1. EBM Journal Club 2013-12-31 GS 謝閔傑

2. 題目 對於治療急性壞死性胰臟炎病患有需要使用抗生 素治療嗎？

3. 實證醫學的 5 個步驟  步驟 1: 形成臨床問題  步驟 2: 尋找証據  步驟 3: 嚴謹評估証據  步驟 4: 臨床應用  步驟 5: 評估效果

4. 步驟 1: 形成臨床問題  Type of Questions (1) Background questions (2) Foreground questions

5. Background Questions?  What is acute pancreatitis ?  What is acute necrotizing pancreatitis  What is the current principles to manage acute necrotizing pancreatitis?  All the above questions can be answered in the medical textbook or Up to date

6. Acute pancreatitis  Acute inflammation of the pancreas  Clinically mild to severe  Severe acute pancreatitis  pancreatic glandular necrosis  morbidity and mortality substantially higher necrosis  especially infected.

7. Presentation and Classification  rapid onset manifested  upper abdominal pain, vomiting, fever, tachycardia,  leukocytosis, elevated pancreatic enzymes  Gallstones and alcohol abuse are the most common causes

8. Severity  Several severity-of-illness classifications  Ranson's score is based on 11 clinical signs with prognostic importance; 5 are measured at the time of admission and the other 6 in the first 48 hours after admission  Acute Physiology and Chronic Health Evaluation (APACHE II) score  12 physiologic variables, the patient's age, and any history of severe organ-system insufficiency or immunocompromised state

9. Severe pancreatitis  >=3 Ranson's criteria  APACHE II score >= 8  Shock  Renal failure  Respiratory failure

10. Severe pancreatitis  Severe pancreatitis  morbidity of 82 %  mortality of 23 %  Mild  morbidity of 6 %  mortality of 0%  glandular necrosis increase, morbidity increase.  overall mortality in severe acute pancreatitis 30%  Deaths  Early mortality 1~2 weeks; multiple organ failure  Late mortality local or systemic infection

11. systemic and local complications  Acute respiratory distress syndrome  Acute renal failure  Shock  Coagulopathy  Hyperglycemia  Hypocalcemia  Local complicationsgastrointestinal bleeding, infected necrosis, and adjacent bowel necrosis  Late :pancreatic abscesses and pancreatic pseudocysts

12. Pancreatic Necrosis  International Symposium on Acute Pancreatitis in 1992: defined pancreatic necrosis as the presence of one or more diffuse or focal areas of nonviable pancreatic parenchyma  Pancreatic glandular necrosis  necrosis of peripancreatic fat  pancreatic necrosis represents a severe form of acute pancreatitis  Necrosis is present in approximately 20 to 30 percent of acute pancreatitis

13. Recognition of Pancreatic Necrosis  Radiographically by intravenous contrast- enhanced computed tomography (CT) of the abdomen.  Contrast-enhanced abdominal CT: gold standard noninvasive diagnosis of pancreatic necrosis  accuracy >= 90% when >=30% glandular necrosis.  pathologically at surgery or autopsy

15. Pancreatic Necrosis  Treatment policy shifted away from early surgical debridement ("necrosectomy") to aggressive intensive medical care  Prompt identification and prevention complications  Intensive care  Nutrition support  Infection prevention ?

16. Foreground Questions  PICO  P 代表 patient 或者 problem  I 代表 intervention 通常為診斷 (diagnostic) 或者是治療 (treatment)  C 代表 comparisons (comparative intervention)  O 代表 outcome

17. 步驟 1: 形成臨床問題  對於治療急性壞死性胰臟炎病患有需要使用 抗生素治療嗎？  P: Patient –acute necrotizing pancreatitis 病患  I: Intervention – 接受 antibiotics 治療  C: Comparison – 不接受 antibiotics 治療  O: Outcome – 併發症或是死亡率是否有差別 ?

18. 步驟 2: 尋找證據  醫學資料庫檢索 MEDLINE Best Evidence Cochrane Database of Systematic Reviews EBM ReviewsTherapeuticsLocal Holdings Articles in EnglishDiagnosisSystematic Reviews Research on Human Subjects PrognosisProtocols Latest UpdateEtiologyNew Reviews

19. 步驟 2: 尋找證據  以 Medline 為例  以 Key word, Text word 查尋  Map to medical subject headings (MeSH)  And, Or, And Not 功能 : 可交集或聯集 Key word  限制功能 : Limited to ( 年代, 英文,Randomized controlled trial)

20. Cochrane library

25. Trial in 2003

26. Trial in 2007

27. RTC in 2009

28. Trial in 2009

31. The Evidence Pyramid

32. Grade of Recommendation Level of Evidence Therapy [A]1a Systemic review of RCTs 1b Single RCT 1c ‘All-or-none’ [B]2a Systemic review of cohort studies 2b Cohort study or poor RCT 2c ‘Outcomes’ research 3a Systemic review of case- control studies 3b Case-control study [C]4 Case series [D]5 Expert opinion, physiology, bench research

33. 步驟 4: 臨床應用  應用於臨床病患  應以 effective, efficiency, equality 的理念應用 於病人  最終結果想法 (the end result idea) 的理想  制定醫療政策  Agent for Healthcare Research and Quality (AHRQ) in USA

34. 結論  Acute necrotizing pancreatitis  Combination with  Intra-abdominal infection – Antibiotics treatment is necessary  No evidence of intra-abdominal infection- Prophylactic antibiotics is not necessary and not proved to be effective in reduction morbidity and morbidity

35. 結論  How to prove intra-abdominal infection?  Ascites tapping  Paracentesis  CT guide aspiration  Blood culture: gram negative bacilli or anaerobe

36. Thank You For Your Attention