Leanna R. Miller, RN, MN, CCRN-CSC, PCCN-CMC, CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN

1. Pancreatitis & Hepatic Failure Leanna R. Miller, RN, MN, CCRN-CSC, PCCN-CMC, CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN

2. Pancreatitis & Hepatic Failure • inflammatory response and potential necrosis of pancreatic endocrine and exocrine cells as the result of premature activation of pancreatic enzymes

3. Pancreatitis & Hepatic Failure Presenting Signs & Symptoms • pain (upper abdomen) – 95% • edema and distension • chemical burn • release of kinin • obstruction of biliary tree

4. Pancreatitis & Hepatic Failure Presenting Signs & Symptoms • protracted vomiting • abdominal tenderness • guarding • distension • tympany Acute Abdomen

5. Pancreatitis & Hepatic Failure Presenting Signs & Symptoms • Severe disease • hypovolemic shock • Grey Turner’s sign • Cullen’s sign

6. Pancreatitis & Hepatic Failure Diagnostics • Serum amylase • elevated during 1st 24 hours after onset of signs • may remain elevated for only 2 days • > 300 mcg/dL

7. Pancreatitis & Hepatic Failure Diagnostics • Serum lipase • elevates within 24 to 48 hours of disease • remains elevated for 5 - 7 days • can indicate pseudocyst

8. Pancreatitis & Hepatic Failure • Hypocalcemia • free fatty acid-albumin complexes bind calcium • decreased PTH function

9. Pancreatitis & Hepatic Failure Radiographic Studies • Computed tomography (CT) • gold standard for diagnosis

10. Pancreatitis & Hepatic Failure Complications • Pancreatic Abscess • high fever, palpable mass, abdominal tenderness, N & V, leukocytosis & hyperglycemia • surgery required

11. Pancreatitis & Hepatic Failure Complications • Pancreatic Pseudocyst • abdominal pain, fever, N & V > 1 week • WBC or amylase remains elevated

12. Pancreatitis & Hepatic Failure Medical Goals • prevent & control shock • relieve pain • suppress pancreatic stimulation

13. Pancreatitis & Hepatic Failure Medical Goals • support the patient • minimize the occurrence of complications

14. Pancreatitis & Hepatic Failure • 64 year old woman develops upper abdominal pain late last night. • Band-like with radiation to back. Initially not severe, but awoke and had several episodes of non-bloody emesis. • The first 8 hours in ED/Hospital the patient required 36 mg MSO4 to control pain.

15. PMHx: HTN, Hyperlipidemia MEDS: Estrace, Plendil SOCIAL: no tobacco or ETOH use BP: 94/45  160/90, HR: 76, T: 97.9, GEN: awake alert HEENT: no icterus, mouth is dry CARDIO: ST ABD: no rebound tenderness, no bruising Pancreatitis & Hepatic Failure

16. ABD CT: marked peri-pancreatic fluid, streaking around pancreas, normal enhancement, no clear gallstones, CBD not dilated LABS: AST/ALT both slightly elevated. T.bilirubinnormal Amylase 2620 Lipase 26,625 Hct normal WBC 14.8 Pancreatitis & Hepatic Failure

17. Admission Age > 55 WBC > 16,000 Glucose > 200 LDH > 350 AST > 250 During first 48 hours Hematocrit drop > 10% Serum calcium < 8 Base deficit > 4.0 Increase in BUN > 5 Fluid sequestration > 6L Arterial PO2 < 60 Pancreatitis & Hepatic Failure Ranson’s Criteria 5% mortality risk with <2 signs 15-20% mortality risk with 3-4 signs 40% mortality risk with 5-6 signs 99% mortality risk with >7 signs

18. Pancreatitis & Hepatic Failure • At 36 hrs the patient has increased work of breathing, crackles at bases of lungs. She is 4 liters ahead on fluids. • What do you want to do?

19. Pancreatitis & Hepatic Failure • “Vigorous intravenous hydration alone is the best available option in the prevention of pancreatic necrosis.” • Pitchhumoni et al. “Mortality in Acute Pancreatitis,” Journal of Clinical Gastroenterology

20. Pancreatitis & Hepatic Failure • AGGRESSIVE FLUID RESUSCITATION • May require 250-500 cc/hr for first 48 hrs • 6 L of fluid is sequestered in abdomen alone • Third spacing can consume up to 1/3 of total plasma volume • 1/3 of people die in the first phase  50% of these are associated to ARDS • PULMONARY EDEMA ≠ CHF

21. Pancreatitis & Hepatic Failure • How do you know you have resuscitated the patient? • Blood pressure • Heart rate • Urine output • SaO2/ABG’s show good oxygenation and no acidemia

22. Pancreatitis & Hepatic Failure • AGGRESSIVE FLUID RESSUCITATION • may create electrolyte imbalances that need to be corrected • may need CVP monitoring (central line) • CXRs help (CHF vs ARDS) • ABGs help (still hypoxic  need more fluids?) • 23% of SAP pts get ARF  80% mortality • 0.5 cc/kg/hr urine output is goal (need a Foley)

23. Pancreatitis & Hepatic Failure NECROSIS • Starts to occur within 4 days of disease • CT with oral & IV contrast is gold standard • necrotic areas do not enhance • will NOT see it on CT before 48hrs

24. Pancreatitis & Hepatic Failure NECROSIS • once diagnosis of necrosis is made - mortality jumps • 40-60% get secondary infection • mortality then approaches 80%

25. Pancreatitis & Hepatic Failure • secondary infection symptoms: • N/V, epigastric pain, distension, fever, elevated WBC • diagnosis of sterile vs infected necrosis • CT-guided needle aspiration • the most devastating complication and marks the second peak in mortality (@ 2 weeks)

