Severity scoring for prognostication in patients with severe acute pancreatitis: comparative analysis of the Ranson score and the APACHE III score

BACKGROUND: Despite a paucity of validation, the Ranson score is still the most popular method for gauging the severity of pancreatitis. HYPOTHESES: The Ranson score more accurately predicts outcomes in patients with severe acute pancreatitis (SAP) when compared with APACHE (Acute Physiology and Chronic Health Evaluation) III scores, and the individual components of the Ranson score differ in their capacities to predict outcome in patients with SAP. METHODS: Patients admitted with SAP to a university surgical intensive care unit (ICU) were studied prospectively. Each component and the total Ranson score were recorded. Also recorded were the APACHE II and III scores. These Ranson variables were compared using univariate analysis of variance for mortality, need for operative debridement, and need for an ICU stay for longer than 7 days. Significant variables were then analyzed by a multivariate analysis of variance to assess independent predictors of mortality, the need for debridement, and prolonged length of stay. Data are given as the mean +/- SEM. RESULTS: Seventy-six patients (21.1% mortality), aged 61.8 +/- 1.9 years, were studied. The mean APACHE III score was 48.2 +/- 3.3, and the mean ICU stay was 10.4 +/- 2.1 days. The number of positive Ranson variables was significantly higher in nonsurvivors compared with survivors (5.6 +/- 0.5 vs 3.4 +/- 0.2; P<.001), as were the APACHE III score (76.9 +/- 9.9 vs 40.5 +/- 2.5; P<.001) and ICU stay (24.9 +/- 7.5 vs 76.5 +/- 1.9 days; P =.002). Ranson variables that predicted mortality included values for blood urea nitrogen, calcium, base deficit, and fluid sequestration. CONCLUSIONS: The Ranson score remains a valid predictor of outcomes in patients with SAP, and individual Ranson variables determined 48 hours after hospital admission predicted adverse outcomes more accurately than early Ranson variables in patients with SAP.     

Acute pancreatitis: a prospective study of its incidence, aetiology, severity, and mortality in Iceland.

OBJECTIVE: To evaluate the incidence, aetiology, severity and mortality of patients with acute pancreatitis. DESIGN: Prospective study. SETTING: University hospital, Iceland. PATIENTS AND METHODS: All 50 patients diagnosed with acute pancreatitis during the one-year period October 1998-September 1999 inclusive. MAIN OUTCOME MEASURES: APACHE II, and Ranson and Imrie scores, and C-reactive protein (CRP) concentrations. The Balthazar-Ranson criteria were used for scoring of computed tomograms (CT). RESULTS: 27 of the 50 patients were male. The median age of the whole series was 60 years (range 19-85). The estimated incidence was 32/100000 for the first attack of acute pancreatitis. The causes were; gallstones 21 (42%), alcohol 16 (32%), miscellaneous 12 (24%), and idiopathic 1 (2%). 15 (33%) of the patients had APACHE II scores > or = 9, 17 (38%) had Ranson scores of > or = 3, 23 (50%) had Imrie scores of > or = 3, and 16 (34%) had CRP concentrations over 210 mg/L during the first 4 days or > 120 mg/L during the first week. Seven patients had severe pancreatitis. 2 patients in the whole group died, and both had clinically severe pancreatitis. CONCLUSIONS: This study indicates that the incidence of less severe acute pancreatitis is rising. Prospective assessment makes it possible to evaluate the aetiological factors more accurately. Measurement of the CRP concentration is an attractive and simple alternative to the severity scoring systems currently in use.     

Severity assessment and prognosis definition in patients with the acute pancreatitis

Investigation of white blood cell and lymphocyte concentration and white blood cell intoxication index (WBCII), integral systems APACHE II and Ranson reliably reflected the severity of clinical status in patients with acute pancreatitis and had prognostic value. At the same time white blood cell concentration and indices of APACHE II reflected to lesser extent the severity of clinical status, and white blood cell concentration didn't have any prognostic value. Application of lymphocyte concentration and WBCII can be recommended in urgent surgery for evaluation of clinical status and prognosis at early stages of diagnostics and treatment of acute pancreatitis.     

