scoring and risk stratification of acute pancreatitis
TRANSCRIPT
REVISED ATLANTA CLASSIFICATION &
SEVERITY SCORING SYSTEMS
DR. ADITI AICH (Internee Malda Medical College and Hospital)
Why speak of a classification
Revised atlanta classification
Need of severity stratification
Different stratification systems
What about Paediatric age group
Recommendation
OVERVIEW
WHY SPEAK OF A CLASSIFICATION
-Early assessment and accurate prediction - Wide spectrum of the disease- Care of patients is highly individualised- Difference of treatment protocol on basis of severity- Difference of treatment protocol in different set ups.
Atlanta classification, 1992.
Determinant based atlanta classification(2012)
Revised Atlanta classification, 2013
ATLANTA CLASSIFICATION FOR ACUTE PANCREATITIS
•ORGAN FAILURE•LOCAL COMPLICATIONS
*RANSON’S SCORE>/=3 *APACHE II SCORE >/=8
Local determinants: Fluid collectionsNecrosis of pancreas +/
Peripancreatic tissue (covered by the term peripancreatic necrosis)
Systemic determinants: Certain degree of OF due
to AP
DETERMINANT BASED CLASSIFICATION
Define Organ failure:ShockPulmonary insufficiencyRenal failure after rehydrationGI bleeding
According to the Revised Atlanta Classification - complications of AP can be
Organ failure Organ failure to be evaluated by the Modified Marshall
Scoring System. Organ failure = Marshall Score ≥ 2
Local complications Systemic complications
Organ failure: Transient: resolves
within 48 h of onset Persistent : persists ≥
48 h
REVISED ATLANTA CLASSIFICATION
Local complications: o Fluid collections
o Gastric outlet dysfunction, o Splenic and portal vein thrombosis, and o Colonic necrosis.
Four discrete types of collections:• Acute peripancreatic fluid collection (APFC), • Pancreatic pseudocyst (PP)• Acute necrotic collection (ANC) • Walled off necrosis (WON)
Atlanta classification(1992)
Revised Atlanta classification (2013)
Determinant based classification(2012)
Mild AP: Minimal organ
dysfunction and uneventful recovery
Absence of organ failure and/or local complications
Severe AP: Organ failure and/or
local complications
Mild AP: No organ failure No local or systemic
complicationsModerately severe AP: Transient organ failure
AND/OR local or systemic complication OR exacerbation of pre-existing co-morbidities
Severe AP: Persistent organ failure
(single/multiple)
Mild AP: No organ failure No (peri) pancreatic
necrosisModerate AP: Sterile (peri) pancreatic
necrosis AND/OR transient organ failure
Severe AP: Infected (peri) pancreatic
necrosis OR persistent organ failure
Critical AP: Infected (peri) pancreatic
necrosis AND persistent organ failure
Definition of severity of acute pancreatitis according to different classification system
WHY A SEVERITY STRATIFICATION IS NEEDED:-
SEVERITY STRATIFICATION OF ACUTE PANCREATITIS
WHY A SEVERITY STRATIFICATION IS NEEDED:-
Diagnosis
Severity stratificationPredicted
mild diseasePredicted
severe disease
Aetiologicalassessment
Management on ward
Treatment of other
aetiological factors
Referral to a specialist unit
Eradication of gallstones
Management on HDU/ITU
Dynamic CT?ERCP
Monitor for complications
Management of complications
SCORING SYSTEMSPathology-specific scoring systems Ranson Glasgow and Imrie
To evaluate patients in intensive care units APACHE scoring systems (APACHE II)
To distinguish and diagnosis local complications. CT severity index(CTSI)
Organ Failure (OF) Based Scoring Systems / should be treated in ICU Marshall
SOFATo predict the mortality risk during the first 24 hours of the diseases. BISAP
