You are on page 1of 6

EJINME-03109; No of Pages 6

European Journal of Internal Medicine xxx (2016) xxx–xxx

Contents lists available at ScienceDirect

European Journal of Internal Medicine
journal homepage: www.elsevier.com/locate/ejim

Original Article

New Atlanta Classification of acute pancreatitis in intensive care unit:
Complications and prognosis☆
María-Consuelo Pintado a,b,⁎, María Trascasa a, Cristina Arenillas a,1, Yaiza Ortiz de Zárate a, Ana Pardo a,
Aaron Blandino c, Raúl de Pablo a,b,2
a
b
c

Intensive Care Unit, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
University of Alcalá, Alcalá de Henares, Madrid, Spain
Intensive Care Unit, Hospital Universitario Ramón y Cajal, Madrid, Madrid, Spain

a r t i c l e

i n f o

Article history:
Received 26 September 2015
Received in revised form 4 January 2016
Accepted 6 January 2016
Available online xxxx
Keywords:
Pancreatitis
Intensive care unit
Complications
Outcomes assessment

a b s t r a c t
Background: The updated Atlanta Classification of acute pancreatitis (AP) in adults defined three levels of severity
according to the presence of local and/or systemic complications and presence and length of organ failure. No
study focused on complications and mortality of patients with moderately severe AP admitted to intensive
care unit (ICU). The main aim of this study is to describe the complications developed and outcomes of these
patients and compare them to those with severe AP.
Methods: Prospective, observational study. We included patients with acute moderately severe or severe AP admitted in a medical–surgical ICU during 5 years. We collected demographic data, admission criteria, pancreatitis etiology, severity of illness, presence of organ failure, local and systemic complications, ICU length of stay, and mortality.
Results: Fifty-six patients were included: 12 with moderately severe AP and 44 with severe. All patients developed
some kind of complications without differences on complications rate between moderately severe or severe AP. All
the patients present non-infectious systemic complications, mainly acute respiratory failure and hemodynamic failure. 82.1% had an infectious complication, mainly non-pancreatic infection (66.7% on moderately severe AP vs.
79.5% on severe, p = 0.0443). None of the patients with moderately severe AP died during their intensive care
unit stay vs. 29.5% with severe AP (p = 0.049).
Conclusions: Moderately severe AP has a high rate of complications with similar rates to patients with severe AP admitted to ICU. However, their ICU mortality remains very low, which supports the existence of this new group of
pancreatitis according to their severity.
© 2016 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.

1. Introduction
The estimated incidence of acute pancreatitis (AP) is about 15–40
episodes/100.000 inhabitants/year, with an increasing trend according
recent studies [1–6]. Approximately 2.9% of patients with AP will
require admission to the intensive care unit (ICU) due to development
of severe complications [7].
The treatment of severe acute pancreatitis admitted to ICU has
changed in recent years, evolving into a conservative manner [8–11].
Some studies have demonstrated that this change on treatment

☆ Grant or other financial support used in the study: This work was not supported.
⁎ Corresponding author at: Intensive Care Unit, Hospital Universitario Príncipe de
Asturias, Carretera Alcalá-Meco SN, Alcalá de Henares, Madrid 28805, Spain. Tel.: +34
91 887 8100x2205; fax: +34 91 883 3430.
E-mail address: consuelopintado@yahoo.es (M.-C. Pintado).
1
Present address: Intensive Care Unit, Hospital Universitario La Princesa. Madrid,
Madrid, Spain.
2
Present address: Section of Intensive Care Medicine, Hospital Universitario Ramón y
Cajal. Madrid, Madrid, Spain.

guidelines is associated with lower mortality [6,7,12,13]; however,
other studies report that mortality of these patients remains unchanged
[2,14]. Mortality has been associated to more severe illness, early
surgical treatment, infected necrosis, and increasing age [2,14–18].
In 2012, the Atlanta Classification of acute pancreatitis in adults
(N18 years) [19] was updated to include modern concepts of the disease,
addressing areas of confusion, improving the clinical assessment of
severity, standardized data report, assisting the objective evaluation of
new treatments, and facilitating the communication among treating
physicians and between institutions [20]. It has defined three levels of
severity according to the presence of local or systemic complications,
and the presence and length of organ failure: mild, moderately severe,
and severe.
Some studies focused on complications and mortality of patients
with severe AP admitted to ICU [12,14,15,21–25], showing that these
patients have an elevated mortality and a high rate of systemic
complications, especially infections and respiratory complications, requiring respiratory support in more than half of the patients [12,18,23].
None of these studies have classified severe AP according to the new
Atlanta Classification [20]. Moreover, there are many uncertainties

http://dx.doi.org/10.1016/j.ejim.2016.01.007
0953-6205/© 2016 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.

