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Richard Flint, MBChB; John A. Windsor, MBChB, MD, FRACS

Arch Surg. 2004;139:438-443.

Hypothesis  The physiological response to treatment is a better predictor of outcome in acute pancreatitis than are traditional static measures.

Design  Retrospective diagnostic test study. The criterion standard was Organ Failure Score (OFS) and Acute Physiology and Chronic Health Evaluation II (APACHE II) score at the time of hospital admission.

Setting  Intensive care unit of a tertiary referral center, Auckland City Hospital, Auckland, New Zealand.

Patients  Consecutive sample of 92 patients (60 male, 32 female; median age, 61 years; range, 24-79 years) with severe acute pancreatitis. Twenty patients were not included because of incomplete data. The cause of pancreatitis was gallstones (42%), alcohol use (27%), or other (31%). At hospital admission, the mean ± SD OFS was 8.1 ± 6.1, and the mean ± SD APACHE II score was 19.9 ± 8.2.

Interventions  All cases were managed according to a standardized protocol. There was no randomization or testing of any individual interventions.

Main Outcome Measures  Survival and death.

Results  There were 32 deaths (pretest probability of dying was 35%). The physiological response to treatment was more accurate in predicting the outcome than was OFS or APACHE II score at hospital admission. For example, 17 patients had an initial OFS of 7-8 (posttest probability of dying was 58%); after 48 hours, 7 had responded to treatment (posttest probability of dying was 28%), and 10 did not respond (posttest probability of dying was 82%). The effect of the change in OFS and APACHE II score was graphically depicted by using a series of logistic regression equations. The resultant sigmoid curve suggests that there is a midrange of scores (the steep portion of the graph) within which the probability of death is most affected by the response to intensive care treatment.

Conclusion  Measuring the initial severity of pancreatitis combined with the physiological response to intensive care treatment is a practical and clinically relevant approach to predicting death in patients with severe acute pancreatitis.

From the Hepatobiliary Pancreatic/Upper Gastrointestinal Unit, Department of General Surgery, Auckland City Hospital, Grafton, Auckland, New Zealand.