Urinary trypsinogen activation peptide as a marker of severe acute pancreatitis

BACKGROUND: Trypsinogen activation peptide (TAP) may be an early marker of severe pancreatitis. Previous studies have included all patients with organ failure in the group with severe pancreatitis, although patients with transient organ failure may have a good prognosis. The aim of this study was to determine the value of urinary TAP estimation for prediction of severity of acute pancreatitis, and to validate use of several markers of prediction of severity against a new, stringent definition of severity. METHODS: Patients with acute pancreatitis were recruited within 24 h of onset of symptoms. Urine and blood samples were collected for 24 h, and Acute Physiology And Chronic Health Evaluation (APACHE) II (24 h), Ranson (48 h) and Glasgow (48 h) scores were calculated. Severe acute pancreatitis was defined by the presence of a local complication or the presence of organ failure for more than 48 h. RESULTS: Urinary TAP levels were significantly greater in patients with severe pancreatitis than in those with mild disease during the first 36 h of admission. The highest of three estimations of TAP in the first 24 h was as effective as APACHE II at 24 h in predicting severity. At 24 h after admission, urinary TAP was better than C-reactive protein (CRP) in predicting severity. The combination of TAP and CRP at 24 h allowed identification of high- and low-risk groups. The new definition of severity excluded 24 of 190 patients with transient organ failure; none of these patients died. CONCLUSION: Use of TAP improved early prediction of the severity of acute pancreatitis. Organ failure that resolves within 48 h does not signify a severe attack of acute pancreatitis.     

Determinants of ICU mortality in necrotizing pancreatitis: the influence of Staphylococcus epidermidis

BACKGROUND: The severity of acute necrotizing pancreatitis ranges from self-limited to rapidly progressive illness leading to multiple organ failure. Several scoring systems and clinical parameters have been used to predict the course of the disease. The aim of this study was to evaluate the clinical and microbiological determinants of poor outcome in necrotizing acute pancreatitis. METHODS: Medical records of 67 consecutive patients admitted to the intensive care unit (ICU) of Oulu University Hospital due to acute necrotizing pancreatitis were retrospectively analyzed. All patients received standard surgical intensive care. RESULTS: Patients who died (n=14) had significantly higher APACHE II, SAPS II and Ranson scores at admission to the ICU and maximum SOFA score achieved during ICU stay than did the survivors. The non-survivors were hospitalized later from the time the symptoms were first manifest (5.3 vs. 2.4 days, P=0.051). Mechanical ventilation (P=0.002), surgical management (P=0.028), open packing surgical management (P=0.03), renal replacement therapy (P<0.001), use of inotropic drugs (P=0.012) and Staphylococcus epidermidis growth (P=0.029) in infected pancreatic tissue were all associated with mortality. CONCLUSIONS: In this study the time to hospitalization, severity of illness, intensity of care, and surgical management were associated with poor outcome. In addition, Staphylococcus epidermidis in pancreatic necrosis was associated with increased mortality.     

Simple scoring system for the prediction of the prognosis of severe acute pancreatitis

BACKGROUND: In severe acute pancreatitis (SAP), it is important clinically to predict the prognosis at the time of admission. Most scoring systems for severity of acute pancreatitis consist of multiple factors and are complicated. This investigation aimed to propose a simple scoring system for the prediction of the prognosis of SAP. METHODS: Prognostic factors were evaluated by receiver operator characteristic curve analyses and multivariate analysis from data that were obtained on admission of 137 patients with SAP. A simple scoring system with 3 most useful factors was made, and its usefulness was investigated in comparison with conventional scoring systems. RESULTS: Three prognostic factors were selected: serum blood urea nitrogen > or = 25 mg/dL, serum lactate dehydrogenase > or = 900 IU/L, and contrast-enhanced computed tomography finding with pancreatic necrosis. On admission, 137 patients were classified from 0 to 3 by the number of positive items (simple prognostic score [SPS]). Mortality rates for patients whose SPS was 0, 1, 2, and 3 were 2% (1/42 patients), 18% (7/40 patients), 48% (12/25 patients), and 67% (20/30 patients), respectively. Furthermore, when usefulness of SPS was compared with conventional scoring systems, the area under the curve by receiver operator characteristic curve analyses in SPS was 0.83; the Ranson score was 0.83; the Japanese severity score was 0.83; the Acute Physiology and Chronic Health Evaluation II score was 0.81, and the Glasgow score was 0.75. After onset, SPS kept almost same levels from day 2 to day 6, and a significant difference was observed between survivors and nonsurvivors from day 1 to day 6. CONCLUSION: This scoring system that comprised 3 items is simple, is feasible for the prediction of prognosis and conventional scoring systems, and is useful for the selection of the extremely severe patients with SAP on admission.     

