EJINME-03109; No of Pages 6

European Journal of Internal Medicine xxx (2016) xxxxxx

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European Journal of Internal Medicine

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Original Article

New Atlanta Classication of acute pancreatitis in intensive care unit:

Complications and prognosis
Mara-Consuelo Pintado a,b,, Mara Trascasa a, Cristina Arenillas a,1, Yaiza Ortiz de Zrate a, Ana Pardo a,
Aaron Blandino c, Ral de Pablo a,b,2
a
b
c

Intensive Care Unit, Hospital Universitario Prncipe de Asturias, Alcal de Henares, Madrid, Spain
University of Alcal, Alcal de Henares, Madrid, Spain
Intensive Care Unit, Hospital Universitario Ramn 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 Classication of acute pancreatitis (AP) in adults dened 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 medicalsurgical 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 1540
episodes/100.000 inhabitants/year, with an increasing trend according
recent studies [16]. 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 [811].
Some studies have demonstrated that this change on treatment

Grant or other nancial support used in the study: This work was not supported.
Corresponding author at: Intensive Care Unit, Hospital Universitario Prncipe de
Asturias, Carretera Alcal-Meco SN, Alcal 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 Ramn 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 [2,1418].
In 2012, the Atlanta Classication 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 dened 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 [12,14,15,2125], 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 classied severe AP according to the new
Atlanta Classication [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 Classication 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

M.-C. Pintado et al. / European Journal of Internal Medicine xxx (2016) xxxxxx

about complications and mortality of patients with moderate AP

admitted in ICU [23].
The main aim of this study is to describe the complications of
patients with moderately severe acute pancreatitis, developed during
their stay in the ICU according to the new Atlanta Classication [20]. In
second place, to described ICU mortality and compared with severe AP.
2. Material and methods
We conducted a prospective observational study in a 14-bed medical and surgical ICU in Spain, during 5 years (20102014). We included
all patients consecutively admitted to the ICU diagnosed with moderately severe or severe acute pancreatitis according to the Atlanta revised
classication of AP [20].
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, severe, epigastric pain
often radiating to the back), elevation of serum amylase and/or lipase
activity at least 3 times greater than the upper limit of normal, and an
imaging method with characteristics ndings of AP (abdominal ultrasound and/or contrast-enhanced computed tomography (CT)) [20].
The Atlanta revised classication 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, in which patients
did not develop organ failure, no local or systemic complications;
b) moderately severe, in which patients developed transient (resolves
in less than 48 h of duration) organ failure or local or other systemic complications; and c) severe, in which patients developed persistent organ
failure (persistent organ failure more than 48 h, local or systemic complications usually present) [20]. We used SOFA score N 3 as criteria of organ
failure because this score is preferred in critical care patients [20].
We examine demographic data (sex, age), reason for ICU admission,
etiology of AP, severity scores of illness (Acute Physiology and Chronic
Health Evaluation (APACHE) II score [26] on admission, Ranson [27]
scores 48 h from admission, Balthazar criteria for severity [28,29],
daily Sequential Organ Failure Assessment (SOFA) score [30], Atlanta revised classication of AP [20]), presence of organ failure (dened as a
score of 3 or 4 on SOFA score [30]), need for mechanical ventilation
and renal replacement therapy, local, other complications which required the evaluation by a surgeon (dened as those pathologies that
according to the judgment of the attending physician, when the clinical
course or imaging guide to the presence of complications that require
surgical treatment, who decides the need for surgery or conservative
treatment) and systemic complications, ICU length of stay, and mortality during hospital and ICU stay.
APACHE II score [26] provides an objective assessment of severity of
illness in critically ill patients: the highest score, the highest probability
of mortality. Ranges from 0 to 71 points. It is made up of 3 components:
1) Acute Physiology Score, which is derived from 12 clinical variables
that are obtained within 24 h after admission in the ICU, the worst recorded value is taken. 2) Age Adjustment, from 1 to 6 points, which
they are added for patients older than 44 years old. 3) Chronic Health
Evaluation, an additional adjustment is made for patients with severe
and chronic organ failure involving the heart, lungs, kidneys, liver, and
immune system.
Ranson criteria [27] are assessed both at admission and at 48 h:
a) On admission: age: N 55 years, white blood count: N16.000/mm3,
blood glucose level: N11.0 mmol/L, lactate dehydrogenase: N350 IU/L,
aspartate aminotransferase: N 250 UI/L. b) At 48 h: packed cell
volume: decrease N 10% from admission, blood urea nitrogen: increase
N1.8 mmol/l from admission, calcium: b2 mml/l, arterial partial
pressure of oxygen: b 60 mm Hg, base decit: N4 mmol/l, uid sequestration: N 6 L. The more of the score, the higher the mortality.
Balthazar criteria for severity [28,29] is used in computer tomography for grading of acute pancreatitis, being 5 grades: a) normal pancreas, b) foal or diffuse pancreatic enlargement, c) pancreatic alterations

