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Panc

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Panc
ICU Case Presentation:
Hypotension and Pyrexia
Bradley J. Phillips, MD
Burn-Trauma-ICU
Adults & Pediatrics
Case #1
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52 yof school teacher POD 5 Lap Chole for
recurrent RUQ with U/S + gallstones
Uncomplicated OR except transient SBP 70
during insufflation corrected with 1 L bolus
IVF
D/C POD1
Returned POD3 with abdominal pain,
nausea, fever (38.7C)
Diff dx ??
Case #1
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Presumptive dx:
Cholangitis
IVF, NPO, ABX (Ceph 3, Flagyl)
Over 24 hrs developed oliguria unresponsive
to fluid challenges ( total 5 L positive balance)
Progressive tachypnea (RR 40) and SBP 8590
Abdominal pain more widespread with focus
RUQ and fever increased 40.4C
?? More information
Case #1
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PMH: HTN, ankle swelling, NIDDM
PSH: appy, hysterectomy, tonsillectomy
Meds: captopril, lasix 40mg qd
Labs:
6.5
15.2
9.6
127
ABG 7.28 / 28 / 54 / 12
133
5.2
13
120
4.0
INR 1.4 PTT 44
184
0.5
Tbil 2.6 AST 98 Alk Phos 428 Amylase 2416 Albumin 3.0
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Abdominal U/S - limited from bowel gas, no
calculi in CBD although dilated upper limit of
normal
Case #1
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DX - Pancreatitis
Transferred to ICU
CVL inserted - CVP 2 cm H20
Dopamine qtt started 10 ug/kg/min for SBP
100
Very distressed, tachypneic and confused
NGT inserted with 1.5 L light brown fluid
RR decreased to 34/min on FiO2 50%
?? Management
Case #1 Pancreatitis
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IVF bolus 1.5 L colloid increased CVP 14
cmH20
Remained tachypneic, UOP 8 ml/hr
Dopamine qtt at 16 ug/kg/min
Repeat labs: ABG pH 7.07 / 45 / 61 / 8
Na 130, K 6.4, Glu 331
?? Issues and management ??
Case #1 Pancreatitis
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Respiratory distress - Intubation
Hyperkalemia
• Amp of D50
• Insulin 10 units
• Amp of calcium chloride
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Continuous venovenous hemofiltration
TPN
Further hypotension requiring norepinephrine
qtt
Pancreatitis Case #1
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Insertion of PA catheter
• Wedge 12 mmHg, CI 5.7 L/min/m2
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Next 3 days continued hemofiltration, norepi
qtt decreased, CI high (4.9)
Hyperglycemia remained a problem despite
insulin in TPN ( 750 cc 10% AA, 750 cc D50)
Increased jaundice with Tbil 9.8 mg/dl
?? Diff dx and management
Pancreatitis Case #1
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Repeat U/S unsatisfactory
CT Abd - moderate bilateral pleural effusions,
marked dilation of CBD, dilated loops of
bowel, extensive pancreatic edema and
phelgmon with question 10% necrosis of
pancreatic head
?? plan
Pancreatitis Case #1
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ERCP - obst. calculus removed and
sphincterotomy performed
Next 48 hrs, bilirubin decreased to 4.8
Continued vasopressors, ventilation,
hemofiltration, and TPN
New onset of fever, 39.7 C accompanied by
increased inotropic drugs to maintain MAP
CVP 8, wedge 14, CI 5.2
?? Diff dx and plan
Pancreatitis Case #1
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Lines changed and cultures obtained
CXR revealed ARDS
Cultures
• sputum leukocytes, no bacteria
• urine no bacteria
• blood - E coli
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?? plan
Pancreatitis Case #1
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Imipemem q 6hrs started
Repeat CT scan - peripancreatic fat necrosis,
extensive edema, and fluid in paracolic
gutters, definitive 15-20% pancreatic head
necrosis
Plan??