A comparison of the Ranson, Glasgow, and APACHE II scoring systems to a multiple organ system score in predicting patient outcome in pancreatitis

BACKGROUND: Systems for evaluating acute pancreatitis are useful in hospitalized patients. Traditional systems of evaluation are well established but might be outdated. We propose a Multiple Organ System Score (MOSS) containing data that are more consistently collected and which are accurate in predicting patient outcome. METHODS: A retrospective chart review of 49 patients was completed. We determined if the physician obtained all of the variables necessary to calculate Ranson, Glasgow, or APACHE II scores, if these scores were predictive of patient outcome in the form of length of hospital stay (LOS), and if new, more frequently evaluated variables could be used. RESULTS: None of the patients could be assigned complete scores. According to Spearman rank correlation, both Glasgow and MOSS showed correlation with patient outcome when APACHE II and Ranson did not. CONCLUSIONS: Although larger studies should be performed, the MOSS is useful in predicting outcomes of patients with acute pancreatitis.     

Identification of severe acute pancreatitis using an artificial neural network

BACKGROUND: The aim of this study was to construct and validate an artificial neural network (ANN) model to identify severe acute pancreatitis (AP) and predict fatal outcome. METHODS: All patients who presented with AP from January 2000 to September 2004 were reviewed. Presentation data on admission and at 48 hours were collected. Acute Physiology and Chronic Health Evaluation (APACHE) II and Glasgow severity (GS) score were calculated. A feed-forward ANN was created and trained to predict development of severe AP and mortality from AP; 25% of the data set was withheld from training and was used to evaluate the accuracy of the ANN. Accuracy of the ANN in predicting severity of AP was compared with APACHE II and GS scores. RESULTS: A total of 664 patients with AP were identified of whom 181 (27.3%) fulfilled the clinical and radiologic criteria for severe pancreatitis and 42 patients died (6.3%). Median APACHE II score at 48 hours was 4 (range, 0 to 23). ANN was more accurate than APACHE II or GS scoring systems at predicting progression to a severe course (P < .05 and P < .01, respectively), predicting development of multiorgan dysfunction syndrome (P < .05 and P < .01) and at predicting death from AP (P < .05). CONCLUSIONS: An ANN was able to predict progression to severe disease, development of organ failure and mortality from acute pancreatitis with considerable accuracy and outperformed other clinical risk scoring systems. Further studies are required to assess its utility in aiding management decisions in patients with AP.     

Clinical value of severity markers in acute pancreatitis.

Acute pancreatitis is a common digestive disease of which the severity may vary from mild, edematous to severe, necrotizing disease. An improved outcome in the severe form of the disease is based on early identification of disease severity and subsequent focused management of these high-risk patients. However, the ability of clinicians to predict, upon presentation, which patient will have mild or severe acute pancreatitis is not accurate. Prospective systems using clinical criteria have been used to determine severity in patients with acute pancreatitis, such as the Ranson's prognostic signs, Glasgow score, and the acute physiology and chronic health evaluation II score (APACHE II). Their application in clinical practise has been limited by the time delay of at least 48 h to judge all parameters in the former two and by being cumbersome and time-consuming in the latter. Contrast-enhanced computed tomography is presently the most accurate non-invasive single method to evaluate the severity of acute pancreatitis. It cannot, however, be performed to all patients with acute pancreatitis. Therefore, considerable interest has grown in the development of reliable biochemical markers that reflect the severity of acute pancreatitis. In this article we critically appraise current and new severity markers of acute pancreatitis in their ability to distinguish between mild and severe disease and their clinical utility.     

