The tragedy of a severe acute pancreatitis
A lot of my blog followers are aware of my interest in the management of acute pancreatitis. The key principle we follow is to avoid the so called 'second hits". Acute pancreatitis is rarely severe at the time of admission. It is in my belief and experience that adequate resuscitation and prevention of second hits allows nearly 95% of the patients to recover without any further deterioration.
I have found the following problems that can lead to delayed recovery for the patient.
Inadequate fluid resuscitation Failure to give adequate fluids leads to microcirculatory failure and death of pancreatic cells and also to transmigration of bacteria from the gut leading to sepsis. This is by the most common medical error in the management of acute pancreatitis that we picked up in our survey. Delayed presentation of the patient also leads to prolonged dehydration and onset of local complications at the initial admission. However, even in these patients, good fluid rescue always mitigates the impact of the local and systemic complications.
Early feeding by enteral route Delay in initiating feeds usually is secondary to inadequate fluid rescues and this leads to persistent pain (this was a surprise for us too, for adequately resuscitated patients usually take less pain killers than those who are not) and more inotropes. Good fluid rescues allows us to initiate enteral feeds within 48 hours even in the presence of pancreatic necrosis. Feeding reduces sepsis and gets the patient to recover quickly.
Too many lines Critical care physicians who take care of acute pancreatitis put more lines and delay the removal also leading to more morbidity. I see more nasojejunal feeding tubes, more central lines and arterial lines that are put in patients with acute pancreatitis. Our policy is to keep the lines to a minimum - a foley catheter and rarely NG tube. We do ABG in the first 24 hours after admission, but we do not place an arterial line. Line sepsis from MDR bugs are a key cause of mortality in these patients.
Delayed decision making Delaying critical decisions in severe acute pancreatitis will invariably lead to tragic outcomes. This was the key element that showed up during our study. We changed our approach so that decision making process is simplified and and done at nursing level so that immediate care is given and that decision making does not wait for the consultant to come and see. There are very few decisions that actually require senior medical attention. Delay in decision making leads to more pancreatic and extra pancreatic complications and increases risk of death.
One of the key things that patient and the family must remember is the fact that all medical gastroenterologists are not having time to pay attention to detail in patients with acute pancreatitis. I have seen the problem with surgeons too. Very few dedicated pancreatologists are available in our country. In this circumstances, HPB surgeons are probably the best option for a patient to have a good treatment in severe acute pancreatitis. Most of the problems in delayed recovery of severe acute pancreatitis are due to these simple problems.
I have found the following problems that can lead to delayed recovery for the patient.
Inadequate fluid resuscitation Failure to give adequate fluids leads to microcirculatory failure and death of pancreatic cells and also to transmigration of bacteria from the gut leading to sepsis. This is by the most common medical error in the management of acute pancreatitis that we picked up in our survey. Delayed presentation of the patient also leads to prolonged dehydration and onset of local complications at the initial admission. However, even in these patients, good fluid rescue always mitigates the impact of the local and systemic complications.
Early feeding by enteral route Delay in initiating feeds usually is secondary to inadequate fluid rescues and this leads to persistent pain (this was a surprise for us too, for adequately resuscitated patients usually take less pain killers than those who are not) and more inotropes. Good fluid rescues allows us to initiate enteral feeds within 48 hours even in the presence of pancreatic necrosis. Feeding reduces sepsis and gets the patient to recover quickly.
Too many lines Critical care physicians who take care of acute pancreatitis put more lines and delay the removal also leading to more morbidity. I see more nasojejunal feeding tubes, more central lines and arterial lines that are put in patients with acute pancreatitis. Our policy is to keep the lines to a minimum - a foley catheter and rarely NG tube. We do ABG in the first 24 hours after admission, but we do not place an arterial line. Line sepsis from MDR bugs are a key cause of mortality in these patients.
Delayed decision making Delaying critical decisions in severe acute pancreatitis will invariably lead to tragic outcomes. This was the key element that showed up during our study. We changed our approach so that decision making process is simplified and and done at nursing level so that immediate care is given and that decision making does not wait for the consultant to come and see. There are very few decisions that actually require senior medical attention. Delay in decision making leads to more pancreatic and extra pancreatic complications and increases risk of death.
One of the key things that patient and the family must remember is the fact that all medical gastroenterologists are not having time to pay attention to detail in patients with acute pancreatitis. I have seen the problem with surgeons too. Very few dedicated pancreatologists are available in our country. In this circumstances, HPB surgeons are probably the best option for a patient to have a good treatment in severe acute pancreatitis. Most of the problems in delayed recovery of severe acute pancreatitis are due to these simple problems.
Comments
Post a Comment