Casefiles 10: pancreatitis, AAA, renal failure Flashcards
presentation of severe acute pancreatitis
fever, abdominal pain, leukocytosis, HEMOCONCENTRATION, elevated serum amylase, and HYPOXEMIA
Acute pancreatitis can cause local complications including ?
can also lead to systemic complications such as ?
hemorrhage, necrosis, fluid collection, and infection
pulmonary, cardiac, and renal dysfunction
degree of amylase elevation (far greater than 3× normal value) is helpful in establishing the diagnosis, but does not correlate with ?
pancreatitis severity
concerning findings in acute pancreatitis
fever, tachycardia, tachypnea, WBC of 18,000/mm3, elevation in LDH, elevations in AST and ALT, and low PaO2 demonstrated on arterial blood gas
-hypoxemia and tachypnea are worrisome signs that he may be on his way to developing respiratory failure
acute pancreatitis management
initial bolus of LR at 20 mL/kg in the emergency department followed by a continuous infusion of 3 mL/kg/hour, with interval assessment of vital signs, laboratory values, and urine output in 6 to 8 hours
Patients whose BUN levels do not decrease during reassessments are given ?, whereas patients whose BUN levels decrease can have ?
a repeat fluid bolus
fluid infusion rate reduced to 1.5 mL/kg/hour
for certain acute pancreatitis patients the likelihood of developing respiratory failure is extremely high during the initial 24 hours, management?
the patient’s respiratory status is expected to worsen and his airways are likely to become more edematous following fluid resuscitation, it is not unreasonable to semielectively intubate the patient to secure his airway before the onset of florid respiratory failure
degree of respiratory dysfunction can be measured using the PaO2/FiO2 ratios
also check what in pancreatitis
cardiac dysfunction: BP and the need for pressers
renal dysfunction can be measured by quantifying UOP and serum Cr values
neurologic dysfunction can be measured by GCS
nutritional dysfunction so nutritional support
NOT ppx abx
moderately severe acute pancreatitis is associated with ?
transient organ failure (less than 48 hours)
-may have local complications or systemic complications
severe acute pancreatitis is associated with ?
persistent organ dysfunction (longer than 48 hours), which carries an overall mortality rate of 4%
may have pancreatic necrosis (mortality rate of 10%). which may become infected (mortality rate of 40% to 70%)
how are peripancreatic fluid collections are different from pancreatic pseudocysts
In peripancreatic fluid collections the fluid is walled off by surrounding tissue rather than a fibrous pseudocapsule
As the severe pancreatitis improves, areas of pancreatic necrosis undergo liquefaction producing a combination of solid and liquid structures that is commonly referred to as ?
pancreatic phlegmon
With continued improvement of the pancreatitis, the solid components of the phlegmon may breakdown, and at the same time, the local inflammatory response produces a fibrous response around the fluid collections to form pseudocysts
infected pancreatic pseudocysts usually occur several weeks following the onset of severe acute pancreatitis and most can be treated with ?
percutaneous drainage
pancreatic abscess is due to ?
which happens generally ? weeks after the onset of severe acute pancreatitis
the abscess contains ?
the preferred initial approach for this problem is ?
secondary infection involving the pancreatic phelgmon
3 to 6 weeks
infected solid and liquid material
drainage is the preferred initial approach for this problem, but some patients need surgical drainage/debridement
Ranson criteria
on admission
WBC more than 16,000/mm3 glucose more than 200mg/dL older than 55 yrs AST more than 250 U/L LDH greater than 350 U/L
Ranson criteria
48 hrs after admission
HCT fall of 10% Ca2+ less than 8 mg/dL serum urea nitrogen increase of 5 mg/dL fluid requirement of more than 6L base excess of more than 4 mEq/L pO2 less than 60 mmHg
treatment of acute pancreatitis is mainly supportive, including ?
Maintenance of hydration is important to prevent secondary organ injuries
oral or NPO for pancreatitis?
Oral diet does not worsen the course of acute pancreatitis and is beneficial in preventing infectious complications related to the pancreatitis.
Delaying surgical debridement ? after disease onset in patients with pancreatic necrosis is associated with improved outcomes in comparison to patients treated with early surgical interventions.
beyond 30 days
The current recommendations for open or endovascular interventions for AAA are based on 3 things
- SIZE: Diameter greater than 5.5 cm in men or diameter 5.0 cm in women (risk of rupture is higher in women)
- GROWTH RATE: Rapid growth of more than 0.5 cm/6 months;
- SYMPTOMS: Symptomatic AAA (pain or distal embolism)
an aneurysm exists when a segment of an artery increases in size to more than ?
caused by conditions that cause weakening of the arterial walls, including ?
50% of the normal diameter (ie, greater than 150% size of native artery)
collagen defects, inflammatory conditions, immune responses, and atherosclerotic changes
inherited conditions associated with aneurysm
Marfan syndrome, Ehlers-Danlos syndrome, and familial thoracic aneurysm and dissection (TAAD) syndrome
non modifiable AAA risk factors
*Older age (age older than 50 for men and age 60 for women) Male sex (4× increased risk vs. female) *Family history Race (more common in Whites) Height
modifiable AAA risk factors
Smoking
Hypertension
Elevated cholesterol levels
Obesity
USPSTF AAA screening recommendations
one-time ultrasound screening in men age 65-75 who have ever smoked
selective screening for men age 65-75 who have never smoked
recommended AAA surveillance based on aneurysm size
- 6-2.9 cm re-examine in 5 years
- 0-3.4 cm every 3 years
- 5-4.4 cm every year
- 5-5.4 cm every 6 months