Early nonenhanced abdominal computed tomography can predict mortality in severe acute pancreatitis

We wondered whether nonenhanced computed tomography (CT) within 48 hours of admission could identify individuals at risk for higher mortality from acute pancreatitis. Data from the international phase III study of the platelet-activating factor-inhibitor Lexipafant was used to analyze noncontrast CT versus acute pancreatitis mortality. Nonenhanced CT examinations of the abdomen from the trial were classified by disease severity (Balthazar grades A-E) and then correlated with patient survival. Among the 477 individuals who underwent CT within 48 hours of admission and 220 individuals who did so over the subsequent 6 days, higher CT grades were associated with increased mortality. Each unit increase in Balthazar grade during the initial 48 hours was associated with an estimated increase in the risk of mortality of 33%, and this trend increased to 50% if pancreatic enlargement and peripancreatic stranding (grades B and C) were combined (P < 0.05). CT grade correlated minimally with Ranson, Glasgow, or APACHE II score during the initial 48 hours; however, this correlation improved over 3–8 days. Early nonenhanced abdominal CT in patients with acute pancreatitis is a valuable prognostic indicator of mortality in acute pancreatitis, even among patients without clinical features of severe acute pancreatitis.     

Diagnosis of acute pancreatitis]

The diagnosis of acute pancreatitis is based on clinical examination as described by Fitz in 1889 and on laboratory tests. Amylase and lipase levels in the blood are the most useful of the latter. The severity of acute pancreatitis is classically graded by the Ranson and Imrie scores: both systems are specific for acute pancreatitis but request 48 hours for a prognosis to be defined. Non specific prognostic scores such as APACHE II and SAPS avoid such a delay. Recent studies suggest that single biologic markers such as C-reactive protein and trypsinogen activation peptides may soon allow a simple and early assessment of the prognosis. In the meantime, CT is the reference diagnostic method whenever pathologic proof of the disease is lacking; such imaging strengthens the prognostic value of the bioclinical scores.     

Acute pancreatitis in children: spectrum of disease and predictors of severity

Background

The aim of this study was to describe the spectrum of disease in children with acute pancreatitis and assess predictors of severity.

Methods

Children (≤18 years) admitted to a single institution with acute pancreatitis from 2000 to 2009 were included. The accuracy of the Ranson, modified Glasgow, and pediatric acute pancreatitis severity (PAPS) scoring systems for predicting major complications was assessed.

Results

The etiology of pancreatitis in these 211 children was idiopathic (31.3%), medication-induced (19.9%), gallstones (11.8%), trauma (7.6%), transplantation (7.6%), structural (5.2%), and hemolytic-uremic syndrome (3.3%). Fifty-six patients (26.5%) developed severe complications. Using the cutoff thresholds in the PAPS scoring system, only admission white blood cell count more than 18,500/μL (odds ratio [OR], 3.1; P = .010), trough calcium less than 8.3 mg/dL (OR, 3.0; P = .019), and blood urea nitrogen rise greater than 5 mg/dL (OR, 4.1; P = .004) were independent predictors of severe outcome in a logistic regression model. The sensitivity (51.8%, 51.8%, 48.2%) and negative predictive value (83.2%, 83.5%, 80.5%) of the Ranson, modified Glasgow, and PAPS scores were, respectively, insufficient to guide clinical decision making.

Conclusion

Commonly used scoring systems have limited ability to predict disease severity in children and adolescents with acute pancreatitis. Careful and repeated evaluations are essential in managing these patients who may develop major complications without early signs.     

Calcitonin precursors in the prediction of severity of acute pancreatitis on the day of admission