Please cite this article as: Pintado M-C, et al, New Atlanta Classification of acute pancreatitis in intensive care unit: Complications and prognosis,
Eur J Intern Med (2016), http://dx.doi.org/10.1016/j.ejim.2016.01.007

19. kidneys.007 .7) on severe (p = 0. in which patients developed persistent organ failure (persistent organ failure more than 48 h. and 52. who decides the need for surgery or conservative treatment) and systemic complications.6% had extra-abdominal infections (mainly pneumonia). p b 0. Material and methods We conducted a prospective observational study in a 14-bed medical and surgical ICU in Spain. Median of days between the onset of acute pancreatitis and admission to ICU were 2. Statistical analysis Normal distribution of variables was assessed using the Kolmogorov–Smirnov test. 5. Balthazar criteria for severity [28. in which patients did not develop organ failure. that are assigned a cut-off value from 0 (normal) to 4 (high degree of dysfunction/failure).8%) patient had mild AP and were excluded from study. 2. ICU length of stay. We included all patients consecutively admitted to the ICU diagnosed with moderately severe or severe acute pancreatitis according to the Atlanta revised classification of AP [20]. calcium: b2 mml/l.5%) and acute renal dysfunction (28. APACHE II score [26] provides an objective assessment of severity of illness in critically ill patients: the highest score.001). severity scores of illness (Acute Physiology and Chronic Health Evaluation (APACHE) II score [26] on admission.1016/j. / European Journal of Internal Medicine xxx (2016) xxx–xxx about complications and mortality of patients with moderate AP admitted in ICU [23].0 mmol/L. lactate dehydrogenase: N350 IU/L.6). of them 44 (77. hepatic. We examine demographic data (sex. The score is obtained on the day of admission and each of the following days in ICU. in which patients developed transient (resolves in less than 48 h of duration) organ failure or local or other systemic complications. fluid sequestration: N 6 L.0 software (SPSS Inc.0 days (1. severe. “other complications which required the evaluation by a surgeon” (defined as those pathologies that according to the judgment of the attending physician.6% developed abdominal compartment syndrome. to described ICU mortality and compared with severe AP.2 M. b) foal or diffuse pancreatic enlargement. the highest probability of mortality.1% of the patients. using the most abnormal value for each variable in a 24-h period on each organ system. no local or systemic complications. and an imaging method with characteristics findings of AP (abdominal ultrasound and/or contrast-enhanced computed tomography (CT)) [20]. white blood count: N16.0–5. And 26. All the patients had some kind of complications.2%) patients developed severe AP during the ICU stay according to revised Atlanta criteria [20] and 12 (21.01. 1 (1. c) pancreatic alterations associated with peri-pancreatic inflammation. respectively. d) single fluid collection. 3) Chronic Health Evaluation. epigastric pain often radiating to the back). 3. Pintado et al. although only 3. It is made up of 3 components: 1) Acute Physiology Score.2% with moderately severe AP and 94.8% of the patients. age).9% of the patients. Quantitative variables with normal distribution are expressed as mean ± standard deviation. Balthazar criteria for severity [28. Renal replacement therapy (RRT) were required in 26. SOFA score [30] is designed to evaluate the function of 6 major organ systems (cardiovascular. during 5 years (2010–2014). Ranson [27] scores 48 h from admission.1. blood urea nitrogen: increase N1. 57 patients with AP were admitted to our ICU. respiratory. On 48. 28. renal. New Atlanta Classification of acute pancreatitis in intensive care unit: Complications and prognosis.000/mm3. although local and “other complications which required the evaluation by a surgeon” were more frequent on severe AP (Table 3). presence of organ failure (defined as a score of 3 or 4 on SOFA score [30]).