Moins par les résultats de l’étude, restreints en raison du petit nombre de patients, mais surtout par la revue de la prise en charge nutritionnelle et d’une tentative d’application à la population pédiatrique, cette thèse apporte une réflexion sur l’importance de la nutrition dans cette maladie sévère que constitue la pancréatite aiguë et met le doigt sur le manque d’études prospectives pédiatriques dans ce domaine.
5 Annexes
5.1 Score de Ranson (traduit selon
4)
Table 11. Critères de Ranson d’origine pour l’évaluation de la sévérité de la pancréatite aiguë : un épisode sévère est prédit par trois ou plus facteurs positifs. 96 Admission Age > 55 ans Leucocytes > 16 x 109/l Glycémie > 10 mmol/l LDH > 350 UI/l ASAT > 120 UI/l
Pendant les 48 premières heures
Diminution hématocrite > 10%
Calcémie < 2.0 mmol/l
Déficit base > 4 mmol/l
Augmentation urée sanguine > 5 mg/dl Séquestration liquidienne > 6 l
PaO2 < 60 mmHg
Table 12. Critères de Ranson modifiés pour l’évaluation de la sévérité de la pancréatite aiguë : un épisode sévère est prédit par trois ou plus facteurs positifs (Ranson et al, 1979).
Admission Age > 70 ans Leucocytes > 18 x 109/l Glycémie > 12 mmol/l LDH > 400 UI/l ASAT > 250 UI/l
Pendant les 48 premières heures
Diminution hématocrite > 10%
Calcémie < 2.0 mmol/l
Déficit base > 5.0 meq/l
Augmentation urée sanguine > 2 mg/dl (> 0.5 mmol/l) Séquestration liquidienne > 6 l
5.2 Score de Glasgow (traduit selon
4)
Table 13. Critères de Glasgow d’origine pour l’évaluation de la sévérité de la pancréatite aiguë : un épisode sévère est prédit par trois ou plus facteurs positifs. 97
Pendant les 48 premières heures
Age > 55 ans PaO2 < 60 mm Hg Albuminémie < 32 g/l Calcémie < 2 mmol/l Leucocytes > 15 x 109/l ASAT > 100 U/l LDH > 600 UI/l
Glycémie > 10 mmol/l (en l’absence de diabète préexistant)
Urémie > 16 mmol/l
Table 14. Critères de Glasgow modifiés pour l’évaluation de la sévérité de la pancréatite aiguë : un épisode sévère est prédit par trois ou plus facteurs positifs (Blamey et al, 1984).
Pendant les 48 premières heures
Age > 55 ans PaO2 < 60 mm Hg Albuminémie < 32 g/l Calcémie < 2 mmol/l Leucocytes > 15 x 109/l LDH > 600 UI/l
Glycémie > 10 mmol/l (en l’absence de diabète préexistant)
Urémie > 16 mmol/l
Table 15. Critères de Glasgow modifiés pour l’évaluation de la sévérité de la pancréatite aiguë : un épisode sévère est prédit par trois ou plus facteurs positifs (Corfield et al, 1985). PaO2 < 60 mm Hg Albuminémie < 32 g/l Calcémie < 2 mmol/l Leucocytes > 15 x 109/l ASAT > 200 U/l LDH > 600 UI/l
Glycémie > 10 mmol/l (en l’absence de diabète préexistant)
5.3 Score Apache II
32, 98Table 16. APACHE-II Severity of Disease Classification System. 32
HIGH ABNORMAL RANGE LOW ABNORMAL RANGE
PHYSIOLOGIC VARIABLE +4 +3 +2 +1 0 +1 +2 +3 +4 Temperature-rectal (°C) ≥41° 39°- 40.9° 38.5°- 38.9° 36°- 38.4° 34°- 35.9° 32°- 33.9° 30°- 31.9° ≤29.9° Mean arterial pressure
(mm Hg) ≥160 130-159 110-129 70-109 50-69 ≤49
Heart rate (ventricular