BACKGROUND: Calcitonin precursors are sensitive markers of inflammation and infection. The aim of this study was to evaluate the role of plasma calcitonin precursor levels on the day of admission in the prediction of severity of acute pancreatitis, and to compare this with the Acute Physiology And Chronic Health Evaluation (APACHE) II scoring system. METHODS: Plasma concentrations of calcitonin precursors were determined on admission in 69 patients with acute pancreatitis. APACHE II scores were calculated on admission. Attacks were classified as mild (n = 55) or severe (n = 14) according to the Atlanta criteria. Plasma calcitonin precursor levels were determined with a sensitive radioimmunoassay. RESULTS: On the day of hospital admission, plasma levels of calcitonin precursors were significantly greater in patients with a severe attack compared with levels in those with a mild attack of pancreatitis (median 64 versus 25 fmol/ml; P = 0.014), but the APACHE II scores were no different (median 9 versus 8; P = 0.2). The sensitivity, specificity, positive predictive and negative predictive values, and accuracy for the prediction of severe acute pancreatitis were 67, 89, 57, 93 and 85 per cent respectively for plasma calcitonin precursor levels higher than 48 fmol/ml, and 69, 45, 23, 86 and 50 per cent respectively for an APACHE II score greater than 7. Differences in the specificity and accuracy of the two prognostic indicators were significant (P < 0.001 and P = 0.001 respectively). A plasma calcitonin precursor concentration of more than 160 fmol/ml on admission was highly accurate (94 per cent) in predicting the development of septic complications and death. CONCLUSION: The assay of plasma calcitonin precursors on the day of admission to hospital has the potential to provide a more accurate prediction of the severity of acute pancreatitis than the APACHE II scoring system.     

Simplified admission criterion for predicting severe complications of gallstone pancreatitis

HYPOTHESIS: Simple admission criteria (white blood cell count, > or =14. 5 x 10(9)/L; blood urea nitrogen level, > or =4.3 mmol/L [> or =12 mg/dL]; heart rate, > or =100 beats per minute; and serum glucose level, > or =8.3 mmol/L [> or =150 mg/dL]) are better predictors of severe complications of gallstone pancreatitis than an Acute Physiology and Chronic Health Evaluation II (APACHE II) score of 5 or greater, a modified Imrie (Glasgow) score of 3 or greater, and a biliary Ranson score of 3 or greater. DESIGN: A prospective consecutive case study. SETTING: A university-affiliated, urban, public hospital. PATIENTS: Ninety-two consecutive patients (77 women and 15 men, aged 18 to 76 years [mean age, 39 years]) with gallstone pancreatitis. Seventy-seven patients were Hispanic. MAIN OUTCOME MEASURES: Major local and systemic complications requiring intensive care unit care, and death. RESULTS: Fourteen patients (15%) had severe complications with a mortality of 2%. On univariate analysis, a white blood cell count of 14.5 x 10(9)/L or more (P =.03), a serum glucose level of 8. 3 mmol/L or more (> or =150 mg/dL) (P<.001), an APACHE II score of 5 or greater (P =.008), a modified Imrie score of 3 or greater (P<.001), and a biliary Ranson score of 3 or greater (P =.03) were statistically associated with the development of severe complications; whereas a blood urea nitrogen level of 4.3 mmol/L or more (> or =12 mg/dL) and a heart rate of 100 beats per minute or more were not. On multivariate analysis, only a serum glucose level of 8. 3 mmol/L or more (> or =150 mg/dL) was predictive of adverse events (P<. 001). CONCLUSIONS: Glucose level (> or =8.3 mmol/L [> or =150 mg/dL]) is the best single admission predictor of severe complications of gallstone pancreatitis and is superior to an APACHE II score of 5 or greater, a modified Imrie score of 3 or greater, and a biliary Ranson score of 3 or greater.     

Serum interleukin-15 level is a useful predictor of the complications and mortality in severe acute pancreatitis

BACKGROUND: In severe acute pancreatitis, multiple organ dysfunction syndrome and infectious complications are contributors to high mortality. Interleukin (IL)-15 is a novel cytokine that shares many biologic properties with IL-2. Serum IL-15 levels have not yet been determined in SAP. METHODS: Serum IL-15 concentrations were measured in 54 patients with severe acute pancreatitis on admission. The relationships with severity, organ dysfunction, infection, and prognosis were analyzed. Utility of IL-15 for the prediction of clinical outcome was evaluated by receiver operator characteristic (ROC) curve analysis. RESULTS: Serum IL-15 levels were increased significantly in severe acute pancreatitis (5.8 +/- 0.5 pg/mL), and they were correlated with Ranson, APACHE II, and Japanese severity score. Serum IL-15 levels were greater in patients with organ dysfunction, patients with infection, and nonsurvivors (P < 05 each). Incidences of organ dysfunction in patients whose IL-15 levels were less than 3.0, 3.0-5.3, and greater than or equal to 5.3 pg/mL, were 8%, 31%, and 89%, respectively (P < .001). Usefulness of IL-15 for the prediction of organ dysfunction was superior to CRP, IL-6, and IL-8, and it was similar to Ranson, APACHE II, and Japanese severity score. Incidences of infection in patients whose IL-15 levels were less than 5.5, 5.5-9.0, and greater than or equal to 9.0 pg/mL, were 7%, 25%, and 50%, respectively (P < .05). Mortality rates in patients whose IL-15 levels were less than 5.5, 5.5-9.0, and greater than or equal to 9.0 pg/mL, were 11%, 25%, and 80%, respectively (P < .001). Usefulness of IL-15 for the prediction of death was superior to CRP, IL-6, and IL-8. CONCLUSIONS: Serum IL-15 level is a useful predictor of the complications (especially organ dysfunction) and mortality in severe acute pancreatitis.     

