case discussion - · pdf filebetter electrolyte balance improved outcome ... goal directed...
TRANSCRIPT
Case Discussion
History
36 year old male navy officer
surgical casualty ward
with one day history of
fever
epigastric pain- radiating to back
sever nausea and vomiting
h/o GORD symptoms
nonsmoker
teetotaler
Examination
severe pain +
Ill looking
Febrile
Not pale
Not icteric
Examination
BP 90/60 mmHg/ Pulse 102/ CRFT< 2s
Lungs – bi-basal reduced air entry
L>R Spo2- 96% on air
Abdomen – slight distension
mild tenderness
What are the differential
diagnoses?
1. Acute cholecystitis
2. Ascending cholangitis
3. Dengue/ viral fever with hepatitis
4. Acute pancreatitis
5. PUD
6. Acute intestinal obstruction
7. Diabetic ketoacidosis
What laboratory
investigations would
you choose?
Initial investigations
FBC - Hb -11 mg/dl
WBC -11,000/mic.l(N-86%)
Platelets-110,000/mic.l
UFR- few pus cells only
CBS- 145mg/dl
Other lab tests
Serum amylase
Serum lipase level
Serum amylase in our patient-
35 iu
would imaging be helpful?
Imaging of the abdomen
X-ray-erect
NCT
CECT
MRI
US Scan
Us scan abdomen was done
Moderate amount of free
fluid +
Emergency laparotomy was
done in the night
Findings???
Saphonification of omental
fat tissue
Findings –small amount of free fluid
bowel, appendix and liver normal
Saphonification of omentum noticed
Abdomen was closed with a drain
Patient was taken to the ICU
BISAP score for pancreatic
mortality
B – BUN > 25mg/dl 0 – 0.2%
I – impaired mental status 1 – 0.6%
S – SIRS criteria ( 2 or more ) 2 – 2%
A - > 60yrs 3 – 5-8%
P- Pleural effusion present 4 – 13-19%
5 – 22-27%
Intensive care management
Hydration
Cardiovascular support
Ventilatory support
Treat infections
Nutrition
DVT prophylaxis
Pain management
ERCP
Is there a specific
management to improve
outcome in ASP ?
Early aggressive intravenous
hydration
How early..
Within first 24 hrs
Patient not responding to aggressive
therapy early(6-12hrs) may not benefit
continuing.
How aggressive?
250-500ml per hour(5-10ml/kg/hr)
Caution in cardiac and/or renal
disease
Which fluid..?
Ringer’s lactate is better than 0.9% saline
Better electrolyte balance
Improved outcome
pH balance
Causes and effects of
hypovolaemia
Multiple causes
Extravasation
Vomiting
Reduced oral intake
Respiratory and evaporator losses
Hypovolaemia activates a vicious cycle that lead to
pancreatic necrosis worsening the clinical condition.
If the patient goes in to shock more
rapid fluid boluses may be needed
under invasive cardiac output
monitoring
Goal directed fluid theraphy
How do you monitor initial
fluid responsiveness?
Goals are to…
Decrease haematocrit
Decrease BUN
Normal creatinine
UOP≥ 0.5ml/kg
Advanced monitoring
Stroke volume variation
CO moitoring
How to determine fluid requirement in patients with
persistent organ failure despite early aggressive therapy
Non responders
Surviving sepsis
CVP line inserted and fluid
resuscitated
During the ICU stay
BP 85/45 mmHg(MAP-58 mmhg)
Pulse rate 130bpm
Vasoactive drugs
Theoretically all vasoactive drugs can
reduce splanchnic blood supply(esp.
phenylephrine) and increase the risk of
necrosis
But MAP should be ≥65 to maintain
organ perfusion
Noradrenalin is the first choice
Noradrenaline started
During the ICU stay
Low oxygen saturation spo2 92%
CPAP started
CPAP 8 and FiO2 50%
oxygenation improved to SpO2 98%
Later patient deteriorated despite NIV with
high O2 ,and invasive ventilation done
with lung protective measures
During the ICU stay
Arterial blood gas analysis;
pH 7.3
Pao2 55mmHg
Paco2 32 mmHg
Hco3 16 mmol/l
Be – 10 mmol/l
SaO2 88% with high flow O2
During the ICU stay
US Scan chest– small, bilateral pleural effusions,
left>right
Chest X-ray- supine x-ray
no definite effusion
lung fields not clear
How to improve oxygenation?
Ventilatory strategy
Majority of SAP develop ARDS
Lung protective ventilation according to
ARDSnet
Ventilatory care bundle
4. Analgesia
morphine infusion 2-3mg /h
fentanyl as sos boluses
5. Antibiotics
What is the
antibiotic policy in
AP?
Extrahepatic infection should be treated
accordingly
Routine use of prophylactic antibiotics in
the early stage SAP is not recommended
Antibiotics should be given
Patients with confirmed infected
necrosis
Patients fail to improve after 7-10days
after hospitalization
SIRS that occur early in AP may
indistinguishable from sepsis syndrome
CT FNA is the only way to distinguish
infected necrosis from sterile necrosis.
60% of AP develop sepsis
Which antibiotic…
Carbapenems
Quinolones
metronidazole
Prophylactic antifungal agents is not
recommended.
6.Nutrition
Are we going to feed
this patient?
NBO is pre historic…
Bowel rest and TPN increase,
mucosal atrophy and bacterial translocation
Catheter-related blood stream infections
Morbidity and mortality
Early enteral nutrition,
decrease hospital stay
Decrease infective complications
Decrease morbidity and mortality
Which route
Oral
NasogastricSafe
no significant increase in aspiration risk
Easy tube placement
Nasojejunal
Feeding jejunostomy
7.DVT prophylaxis
Only TED stockings were used in addition
to the general measures
Anticoagulants not used due to high INR
What is the role of
antisecretory drugs?
Role of drug therapy in AP
No proven benefit in
Gabexate – anti-protease
Octeotride – anti-secretory
Bladder pressure was
monitored
60% to 80% of SAP can develop intra
abdominal hypertension
intra-vesical pressure should be
monitored frequently
6hrly in all the patients with SAP
4hrly in IAH
Second week CECT abdomen – necrotic
pancreatitis – conservatively managed
After thre weeks patient was
extubated
Off noadrenaline
Feeding established
Sent to ward
Thank You!