response) ≥180 140-179 110-139 70-109 55-69 40-54 ≤39 Respiratory rate (nonventilated or ventilated) ≥50 35-49 25-34 12-24 10-11 6-9 ≤5 Oxygenation: A-aDO2 or PaO2 (mm Hg) a. FIO2 ≥0.5 record A- aDO2 ≥500 350-499 200-349 <200
b. FIO2 <0.5 record only
PaO2 PO2 >70 PO2 61- 70 PO2 55- 60 PO2 <55 Arterial pH ≥7.7 7.6-7.69 7.5-7.59 7.33- 7.49 7.25- 7.32 7.15- 7.24 <7.15 Serum Sodium (mmol/L) ≥180 160-179 155-159 150-154 130-149 120-129 111-119 <110
Serum potassium ≥7 6-6.9 5.5-5.9 3.5-5.4 3-3.4 2.5-2.9 <2.5
Serum creatinine (mg/dl) (Double point score for acute renal failure)
>3.5 2-3.4 1.5-1.9 0.6-1.4 <0.6
Hematocrit (%) ≥60 50-59.9 46-49.9 30-45.9 20-29.9 <20
White blood cell count
(total/mm3) (in 1000s) ≥40 20-39.9 15-19.9 3-14.9 1-2.9 <1
Glasgow Coma Score (GCS): Score 15 minus actual GCS
A Total Acute Phyiology
Score (APS): Sum of the 12 individual variable points
Serum HCO2 (venous-
mmol/L) (Not preferred, use if no ABGs)
≥52 41-51.9 32-40.9 22-31.9 18-21.9 15-17.9 <15
B AGE POINTS
Assign points to age as follows: Age (yr) Points ≤44 0 45-54 2 55-64 3 65-74 5 ≥75 6
C Chronic health points
If the patient has a history of severe organ system insufficiency or is immuno-compromised assign points as follows: a. For nonoperative or emergency postoperative patient – 5 points or
b. For elective postoperative patients – 2 points.
Definitions. Organ insufficiency or immunocompromised state must have been evident prior to this hospital admission and conforms to the
following criteria:
Liver. Biopsy proven cirrhosis and documented portal hypertension, episodes of past upper GI bleeding attributed to portal hypertension ; or prior
episodes of hepatic failure/encephalopathy/coma.
Cardiovascular. NY Heart Association Class IV.
Respiratory. Chronic restrictive, obstructive, or vascular disease resulting in severe exercise restriction, e.g. unable to climb stairs or perform
household duties; or documented chronic hypoxia, hypercapnia, secondary polycythemia, severe pulmonary hypertension (>40 mmHg), or respirator dependency.
Renal. Recurring chronic dialysis.
Immunocompromised. The patient has received therapy that suppresses resistance to infection (e.g. immuno-suppression, chemotherapy,
lymphoma, AIDS).
APACHE-II SCORE Sum of A + B + C
A APS Points B Age points
C Chronic Health points
5.4 Score CT-scan (traduit selon
5, 32)
Table 17. Score CT-scan selon Balthazar et al. 47. La pancréatite est prédite comme sévère avec un score D ou E.
Grade Morphologie CT-scan
A Normal
B Elargissement de la glande, petite collection liquidienne intrapancréatique C A et/ou B plus inflammation péripancréatique et nécrose pancréatique < 30%
D A et/ou B et/ou C plus collection liquidienne extrapancréatique unique et 30-50% de nécrose pancréatique
E A et/ou B et/ou C et/ou D plus collection liquidienne extrapancréatique extensive, abcès pancréatique et nécrose pancréatique > 50%
Table 18. Index de sévérité CT. 47
Score Total = Grade CT (0-4) + Nécrose (0-6). L’indexe de sévérité est léger de 0-1 point, modéré de 2-6 points et sévère de 7-10 points.
Grade CT Score Nécrose Score
A 0 Aucune 0
B 1 < 33% 2
C 2 33-50% 4
D 3 > 50% 6
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