Improved prediction of outcome in patients with severe acute pancreatitis by the APACHE II score at 48 hours after hospital admission compared with the APACHE II score at admission. Acute Physiology and Chronic Health Evaluation

HYPOTHESIS: The 48-hour APACHE (Acute Physiology and Chronic Health Evaluation) II score is a better predictor of pancreatic necrosis, organ failure, and mortality in patients with severe acute pancreatitis than the score at hospital admission. DESIGN: A retrospective analysis of 125 patients with acute pancreatitis. SETTING: A tertiary public teaching hospital. PATIENTS: Patients with severe acute pancreatitis as defined by 3 or more Ranson criteria or a hospital stay of longer than 6 days. MAIN OUTCOME MEASURES: Pancreatic necrosis, organ failure, and mortality. RESULTS: A significant association was found between the 48-hour score and the presence of pancreatic necrosis (P<.001), organ failure (P =.001), and death (P<.001). By contrast, the APACHE II score at admission was significantly associated only with the presence of organ failure (P =.007). Deteriorating APACHE II scores over 48 hours were significantly associated with a fatal outcome (P =.03). The combined APACHE II score (defined as the sum of the admission and 48-hour scores) was significantly higher among nonsurvivors than survivors (P<.001), and was strongly associated with the presence of pancreatic necrosis (P =.001) and organ failure (P<.001). The 48-hour and combined scores accurately predicted outcome in 93% of the patients compared with 75% by the admission score. CONCLUSIONS: The 48-hour APACHE II score has improved predictive value compared with the admission score for identifying patients with severe acute pancreatitis who have a poor outcome. A deteriorating APACHE II score at 48 hours after admission may identify patients at risk for an adverse outcome.     

Scoring systems for predicting outcome in acute hemorrhagic necrotizing pancreatitis.

Five scoring systems for predicting the severity and outcome of acute haemorrhagic necrotizing pancreatitis were retrospectively evaluated in 39 patients. The respective scores were Ranson, Imrie, APACHE II, multiple organ failure (MOF) and Sepsis Sensitivity Score (SSS). Twenty-two (56%) of the patients died. The survivors were significantly younger than the non-survivors, 68% of whom died within 3 weeks of admission to the intensive care unit. Stay in the unit was significantly longer in the former group. Sensitivity in prediction of death was best with APACHE II score greater than 9 (96%) and Ranson score greater than or equal to 3 (95%). Of the five scores, MOF greater than or equal to 4 gave the best equilibration between sensitivity (73%) and specificity (76%) and the strongest prediction of lethal outcome (80%). Although the independent factor age had low sensitivity (55%), it showed the highest values for specificity (88%) and prediction of death (86%). APACHE II scoring is concluded to be best for grading the severity of disease on admission to intensive care, while the MOF score is best for monitoring the degree of organ dysfunction and the intensity of supportive treatment.     

Sequential organ failure assessment score in predicting outcome in patients with acute pancreatitis

Aims/Objectives

To evaluate the sequential organ failure assessment (SOFA) score pertaining to the severity and outcome in acute pancreatitis, and compare its outcome with the APACHE II score in terms of accuracy and ease of operation with a view to establishing whether the SOFA scoring system can replace APACHE II in predicting severity and outcome of acute pancreatitis.

