Pancreatic Problems

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Pancreatic Problems
2011-09-29 18:03:02
Pancreatic Problems

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  1. Acute pancreatitis
    • Sudden onset of inflammation of pancreas
    • Abd pain
    • Pancreatic tissue edema
    • Necrosis of pancreatic tissue
    • Possible pancreatic hemmorhage
    • Results in autodigestion of itself
    • Self-limiting if mild
  2. Severe Acut pancreatitis
    • Necrotizing or hemorrhagic pancreatitis
    • Extensive necrosis in and around pancreas
    • Pancreatic cell necrosis
    • Hemmorhage
    • Digestive enzymes are release when pancreas dies, eats cells tissues and vessel walls...leads to bleeding
  3. Pancreatitis pathogenesis
    Inital injury of acinar cells, premature enzyme activation (trypsin), overwhelms protective mechanisms, autodigestion of pancreas and surrounding tissues
  4. Most damaging enzymes
    • Phospholipase A: digests cell membranes
    • Elastase: digests vessel walls
    • Kallikrein: inflammatory mediator secreted by basophils, increases local damage; potentiates hypotension, shock, MODS
  5. Pancreatitis causes
    • Gallstones: most common in females, fatty greasy diet, obstruction of common bile duct
    • Chronic alcohol abuse: most common in males, cause spasm of sphincter of Oddi...leads to obstruction
    • Idiopathic
    • Drug induced: hypersensitivity or toxix metabolism
    • Metabolic Problem: hypoglycemia, hypertriglyceridemia (plaque build up, stenosis of vessel, Ca)
  6. Pancreatitis Clinical presentation
    • Pain (constant, dull, collicky, worse when lying supine): radiation to flank, back, or both, heavy meal or drinking triggers pain
    • N/V
  7. Pancreatitis Dx
    PE: abd distention, muscle spasms, epigastric pain, LUQ tenderness, fever, tachycardia, jaundice, restless, dehydrated (N/V)
  8. Amylase
    • Most widely used indicator
    • Quick and inexpensive
    • Lacks sensitivity and specifity
    • Peaks 2-12hrs post onset, elevated for 3-5 days
    • Tells us more by being negative than it does by being positive
    • Highers levels doesn't mean severe
  9. Lipase
    • Greater sensitivity and specifity than amalyse
    • Peaks at 24hrs, elevated for 4-8hrs post onset
    • Peaks 3x normal
    • May remain elevated after amalyse isn't
    • If both amylase and lipase elevated, more likely to be pancreatitis
  10. Trypsin
    Most accurate but not commonly used test
  11. Elastase
    Not as accurate as trypsin or lipase
  12. LFTs
    • Not reliable for testing pancreatitis
    • Only want to kow if liver dysfunction associated and/or coags
  13. Labs Dx
    • Glucose: increased; >180-200, beta cells out of pancreas aren't functioning well; associated w/ insulin
    • Calcium: decreased; associated liver problems bc of low albumin and nutrition
    • WBC: increased; 15,000-18,000; inflammation
    • BUN: increased; dehydration
    • HCT: increased; dehydration, dilutional bc of low fluid
    • Albumin: decreased; liver dysfunction, malnutrition
  14. Steatorrhea
    • Pale of gray stool
    • Foul smelling
    • Caused by deficiency in pancreatic enzymes in the bowel
    • Big indicator
  15. Edoscopic Retrograde Cholangiopancreatography (ERCP)
    • Used when biliary obstruction suspected
    • Inject dye into ducts to see obstruction in pancreas
    • Can precipitate acute pancreatitis
    • Hydration and pain control
  16. ERCP Complications
    • Abscess
    • Necrosis
    • Psedocyst: encapsulated infectious material in organ, can further cause autodigestion of pancreas
  17. Systemic complications of pancreatitis
    • Pulmonary: Hypoxemia, insufficiency/failure, effusions, ARDS (r/t phospholipase A)
    • Cardiovascular: hypovolemic shock (trypsin vasodilates)
    • Renal: ARF
    • Neuro: decreased LOC (pain control is difficult and pancreatic encelphalopathy, decreased perfusion)
    • Hematologic: DIC (liver dysfunction, platelets/clotting factors)
  18. Stabilizing hemodynamic status
    • Fluid resuscitation: crystalloids, colloids, plasma expanders, monitor status
    • Inotropic therapy: Dopamine
  19. Controlling Pain
    • Difficult to control
    • Morphine
    • Fentanyl
    • Dilaudid
    • May not be able to bring pain to 0
  20. Minimizing pancreatic stimulation
    • Rest the GI track
    • Meds: antacids, PPIs, anticholinergics
  21. Meeting nutritional needs
    • Initial NPO
    • Initiate nutritional support if NPO >5-7 days
    • Nasal jejunal feeding: Post ligament of Treitz, preferred tip location
    • Improve outcomes
  22. Curative therapy
    • Correct underlying problem: remove gallstone, stop drinking
    • Prevent/treat complications: early recognition, close multi-system monitoring
  23. Nursing Care
    • Control of pain: PCA narcotics, monitor for non/therapeutic effects
    • Maintain nutrition
    • Managing N/V: antiemetic therapy
    • Monitor for complications