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Acute Pancreatitis: • differentiate between categories of acute pancreatitis • list the most common etiologic factors for acute pancreatitis • differentiate between new and old management concepts of acute Robin Donohoe Dennison, DNP, copyright Robin Donohoe Dennison 2015 • Mild (previously referred to as • Severe (previously referred to as Acute Pancreatitis interstitial pancreatitis) necrotizing pancreatitis) • Edema with little or no necrosis • Extensive necrosis of pancreas and peripancreatic fact • Hypovolemia as a result of fluid • Erosion into blood vessels with Acute Inflammation of the Pancreas leak into peritoneal cavity • Usually resolves within 7 days • SIRS frequently occurs • High complication rate and • Obstruction of common bile duct: • Thiazide diuretics • Sulfonamides second most common cause • Post-endoscopic retrograde • Azathioprine (Imuran) cholangiopancreatography (ERCP) • Alcoholism: most common cause • Procainamide • Chronic alcohol intake leads to • Tetracycline secretory and structural changes in the pancreas contributing to duct • Alcohol increases the amount of • Hypertriglyceridemia

• Peptic ulcer with perforation • Pregnancy: third trimester; ectopic pregnancy • Cancer especially tumors of pancreas or lung • Ovarian cyst • Injury to pancreas • Hypercalcemia • Lupus erythematosus • Coxsackievirus B • Infectious mononucleosis • Radiation injury • Viral hepatitis Dennison, 2013 • Ischemia (e.g., shock and multiple organ dysfunction syndrome) • Post-cardiopulmonary bypass • Infection, sepsis • Hereditary factors • Idiopathic (20% of cases) Clinical presentation: Subjective Clinical presentation: Subjective • May have history of precipitating event • Associated symptoms • Abdominal pain • Abdominal tenderness, guarding • Precipitating: may occur after a heavy meal, especially if fatty, or a drinking • Nausea, vomiting, retching • Palliation: may be eased by leaning forward or fetal position • Flatulence, diarrhea • Quality: "boring" • Region: diffuse in epigastrium but may be in left upper quadrant • Radiation: to back or flanks • Severity: moderate to very severe • Timing: sudden onset; constant

Clinical presentation: Objective Clinical presentation: Objective • Grey Turner's signs or Cullen's sign may be seen in with hemorrhage • Hypotension may be seen due to decreased circulating volume due to • Abdominal distention effusion or hemorrhagic; may be decreased due to SIRS and/or sepsis • Decreased bowel sounds • Fever: usually low-grade (e.g., 37.8-39C) • Indications of peritoneal irritation: involuntary guarding during Jaundice possible if biliary obstruction palpation of the abdomen • Epigastric mass may be palpable especially if pseudocyst • Ascites may be present • Steatorrhea (i.e., bulky, pale, foul- smelling, floating) SIRS: 30% of patients with acute pancreatitis Clinical presentation: Objective have SIRS within 48 hours after admission • Breath sounds changes: may be diminished due to atelectasis, pleural • 2 or more of the following effusion, or ARDS; crackles may also be heard • Tachycardia (more than 90 beats/min) • Chvostek's or Trousseau's signs may be positive in hypocalcemia • Hyperpnea (respiratory rate > 20 breaths/min or PaCO2 < 32 mm Hg) • Hyperthermia (temperature > 38 C) or hypothermia (temperature < 36 C) • Leukocytosis (WBC count > 12,000 cells/mm3) or leukopenia (WBC count < 4000 cells/mm3 or > 10% bands) Clinical presentation: Diagnostic Clinical presentation: Diagnostic • Lipase: elevated • Potassium: may be decreased especially if vomiting • Stays elevated longer than amylase • Calcium: decreased • More specific than amylase • Magnesium: decreased • Albumin: decreased • Glucose: elevated if endocrine function of the pancreas is • BUN: may be elevated due to hypovolemia • AST, ALT, LDH, alkaline phosphatase, bilirubin: elevated in liver or • Triglycerides: may be