-C. central nervous system. and chi-square test (Holm method were applied to adjust p value in case of multiple comparisons).2% of cases.1%) patients had moderately severe AP. b) At 48 h: packed cell volume: decrease N 10% from admission. being the most frequent the non-infectious systemic complications. Comparisons between patients according to severity of AP were based on the Student's t test. Ranges from 0 to 71 points. the AP had a gallstone etiology. Infectious complications were detected in 82.8% of the patients had intra-abdominal hypertension. b) moderately severe.29]. Please cite this article as: Pintado M-C. 2.29] is used in computer tomography for grading of acute pancreatitis. need for mechanical ventilation and renal replacement therapy.2016. continuous variables with non-normal distribution.7) on moderately severe pancreatitis and 2. 2) Age Adjustment. Chicago. base deficit: N4 mmol/l. In this study. Vasoactive support was needed in 67. local. local or systemic complications usually present) [20]. Ranson criteria [27] are assessed both at admission and at 48 h: a) On admission: age: N 55 years. In second place. Results During the study period. e) 2 or more fluid collections poorly defined or presence of gas within the pancreas or within the peri-pancreatic inflammation. developed during their stay in the ICU according to the new Atlanta Classification [20]. non-normal distribution variables are shown as median and interquartile ranges. in less proportion on patients with moderately severe AP (16.7% with severe AP (p b 0.001).8 mmol/l from admission.024). blood glucose level: N11. the higher the mortality. when the clinical course or imaging guide to the presence of complications that require surgical treatment. 81. lungs. Baseline characteristics are shown in Table 1.ejim. Qualitative variables are shown as number and percentages. all of them with severe AP (p = 0. being 5 grades: a) normal pancreas. Level of statistical significance was set to p values less than 0. Atlanta revised classification of AP [20]). with a maximum punctuation of 24. an additional adjustment is made for patients with severe and chronic organ failure involving the heart. etiology of AP. and qualitative variables.6%).0): 3. The more of the score.7% vs. and immune system.org/10. arterial partial pressure of oxygen: b 60 mm Hg. Statistical analysis was performed using SPSS 18. http://dx. The Atlanta revised classification of AP divided the severity of AP into three groups according to the presence of local or systemic complications and the presence and length of organ failure: a) mild.3% of these patients had intra-abdominal infections (mainly abdominal abscess). During this study.0 days (1. and coagulation) over time. 67. The diagnosis of AP was based on the presence of at least two of the following three criteria: acute onset abdominal pain consistent with acute pancreatitis (acute onset of a persistent. for quantitative variables with normal distribution.8% with severe AP.0–5. The study was approved by the Institutional Ethics and Clinical Trials Committee Principe de Asturias University Hospital. daily Sequential Organ Failure Assessment (SOFA) score [30]. which they are added for patients older than 44 years old. The main reasons for admission were hemodynamic instability (37. Eur J Intern Med (2016). Mann–Whitney test.3%) and less severe in patients with moderately severe AP than in patients with severe AP (Table 2).9% of the patients required mechanical ventilation. We used SOFA score N 3 as criteria of organ failure because this score is preferred in critical care patients [20].. no patient was diagnosed of chronic pancreatitis.05 and results are expressed with their 95% confidence intervals.doi. elevation of serum amylase and/or lipase activity at least 3 times greater than the upper limit of normal. et al. reason for ICU admission. The incidence of multiple organ failure was lower (8. all of them had severe AP. and c) severe. The main aim of this study is to describe the complications of patients with moderately severe acute pancreatitis. which is derived from 12 clinical variables that are obtained within 24 h after admission in the ICU. from 1 to 6 points. There were no differences on systemic complications and non-pancreatic infectious complications according to severity of AP.0 days (1. Illinois). and mortality during hospital and ICU stay. liver. the worst recorded value is taken.2% had a combination of the two. aspartate aminotransferase: N 250 UI/L.2–4.