Pancreatitis Case #1
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Taken to OR for debridement ( EBL 500 cc)
ICU return very unstable with fever 40.2, increased
amount of norepi qtt and now epi qtt added
Wedge 12 despite 4L blood and colloid (Hgb 12.4)
Worsening O2 requiring FiO2 100%, PEEP 10
ABG 7.18 / 48 / 63/ 14 lactate 6.2
CXR 0 extensive bilateral pulmonary infiltrates with
interstitial edema
?? management
Pancreatitis Case #1
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Hemofiltration restarted with negative balance
of 100 ml/hr
Next 12 hrs, gradual decrease of FiO2 to 0.6
Decreased inotropic qtt
Repeat laparotomy x2 with debridement
Temperature 37-3C and pressors weaned off
Pancreatitis Case #1
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Traps
• Insertion of NGT
• rarely needed in mild/mod pancreatitis
• acute pancreatitis causes acute dilatation
• obstruction from pancreatic head swelling
• diabetic autonomic neuropathy
• Jaundice etiology
• swelling of the head of the pancreas
• reabsorption of hematoma
• sepsis
• biliary obstruction from gallstone
Pancreatitis Case #1
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Traps
• ARDS
• pulmonary edema worsens oxygenation
• monitor intravascular volume closely
• may require PA catheter
• may require dialysis if renal failure ensues
• Fevers
• common sources of infection common in ICU
• rule out infected pancreas if necrotizing
pancreatitis
Pancreatitis Case #1
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Tricks
• Diagnosis of biliary obstruction
• U/S commonly unsatisfactory in early
pancreatitis and limited by bowel gas (ileus
common)
• ERCP indications
• suspicion of gallstone induced pancreatitis, not
improving by 24 hrs
• traumatic pancreatitis if CT scan nondiagnostic
Pancreatitis
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Etiology (common)
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EtOH
Gallstone
Bilary sludge
Hyperlipidemia
Hypercalcemia
Anatomic
• tumor
• divisium
• stricture
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Etiology (uncommon)
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Trauma
ERCP
Infection (viral)
Drugs ( thaizides, lasix,
steroids, estrogens, valproic
acid, clonidine, tetracyclins,
sulfonamides)
Toxins ( scorpion, methanol,
insecticides
Hereditary
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Pancreatitis
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Signs/Symptoms
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Epigastric pain
N/V
Anorexia
Ileus
Sepsis
Jaundice
Cullen’s sign
Grey Turner’s sign
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Tests
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ABG
CBC/Plts/PT/PTT
Lytes/BUN/Cr
Ca/Mg/Phos
LFT’s, Triglycerides
Amylase (S60-90,Sp 70)
Lipase (S/Sp 90-99)
CXR/AXR
U/S
CT
Pancreatitis
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Complications
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Death
Renal failure
Sepsis
ARDS
Infected pancreas (early as 1st week)
Hemorrhage
Pancreatic abscess (late)
Pseudocyst (late)
Diabetes
Pancreatitis - Current Issues
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Antibiotic coverage
Role of fine needle aspiration
Role of octreotide
Predictive criteria of mortality
Pancreatitis - Antibiotic Coverage
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Common isolates
• E coli (26%), Pseudomonas (16%), anaerobic (16%), S. aureus
(15%), Klebsiella (10%), Proteus (10%)
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Need broad coverage if indicated
Indications?
• Prophylatic use in necrotizing pancreatitis
• Early studies no benefit (use ampicillin)
• Imipenem drug of choice
• Clinical trials show benefit by decreased frequency in
infection
• Imipenem and quinolones highest in pancreatic tissue
with aminoglycosides lowest, PCN intermediate
Pancreatitis - Antibiotics
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Gut decontamination
• experimental studies show bacterial translocation and
hematogenous seeding
• clinical trial with oral norfloxacin, colistin, and ampho B
shows significant reduction in GNR pancreatic infection
• adjusted for illness severity, improved outcome
• not achieved widespread acceptance
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Anti-fungal
Pancreatitis -Role of FNA
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Pancreatic necrosis - r/o infected necrosis
Options
• observation and antibiotics for selected organisms
• percutaneous drainage?
• debridement
• percutaneous/endoscopic - reported cases/trials
• operative
• controversial ( must weigh hemodynamics/MSOF)
• worse in EtOH pancreatitis secondary to nutritional
status
• consensus improved survival with infected
pancreatic necrosis
Pancreatitis - Role of Octreotide
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SQ vs IV dosing
• SQ dose 100-200ug tid
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Trials
• Numerous both retro and prospective
• No benefit
Pancreatitis - Predictive Mortality
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Ranson criteria
Risk Factors
• APACHE II score > 8
• Organ failure ( higher in infected necrosis)
• Substantial necrosis ( > 30%)
Pancreatitis Management
Severity
Mod/Severe (SICU)
Mild/Mod (Floor)
Routine Management
NPO, IVF
+/- NGT
H2 Blockers
?TPN vs Jejunal
?etiology
Necrosis?
No
No antibiotics
Observation
Unstable
Operation
Yes
Antibiotics
noninfected
infected
FNA
Pancreatitis Case #1
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Follow up
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Slow improvement in respiratory function
12 days after last laparotomy, UOP returned
Extubated 24 hours later
Discharged to floor 2 weeks after last operation with enteral
feeding established
• Still required SQ insulin for BS control
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