26. SECONDARY INFECTIONS • What bugs? • Gram (-) bacteria cross from gut • E. coli (35%) • Klebsiella (24%) • Enterococcus (24%) • Staph (14%) • Pseudomonas, proteus, strep, enterobacter, bacteroides, anaerobes

27. Pancreatitis & Hepatic Failure ANTIOBIOTICS • Controversial • DO decrease incidence of infection in necrosis, but do NOT decrease mortality • Gotta cover multiple bugs • Gotta get into pancreas • If you see necrosis  start antibiotics

28. Pancreatitis & Hepatic Failure NUTRITION • normal pancreas secretes up to 2 liters/day of secretions • pancreatic stimulation during AP releases proteolytic enzymes  autodigestion • oral feeding increases release of secretin and cholecystokinin  stimulates pancreas • “rest the pancreas”  “NPO”

29. Pancreatitis & Hepatic Failure • ENTERAL vs TPN Feedings: • If distal to Ligament of Treitz (nasojejunal tube or J-tube) pancreatic secretion = basal rate • Both started after 48 hours • Easier to restart po feedings • Average length of nutritional support shorter • 7 vs 11 days • Fewer septic complications • $23/day vs $222/day

30. Pancreatitis & Hepatic Failure • NEW THOUGHTS • Meta-analysis of 15 randomized studies: • Compared early vs delayed ENTERAL feedings in 753 critically ill pts • Early was 36 hrs! • Improved: • Wound healing • Host immune function • Preservation of intestinal mucosal integrity • Decreased infections • BUT, no decreased mortality

31. Pancreatitis & Hepatic Failure Case continues • By 48 hours patient’s abdominal pain is worsening • HR is 140, afebrile, BP normal • Abdomen shows very subtle guarding • WBC: 27.6 • Ca++: 6.6

32. Pancreatitis & Hepatic Failure Case continues • PO2: 61 • Base deficit: 8 • BUN rise: 9 • LDH: 976 • RANSON SCORE: 3

33. Pancreatitis & Hepatic Failure Case continues • Patient transferred to ICU • Central line & Arterial line • Repeat Abdominal CT: new bilateral pleural effusions, pancreas enhanced in tail only. • Patient died 5 weeks after admission

34. Pancreatitis & Hepatic Failure SUMMARY • They may look good, but… • Score severity early • Use lots of IVF • Go to ICU early • Early enteral feedings work better

35. Pancreatitis & Hepatic Failure Hepatic Failure • cirrhosis: • alcoholic with malnutrition • biliary cirrhosis • hepatitis • hepatatoxins • hypoperfusion

36. Pancreatitis & Hepatic Failure Hepatic Failure • Signs & Symptoms • asterixis • jaundice • obtundation • distended abdomen & ascites • renal failure • GI bleed

37. Pancreatitis & Hepatic Failure Hepatic Failure • Treatment • encourage rest • limit protein, amino acids & fat • prevent exposure to stress

38. Pancreatitis & Hepatic Failure Hepatic Failure • Treatment: Monitor • hemodynamic status • serum drug levels • lab tests

39. Pancreatitis & Hepatic Failure Hepatic Failure • Treatment • monitor EEG • maintain glucose • monitor for  ICP

40. Pancreatitis & Hepatic Failure Hepatic Failure • Treatment • jaundice = vitamin K • thrombocytopenia = folic acid & FFP, platelets • DIC = fibrinogen & heparin

41. Pancreatitis & Hepatic Failure Hepatic Failure • Treatment for varicies • saline lavage • administer blood • IV vasopressin or somastatin • Sengstaken – Blakemore tube • portacaval shunt

42. Pancreatitis & Hepatic Failure On May 3 (approx. 2200 hours) a 35 year old alcoholic male began to take 2-3 acetaminophen 500 mg tablets per hour because of a toothache. He continued this through the night until 0800 hours. What is the recommended therapeutic dose for acetaminophen?

43. Pancreatitis & Hepatic Failure • Adults: 4 grams per day. • Children: 75 mg/kg/day to a maximum of 4 grams per day.

44. Pancreatitis & Hepatic Failure • On May 4,the patient presented to the ED because of his toothache and was discharged home with Tylenol #3. • He went home and took 3-4 Tylenol #3 at 0900 hours. • At approx. 1100 hours he developed abdominal pain and N/V and returned to the ED.

45. Pancreatitis & Hepatic Failure His acetaminophen level was 212 umol/L and his AST was 990 IU/L. How do you interpret these numbers?

46. Pancreatitis & Hepatic Failure • Because it is a chronic ingestion you can not plot it on the nomogram. • In instances where it is a chronic ingestion or the time of ingestion is unknown, send an acetaminophen level and an AST(ALT) and if either are elevated start N-acetylcysteine

47. Rumack-Matthew Nomogram

48. Pancreatitis & Hepatic Failure • IV NAC is initiated. • How does ethanol affect acetaminophen toxicity?

49. Pancreatitis & Hepatic Failure • Chronic alcoholics are at increased risk with an acetaminophen overdose. • Chronic ethanol consumption induces the cytochrome P450 pathway resulting in increased metabolism through this pathway and therefore increased NAPQI formation. • Malnourishment decreases glutathione stores.

50. Pancreatitis & Hepatic Failure On May 5 his acetaminophen level was non-detectable and his AST was 22,733 (2305 hours) and his INR was 19. Is his liver failure secondary to chronic alcohol abuse or acetaminophen toxicity? How long would you continue his NAC and why?