p = 1.0).52 ± 3.7%) 1 (8. Regarding the organ support our findings are similar than these previous studies. We also found higher ICU mortality among patients who need surgery (42.7% of patients had non-pancreatic infection on moderately severe AP vs. Despite it.64 7 (58. p = 0. We have not found statistically significant difference on rate of noninfectious systemic complications between moderately severe or severe AP.org/10. ICU: Intensive care unit.2%.2%) 12 (27.3 days on moderately severe AP vs. p = 0.2% of cultures.5%) 7 (12.1%) 2 (4. all of these patients had severe AP (none of patients with moderately severe AP died vs. and 12–38% with acute kidney injury or failure. mainly Enterococcus sp. Unlike several studies that have reported an elevated number of systemic complications in patients with severe AP during their ICU stay.doi. on intraabdominal infections and Pseudomonas sp.48 ± 1.20 ± 15.02 0 (0. mainly organ dysfunction or failure.9%) 6 (10. RRT (38–44%). Abbreviations: ERCP: endoscopic retrograde cholangiopancreatography.87 15.9%) 4 (7.5%) 10.000 b0.024 1. on severe AP (54. Gram positive bacterial pathogens were detected in 32. mainly non-infectious systemic complications.0 (1.7%) 38 (86.1%) 14 (25.3%) 2 (16. without differences on mortality according to presence of infection (mortality of 23.-C.0%) 1 (8. New Atlanta Classification of acute pancreatitis in intensive care unit: Complications and prognosis.3%) 4.1016/j.4%) 6 (13. et al. urinary tract infections. patients with moderately severe AP have very low mortality.7%.6%) 4 (9.32 ± 4.143 0.48 0 (0.8%) 5 (11.3%) 0 (0%) 22 (50.4%) 0.4%) 3. Due to these complications. Pintado et al.3% vs. All the patients in our study developed some kind of complication during their ICU stay.0%) 2 (16. 79.004).65 ± 7. 0%. Eur J Intern Med (2016). Main isolated microorganism was Gram-negative bacteria (51.18 33 (75.31]. SOFA Sequential Organ Failure Assessment.0 infections per patient (1. 45–52% with cardiovascular complications.002 0.0) on severe AP.26 ± 7.5%) 13 (29.8% of the patients.2%) 7 (12. years† Sex: male Etiology Gallstone Alcohol Idiopathic After ERCP After surgery Hypertriglyceridemia Others Reason for ICU admission Ranson score N 3 Respiratory failure Hemodynamic instability Acute renal dysfunction Others Ranson score† APACHE II† SOFA† Presence of multiple organ failure at ICU admission All (n = 56) Moderately severe (n = 12) Severe (n = 44) p 62. there is a large number of patients requiring ventilatory support (78–90%).0%) 12 (21.3%) 9 (20. ICU: Intensive care unit.0%) 0.7%) 1 (8.0–3.1%) 5 (8. Abbreviations: SOFA: Sequential Organ Failure Assessment.0) infections per patient on moderately severe AP vs.0–2.085 b0.4 ± 29.0%) 3 (25. 6.3%) 5 (11.9% infected patients vs. Age. Non-pancreatic infectious complications were diagnosed in 76. mainly non-infectious systemic complications. p = 0. on intra-abdominal infections.3%) 3.7%) 4 (33.01.6%) 10 (17.0%) 0 (0.6%) 39 (69.7%) 3 (25.11 ± 3. with an incidence of 57–62% of patients with respiratory failure.6% of isolated cultures): Escherichia coli and Pseudomonas sp.6%) 2 (16. on extra-abdominal infections.3%) 1 (2.96 ± 27.50 ± 3.1%) 5 (41.85 16 (36.002) and those who developed multiple-organ failure (33.25 ± 10.007 .1%) 2 (4.24 7.293 0. p = 0.7%) 21 (37.86 17.5%.4%) 57. Please cite this article as: Pintado M-C.353).78 9.13 4.7%) 1 (8.1%) 2 (3.59 ± 14.3%) 63. 29. mainly on abdominal abscess.005).8%) 2 (3. Worse Balthazar score A B C D E Worse SOFA score† Intra-abdominal hypertension Abdominal compartment syndrome Multiple organ failure during ICU stay All (n = 56) Moderately severe (n = 12) Severe (n = 44) 4 (7. Discussion In our study.6%) 4 (7.11 15 (26.92 ± 6.6%) 3 (25.049). p = 0.4%.674 0.5%) 9 (20.001 Data are shown as number (percentage). Pancreatic infections were less frequent on moderately severe AP (8.29 ± 1.001 0.012 Data are shown as number (percentage).348 0.0.0–2.5%.601 27 (48.00).7%) 2 (16. 20%. longer on patients with severe AP (7.3%) 2 (16.0%) 5 (11.3%) 12 (27. 2.443/median 1. without differences according to severity of AP (66.4 days.002).010 0.71 15 (34. or treatment with vasoactive support (62–70%) [12.2016.9%) 9. Mean ICU stay was 23.3% vs.4%) 16 (28. with a median of 2.3%) 3 (25. we found that patients with moderately severe AP admitted to ICU have a high rate of complications.6%) 8 (14.5%) 16 (28.ejim.4%) p 0. and blood cultures. About 77–100% of patients with Table 2 Severity developed during ICU stay. 4. with similar rates of these complications than severe AP.4%) 19 (43.25. The mortality in the ICU was 23. p = 0.0%) 2. † Expressed as median (percentile 25–percentile 75). 28.67 16 (28.60 6. Fungus were isolated on 7. † Expressed as media ± standard deviation. APACHE II: Acute Physiology and Chronic Health Evaluation II.M.0%) 3 (6.5%) 5 (8.92 ± 2.58 ± 9. / European Journal of Internal Medicine xxx (2016) xxx–xxx 3 Table 1 Baseline characteristics of AP admitted to ICU. http://dx.08 ± 20.80 40 (71.3%) 4 (9.0%) 1 (8.3%) 1 (8. p = 0.5%) 1 (2.3%) vs.6% of the isolated cultures.5 (1.58 ± 1.

