6. No significant past medical or surgical
history.
She has a family history of diabetes
Drug history :
- Oral hypoglycemic agents .. Glimepride
off treatment for 2 months
9. ill,tachypnic, not pale, jaundiced or cyanosed.
vitals
pulse
86
Blood pressure Respiratory rate
110/60
20
temperature
febrile
10. CNS: Confused, GCS: 14/15
CVS: Normal heart sounds, no murmers.
Respiratory: Good air flow, no added sound
on auscultation.
Abdominal tenderness at epigastric area, no
palpable masses.
13. Renal profile:
B. urea
S. creatinin
31 mg/dl
1 g/dl
S. Na
S.K
142 mmol/l
3.3 mmol/l
S.Ca
8.5mmol/l
Liver function tests
Total
Direct
bilirubin bilirubin
0.3
mg/dl
0.2
mg/dl
Total
protein
S.
Albumin
S.
globulin
ALP
AST
ALT
6.9
g/dl
3.9
g/dl
3
g/dl
37
U/L
3.9
U/L
39
U/L
19. Pancreas:
edematous, hypo echoic, with
calcifications.
liver, gall bladder, spleen, kidneys, urinary
bladder were normal with no marked
significance.
No ascitis.
23. NPO.
IV. FLUIDS 125 ml/ hr.
Antibiotics ( ceftrixon , metronidazol).
PPI.
KCl 20 mmol in N.S over 4 hours.
RBG 4 hourly and soluable insulin with sliding
scale accordingly s/c.
Enoxaparine( Clexane®) 40 mg.
Planed for an abdominal CT.
24. Acute pancreatitis is an inflammatory condition
of the pancreas characterized clinically by
abdominal pain and elevated levels of
pancreatic enzymes in the blood.
25. The pathogenesis of acute pancreatitis is not
fully understood. Nevertheless, a number of
conditions are known to induce this disorder
with varying degrees of certainty, with
gallstones and chronic alcohol abuse
accounting for majority of cases.
27. Acute pancreatitis can be suspected clinically,
but requires biochemical, radiologic, and
sometimes histologic evidence to confirm the
diagnosis.
none of them alone is diagnostic.
28. Abdominal pain at epigastric area or
radiating to the back.
It worsen after eating.
Nausea.
Vomiting.
Tender abdomen.
Indigestion.
Oily smelly stool.
29. Pancreatic enzymes
Serum lipase and serum amylase.
Currently guidelines suggest that lipase
measurement is the most sensitive marker
for diagnosis of acute pancreatitis.
30. A commonly used classification system (the
Atlanta classification) divides AP into two
broad categories:
Mild (edematous and interstitial) acute
pancreatitis.
Severe (usually synonymous with necrotizing)
acute pancreatitis.
31. The criteria for severe AP included any of the
following:
A Ranson's score of 3 or more
An APACHE II score of 8 or more within the
first 48 hours
Organ failure (respiratory, circulatory, renal,
and/or gastrointestinal bleeding)
Local complications (pancreatic necrosis,
abscess, or pseudocyst).
32. When do you do “early” transfer to ICU?
When do you consult critical care team?
When do you start antibiotics?
“They” say people crash fast – who are these
people?
What is “aggressive fluid resuscitation?”
33. Early identification of severity and
appropriate ICU care has significantly
reduced mortality over the last 20 years.