elevated • Amylase: usually elevated to greater than 3x normal • Peaks at 4-24 hours after onset of symptoms; usually returns to normal • May not be elevated if pancreatitis is due to hypertryiglyceremia Clinical presentation: Diagnostic Clinical presentation: Diagnostic • Stool: increase in fecal fat • Decreased with hemorrhage • Elevated with hemoconcentration due to third-spacing • ECG: may suggest MI (e.g., ST-T wave elevations) • WBC: usually elevated with left shift • Arterial blood gases • May show left pleural effusion, elevated left hemidiaphragm, left atelectasis • Metabolic acidosis • May show pulmonary complications of pancreatitis (e.g., atelectasis, pneumonia, ARDS, pleural effusion) Respiratory complications may cause respiratory acidosis and hypoxemia • Flat plate of abdomen • May show cause (e.g., cholelithiasis) • May show ileus and bowel dilation Amylase: usually elevated • May show calcified pancreatic stones Clinical presentation: Diagnostic Balthazar and Ranson's system for grading pancreatitis by CT findings • May show delayed gastric emptying Grade A: Normal pancreas May show enlargement of duodenum • May show presence of dilated loop of smooth bowel adjacent to the pancreas • Grade B: Focal or diffuse enlargement of pancreas • Abdominal ultrasound: may show pancreatic swelling, edema, • Grade C: Mild peripancreatic inflammatory changes gallstone, pseudocyst, or peripancreatic fluid collections • Grade D: Fluid collection in a single location • Grade E: Multiple fluid collections or gas within the pancreas or • May show enlargement, edema, or necrosis of the pancreas peripancreatic inflammation • May show complications of pancreatitis (e.g., pancreatic pseudocyst or Clinical presentation: Diagnostic Ranson's Prognostic Criteria • At the time of admission or • MRI: shows inflammatory changes within the pancreas • Mild or Severe • Age over 55 years • WBC over 16,000/mm3 • Endoscopic retrograde cholecystopancreatography (ERCP) • Mild: scores only 1-2 • Serum glucose greater than 200 Contraindicated in acute pancreatitis Severe: scores more than • Serum lactate dehydrogenase (LDH) Remember that pancreatitis is a complication of this study greater than 350 units/L • Used more often in chronic pancreatitis; identifies ductal changes or calculi • Serum aspartate aminotransferase (AST) greater than 250 units/L • HIDA scan: may identify hepatocellular disease from biliary • 0 to 2 : 2% mortality • After 48 hours obstruction as cause of pancreatitis • 3 to 4 : 15% mortality • Hct drop greater than 10% • Increase in BUN greater than 5 mg/dL 5 to 6 : 40% mortality Peritoneal lavage: positive for blood if hemorrhage • 7 to 8 : 100% mortality • Calcium less than 8 mg/dL • Base deficit greater than 4 mEq/L • Estimated fluid sequestration greater • PaO2 less than 60 mm Hg Maintain airway, oxygenation, ventilation • Elevate head of bed 30-45 especially if ascites restricts diaphragmatic excursion Collaborative management • Administer oxygen as necessary to maintain SaO2 94% unless • In patients with COPD, administer oxygen to achieve a SaO2 of 90% by pulse • Monitor SaO2 closely and evaluate work of breathing in detection of development of atelectasis and/or ARDS Maintain adequate circulating volume and fluid Decrease release of and destruction by and electrolyte balance pancreatic enzymes • Administer crystalloids and colloids as required to restore circulating blood volume: 5-10 ml/kg/hr • Assist with treatment of cause • Hemodynamic monitoring may be necessary • Alcohol cessation if alcohol related • Cholecystectomy after resolution of pancreatitis if caused by cholelithiasis • Fluid sequestration: abdominal hypertension, abdominal compartment • Discontinuance of offending drug if drug induced • Statins, niacin, fibrates, and/or omega-3 fatty acids if related to • Monitor sodium, calcium, potassium, magnesium, and phosphate hypertriglyceridemia Administer calcium