[32] in their study about early oral refeeding based on hunger. unlikely authors describes lower rates of infection in patients with severe AP (around 20–48%) [31.3% developed acute respiratory failure of without any case of multiple organ failure.1016/j.7%) 0 1 0 0 1 0 11 (91. Data are shown as number (percentage). Zhao et al.7% of patients with severe AP.† Local complications Infection of necrotic tissue Abdominal abscess Pancreatic pseudocyst Pancreatic fistula Splenic vein thrombosis Others‡ Other complications which requires evaluation by a surgeon GI tract perforation Hemoperitoneum Biliary tract obstruction Bile leaks/gallstone perforation Mesenteric ischemia Others§ Non-infectious systemic complications Acute coronary syndrome Cardiac arrhythmias Encephalopathy Hemodynamic failure Acute renal failure Acute respiratory failure Acute hepatic failure Acute hematological failure Infectious non-pancreatic complications Nosocomial pneumonia Urinary tract infection Catheter related bloodstream infection Bacteriemia Cholangitis Upper respiratory tract infection Peritonitis Diarrhea Surgical wound infection Others¶ All (n = 56) Moderately severe (n = 12) Severe (n = 44) p 27 (48.002 0. [23] described a rate of local complications of 16. we also found that 8.8% of patients having more than one infection.7% being the pancreatic pseudocyst the main local complication.2% of gastrointestinal bleeding. Jin et al.doi. and 34. In our study.3%) 0 1 0 0 0 1 2 (16. mainly bloodstream infection. Nevertheless. et al. pneumonia was the most frequent infection. [31] described 34 episodes of extrapancreatic infection on 44 patients with infection and severe AP.7%) 2 1 1 2 4 0 1 1 0 0 26 (59.6%) 4 6 3 3 6 3 54 (96. 1 hepatic abscess.0% of pleural effusion. the rate of infectious complications (systemic or localized) is elevated (82. included 138 patients of which 101 had moderately severe AP (73. with similar rates of renal failure and multiple organ failure. being the pancreatic fistula and thrombosis of splenic vein the mainly complications. Only one study [23] describes what happens with patients with mild AP admitted in the ICU.3%) 4 5 3 3 5 3 43 (97.1%).2016.7%.01. any of these was restricted to patients admitted in the ICU nor evaluated moderately severe AP. § Other surgical complications: 1 splenic rupture.2%).7%) 4 9 5 36 15 41 13 8 35 (79. Millian et al.org/10. [18] described a prevalence of bloodstream infection of 30% in patients with severe AP.3%. 1 cellulitis. 5. [15] who compared conservative medical treatment versus surgical treatment of patients with necrotic acute pancreatitis admitted to ICU.7%) developed pancreatic pseudocyst during the ICU stay and at 1-year follow-up.3% of patients with moderately severe AP developed multiple organ failure during ICU stay. Noor et al.8% of persistent organ failure. we found higher rates of respiratory and cardiovascular failure in patients with severe AP than those in previous studies.1%) 5 20 1 2 2 1 23 (52. severe AP admitted to the ICU had multiple organ failure or dysfunction [22.6% of patients with moderately severe AP developed transient organ failure and 45.028 0. and acute renal failure rate of 8. 2. reports rates of 26. reports 80 episodes of bacteremia (18%) and 168 episodes of Please cite this article as: Pintado M-C. infected abdominal hematoma.2%). / European Journal of Internal Medicine xxx (2016) xxx–xxx Table 3 Complications during ICU stay. catheter-related bloodstream infections (39.7%) 0 2 1 2 1 3 1 0 8 (66. [33] who compared severe with moderately severe AP admitted to hospital. Eur J Intern Med (2016).5%) 26 7 3 13 8 5 6 3 5 4 0. † One patient could have more than one infection episode or complication during ICU stay.7% of patients with moderately severe AP required mechanical ventilation). with 76. ¶ Other non-pancreatic infections: 1 empyema. Arroyo et al. Regarding this.4 M.6%). We found that non-infectious local complications are rare in moderately severe AP. upper mesenteric vein thrombosis.8% of pancreatic infections. in this study. http://dx. Some authors report similar rates than us (73–74% [18. the data reported on previous studies are discordant.386 0. 1 gastrointestinal hemorrhage.2%) 5 21 1 2 2 2 25 (44. And are more frequent in severe AP.443 Abbreviations: NA: not applicable. and urinary tract infections (13.24]). ‡ Other local complications: splenic abscess.-C. New Atlanta Classification of acute pancreatitis in intensive care unit: Complications and prognosis. [36] in their study with 447 patients included with necrotizing pancreatitis. [35] reported the presence of extra-pancreatic infection on 62.ejim. Cacopardo et al.5% pancreatic necrosis.34].007 . and few of them describes the complications of these patients during the hospital stay. A few studies report the presence of non-infectious local complications in patients with AP admitted in the ICU. In our study. with a higher rate in severe AP as expected. with a rate of acute respiratory failure of 25% (16. Xue et al. and 1 paravertebral abscess. described that 66.4%) 4 11 6 38 16 44 14 8 43 (76. Guo et al. None of the previous studies have focused on complications in the patients with moderately severe AP admitted in the ICU. reported 8. followed by pseudocyst. Pintado et al. cardiovascular failure rate of 16. There are four studies that focus on non-pancreatic infections complicating severe AP.25].8%) 28 8 4 15 12 5 7 4 5 4 1 (8. reports that 18 patients (25.