Methods

Fifty cases of acute pancreatitis were evaluated in this prospective study. These patients were treated as per standard protocols and followed up daily. Both SOFA and APACHE II scores were calculated at admission and thereafter at 48-hour intervals till discharge or death. Subsequently, the data were analysed, and receiver operating characteristic curves were made for SOFA, APACHE II and other biochemical parameters; a p-value < 0.05 was taken as significant.

Results

The SOFA score showed a significant association in predicting the severity of the disease, especially during the first week. Moreover, it decreased the predicted severity of APACHE II by 18% and mortality by 4.5%.

Conclusion

On the day of admission, SOFA scores were comparable with APACHE II in predicting the outcome with a higher area under the ROC curve, and displayed better predicting capability as compared to APACHE II.     

急性重症胰腺炎患者死亡预后因素临床分析

目的探讨影响急性重症胰腺炎预后的可能有关因素。方法回顾性分析1998年1月～2010年3月76例急性重症胰腺炎(Ranson评分≥3分,且APACHEⅡ评分≥8分)患者的临床资料。按照患者是否于入院60日内死亡分为死亡组(n=11)和存活组(n=65)。分析患者APACHEⅡ评分、Ranson评分、年龄、氧合指数、血肌酐等12项指标。结果入院60日内死亡患者共11例。与存活组相比,死亡组APACHEⅡ评分高(16.57±3.10vs12.04±2.95,t=2.859,P=0.006),Ranson评分高(4.71±0.76vs3.87±0.73,t=2.859,P=0.006),氧合指数低[(221±41)mmHgvs(285±48)mmHg,t=-3.353,P=0.002],血钙低[(1.77±0.39)mmol/Lvs(1.98±0.39)mmol/L,t=-2.187,P=0.033],血肌酐高[(103.1±24.4)μmol/Lvs(78.4±14.5)μmol/L,t=2.607,P=0.037],血糖水平高[(13.7±2.8)mmol/Lvs(11.0±1.5)mmol/L,t=2.448,P=0.047],碱剩余值低[(-1.33±2.93)mmol/Lvs(0.70±2.23)mmol/L,t=-2.149,P=0.036],血红细胞压积值低(0.35±0.04vs0.40±0.04,t=-2.957,P=0.013)。结论 APACHEⅡ评分、Ranson评分、氧合指数、血钙、血肌酐、血糖水平、碱剩余、血红细胞压积值可能是早期判断急性重症胰腺炎患者预后的指标。     

Early physiological response to intensive care as a clinically relevant approach to predicting the outcome in severe acute pancreatitis

HYPOTHESIS: The physiological response to treatment is a better predictor of outcome in acute pancreatitis than are traditional static measures. DESIGN: Retrospective diagnostic test study. The criterion standard was Organ Failure Score (OFS) and Acute Physiology and Chronic Health Evaluation II (APACHE II) score at the time of hospital admission. SETTING: Intensive care unit of a tertiary referral center, Auckland City Hospital, Auckland, New Zealand. PATIENTS: Consecutive sample of 92 patients (60 male, 32 female; median age, 61 years; range, 24-79 years) with severe acute pancreatitis. Twenty patients were not included because of incomplete data. The cause of pancreatitis was gallstones (42%), alcohol use (27%), or other (31%). At hospital admission, the mean +/- SD OFS was 8.1 +/- 6.1, and the mean +/- SD APACHE II score was 19.9 +/- 8.2. INTERVENTIONS: All cases were managed according to a standardized protocol. There was no randomization or testing of any individual interventions. MAIN OUTCOME MEASURES: Survival and death. RESULTS: There were 32 deaths (pretest probability of dying was 35%). The physiological response to treatment was more accurate in predicting the outcome than was OFS or APACHE II score at hospital admission. For example, 17 patients had an initial OFS of 7-8 (posttest probability of dying was 58%); after 48 hours, 7 had responded to treatment (posttest probability of dying was 28%), and 10 did not respond (posttest probability of dying was 82%). The effect of the change in OFS and APACHE II score was graphically depicted by using a series of logistic regression equations. The resultant sigmoid curve suggests that there is a midrange of scores (the steep portion of the graph) within which the probability of death is most affected by the response to intensive care treatment. CONCLUSION: Measuring the initial severity of pancreatitis combined with the physiological response to intensive care treatment is a practical and clinically relevant approach to predicting death in patients with severe acute pancreatitis.