker
And now
00:25:39
Speaker
We have the POINTER trial that you published recently in the New England Journal of Medicine.
00:25:43
Speaker
Could you just tell us a little bit about that trial, what you were looking at and what you found?
00:25:48
Speaker
Yeah, basically for the fourth or the fifth time in a row, I lost count.
00:25:51
Speaker
The same thing.
00:25:53
Speaker
We tried to be better by being more aggressive.
00:25:56
Speaker
So we thought, okay, let's do as we do in pancreatic surgery, which is any infected fluid drain as soon as possible, no matter how small aggressive drainage showed.
00:26:06
Speaker
We randomized patients who had documented or highly suspicion of infection to percutaneous or endoscopic transgastric drainage within 24 hours.
00:26:16
Speaker
So very aggressive versus antibiotics.
00:26:20
Speaker
Wait and wait and see if we can reach the stage of walled off necrosis and then drain.
00:26:24
Speaker
And surprisingly, contrary to what we were expecting, later delaying waiting was better.
00:26:31
Speaker
These patients, the ones who recovered, actually were home two weeks earlier.
00:26:37
Speaker
two weeks earlier, which was a big surprise.
00:26:40
Speaker
Yeah.
00:26:40
Speaker
And also they required, from what I read, far less interventions, which is always a good thing for patients from the patient perspective, because every intervention is associated with its own potential complications, like you mentioned.
00:26:53
Speaker
And the other thing that also struck me as very, very interesting was that a lot of these patients actually did not require intervention at all, that there was a percent that was not insignificant, that with conservative management got better.
00:27:08
Speaker
Absolutely, 39%, only antibiotic treatment, no drain needed, 39%.
00:27:14
Speaker
So I think that's another lesson of less is more and really being very thoughtful about these patients and trying to manage those impulses.
00:27:23
Speaker
Another question as we wrap up the complication, the local complication management is, are there other indications other than surgery that might require, I'm sorry, other than infection that might require intervention?
00:27:37
Speaker
I know that's not very common, but a lot of times these can cause obstructions and other problems.
00:27:43
Speaker
Yeah, absolutely.
00:27:44
Speaker
No, so you need to be on the lookout for abdominal compartment syndrome.
00:27:47
Speaker
So any patient that you have progressive difficulty ventilating or needs to go on his abdomen to be ventilated, you need to get a bladder pressure.
00:27:57
Speaker
So if you have new, and it's a standard definition, if you have new progressing organ failure and the bladder pressure goes up above 21,
00:28:07
Speaker
Think of it is basically abdominal compartment syndrome and that that requires a full length midline laparotomy and then with temporary closure of the oven with some system that may save the patient.
00:28:19
Speaker
There are some specialists I know who say abdominal compartment syndrome is just an early sign of death.
00:28:26
Speaker
But in fact, I think to about one in three, maybe even up to one in two of the patients can be saved.
00:28:33
Speaker
with adequate early management of abdominal compartment syndrome, one and two, clearly bleeding, which may occur after as quickly as a week already, one to three weeks out, especially with infection that may need usually intervention or radiology to coil the bleeding and then third, bowel ischemia.
00:28:52
Speaker
Excellent.
00:28:53
Speaker
And are there any concerns, I mean, in terms of obstruction of biliary ducts?
00:28:59
Speaker
Is that something that can occur with these collections?
00:29:02
Speaker
I have definitely not seen a lot of it, but obviously this is your area of expertise.
00:29:06
Speaker
Yeah, there's a lot of talk of it.
00:29:07
Speaker
There may be some mild color stasis, but it's very, very, very rare that the collection fully obstructs the extrahepatic bile duct.
00:29:17
Speaker
So that's not a clinical scenario you should worry about.
00:29:22
Speaker
Perfect.
00:29:23
Speaker
And one further question from a surgical perspective, which is not something that really we deal with in the ICU, but it's very important for our patients.
00:29:31
Speaker
And they usually ask us about this.
00:29:33
Speaker
You mentioned that the vast majority or the most important etiology relates to gallstones.
00:29:39
Speaker
And what's the timing of gallbladder removal and surgery for these patients?
00:29:44
Speaker
Yeah, so that was actually one of the trials that we did at a positive result with the proactive intervention.
00:29:52
Speaker
is that if it's a mild pancreatitis, it should not be a patient that you get in the ICU, a mild patient, so no organ failure, no collection.
00:30:01
Speaker
That patient should not go home with the gallbladder.
00:30:04
Speaker
So that patient should have a gollocystectomy during the same admission.
00:30:09
Speaker
The only thing that the current idea is that if you have a severe pancreatitis, then the gallbladder needs to be removed after six weeks after discharge.
00:30:20
Speaker
But that may change in the future.
00:30:22
Speaker
So we are planning a study on that topic actually as well.
00:30:24
Speaker
But so mild pancreatitis, same admission called cystectomy, non-mild pancreatitis, outpatient clinic of the surgeon first.
00:30:33
Speaker
As we close the clinical conversation, Mark, you obviously have done an amazing job with the Dutch pancreatic group pancreatitis group in terms of all the studies that you have really applied a rigorous scientific approach.