associated with peri-pancreatic inammation, d) single uid collection,

e) 2 or more uid collections poorly dened or presence of gas within
the pancreas or within the peri-pancreatic inammation.
SOFA score [30] is designed to evaluate the function of 6 major organ
systems (cardiovascular, respiratory, renal, hepatic, central nervous
system, and coagulation) over time. The score is obtained on the day
of admission and each of the following days in ICU, using the most abnormal value for each variable in a 24-h period on each organ system,
that are assigned a cut-off value from 0 (normal) to 4 (high degree of
dysfunction/failure), with a maximum punctuation of 24.
The study was approved by the Institutional Ethics and Clinical Trials
Committee Principe de Asturias University Hospital.
2.1. Statistical analysis
Normal distribution of variables was assessed using the KolmogorovSmirnov test. Quantitative variables with normal distribution are
expressed as mean standard deviation, non-normal distribution
variables are shown as median and interquartile ranges. Qualitative
variables are shown as number and percentages.
Comparisons between patients according to severity of AP were
based on the Student's t test, MannWhitney test, and chi-square test
(Holm method were applied to adjust p value in case of multiple comparisons), for quantitative variables with normal distribution, continuous variables with non-normal distribution, and qualitative variables,
respectively.
Level of statistical signicance was set to p values less than 0.05 and
results are expressed with their 95% condence intervals.
Statistical analysis was performed using SPSS 18.0 software (SPSS
Inc., Chicago, Illinois).
3. Results
During the study period, 57 patients with AP were admitted to our
ICU, of them 44 (77.2%) patients developed severe AP during the ICU
stay according to revised Atlanta criteria [20] and 12 (21.1%) patients
had moderately severe AP; 1 (1.8%) patient had mild AP and were
excluded from study. During this study, no patient was diagnosed of
chronic pancreatitis.
The main reasons for admission were hemodynamic instability
(37.5%) and acute renal dysfunction (28.6%). On 48.2% of cases, the AP
had a gallstone etiology. Median of days between the onset of acute
pancreatitis and admission to ICU were 2.0 days (1.05.0): 3.0 days
(1.24.7) on moderately severe pancreatitis and 2.0 days (1.05.7) on
severe (p = 0.6). Baseline characteristics are shown in Table 1.
In this study, 67.9% of the patients required mechanical ventilation;
5.2% with moderately severe AP and 94.7% with severe AP (p b 0.001).
Renal replacement therapy (RRT) were required in 26.8% of the patients,
all of them with severe AP (p = 0.024). Vasoactive support was needed
in 67.9% of the patients, in less proportion on patients with moderately
severe AP (16.7% vs. 81.8% with severe AP, p b 0.001). And 26.8% of the
patients had intra-abdominal hypertension, although only 3.6% developed abdominal compartment syndrome; all of them had severe AP.
The incidence of multiple organ failure was lower (8.3%) and less
severe in patients with moderately severe AP than in patients with
severe AP (Table 2).
All the patients had some kind of complications, being the most
frequent the non-infectious systemic complications. There were no
differences on systemic complications and non-pancreatic infectious
complications according to severity of AP, although local and other
complications which required the evaluation by a surgeon were more
frequent on severe AP (Table 3).
Infectious complications were detected in 82.1% of the patients,
28.3% of these patients had intra-abdominal infections (mainly abdominal abscess), 19.6% had extra-abdominal infections (mainly pneumonia), and 52.2% had a combination of the two.

Please cite this article as: Pintado M-C, et al, New Atlanta Classication 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

M.-C. Pintado et al. / European Journal of Internal Medicine xxx (2016) xxxxxx

Table 1
Baseline characteristics of AP admitted to ICU.

