重症急性胰腺炎英文PPTSevereacutepancreatitisppt课件.ppt

1、常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Severe acute pancreatitis S_c7 Academy for Infection Management 2006(All Rights Reserved).常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料History 33-year-old male Alcohol binge:vodka Awake and conve

2、rsant Severe abdominal pain,vomiting,dyspnoea.常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Physical and laboratory examinationsTemperature 38.1CPulse 96 bpm,respirations 20/minBlood pressure 110/70 mmHgAbdomen tender,distended,quietAmylase 3500 IU/LLipase 1100 IU/LAST 2

3、50 IU/LLDH 350 IU/L WBC count 16 000/mm3 Arterial blood gases:pH 7.30,PaCO2 32,PaO2 58,BE-5.常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Which evaluations would you perform to determine if the patient has severe pancreatitis?C-reactive proteinComputed tomography(CT)scan

4、Severity scoresRanson scoreGlasgow(Imrie)scoreAPACHE II or III scoreBalthazar score.常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Initial tests and treatment Fluid resuscitation Chest radiography CT Calculation of Ranson score(at 48 hours).常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些

5、事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料The patient has severe pancreatitisby CT criteriaCentral necrosis of the pancreas 30%Peripancreatic oedema and inflammation.常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Ranson score:a pancreatitis-specific severity of illness

6、score Age 55 years WBC 16 000/mm3 Glucose 200 mg/dL LDH 350 IU/L AST 250 IU/L Haematocrit decrease 10%points BUN increase 5 mg/dL Serum calcium 8 mg/dL PaO2 60 mm Hg Base deficit 6 LPresent on admissionDuring the first 48 hours.常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培

7、训材料The patient has eight positive Ranson criteriaSGOT 250 IU/LLDH 350 IU/L WBC count 16 000/mm3PaO2 60 mm HgBase deficit 6 LCalcium concentration 0 percentage pointsThe predicted mortality rate for a Ranson score of 8 is 60%Eachempati et al.Arch Surg 2002Figure reproduced with permission from Arch S

8、urg.常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Would you start prophylactic antibiotics?NoYes,with Ceftriaxone?Gentamicin plus metronidazole?Imipenem/cilastatin or meropenem?Ciprofloxacin plus metronidazole?Other?Yes,plus fluconazole.常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈

9、用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Penetration of pancreatic tissue and pancreatic juice by antimicrobial agents Poor Aminoglycosides Vancomycin Variable Penicillins Cephalosporins Good Carbapenems Metronidazole Quinolones FluconazoleBassi et al.Antimicrob Agents Chemother 1994;38:830836.常见心律失

10、常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料What is this patients risk of developing infection?50%.常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Incidence of peripancreatic infection after acute pancreatitisAll episodes 3%7%Any pancreatic necros

11、is 20%70%Pancreatic necrosis 30%15%30%Pancreatic necrosis 50%40%70%Beger et al.Gastroenterology 1986;91:433438Beger et al.Pancreatology 2003;3:93101Buchler et al.Ann Surg 2000;232:619625.常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Day 14Day 7Day 21Should prophylaxis be

12、 given?for the entire at-risk period?Pancreatic infections almost never occur before Day 7 The peak incidence is at Day 14Beger et al.Gastroenterology 1986;91:43343899%of data95%of data68%of data.常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料How long would you administer

13、 antibiotic prophylaxis?Would not administer prophylaxis1 week2 weeks3 weeksUntil ICU dischargeShould prophylaxis be administered for the entire risk period?.常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Prophylactic antibiotics for severe acute pancreatitisFirst double-

14、blind,placebo-controlled trial 114 patients enrolled,76 with necrosis Entry criteria C-reactive protein 150,or Necrosis on contrast-enhanced CT,and 120 mg/dL,or Multiple organ dysfunction score 2 points Meropenem 1 g q8h vs placebo Primary end-point Pancreatic/peripancreatic infection within 42 days

15、Dellinger et al.Ann Surg(in press).常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Prophylactic antibiotics for severe acute pancreatitis:trial resultsOutcomeMeropenem%Placebo%p-valuePancreatic/peripancreatic infection18120.41Surgical intervention26200.48Mortality20180.80D

16、ellinger et al.Ann Surg(in press).常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料The downside of prolonged antibiotic prophylaxis Allergy Expense Resistance Superinfection.常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Prophylactic antibiotics

17、for severe acute pancreatitis Recovery of resistant bacteriap Week 1Sensitivity(%)8897Specificity(%)90100Pos.pred.value(%)83100Neg.pred.value(%)9398Accuracy(%)8998.常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Results of culture and susceptibility testing Patient underwe

18、nt CT-guided fine-needle aspiration Peripancreatic fluid Proteus mirabilis(pan-sensitive)Blood No growth Urine No growth Sputum No growth.常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Microbiology of infected pancreatic necrosis(%)Fernandez-del Castillo 1998Buchler 2000G

19、ram-positive5546Gram-negative2636Anaerobes 2 4Candida spp.17 6MixedNot reported10Fernandez-del Castillo et al.Ann Surg 1998;228:676684Buchler et al.Ann Surg 2000;232:619626.常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Therapy Formal operative debridement and drainage On

20、ly one operation required Meropenem x 14 days Choice based on tissue penetration Dosage reduction for creatinine clearance 35 mL/min.常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Outcome Fever and leukocytosis resolve Organ dysfunction resolves Renal function improves Cr

21、eatinine stabilises at 2.0 mg/dL Patient recovers.常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Key learning pointsMost patients(85%)with acute pancreatitis do not develop severe diseaseDetermination of severity of illness provides prognostic information and can guide th

22、erapyAntimicrobial prophylaxis does not prevent secondary infection in severe acute pancreatitis,but does increase risk of resistant pathogens if infection does occurAntibiotics may be withheld until needed for therapy.常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料AIM co

23、re principles Select the most appropriate antibiotic depending on the patient,risk factors,suspected infection and resistance Recognise that prior antimicrobial administration is a risk factor for the presence of resistant pathogens Ensure adequate containment of the infection source by removing contaminated devices and draining/debriding infectious tissue.