replacement orally or intravenous as prescribed • Administer potassium replacement as prescribed • Restrict sodium to 500 mg/daily for patients with ascites • Measure abdominal girth daily for patients with ascites • Weigh daily at same time on same scale Decrease release of and destruction by Decrease release of and destruction by pancreatic enzymes pancreatic enzymes • Maintain NPO status during acute phase and with any recurrence of • Keep environment free of food odors • Perform mouth care with water or normal saline only; do not use • Insert nasogastric tube and maintain suction to keep stomach alcohol-containing or flavored mouthwash or toothpaste decompressed and inhibit secretion of pancreatic juices • Administer drugs to decrease pancreatic enzymes • Octreotide acetate (Sandostatin) 50 mcg/hr IV for 72 hours in the early stage of AP could prevent the development of SAP • H2 receptor antagonists IV: no longer recommended Decrease release of and destruction by Prevent and treat pain and discomfort pancreatic enzymes • Maintain bedrest; encourage knee flexing while in supine position to • Perform peritoneal lavage: may be used for severe pancreatitis relax abdominal muscles • Performed percutaneous or via laparotomy • Maintain quiet environment, comfortable temperature, dim lighting • Intraperitoneal space is rinsed with lavage fluid to remove toxic substances released from the pancreas • Administer analgesics • May be done for 2-3 days • Opiates (fentanyl, hydromorphone, morphine) • Technique is the same as for peritoneal dialysis for renal failure • PCA preferred • HOWEVER: the lavage of the peritoneal cavity in patients with severe acute
pancreatitis does not appear to confer a clinical benefit. • Dong, Z., Petrov, M. S., Xu, J., Shanbhag, S., Windsor, J. A., & Pang, S. (2010). Peritoneal lavage for severe acute pancreatitis: A systematic review of randomised trials. World J Surg, 34(9), 2103-2108. doi: 10.1007/s00268-010-0665-3 Prevent and treat pain and discomfort Note: though meperidine (Demerol) for • Consider neurolytic block of celiac plexus for severe persistent pain years has been considered the analgesic • Utilize nonpharmacologic pain relief methods (e.g., imagery, of choice in acute pancreatitis, recent • Treat nausea with prescribed antiemetics; perform mouth care after studies show no significant difference emesis should it occur • Ensure adequate sleep and rest between morphine and meperidine in • Consider increase in pain as ominous: may indicate pancreatic necrosis, abscess formation, or hemorrhage the degree of spasm of the sphincter of Oddi Administer appropriate nutritional support Prevent and monitor for infection considering restrictions • Administer nutritional support parenterally during acute phase of illness • Antibiotics that effectively penetrate the pancreatic tissue and provide • Administer enteral nutrition below the duodenum after ileus is resolved good coverage against gram-negative enteric and anaerobic organisms (e.g., imipenem/cilastatin [Primaxin], ofloxacin [Floxin], metronidazole Elemental (i.e., Vivonex) [Flagyl]) may be prescribed. • Below the ligament of Treitz (e.g., jejunostomy tube) Clear liquids or elemental diet such as Vivonex after inflammation subsides If there is no improvement after 1 week, a CT-guided aspiration may be (pain subsides, serum amylase normal) low fat, full liquids  eventually performed. Bacteria found present in the aspirate suggests pancreatic necrosis with infection and indicates the need for surgery. Avoid alcohol and food high in fat Monitor for clinical indications of abscess formation • Increase in abdominal pain • Administer fat-soluble vitamins, thiamine, folic acid • Monitor serum glucose levels closely and administer glucose or insulin as • Leukocytosis Prepare patient for surgical measures for Prepare patient for surgical measures for relief of pancreatitis if necessary relief of pancreatitis