Age, 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)

62.20 15.80
40 (71.4%)

57.08 20.64
7 (58.3%)

63.59 14.18
33 (75.0%)

0.348
0.293
0.601

27 (48.2%)
7 (12.5%)
7 (12.5%)
5 (8.9%)
4 (7.1%)
2 (3.6%)
4 (7.1%)

5 (41.7%)
2 (16.7%)
1 (8.3%)
1 (8.3%)
2 (16.7%)
1 (8.3%)
0 (0%)

22 (50.0%)
5 (11.4%)
6 (13.6%)
4 (9.1%)
2 (4.5%)
1 (2.3%)
4 (9.1%)

5 (8.9%)
6 (10.7%)
21 (37.5%)
16 (28.6%)
8 (14.3%)
3.29 1.87
15.65 7.60
6.50 3.67
16 (28.6%)

2 (16.7%)
1 (8.3%)
2 (16.7%)
4 (33.3%)
3 (25.0%)
2.58 1.78
9.92 6.13
4.25 10.48
0 (0.0%)

3 (6.8%)
5 (11.4%)
19 (43.2%)
12 (27.3%)
5 (11.4%)
3.48 1.86
17.26 7.24
7.11 3.85
16 (36.4%)

0.674

0.143
0.002
0.010
0.012

Data are shown as number (percentage).

Abbreviations: ERCP: endoscopic retrograde cholangiopancreatography. ICU: Intensive care unit. APACHE II: Acute Physiology and Chronic Health Evaluation II. SOFA Sequential Organ
Failure Assessment.

Expressed as media standard deviation.

Non-pancreatic infectious complications were diagnosed in 76.8% of

the patients, with a median of 2.0 infections per patient (1.02.0),
without differences according to severity of AP (66.7% of patients
had non-pancreatic infection on moderately severe AP vs. 79.5%, p =
0.443/median 1.5 (1.02.0) infections per patient on moderately severe
AP vs. 2.0 (1.03.0) on severe AP, p = 0.353).
Pancreatic infections were less frequent on moderately severe AP
(8.3%) vs. on severe AP (54.4%; p = 0.004).
Main isolated microorganism was Gram-negative bacteria (51.6%
of isolated cultures): Escherichia coli and Pseudomonas sp. on intraabdominal infections and Pseudomonas sp. on extra-abdominal
infections. Gram positive bacterial pathogens were detected in 32.6%
of the isolated cultures, mainly Enterococcus sp. on intra-abdominal
infections. Fungus were isolated on 7.2% of cultures, mainly on
abdominal abscess, urinary tract infections, and blood cultures.
The mortality in the ICU was 23.2%, all of these patients had
severe AP (none of patients with moderately severe AP died vs.
29.5%, p = 0.049).
We also found higher ICU mortality among patients who need
surgery (42.3% vs. 6.7%, p = 0.002) and those who developed
multiple-organ failure (33.3% vs. 0%, p = 0.005), without differences
on mortality according to presence of infection (mortality of 23.9%
infected patients vs. 20%, p = 1.00). Mean ICU stay was 23.96

27.4 days, longer on patients with severe AP (7.58 9.3 days on

moderately severe AP vs. 28.4 29.0, p = 0.002).
4. Discussion
In our study, we found that patients with moderately severe AP admitted to ICU have a high rate of complications, mainly non-infectious
systemic complications, with similar rates of these complications than
severe AP. Despite it, patients with moderately severe AP have very
low mortality.
All the patients in our study developed some kind of complication
during their ICU stay, mainly non-infectious systemic complications.
We have not found statistically signicant difference on rate of noninfectious systemic complications between moderately severe or severe
AP. Unlike several studies that have reported an elevated number of
systemic complications in patients with severe AP during their ICU
stay, mainly organ dysfunction or failure, with an incidence of 5762%
of patients with respiratory failure, 4552% with cardiovascular complications, and 1238% with acute kidney injury or failure. Due to these
complications, there is a large number of patients requiring ventilatory
support (7890%), RRT (3844%), or treatment with vasoactive support
(6270%) [12,25,31]. Regarding the organ support our ndings are
similar than these previous studies. About 77100% of patients with

Table 2
Severity developed during ICU stay.

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 (7.1%)
14 (25.0%)
12 (21.4%)
16 (28.6%)
10 (17.9%)
9.32 4.11
15 (26.8%)
2 (3.6%)
39 (69.6%)

3 (25.0%)
2 (16.7%)
3 (25.0%)
3 (25.0%)
1 (8.3%)
4.92 2.02
0 (0.0%)
0 (0.0%)
1 (8.3%)

1 (2.3%)
12 (27.3%)
9 (20.5%)
13 (29.5%)
9 (20.5%)
10.52 3.71
15 (34.1%)
2 (4.7%)
38 (86.4%)

p
0.085

b0.001
0.024
1.000
b0.001

Data are shown as number (percentage).