34. 0 hours
Age
>55
White blood cell count
>16,000/mm3
Blood glucose
>200 mg/dL (11.1 mmol/L)
Lactate dehydrogenase
>350 U/L
Aspartate aminotransferase
(AST)
>250 U/L
48 hours
Hematocrit
Fall by ≥10 percent
Blood urea nitrogen
Increase by ≥5 mg/dL (1.8 mmol/L) despite
fluids
Serum calcium
<8 mg/dL (2 mmol/L)
pO2
<60 mmHg
Base deficit
>4 MEq/L
Fluid sequestation
>6000 mL
35. <2 signs ……… With 5% risk of mortality
3-4 signs …….. With 15-20% risk of mortality
5-6 signs …….. With 40%
>7 signs …….. With 99% risk of mortality
36. Scoring systems for ICU and surgical patients:
APACHE II (Acute Physiology And Chronic
Health Evaluation)
≥ 8 is severe
37. Patient became very ill, febrile, distress ,
tachycardic and desaturated with a
saturation of 92% and irrecordable blood
pressure and uncontrolled blood glucose
39. Non re-breathing mask 15l/min
Non re-breathing mask 15l/min
Received about 33liters of IV. Fluids
Received about liters of IV. Fluids
(Normal saline)
(Normal saline)
Patient was admitted to the ICU
Patient was admitted to the ICU
Insulin infusion
Insulin infusion
Inotropes were started by portocol
Inotropes were started by portocol
(noradrenaline, adrenaline)
(noradrenaline, adrenaline)
Antibiotics was upgraded to
meropenem 1g bd inj
46. SvO2( mixed venous oxygen saturation)
It is the percentage of oxygen bounded to
hemoglobin in blood retaining to the right side of the
heart.
It reflects the amount of oxygen “left over” after the
tissue extracts its need.
Normal value > 70%
47. SvO2( mixed venous oxygen saturation)
pH
PCO2
PO2
so2
6.9
65.6
10
40%
it indicates that the tissue are extracting
higher percentage of oxygen from the blood
than normal
50. Treatment of acute pancreatitis is based upon the
severity of the condition:
Mild AP
supportive care (pain control, IV
fluids, and correction of electrolyte and metabolic
abnormalities.
Severe AP
intensive care unit monitoring
and support of pulmonary, renal, circulatory, and
hepatobiliary function may minimize systemic
sequelae
52. May require 250-500 cc/hr for first 48 hrs
▪ 6 L of fluid is sequestered in abdomen alone
▪ Third spacing can consume up to 1/3 of total plasma
volume
▪ Inadequate hydration can lead to hypotension and
acute tubular necrosis.
▪ aggressive fluid replacement can lead to peripheral and
pulmonary edema
53.
54. You may create electrolyte imbalances that need
to be corrected
You may need CVP monitoring (central line)
CXRs help (CHF vs ARDS)
ABGs help (still hypoxic need more fluids?)
55. How do you know you are resuscitated?
Blood pressure
Heart rate
Urine output
SPO2/ABG’s show good oxygenation and no
acidemia
57. Controversial
They
Do decrease incidence of infection in
necrosis, but do NOT decrease mortality
Imipenem
Ciprofoxacine + metronidazole
One study showed 24% of pts had fungus
58. Pancreatic stimulation during AP releases
proteolytic enzymes autodigestion
Oral feeding increases release of secretin and
cholecystokinin stim pancreas
“rest the pancreas” “NPO”
In patients with severe acute pancreatitis
Enteral feeding is recommended rather than
parentral feeding
59. In patients with severe acute pancreatitis
Enteral feeding is recommended rather than
parentral feeding.
▪ Easier to restart with
▪ Average length of nutritional support shorter
▪ 7 vs 11 days
▪ Fewer septic complications
▪ It cost much less
60. ▪ Compared early vs delayed ENTERAL
feedings in 753 critically ill pts
▪ Early was 36 hrs!
Improved:
- Wound healing
- Host immune function
- Preservation of intestinal mucosal integrity
- Decreased infections
62. Patient became hypoxic.
Blood pressure is still irrecordable.
Further ABGs showed also sever
decompensated metabolic acidosis
63.
64. Patient went into cardiac arrest .
Cardiopulmonary resuscitation was done but
patient didnt recover.
65. Acute pancreatitis is a common illness
with many potential highly morbid
complications.
Many cases are diagnose clinically and
managed supportively with bowel
rest, aggressive fluid administration
and analgesics.
Early intensive care unit admission
decreases mortality.
Pain was constant sever not radiating to any area, notaggravated or relieved by any factor associated with vomiting of large amounts, not containing blood.
