PRACTICE GUIDELINE
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[Practical guidelines for management of severe acute pancreatitis with integrated Chinese traditional and Western medicine (Draft)].

OBJECTIVE: To draft the practical guidelines for management of severe acute pancreatitis (SAP) with integrated Chinese traditional and Western medicine.

METHODS: With evidence based data as the foundation, a systematic review of literature was undertaken, with reference of published guidelines and solicitation of opinions from specialists, a preliminary guideline was drafted. The recommendations were categorized into five grades from A to E, with A being the highest, according to a modified Delphi criteria, which were adopted by the International Sepsis Forum held in 2001.

RESULTS: SAP is a critical acute abdomen which usually has three clinical phases. It is essential to manage the patients in an intensive care unit with full monitoring and systems support in the early phase. Adequate prompt fluid resuscitation is crucial in the Prevention of systemic complications. Despite initial encouraging results, antiproteases such as gabexate, antisecretory agents such as octreotide, and anti-inflammatory agents such as lexipafant have all proved disappointing in large randomized studies, and they are not recommended for routine use. Antibiotic Prophylaxis may be potentially beneficial in preventing infection, but there remains no consensus of opinion regarding the value of antibiotic prophylaxis. If antibiotic prophylaxis is used, it should be given for a maximum of 14 days. Nutritional support is required in patients with SAP. The enteral route should be used if tolerated, and the nasogastric route for feeding is feasible. Urgent therapeutic endoscopic retrograde cholangiopancreatography (ERCP) should be performed in patients with gallstone-associated SAP, with co-existing cholangitis, jaundice, or a dilated common bile duct. Fine-needle peritoneal aspiration for bacteriology should be performed to differentiate sterile from infected pancreatic necrosis in patients with sepsis syndrome. Infected pancreatic necrosis in patients with clinical signs and symptoms of sepsis is an indication for intervention, including surgery and drainage under radiological guide. The option of surgical intervention for removal of necrotic tissue, and subsequent postoperative management depends on patient's general condition and expertise of the attending surgeon. The Chinese traditional medicine therapy has been proved to be a valuable treatment strategy in reducing mortality rate and clinical course.

CONCLUSION: The present guideline is drafted with evidence-based recommendations and should be updated when new evidence based opinions are gathered.

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