A 55-year-old previously healthy lady was admitted with pancreatitis secondary to gallstones. Her admission modified Glasgow Score was 4, and CT scan showed approximately 70% necrosis of the pancreas encompassing the neck, body and tail with sparing of the head. She rapidly developed ARDS, AKI and vasoplegia, and subsequently developed abdominal compartment syndrome requiring decompressive laparotomy. Her later complications included intraabdominal collections requiring percutaneous drainage, upper GI bleeding, and staged closure of her laparostomy. She was initially commenced on enteral NG feeding but developed high NG aspirates despite pro-kinetics. Parenteral nutrition (PN) was commenced in combination with a ‘trophic’ enteral feed. Four weeks into her admission her triglyceride level was found to be elevated, necessitating lipid free PN and cessation of propofol. This led to a drop in her triglyceride level.
How should we manage the provision of nutrition in acute pancreatitis?
A middle aged man is admitted with abdominal pain and vomiting. He has a history of alcohol excess. A CT scan shows evidence of pancreatic necrosis. Supportive care is initiated and an NGT placed for supplementary enteral nutrition. After 3 days, he is referred to ICU as his oxygen requirements have increased and he is requiring non-invasive ventilation. It is noted that he has had very large gastric aspirates. Parenteral nutrition is commenced at this point.
What is the evidence for enteral versus parenteral feed as a source of nutrition in critically ill patients?Read More »
A 54 year old man with a history of alcohol excess was admitted under the medical team with an upper gastro-intestinal bleed. He had a background of pulmonary fibrosis that limited his exercise tolerance to 30 yards. Antibiotics, terlipressin and fluid resuscitation, including blood, were given. An oesophago-gastro-duodenoscopy demonstrated severe portal gastropathy but no active bleeding or varices. An abdominal ultrasound demonstrated cirrhosis and some moderate ascites. On day two of the patient’s hospital admission he was admitted to the intensive care unit (ICU) with respiratory failure and non-invasive ventilation was started. Over the next few days his condition deteriorated and he required vasopressor support. By day 6 the patient was oliguric, and his creatinine had risen from 102 to 155 µmoles/l.
What is the cause for his acute kidney injury? Could it be hepatorenal syndrome? Read More »
A young man is admitted to the surgical unit with several months of worsening abdominal pain. It has become much more severe over the last 24 hours. A CT scan shows evidence of acute pancreatitis with no gallstones or biliary duct dilatation.. He is normally well with no history of alcohol excess. His triglyceride level is elevated at 83.7mmol/L and a diagnosis of hypertriglyceridaemia induced acute pancreatitis is made.
What is hypertriglyceridaemia induced acute pancreatitis and how is it treated?
A 55 yr old man developed severe necrotizing pancreatitis with multiorgan failure. One week into his illness he had developed multiple intra-abdominal collections and had high intra-abdominal pressures. Initial conservative management failed, percutaneous drainage of his collections failed to reduce the abdominal pressures, and he underwent decompressive laparotomy.
What is the evidence behind the current guidelines for the measurement of intra-abdominal hypertension and the use of decompressive laparotomy in the management of Abdominal Compartment Syndrome?Read More »
A middle aged woman presented with an acute abdomen. At laparotomy she was found to have generalised peritonitis secondary to small bowel perforation due to adhesional obstruction. She remained ventilated and on noradrenaline support for several days post-op. Trophic enteral feeds were introduced at 24hrs post-op, but NG aspirates remained high for a further 48 hours despite prokinetics. The decision was made to institute parenteral nutrition if no improvement at day 5 post-op, but was never commenced as NG aspirates improved and enteral nutrition was gradually increased.
What is the evidence for enteral versus parenteral feed as a source of nutrition in critical ill patients?Read More »
A middle aged man presented with a week long history of severe abdominal pain and distension. CT scans confirmed free air, fluid and probable large bowel perforation. Laparotomy revealed multiple large bowel perforations and four quadrant peritonitis. He had an extensive washout, a colectomy and a laparostomy with negative pressure dressing applied. He returned to theatre at 24 hrs for further washout, and at 48hrs for stoma formation. He had several further relook laparotomies, and abdominal wall closure was achieved on day 10. During this time he had been treated for septic shock and acute kidney injury and had been commenced on parenteral nutrition. His recovery was further complicated by healthcare associated infections but he left hospital nearly a month later.
How is an open abdomen managed after severe abdominal sepsis?Read More »
A 35 year old was admitted following a simultaneous kidney pancreas transplant. The procedure had been complicated and she had received a large volume transfusion and crystalloid infusion.Her initial intraabdominal pressures were elevated at 22cmH2O on admission to the intensive care. It continued to escalate over the next 48 hours peaking at 29. She was managed with sedation, NG tube and abdominal perfusion pressures kept above 60mmHg. The tranplanted pancreas remained functional, but the renal transplant showed delayed graft function. On day 4 there was a reduction in her abdominal pressure and her urine output correspondingly increased.
What is the current evidence for the management of intra abdominal hypertension (IAH)?Read More »
An elderly man underwent an elective open left hemicolectomy for a splenic flexure tumour. On day 4 he was admitted to the intensive care due to fevers, fast AF and hypotension. He developed respiratory failure and required intubation. CT abdomen revealed free fluid in the abdomen, and emergency laparotomy found anastomotic breakdown and faecal peritonitis. He was washed out, and had further bowel resection and his abdomen was closed. He developed anuria requiring renal replacement therapy and continued to have persistently raised inflammatory markers. On day 9 he had a further deterioration and repeat CT revealed several large collections. He underwent relook laparotomy and washout, but continued to deteriorate and died 48 hours later.
Do patients with severe secondary peritonitis benefit from on-demand relaparotomy or planned relaparotomy?Read More »