Acute pancreatitis is a disease with several degrees of severity - from mild, with a tendency to self-cure, which requires a short hospital stay, to a rapidly evolving malignant form, accompanied by multiple organ failure (SOP) and sepsis. Severe forms of pancreatitis requiring hospitalization in the intensive care unit (ICU) are observed in a small number of patients, but mortality in this category of patients reaches 30 to 50% and the average length of hospitalization is more than 1 month.

In 2004, an international conciliation conference was held, attended by representatives from the American Thoracic Society (ATS), the European Respiratory Society (ERS), the European Intensive Care Society (ESICM), the Society of Critical Medicine (SCCM) and the French Resuscitation Society (SRLF). The purpose of the conference was to develop recommendations for the treatment of patients with severe acute pancreatitis (TOP) who are in critical condition and hospitalized in the ICU. The new recommendations, unlike those previously proposed, are based on evidence. 10 experts participated in coordinating the recommendations - specialists in the field of surgery, therapy and critical condition medicine. In total, 23 recommendations have been proposed which affect the main aspects of the treatment of patients with TOP:

One of the risk factors for a negative result in patients with severe acute pancreatitis is the early development of organ failure. The presence of several systems for assessing the severity of the disease in patients with pancreatitis, biological markers and radiological signs of the severity of the process of early identification of patients at risk of developing multiple organic failure implies an observation dynamic in intensive care conditions. The basis of management is also the early onset of infusion therapy, which is most recommended for performing in intensive care.

Recommendation 1. There are no specific criteria for hospitalization in patients with severe acute pancreatitis in the ICU. You should focus on traditional and generally accepted indications for hospitalization. Particular attention should be paid to patients at high risk of rapid negative dynamics: the elderly, with excess body weight (more than 30 kg / m2), requiring a continuous infusion and patients with significant pancreatic necrosis (more than 30%). Level of evidence 5, category D.

Recommendation 2. If possible, patients with severe acute pancreatitis should be monitored by a multidisciplinary team of doctors under the supervision of a resuscitator. It is necessary to provide access to additional research methods: endoscopy, endoscopic retrograde cholangiopacreatography (ERCP), the usual operating room, as well as an office for interventions under radiological control. Level of evidence 3a, category B.

Recommendation 3. Invasive hemodynamic monitoring should be performed. It is necessary to carry out a daily assessment of the condition (clinical examination, diuresis, blood gases) with an assessment of the pulmonary function (hypoxemia). Specific scales should be used to identify patients at risk of developing complications, but this should not replace dynamic observation of the patient. Level of evidence 5, category D.

Recommendation 4. Instead of determining the level of markers, such as, for example, C-reactive protein and procalcitonin, it is recommended to use general clinical data to clarify the dynamics of severe acute pancreatitis and to sort the patients. Level of evidence 5, category D.

Recommendation 5. If it is difficult to diagnose at the first examination, to confirm the diagnosis and the differential diagnosis, in the absence of contraindications, the CT scan of the digestive tract (with iv contrast) recommended after an adequate infusion is recommended. Level of evidence 5, category D.

Recommendation 6. To identify local complications, computed tomography, if possible, is recommended to be postponed from 48 to 72 hours due to the fact that pancreatic necrosis may not be seen earlier than this period. Level of evidence 5, category D.

Infectious complications with pancreatic necrosis develop in 30 to 50% of patients, which is confirmed by research data using computed tomography or directly during surgery. These patients also have a higher risk of multiple organ failure and death.

Recommendation 7. Due to the low level of evidence obtained from several clinical studies and meta-analyzes, the prophylactic use of systemic antibacterial and antifungal drugs in patients with pancreatic necrosis is not recommended. Level of evidence 2b, category B.

Recommendation 8. Selective bowel decontamination is not recommended in patients with pancreatic necrosis. More studies are needed to confirm this management strategy for patients with severe acute pancreatitis.

The condition of patients with severe acute pancreatitis is often characterized by an increase in metabolism, so the timely appointment of nutritional support is necessary to prevent malabsorption.

Recommendation 9. In patients with severe acute pancreatitis, enteral nutrition is preferable to parenteral nutrition. Enteral nutrition should be prescribed after compensation for hemodynamic disturbances after the infusion. If possible, enteral nutrition should be carried out through a small tube in the small intestine. Level of evidence 1a, category A.

Recommendation 10. Parenteral nutrition is prescribed after enteral nutrition is ineffective for 5-7 days of use. Level of evidence 5, category D.

Recommendation 11. When prescribing parenteral nutrition, preference should be given to environments rich in glutamine. Level of evidence 5, category D.

Recommendation 12. In patients receiving parenteral and enteral nutrition, it is necessary to control the level of glucose in the blood. Level of evidence 1b, category A.

Recommendation 13. Systematic use for enteral nutrition in formulations containing immunomodulators and probiotics is not recommended. Level of evidence 5, category D.

Recommendation 14. A fine needle aspiration biopsy under ultrasound or CT control with Gram staining and culture studies of the material obtained in patients with radiological signs of pancreatic necrosis and clinical signs of infection is recommended.

Recommendation 15. In patients with uninfected pancreaticecrosis, necrectomy and / or drainage is not recommended. Level of evidence 4, category C.

Recommendation 16. Surgical necrectomy and drainage are recommended in patients with infected pancreatic necrosis and / or in the presence of an abscess, confirmed radiologically by the presence of free gas or according to a study using a fine needle aspiration biopsy. The "gold standard" is open surgical necrectomy. In certain patient categories, minimally invasive procedures, such as laparoscopic and / or percutaneous procedures, may be used. Level of evidence 4, category C.

Recommendation 17. The delayed implementation (2-3 weeks) of surgical necrectomy and / or drainage is recognized to ensure a better demarcation of the necrotic pancreas. However, the priority indications for the time of surgery must be the clinical picture (severity and dynamics of symptoms). Level of evidence 4, category C.

Recommendation 18. Biliary pancreatitis should be suspected in all patients with severe acute pancreatitis; therefore, in this category of patients there is a need for research using ultrasound and biochemical tests. Level of evidence 4, category C.

Recommendation 19. In cases of obstructive jaundice (or other signs of obstruction of the bile ducts and / or pancreatic ducts) and acute biliary pancreatitis, confirmed or suspected, it is recommended to perform the ERCP within 72 hours of onset of symptoms. If for technical reasons it is impossible to perform the ERCP, it is necessary to use alternative methods of bile duct drainage. Level of evidence 5, category D.

Recommendation 20. In the absence of obstructive jaundice, but in the presence of severe acute pancreatitis which has developed as a result of suspected or confirmed cholelithiasis, ERCP should be performed within 72 hours of the first onset of symptoms. Level of evidence: 1c, category B.

Recommendation 21. An early infusion appointment is necessary to replenish the volume of circulating blood (level of evidence 1b, category A) and measures to eliminate respiratory failure in patients with acute respiratory distress syndrome (level of evidence 1b, category A).

Recommendation 22. After confirmation or a high probability of pancreatic necrosis infection, treatment should be carried out in accordance with current recommendations for the treatment of patients with sepsis. Among the new drugs and regimens, activated recombinant protein C (drotrecogin alpha) (level of evidence 1b, category A) and low doses of glucocorticoids for the correction of shocks (level of evidence: 1b, category B).

Recommendation 23. Immunomodulators, such as TNF-alpha and lexipathant, are not recommended for use in this category of patients. Level of evidence 5, category D.