Abbreviations: SOFA: Sequential Organ Failure Assessment. ICU: Intensive care unit.

Expressed as median (percentile 25percentile 75).

Please cite this article as: Pintado M-C, et al, New Atlanta Classication 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

M.-C. Pintado et al. / European Journal of Internal Medicine xxx (2016) xxxxxx

Table 3
Complications during ICU stay.

Local complications
Infection of necrotic tissue
Abdominal abscess
Pancreatic pseudocyst
Pancreatic stula
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)

27 (48.2%)
5
21
1
2
2
2
25 (44.6%)
4
6
3
3
6
3
54 (96.4%)
4
11
6
38
16
44
14
8
43 (76.8%)
28
8
4
15
12
5
7
4
5
4

1 (8.3%)
0
1
0
0
0
1
2 (16.7%)
0
1
0
0
1
0
11 (91.7%)
0
2
1
2
1
3
1
0
8 (66.7%)
2
1
1
2
4
0
1
1
0
0

26 (59.1%)
5
20
1
2
2
1
23 (52.3%)
4
5
3
3
5
3
43 (97.7%)
4
9
5
36
15
41
13
8
35 (79.5%)
26
7
3
13
8
5
6
3
5
4

0.002

0.028

0.386

0.443

Abbreviations: NA: not applicable.

Data are shown as number (percentage).

One patient could have more than one infection episode or complication during ICU stay.

Other local complications: splenic abscess, upper mesenteric vein thrombosis.

Other surgical complications: 1 splenic rupture, 1 cellulitis, 1 gastrointestinal hemorrhage.

Other non-pancreatic infections: 1 empyema, 1 hepatic abscess, infected abdominal hematoma, and 1 paravertebral abscess.

severe AP admitted to the ICU had multiple organ failure or dysfunction

[22,25]. In our study, we found higher rates of respiratory and
cardiovascular failure in patients with severe AP than those in previous
studies, with similar rates of renal failure and multiple organ failure.
Nevertheless, we also found that 8.3% of patients with moderately
severe AP developed multiple organ failure during ICU stay, with a
rate of acute respiratory failure of 25% (16.7% of patients with moderately severe AP required mechanical ventilation), cardiovascular failure
rate of 16.7%, and acute renal failure rate of 8.3%. None of the previous
studies have focused on complications in the patients with moderately
severe AP admitted in the ICU, and few of them describes the complications of these patients during the hospital stay. Zhao et al. [32] in their
study about early oral refeeding based on hunger, included 138 patients
of which 101 had moderately severe AP (73.2%), reports rates of 26.8%
of persistent organ failure, 5.8% of pancreatic infections, 2.2% of
gastrointestinal bleeding, and 34.0% of pleural effusion. Jin et al. [33]
who compared severe with moderately severe AP admitted to hospital,
described that 66.6% of patients with moderately severe AP developed
transient organ failure and 45.5% pancreatic necrosis. Only one study
[23] describes what happens with patients with mild AP admitted in
the ICU, reported 8.3% developed acute respiratory failure of without
any case of multiple organ failure.
A few studies report the presence of non-infectious local complications in patients with AP admitted in the ICU. Arroyo et al. [23] described
a rate of local complications of 16.7% being the pancreatic pseudocyst
the main local complication. Millian et al. [15] who compared

conservative medical treatment versus surgical treatment of patients

with necrotic acute pancreatitis admitted to ICU, reports that 18
patients (25.7%) developed pancreatic pseudocyst during the ICU stay
and at 1-year follow-up. We found that non-infectious local complications are rare in moderately severe AP. And are more frequent in severe
AP, being the pancreatic stula and thrombosis of splenic vein the
mainly complications, followed by pseudocyst.
In our study, the rate of infectious complications (systemic or
localized) is elevated (82.1%), with a higher rate in severe AP as
expected, with 76.8% of patients having more than one infection.
Regarding this, the data reported on previous studies are discordant.
Some authors report similar rates than us (7374% [18,24]), unlikely
authors describes lower rates of infection in patients with severe AP
(around 2048%) [31,34].
There are four studies that focus on non-pancreatic infections complicating severe AP, any of these was restricted to patients admitted in
the ICU nor evaluated moderately severe AP. Noor et al. [35] reported
the presence of extra-pancreatic infection on 62.7% of patients with
severe AP, mainly bloodstream infection, catheter-related bloodstream
infections (39.6%), and urinary tract infections (13.2%). Cacopardo
et al. [18] described a prevalence of bloodstream infection of 30% in
patients with severe AP. Xue et al. [31] described 34 episodes of
extrapancreatic infection on 44 patients with infection and severe AP,
in this study, pneumonia was the most frequent infection. Guo et al.
[36] in their study with 447 patients included with necrotizing pancreatitis, reports 80 episodes of bacteremia (18%) and 168 episodes of

