GI: Part 2

Question 1

Acute Pancreatitis

Answer 1

PATHOLOGY:
Premature activation of pancreatic digestive enzymes before release in duodenum. All etiologies, however, show premature activation of digestive enzymes-autodigestion. In essence, the pancreas eats itself.

*****Can be life-threatening. LIPASE elevation is a huge sign. Abdominal pain is hallmark. Deep, midepigastric or periumbilical. Begins abruptly and increases in intensity over several hours. Relieved best when leaning forward. Restless and agitated.

Question 2

Pancreatitis Presentation

Answer 2

PRESENTATION: 
Abdominal pain (knife-like)
Fever
Abdominal guarding/distension
Nausea/Vomiting
May have Grey-Turner’s sign if hemorrhagic (flank bruising)

LABS & Diagnostics: 
***Elevated serum amylase and lipase
Severe hypocalcemia (may require calcium drip)
Hypokalemia
Hyperglycemia
Elevated WBC

Question 3

Pleural effusion with pancreatitis

Answer 3

Pancreatic enzymes (especially Trypsin) leak out of the pancreas and can leak into the pleural space, causing severe inflammation and pleural effusion. Pleural effusion is considered a sign of poor prognosis.

SIRS can follow and result in MODS –responsible for the majority of morbidity ans mortality assoc. with pancreatitis

Question 4

Management of Pancreatitis

Answer 4

***Fluid resuscitation-very important, typically 0.9% NS or LR to increase intravascular volume.
Surgical intervention for necrotizing pancreatitis
Sometimes drains placed in Radiology to facilitate drainage of pus from pancreatic bed.
Antibiotics (Imipenem best choice)

Promote oxygenation-patients often require extended ICU stays with ventilatory support.
Pain control (use opioids—Hydromorphone)

Question 5

CHVOSTEK’S SIGN for Pancreatitis

Answer 5

CHVOSTEK’S SIGN
Elicitation: Tapping on the face at a point just anterior to the ear and just below the zygomatic bone

Positive response: Twitching of the ipsilateral facial muscles, suggestive of neuromuscular excitability

Question 6

Management of Pancreatitis cont.d

Answer 6

Maintain fluid / electrolyte balance. Will need a central line for CVP monitoring and administration of large volumes of fluids
Resting the pancreas (gut rest)—NPO until amylase back to normal
Maintain nutritional status with TPN but evidence now suggests enteral feeding with a tube in the jejunum may be safe
Provision of patient / family education including possibility of terminal care.

Question 7

What is Intra-abdominal pressure (IAP)

Answer 7

Normal in adult 0-5mmHg
Typical ICU patient 5-7mmHg
Increases with inspiration and decreases with expiration.

IAH is defined as the sustained or repeated pathological elevation in IAP greater or equal to 12mmHg.

Question 8

IAH Grading System

Answer 8

Grade I—12-15mmHg : decompression not indicated
Grade II—16-20mmHg: treatment based on patient’s clinical condition require close monitoring
Grade III—21-25mmHg: Abdominal decompression indicated even in the absence of overt signs and symptoms.
Grade IV > 25mmHg: Surgical emergency.

Question 9

Abdominal Perfusion Pressure (APP)

Answer 9

Calculated the same as cerebral perfusion pressure
APP= MAP-IAP

A target APP of at least 60mmHg has been demonstrated to correlate with improved survival.

Question 10

Parenteral Nutrition

Answer 10

TPN -high dextrose content-may be 20-25%. Risk of hyperglycemia and infection (central line necessary). Long term therapy with TPN can lead to liver failure

PPN (lower dextrose content (10%) because of peripheral IV delivery)

Glucose control paramount when utilizing PPN / TPN—may need insulin drip

Question 11

Complications of TPN

Answer 11

Infection (central line, high glucose content)

Electrolyte imbalances

Don’t stop abruptly—if TPN bag runs out, hang a liter of D10 or D20 at the same rate until replacement available.

Question 12

Enteral Nutrition

Answer 12

Gastric access
NG or orogastric route for short term–risk of aspiration
PEG if >30 days
GI motility does slow in acute / critical illness

Small bowel access
Nasal-jejunostomy tube
PEJ
Used when underfeeding is a problem

Question 13

Nursing Management for Nutrition

Answer 13

Always evaluate tolerance to feedings
Check placement, residual (only NGT), aspiration
Bowel sounds, lung sounds assessed frequently
Hyperglycemia
Monitor for s/sx of infection

Tube clogging
Warm water mixes for medications
ALWAYS flush tube well after medication administration. Check with pharmacy for liquid form if possible.
If SBFT gets clogged, can use “clog-zapper” to unblock. Also coca-cola or bicarb.