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Critical Care  2005 

Contemporary management of infected necrosis complicating severe acute pancreatitis

DOI: 10.1186/cc3928

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Abstract:

Pancreatic necrosis complicating severe acute pancreatitis is a challenging scenario in contemporary critical care practice. Patients are often relatively young (the median age was 55 years [range 19–74 years] in a recent cohort report [1]) and postrecovery quality of life should be good [2], and so there is much to strive for. However, length of stay can be prolonged, and the evidence guiding treatment is limited and contradictory in nature. Crucially, care for these patients involves close multidisciplinary cooperation because the margin for therapeutic error in decision making in relation to the timing and nature of intervention is small.It is generally accepted that death from acute pancreatitis has a bimodal temporal distribution; early deaths are related to multiple organ failure [3] and may in particular affect elderly patients, in whom decisions on thresholds for intervention may influence treatment and outcome. Death from infected necrosis or the sequelae of peri-pancreatic sepsis is responsible for most late mortality [4]. Management of this group of patients is complex, but there has been a recent increase in the scope of available therapeutic options.Recent developments can be categorized into those directed at diagnosing infected necrosis, new pharmacological interventions and recent surgical trends.The path finding study conducted by Beger and coworkers [5] showed that the proportion of patients with pancreatic necrosis with evidence of bacterial colonization increased as the disease progressed. Infection of peripancreatic necrosis is relatively uncommon during the first 10 days of illness, and accordingly there is little to be gained by attempts at radiologically guided aspiration of fluid at this stage. Fine-needle aspiration of peripancreatic necrosis to look for evidence of infection comes into play between days 10 and 14 of the illness and, if negative, aspirates should be repeated at regular intervals thereafter. The area to be targeted requires

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