Please cite this article as: Pintado M-C, et al, New Atlanta Classication of acute pancreatitis in intensive care unit: Complications and prognosis,
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M.-C. Pintado et al. / European Journal of Internal Medicine xxx (2016) xxxxxx

pneumonia (38%). In our study, 43 of 56 patients (76.8%) have an extrapancreatic infection, mainly of respiratory system, without differences
between moderately severe or severe AP.
Regarding pancreatic infection, we found that it was present in 44.6%
of the patients in our study, mainly due to Gram-negative bacteria, as reported in previous studies (1973%) in severe AP [15,18,24,31,3436].
Although in these previous studies, infection has been reported to be a
major determinant of ICU mortality [18,24,31,3436], we did not nd
higher mortality among patients with infection, maybe due to the
high rate of infectious complications on moderately severe AP.
There are few data about complications on patients with moderately
severe AP admitted in the ICU. 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), with
a median ICU length of stay of 2.5 (2.03.8) days and without
in-hospital mortality. Chen et al. [37] in their study of acute pancreatitis
admitted to surgical ICU describes an incidence of multiple-organic syndrome of 12%, single organ failure of 23%, sepsis 11%, and without any
case of intraabdominal hemorrhage in 208 patients with moderately
severe AP; with a hospital mortality of 2%. 24% of these patients needed
surgical drainage, with a median time of mechanical ventilation and RRT
of 0.10 (00) days and 0.36 (00) days, respectively. De Madaria et al.
[38] showed in their cohort of 144 patients with AP that 2.4% of patients
with moderately severe AP needed ICU care due to non-persistent organ
failure or complications, none of them required surgical treatment or
died. Lakhey et al. [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 9.8 days, and Lee [40] in 43 patients with moderately
severe AP, of which 12 (27.9%) needed admission in the ICU, but only
2 (4.7%) developed organ failure. Talukdar et al. [41] describes an
infection rate of 25.9% on patients with moderately severe AP, mainly
primary infected necrosis and pneumonia, 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. Jin et al. [33] in their study with 92 patients
with acute pancreatitis, of which 33 patients had moderately severe
AP, describes an infection rate (infected pancreatic necrosis and
extrapancreatic infections) of 9.1%, and 12% of patients with pancreatic
necrosis (N30% of pancreatic tissue), but none of them needed
admission in the ICU or surgery or died during their hospital stay.
In our study, ICU mortality was 23.2% similar than described in
previous studies of patients with AP admitted in the ICU, which varies
between 11 and 53.6% [12,14,15,21,23]. As has been seen in previous
studies, no patient with moderately severe AP died during the stay in
the ICU [7,21,23,39,42].
We found higher mortality among patients who need surgical treatment or developed multiple-organ failure. Most of AP admitted to ICU
are due to organ failure associated to AP, which have been found to be
a mayor determinant of mortality in several studies [36,43]. In a recent
meta-analysis about multiple organ failure in AP and mortality, it was
found an incidence or multiple organ failure of 40% and mortality of
30% in this patients [43].
The limitations of this study are that it was conducted in a single
center, and that could inuence an increase in the percentage of surgical
patients compared to other centers where there are more patients who
are managed with percutaneous drainage; and that most of the patients
with moderately severe AP are admitted to ward. The strength of the
study is the description of all the complications associated to AP admitted in the ICU, being the rst study who describe all the complications
associated to moderately severe AP admitted in the ICU.
5. Conclusions
In conclusion, the patients admitted in the ICU because of moderately severe acute pancreatitis suffer a high rate of complication, mainly

non-infectious systemic complications and infectious non-pancreatic

complications, with similar rates of these complications than in severe
AP cases admitted in the ICU. However, ICU mortality rate in moderately
severe acute pancreatitis is lower, which supports the existence of this
new group of pancreatitis according to severity.
Conicts of interest
The authors state that they have no conicts of interest.
Acknowledgements
We wanted to thank all staff and patients of Principe de Asturias University Hospital that have worked or collaborated selessly in this study.
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Eur J Intern Med (2016), http://dx.doi.org/10.1016/j.ejim.2016.01.007