Gastroenterol Res Pract 2013. Pettila V. Bollen TL.6% of the patients in our study. We found higher mortality among patients who need surgical treatment or developed multiple-organ failure. we did not find higher mortality among patients with infection. infection has been reported to be a major determinant of ICU mortality [18. Lowenfels AB. Br J Surg 2014. Milic S. Carter CR. Med Intensiva 2013. Although in these previous studies.9%) needed admission in the ICU. 13(Suppl. outcome. Factors influencing mortality in patients undergoing surgery for acute pancreatitis: importance of peripancreatic tissue and fluid infection. Atkinson S. Incidence and mortality of acute and chronic pancreatitis in The Netherlands: a nationwide record-linked cohort study for the years 1995-2005.19:3018–26. D'Amico G.41:306–9. Crit Care Med 2002. [13] Apodaca-Torrez FR. Jovanovic B.31. Secanella L.31.01.8 days. Radenkovic D. Herani B. Case mix. De Madaria et al. but none of them needed admission in the ICU or surgery or died during their hospital stay. Flaatten H.25:1068–75. de Melo GR. Localized and systemic bacterial infections in necrotizing pancreatitis submitted to surgical necrosectomy or percutaneous drainage of necrotic secretions.101:e65–79. 5. Karamarkovic A. Bruno MJ. Frulloni L. Multiple organ dysfunction associated with severe acute pancreatitis. Williams JG.21. Lobo EJ. and 12% of patients with pancreatic necrosis (N30% of pancreatic tissue).37:163–79. [2] Spanier B. Dale J. [33] in their study with 92 patients with acute pancreatitis. with similar rates of these complications than in severe AP cases admitted in the ICU. [18] Cacopardo B. Clemens M. [19] Bradley III EL. Zanghi G. with a median time of mechanical ventilation and RRT of 0. [12] Pavlidis P. Fisichella R. Aliment Pharmacol Ther 2008. HPB (Oxford) 2010. but only 2 (4. but only 25 of the 58 patients with moderately severe AP needed admission in the ICU without specifying how many of these patients admitted to the ICU had an infectious complication.23]. [38] showed in their cohort of 144 patients with AP that 2. Navarro S. Severe acute pancreatitis: overall and early versus late mortality in intensive care units. and Lee [40] in 43 patients with moderately severe AP. [7] Talukdar R. [9] Baron TH. Pancreatology 2010. Lie SA. van Santvoort HC. Milic N.39. et al. Vege SS.43].62:102–11. Berretta S. New Atlanta Classification of acute pancreatitis in intensive care unit: Complications and prognosis. Di CV.8%) have an extrapancreatic infection. [3] Stimac D. it was found an incidence or multiple organ failure of 40% and mortality of 30% in this patients [43]. 24% of these patients needed surgical drainage.12:597–604. sepsis 11%. and outcome. Morrison D.10:523–35. [11] Maravi E. without differences between moderately severe or severe AP. Dervenis C.42:285–92.8) days and without in-hospital mortality. A clinically based classification system for acute pancreatitis. alcohol consumption and aetiology–a record linkage study. Ovrebo K. Pancreas 2009. maybe due to the high rate of infectious complications on moderately severe AP. Chen et al. describes an infection rate (infected pancreatic necrosis and extrapancreatic infections) of 9. Gooszen HG. Practical guidelines for acute pancreatitis.9% on patients with moderately severe AP. Acknowledgements We wanted to thank all staff and patients of Principe de Asturias University Hospital that have worked or collaborated selflessly in this study. etiology. Pintado et al. Sarr MG.2% similar than described in previous studies of patients with AP admitted in the ICU.15. et al. Classification of acute pancreatitis–2012: revision of the Atlanta classification and definitions by international consensus. Conflicts of interest The authors state that they have no conflicts of interest. Barreda CL.7%) developed organ failure. et al. Pancreas 2006. Please cite this article as: Pintado M-C. mainly 5 non-infectious systemic complications and infectious non-pancreatic complications.42]. being the first study who describe all the complications associated to moderately severe AP admitted in the ICU. mainly of respiratory system.23. with a median ICU length of stay of 2. ICU mortality rate in moderately severe acute pancreatitis is lower. which supports the existence of this new group of pancreatitis according to severity.4% of patients with moderately severe AP needed ICU care due to non-persistent organ failure or complications. In our study. the patients admitted in the ICU because of moderately severe acute pancreatitis suffer a high rate of complication.doi. Monteiro LM. and that could influence an increase in the percentage of surgical patients compared to other centers where there are more patients who are managed with percutaneous drainage. [5] Roberts SE. [10] Pezzilli R. Singer M. [17] Busquets J. social deprivation. Eur J Intern Med (2016).128:586–90. no patient with moderately severe AP died during the stay in the ICU [7. Zubia F. 1992. Vidarsdottir H. Zerbi A. There are few data about complications on patients with moderately severe AP admitted in the ICU. Radic M. [Necrotic acute pancreatitis in the intensive care unit: a comparison between conservative and surgical medical treatment]. Most of AP admitted to ICU are due to organ failure associated to AP.2016. Staged multidisciplinary step-up management for necrotizing pancreatitis. 