if necessary • During acute phase, surgery is performed only if absolutely necessary • Pancreatic resection/total • Cholecystectomy if bile reflux is the cause of pancreatitis Used if pancreas and/or other organs Drainage and removal of abscess or pseudocysts • Pancreatic pseudocysts occur when digestive juices break through the normal • Total pancreatectomy ducts of the pancreas and collect in spaced lined by fibroblasts and surfaces • Results in diabetes and other metabolic of adjacent organs • Islet cell autotransplantation is sometimes performed • Segmental pancreatic autotransplantation is sometimes performed: part of viable pancreatic tissue reimplanted following total pancreatectomy Maintain normal serum glucose levels Assess for alcohol withdrawal syndrome • Monitor serum glucose levels closely • If present, administer sedatives (e.g. chlordiazepoxide [Librium]) as • Administer insulin as indicated and prescribed Most drugs used for this purpose including chlordiazepoxide (Librium) have Maintain constant infusion rate of TPN or enteral feedings potential for liver toxicity; dosage is adjusted and liver function studies are monitored • Avoid alcohol-containing mouthwash or medications Monitor for complications Monitor for complications • Hypoglycemia or hyperglycemia • Disseminated intravascular • Pseudocysts: collection of inflammatory debris, pancreatic • Hypocalcemia coagulation (DIC) secretions, and necrotic tissue; may cause compression of portal vein and bile duct or rupture and peritonitis and sepsis • DVT, PE: SCD • Causes pain or ache in abdomen, feeling of bloating, or poor digestion • Acute renal failure • Treatment: nothing for small cysts or drainage by surgical, endoscopic, or percutaneous approach for larger cysts Pancreatic fistula: communication between the pancreas and the skin; pancreatic secretions drain onto the skin • Treatment : replacement of fluids and electrolytes; octreotide

• Andris, A. (2010). Pancreatitis: understanding the disease and implications for care. AACN Adv Crit Care, 21(2), 195-204. • de-Madaria, E. (2014). Fluid therapy in acute pancreatitis - Aggressive or adequate? Time for reappraisal. Pancreatology, 14(6), 433-435. • Dennison, R. D. [2013]. Pass CCRN! [4 ed]. Philadelphia: Elsevier. • Kramer, C., & Jeffery, A. (2014). Pancreatitis in children. Crit Care Nurse, 34(4), 43- • Marchiondo, K. (2010). Acute pancreatitis. Medsurg Nurs, 19(1), 54-55. • Schepers, N. J., Besselink, M. G. H., van Santvoort, H. C., Bakker, O. J., & Bruno, M. J. (2013). Early management of acute pancreatitis. Best Practice & Research Clinical Gastroenterology, 27(2013), 727-743. • Siow, E. (2008). Enteral versus parenteral nutrition for acute pancreatitis. Crit Care Nurse, 28(4), 19-25, 27-31; quiz 32. • Wang, S., Feng, X., Li, S., Liu, C., Xu, B., Bai, B., . . Zhao, Q. (2014). The ability of current scoring systems in differentiating transient and persistent organ failure in patients with acute pancreatitis. J Crit Care, 29(4), 693 e697-611. 1. Which of the following would be appropriate for 2. Which of the following would be a serious complication pain management of a patient with acute pancreatitis? of overhydration of a patient with acute pancreatitis? (more than one may be correct) (more than one may be correct) a. pancreatic necrosis b. intraabdominal hypertension c. acute renal failure d. hydromorphone d. pulmonary edema


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February 16, 1996 / Vol. 45 / No. RR-1 Defining the Public Health Impact Streptococcus pneumoniae : Report of a Working Group U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service Centers for Disease Control and Prevention (CDC) Atlanta, Georgia 30333 The MMWR series of publications is published by the Epidemiology Program Office,Centers for Disease Control and Prevention (CDC), Public Health Service, U.S. Depart-ment of Health and Human Services, Atlanta, GA 30333.