Variables of the Ranson criteria and Modified Glasgow system:For Acute Non Gall Stone Pancreatitis
Ranson criteriaUpon admission:1) Age > 55 years2) WBC > 16000/mm3
3) Glucose > 200 mg /dl4) LDH > 350 IU/L5) AST > 250 IU/LWithin 48 hours6) Drop in HCT > 10%7) Serum Calcium < 8 mg/dl8) Base deficit > 4mE/L9) Increase BUN > 5 mg/dl10) Fluid deficit > 6L11) Arterial PO2 < 60 mm Hg
Modified Glasgow System1) Arterial PO2 <60 mm
Hg2) Ser albumin<3.2
mg/dl3) Ser Calcium<8 mg/dl4) WBC > 15000/mm3
5) AST > 200 IU / L6) LDH > 600 IU/L7) Glucose > 180 mg /dl8) BUN > 45 mg/dl
Variables of the Ranson criteria: For Acute Gall Stone PancreatitisUpon admission:1) Age > 70 years2) WBC > 18000/mm3
3) Glucose > 220 mg /dl4) LDH > 400 IU/L5) AST > 440 IU/L
Within 48 hours1) Drop in HCT > 10%2) Serum Calcium < 8 mg/dl3) Base deficit > 4mE/L4) Increase BUN > 2 mg/dl5) Fluid deficit > 6L6) Arterial PO2 < 60 mm Hg
0-2(mortality 0%)
3-4(mortality 3-4%)
5-6(mortality 50%)
>6(mortality70-90%)
APACHE The acute physiology score and the chronic health evaluation: First major attempts to quantify the severity of the illness in ICU patients
It contains 12 continuous variables
The major advantage of the APACHE II scoring system:
It can be used in monitoring the patient’s response to therapy(Ranson and the Glasgow scales are mainly meant for the assessment at presentation)
The APACHE II scoring system: 12 variables (1) Body temperature, (2) mean arterial pressure
(mm Hg), (3) Heart rate(HR), (4) respiratory rate (R.R/mt), (5) Oxygenation (mm Hg), (6) PH,
(7) Na (mmol/l), (8) k (mmol/l), (9) Creatinine
(mg/100ml), (10) Haematocrit, (11) total leucocyte count
and the (12) Glasgow coma score.
APACHE II - Score ≥ 8: organ failure / Substantial pancreatic necrosis Score ≥ 3: severe pancreatitis likely. Score Mortality 0-2 2%3-4 15%5-6 40%7-8 100%
APACHE II score > 8 points predicts 11% to 18% mortality.
APACHE О is proposed by Johnson et al
In patients with a BMI > 30,
It showed similar results between APACHE O and APACHE II
CTSI: Computed Tomography Severity Index
Grading system used to determine the severity of acute pancreatitis.
The numerical CTSI has a maximum of ten points It is the sum of the Balthazar grade points and
pancreatic necrosis grade points
CT SEVERITY INDEX (BALTHAZAR, 1990)
MODIFIED CT SEVERITY INDEX (MORTELE, 2004)
PROGNOSTIC INDICATOR
POINTS
PROGNOSTIC INDICATOR
POINTS
PANCREATIC
INFLAMMATION
PANCREATIC INFLAMMATION
NORMAL PANCREAS
0 NORMAL PANCREAS
0ENLARGED PANCREAS
1 PANCREATIC ABN +/-
PERIPANCREATIC INFLAMMATION
2
PANCREATIC ABNORMALITIES
WITH PERIPANCREATI
C INFLAMMATION
2 PANCREATIC OR PERIPANCREATIC
FLUID COLLECTION/ FAT
NECROSIS
4
SINGLE FLUID COLLECTION
32/MORE
COLLECTION OR GAS
4
CT SEVERITY INDEX (BALTHAZAR,1990)
MODIFIED CT SEVERITY INDEX (MORTELE,2004)
PROGNOSTIC INDICATOR
POINTS
PROGNOSTIC INDICATOR
POINT
SPANCREATIC NECROSIS
PANCREATIC NECROSIS
NONE 0 NONE 0
<30% 2 <30% 2 30-50% 4 >30% 4 >50% 6 EXTRAPANCREATIC
COMPLICATIONS 2
CT SEVERITY INDEX AND MODIFIED CTSI
Defining severity of Pancreatitis in terms of Ranson’s criteria, APACHE II, CT Severity Index
Type of Pancreatitis
Ranson’s criteria
APACHE II CT Severity Index
Mild Pancreatitis
≤ 3 < 8 < 7
Severe Pancreatitis
> 3 ≥ 8 ≥ 7
Marshall Scoring System
Most sensitive for evaluation of AP patients. 50% of the patients with necrotising acute pancreatitis develop organ
failure with severe acute pancreatitis. 15% of edematous acute pancreatitis develop organ failure.