1):S1.24.2013:897107.46:1389–98.36 (0–0) days. Scand J Gastroenterol 2011. et al. SEMICYUC 2012. Millan M. et al. In our study. Talukdar et at [7] describes that 15% of patients with moderately severe AP required admission in the ICU for intensive monitoring after they underwent complex intervention for local complications (necrosis and peri-pancreatic collections).33:323–30.34–36]. References [1] Vidarsdottir H.38:122–5. Leppaniemi AK. Kemppainen EA. Ga. World J Gastroenterol 2013. single organ failure of 23%. Pancreas 2013. 43 of 56 patients (76. BMC Surg 2013.007 . of which 33 patients had moderately severe AP. Goldacre MJ. Jin et al. of which 12 (27.14. / European Journal of Internal Medicine xxx (2016) xxx–xxx pneumonia (38%). Puolakkainen PA. Recommendations for intensive care management of acute pancreatitis. with a hospital mortality of 2%. Haapiainen RK.6% [12. Crichton S.80:354–9. et al. and without any case of intraabdominal hemorrhage in 208 patients with moderately severe AP.24.1016/j. Regarding pancreatic infection. In a recent meta-analysis about multiple organ failure in AP and mortality. [8] da Costa DW. Moller PH. Rodriguez AC.5 (2. Delle Fave GF. Pinzone M.-C. [14] Bumabasirevic V. et al. Laplaza C.2013:956149. Krznaric-Zrnic I. Horvath KD. Laynez CR. Werner J. Mikolasevic I.ejim. [37] in their study of acute pancreatitis admitted to surgical ICU describes an incidence of multiple-organic syndrome of 12%. Lakhey et al. Arch Surg 1993. [41] describes an infection rate of 25. Lemmich SJ.21. Rev Gastroenterol Peru 2010. Morales F. Cleve Clin J Med 2013. mainly primary infected necrosis and pneumonia. none of them required surgical treatment or died. The limitations of this study are that it was conducted in a single center. Severe acute pancreatitis: results of treatment. Time trends in incidence. [16] de Rai P. Targona J. etiology. As has been seen in previous studies. Johnson CD.18. [6] Omdal T. 28:931–41. Boerma D. 2):S50. Castoldi L. Uomo G. which varies between 11 and 53. Pelaez N. Dijkgraaf MG. Bjornsson ES. et al. mainly due to Gram-negative bacteria.org/10. [4] Yadav D. Zerbi A. Wyncoll D. Meddings D. [22] Halonen KI.30:1274–9. we found that it was present in 44. Jankovic Z. Di Vita M. ICU mortality was 23. Garcia-Borobia F. [20] Banks PA. Thorarinsdottir H. and that most of the patients with moderately severe AP are admitted to ward. Eur J Gastroenterol Hepatol 2013. However.30:195–200. and activity for admissions to UK critical care units with severe acute pancreatitis: a secondary analysis of the ICNARC Case Mix Programme Database. Epidemiology of acute pancreatitis in the North Adriatic Region of Croatia during the last ten years. Bassi C. Conclusions In conclusion. Atlanta. Pancreas 2012. Fabregat J.M. September 11 through 13. Acute pancreatitis: a prospective study on incidence. Gut 2013. Talukdar et al.39:385–8. et al. Incidence and case fatality for acute pancreatitis in England: geographical variation. et al. Bassi C. Moderately severe acute pancreatitis: prospective validation of this new subgroup of acute pancreatitis. Iversen KB. Crit Care Res Pract 2013. Petrov MS. Rev Col Bras Cir 2012. [21] Harrison DA. Managing severe acute pancreatitis. [15] Milian JW.34–36]. respectively. Portugal SJ. [39] in 57 patients with moderately severe AP of which 11 needed admission in the ICU describes a mean length of ICU length of stay of 9. Trends in the epidemiology of the first attack of acute pancreatitis: a systematic review. Crit Care 2007.0–3.1%. as reported in previous studies (19–73%) in severe AP [15. The strength of the study is the description of all the complications associated to AP admitted in the ICU. Surgical management of acute pancreatitis in Italy: lessons from a prospective multicentre study.11(Suppl. and case fatality rate of the first attack of acute pancreatitis. Goldenberg A. Improved outcome of severe acute pancreatitis in the intensive care unit. Summary of the International Symposium On Acute Pancreatitis. http://dx. which have been found to be a mayor determinant of mortality in several studies [36.10 (0–0) days and 0.

