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Prognose und Monitoring bei akuter Pankreatitis

Prognosis and monitoring of acute pancreatitis

  • Leitthema
  • Published:
Intensivmedizin und Notfallmedizin

Zusammenfassung

Die akute Pankreatitis (AP) ist ein potenziell tödliches Krankheitsbild mit in Deutschland steigender Inzidenz. Prognostisch entscheidend ist die möglichst frühe Erkennung der schweren/nekrotisierenden AP mit einer Mortalität von 15–42%. Dagegen verläuft die leichte/ödematöse Pankreatitis in <1% tödlich. Der Stellenwert verschiedener Prognoseparameter und Scores variiert abhängig vom zeitlichen Stadium der Erkrankung. Daher ist eine exakte Festlegung des Krankheitsbeginns mit Schmerzbeginn von großer Bedeutung. Abhängig davon sind mindestens 3 „prognostische Szenarien“ zu unterscheiden und die jeweilig validen Prädiktoren zu bestimmen. Für das „Szenario der Primärversorgung“ haben v. a. einfache Einzelparameter herausragende Bedeutung: Frühe Erstvorstellung, erhöhter Blutzucker, erhöhter Hämatokrit und erhöhter BUN sind Prädiktoren mit hoher Sensitivität und hohem negativ-prädiktivem Wert bei niedriger Spezifität und niedrigem positiv-prädiktivem Wert. Patienten, die eines oder mehrere dieser Kriterien erfüllen, sollten intensivmedizinisch behandelt werden. Nach ca. 48 h ergibt sich das „Szenario der frühen Reevaluation“. Zu diesem Zeitpunkt erreichen der APACHE-II-Score (Grenzwert >8) und der Ranson-Score (Grenzwert >3) sowie das CRP (>15 mg/dl) eine ausreichende Treffsicherheit. Für Intensivpatienten wurde ein eigener Prognosescore entwickelt, der als wesentliche Prädiktoren des „Szenarios der Intensivaufnahme“ arteriellen pH, Alter, MAP und BUN beinhaltet. Retrospektive Analysen am Ende des Intensivaufenthaltes belegen eine Assoziation der Mortalität mit der Notwendigkeit einer Nierenersatztherapie, minimalem Gesamteiweiß, minimalem Serumkalzium und minimalem arteriellem Bikarbonat.

Abstract

Acute pancraetitis is a potentially life-threatening disorder with increasing incidence. Early diagnosis and therapy of severe/necrotizing pancreatitis with a mortality of 15–42% is of paramount importance. By contrast, mild/edematous pancreatitis has a mortality below 1%. Prediction of severity as well as prognosis are further impeded by a marked time dependency of the prognostic value of the different predictors. Therefore, exact determination of the onset of symptoms (pain) is highly relevant. Depending on the time that the symptoms started, at least three prognostic scenarios with different values of prognostic markers have to be taken into account. Regarding the first presentation/emergency room scenario, several “simple” parameters have high prognostic value: early presentation (within <24 h after the onset of symptoms), increased blood glucose, increased hematocrit, and increased blood urea nitrogen (BUN) have been demonstrated to be predictors with high sensitivity and high negative predictive value, but low specificity and low positive predictive value. Patients fulfilling at least one of these criteria should be transferred to the ICU, although not all of these patients will develop severe/necrotizing pancreatitis. After 48 h (early re-evaluation scenario), the APACHE-II score (cut-off >8), the Ranson score (cut-off >3 points), and a serum CRP level >15 mg/dl have appropriate prognostic accuracy. For the subgroup of patients admitted to an ICU (ICU admission scenario), a specific score has been introduced with arterial pH, age, mean arterial pressure (MAP), and BUN being the most important predictors for mortality. Retrospective analyses at the end of the ICU stay demonstrated an association of mortality with the requirement of renal replacement therapy and minimum levels of serum protein, calcium, and arterial bicarbonate.

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  1. II. Medizinische Klinik, Intensivstation 2/11, Klinik Klinikum Rechts der Isar, Ismaningerstr. 22, 81675, München, Deutschland

    W. Huber & R.M. Schmid

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  2. R.M. Schmid
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Correspondence to W. Huber.

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Huber, W., Schmid, R. Prognose und Monitoring bei akuter Pankreatitis. Intensivmed 47, 243–250 (2010). https://doi.org/10.1007/s00390-009-0157-6

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