Score > 3 is associated with Severe course, Systemic complications and Significant correlation with fatal outcome (Р = 0.007) .
Criteria for organ failure based on Marshall scoring system:Organ system
Score0 1 2 3 4
Respiratory (PaO2/FiO2)
>400 301-400 201-300 101-200 <100
Renal (Serum Creatinine md/dl)
≤1.5 >1.5 - ≤ 1.9
>1.9 - ≤ 3.5 >3.5 - ≤ 5.0
> 5.0
Cardiovascular (systolic blood pressure, mm Hg)
>90 <90, fluid responsiv
e
<90, fluid unresponsi
ve
<90, pH<7.3
<90, pH<7.2
SOFA: SEQUENTIAL ORGAN FAILURE ASSESSMENT
It is a mortality prediction score that is based on the degree of dysfunction of 6 organ systems.
The score is calculated on admission and every 24 hours until discharge using the worst parameters measured during the prior 24 hours.
SOFA SCORESOFA Score
Variables 0 1 2 3 4
Respiratory(PaO2/FiO2)
> 400 ≤ 400 ≤ 300 ≤ 200 ( with respiratory support)
≤ 100(with respiratory support)
Coagulation ( Platelets x 103/µL)
> 150 ≤ 150 ≤ 100 ≤ 50 ≤ 20
Liver( Bilirubin: mg/dl)
< 1.2 1.2 – 1.9 2.0 – 5.9 6.0 – 11.9 > 12.0
Cardiovascular (Hypotension)
No hypotension
Mean Arterial Pressure < 70 mm of Hg
Dopamine ≤ 5 (microgram/kg/min) or Dobutamine (any dose)Adrenergic agents administered for atleast one hour
Dopamine > 5 (microgram/kg/min), Epinephrine ≤ 0.1 (microgram/kg/min), or Norepinephrine ≤ 0.0Adrenergic agents administered for atleast one hour
Dopamine > 15 (microgram/kg/min), Epinephrine > 0.1 (microgram/kg/min), or Norepinephrine > 0.0Adrenergic agents administered for atleast one hour
Central nervous system(Glasgow coma scale)
15 13-14 10-12 6-9 <6
Renal(Creatinine – mg/dl or Urine output ml/day
<1.2 1.2-1.9 2.0-3.4 3.5-4.9 or < 500 > 5.0 or < 200
BISAP: Bedside index for severity in Acute Pancreatitis
1. BUN > 25mg/dl.
2. Impaired mental status ( Glasgow Coma Score < 13)3.
SIRS
4. Age > 60 years
5. Pleural effusion detected on imaging.
One point is assigned for each variable within 24 hours of presentation and added for a composite score of 0-5.
• Incremental increases in the BISAP score (3 or more) have been shown to correlate with an increased risk of organ failure pancreatic necrosis and mortality
WHAT WE ARE USING IN MLDMCH
• RANSON’S *BALTHAZAR *APACHEII
WHAT WE AIM AT USING
• APACHEII *MARSHALL’S *SOFA
A STEP TOWARDS BETTERMENT
RECOMMENDATION
Severity stratification should be made in all patients within 48 hrs. It is recommended that all patients should be assessed by glasgow score and CRP.
The APACHE II score is equally accurate and may be used for initial assessment and ongoing monitoring in severe cases.
THANK YOU