6 M.27:19–37. Crit Care Med 1998.28:133–9. Yang XN. The role of organ failure and infection in necrotizing pancreatitis: a prospective study. Eur J Intern Med (2016). Hepatobiliary Pancreat Dis Int 2014. prospective study. Li A. Wan MH. New Atlanta Classification of acute pancreatitis in intensive care unit: Complications and prognosis. Please cite this article as: Pintado M-C. et al. Moreno R. Gomez-Escolar L. Li Z. Kim YS. [Acute pancreatitis in intensive care unit: review and evolution of 36 cases Victor Lazarte E. Gastroenterology 2010. et al.ejim. Microbiological findings in secondary infection of severe acute pancreatitis: a retrospective clinical study. in acute pancreatitis: a clinical retrospective study.94. Use of the SOFA score to assess the incidence of organ dysfunction/failure in intensive care units: results of a multicenter. Kim HM. Song B. et al. / European Journal of Internal Medicine xxx (2016) xxx–xxx [23] Arroyo-Sanchez AS. Khakurel M. Mai G. [30] Vincent JL. Aguirre Mejia RY.259:1201–7. Rao B. Hospital. Li W. Phillips AR.31:243–52. [36] Guo Q.14:257–62.01.15:394–8. Determinant-based classification and revision of the Atlanta classification. Xue P. Medicine (Baltimore) 2015.16:1–84. Liu YL. Association between severity and the determinantbased classification. Wan MH. e638.10:613–9. Dig Dis Sci 2009. et al. Singh KP. Cui Y. et al.52:580–5.org/10. Peru]. Rev Gastroenterol Peru 2008. [29] Balthazar EJ. et al. Xue GJ. [35] Noor MT. Singhal S.31:171–5. Acute pancreatitis: value of CT in establishing prognosis. Poddar B. et al. Infectious complications in patients with severe acute pancreatitis.007 . Zapater P. Curr Probl Surg 1979. Draper EA. Nageshwar RD.13:818–29.2016. [42] Guo Q. et al. Chen Y. Tong Z. Nutrition 2015. Gurjar M. Moreno R. Radiol Clin North Am 1989. Chakraborty M. Ranson JH. Rello J.12:19–25. Yang XN. [27] Ranson JH. Atlanta 2012 and Atlanta 1992. [28] Balthazar EJ. Anzueto A. Bhattacharrya A. Acute pancreatitis. [24] de Waele JJ. Ke L. Organ failure and infection of pancreatic necrosis as determinants of mortality in patients with acute pancreatitis. Li J.15:331–6. [31] Xue P. Hu W. Comparison of predictive systems in severe acute pancreatitis according to the revised Atlanta classification. Takala J. [26] Knaus WA. Shen Y. Early oral refeeding based on hunger in moderate and severe acute pancreatitis: a prospective controlled. [41] Talukdar R. Kafle B. Tian B. Lipman J.-C. Ann Surg 2014. Kim YJ. http://dx. Liu X. Audit of patients with severe acute pancreatitis admitted to an intensive care unit. Pancreas 2009. Ray P. Pintado et al. Windsor JA. which one should we choose to categorize acute pancreatitis? Pancreatology 2015. Sharma M. Sinha SK. et al. Update of the Atlanta Classification of severity of acute pancreatitis: should a moderate category be included? Pancreatology 2010. Shanbhag S. Sakr Y. randomized clinical trial. Clinical utility of the revised Atlanta classification of acute pancreatitis in a prospective cohort: have all loose ends been tied? Pancreatology 2014. Crit Care Med 1985. JOP 2011. Lopez-Font I. [39] Lakhey PJ.54:2748–53. Validation of the moderate severity category of acute pancreatitis defined by determinant-based classification. Deng LH. Robinson DL. Indian J Gastroenterol 2012. Wig JD. Zhao E. Javed MA. Li M. et al. Altaf K. Zhang ZD. [25] Singh RK. Huang W. Bacteriology of infection in severe acute pancreatitis. [32] Zhao XL. Radhakrishna Y. Choi JS. Martinez J. Pancreas 2016. Azim A. Garcia VJ.1016/j. et al. Li J. Suter PM. Validation of 'moderately severe acute pancreatitis' in patients with acute pancreatitis. [34] Tsui NC. Kochhar R. Zimmerman JE.doi. Radiology 1990. [40] Lee KJ.26:1793–800. de Mendonca A. Infections and use of antibiotics in patients admitted for severe acute pancreatitis: Data From the EPIC II study.38:499–502. CT diagnosis and staging of acute pancreatitis. Soler-Sala G. [43] Petrov MS. JNMA J Nepal Med Assoc 2013. APACHE II: a severity of disease classification system. Trujillo. Working group on “sepsis-related problems” of the European Society of Intensive Care Medicine.139:813–20. Surg Infect (Larchmt) 2014. Bhandari RS. Miao B. Xia Q. Cantraine F.174:331–6. Cho JH. Wagner DP. Baronia AK. Megibow AJ. [33] Jin T.45:46–50. [37] Chen Y. [38] de Madaria E.13:323–7. Zhu SF.