00:30:47
Speaker
And like you said, that's why we do the studies because a lot of times you're,
00:30:50
Speaker
clinical intuitions are proven wrong and you've demonstrated, right, that a lot of times perhaps a more moderate approach is better for patients.
00:31:00
Speaker
What are the next big questions that you think remain unanswered in acute pancreatitis?
Controlling Inflammatory Response
00:31:07
Speaker
So the holy grail in pancreatitis is how to sort of put a cap, how to damp the initial pro-inflammatory response because we just looked at 10-year
00:31:19
Speaker
uh, ICU mortality in early pancreatitis.
00:31:22
Speaker
And we've improved very, very little in the early pancreatitis mortality, a bit, but really surprisingly little.
00:31:30
Speaker
So, so we, that's, that's the next big thing.
00:31:33
Speaker
We need to find a way to, to, to make sure that pro-inflammatory peak is, is less high.
00:31:39
Speaker
And, and, and, and so, so studies are coming, but, but that's, that's the next big thing.
00:31:45
Speaker
Excellent.
00:31:46
Speaker
Well, I really want to be respectful of your time and appreciate you sharing your expertise.
00:31:50
Speaker
Again, thanks for the wonderful trial that was recently published, and we'll include all these trials in the show notes.
00:31:57
Speaker
Mark, we usually close the podcast with some questions unrelated to the clinical topic.
00:32:02
Speaker
Would that be okay?
00:32:04
Speaker
Absolutely.
00:32:05
Speaker
Are there any books that have influenced you significantly or that you have gifted to others?
00:32:12
Speaker
House of God.
00:32:15
Speaker
So that's a, it's interesting because obviously when, when I went to training, that was a, a perfect read.
00:32:22
Speaker
I think that newer generations probably a bit detached from that, but a lot of it still holds true.
00:32:27
Speaker
So we'll definitely put that in the, in the, in the, in the show, in the show notes.
00:32:32
Speaker
The second question relates to something that you believe to be true in medicine or in life that most other people don't believe or don't act like they believe.
00:32:43
Speaker
Yeah.
00:32:43
Speaker
So,
00:32:44
Speaker
So randomized trials, so they are a pain and a nuisance and they cost years to complete.
00:32:51
Speaker
But if you find a group of friends and you can pull it off, you save more patients potentially with one trial than treating patients as a doctor during your entire career.
Importance of RCTs in Medical Advances
00:33:06
Speaker
And I think this is a very timely comment.
00:33:10
Speaker
One of the reasons why I was so excited to talk with you and read your paper is that it was not related to COVID.
00:33:15
Speaker
And we've been kind of immersed in COVID for almost two years in the ICUs, and we're just coming off our fourth wave here in Texas.
00:33:25
Speaker
But I think that we see that still in COVID that even in a pandemic, getting together and doing the trials is what moves us forward.
00:33:37
Speaker
And there's no reason why we shouldn't be doing that in 2021 and finding a way to collaborate and find the right answers.
00:33:44
Speaker
Because over and over again, when we do the studies, we find surprises.
00:33:49
Speaker
And a lot of what we think makes sense does not pan out.
00:33:53
Speaker
But also, I think that there's no, like you said, one trial, despite the pain and the difficulty, ultimately will have an impact for years to come on patients that is hard to measure.
00:34:05
Speaker
Absolutely.
00:34:07
Speaker
And the last question is just, is there anything that you would want to share with our audience?
00:34:13
Speaker
Something that you want every intensivist to know could be a quote or fact or just a comment.
00:34:19
Speaker
Well, it's often if you treat these sick patients, you may get into like a sort of a discussion with the surgeon.
00:34:27
Speaker
And I've had this feeling recently.
00:34:30
Speaker
often.
00:34:30
Speaker
But what I think what we should do more is say to the surgeon, well, please, find five minutes, come here, let's sit down, two of us, look at the scan and discuss this case.
00:34:41
Speaker
Because I think the typical phone call of the intensivist to the surgeon, you need to come over and do an operation or the other way around is usually what isn't the best way to treat our patients.
00:34:51
Speaker
And I make these mistakes still every day myself.
00:34:54
Speaker
But I think just get down here.
00:34:56
Speaker
So let's sit down together.
00:34:58
Speaker
I'll come to you.
00:34:58
Speaker
I don't care.
00:34:59
Speaker
But just
00:35:00
Speaker
look at the patient, sit down to get a look at the scan and come up with a plan.
00:35:03
Speaker
That is, that is something we should do more than we probably all of us do.
00:35:07
Speaker
I think it's a great point, Mark.
00:35:09
Speaker
And I guess in terms of summary, the summarize of that is what I always try to remind myself, like you said, because we all fall in those same traps is we should listen more and ask more questions.
00:35:20
Speaker
Agree.
00:35:22
Speaker
Excellent.
00:35:22
Speaker
Well, thank you so much for your time and I really appreciate it.
00:35:26
Speaker
We'll definitely, uh,
00:35:28
Speaker
include all the trials you mentioned in the show notes.
00:35:31
Speaker
And I hope you have a wonderful rest of the day.
00:35:33
Speaker
Thank you so much, Mark.
00:35:35
Speaker
Thank you very much.
00:35:38
Speaker
Thank you for listening to Critical Matters, a sound podcast.
00:35:42
Speaker
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00:35:48
Speaker
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00:35:52
Speaker
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