What is pain control for pancreatitis? #1
- Pain control with opiods like Dilaudid becuase it carries less risk.
- Demerol: don't use for pancreatitis toxic Wiki
- Wiki says use MS.
- Kaplin says don't use Morphine: causes spasm to sphincter of oddi (bile & enzyme outlet)=further injury to pancreas
- Hydromorphone: carries less risk & is stronger than MS & demerol
What is pancreatitis? #2
Autodigestion of pancreas by its own enzymes (lipase, trypsin, amylase)
- Inflammation> cell breakdown > necrosis > massive blood loss
- Acute inflammation & enzymic necrosis of pancreatic fat and vessel necrosis=hemorrhage. Digestion of vascular walls results in thrombosis and hemorrhage.
Cause of pancreatits? #3
- Gallstones!= 85% of cases
- Use of certain drugs: thiazide diuretics, furosemide, steroids, transplant meds, valporic acid, statins
- Infection (mumps)
- Unknown causes 20%
Common (simple 5) symptoms of Pancreatitis (not including labs). #4
- Severe pain: LUQ, radiate to mid back
- Nausea & severe Vomiting
- Grey Turner's sign: ecchymosis in flank region (blood in these areas)
- Cullens sign: ecchymosis in umbilical area
- Steatorrhea: diarrhea foul smelling (lack of fat digestion)
- Weight loss/malnutrition/dehydration
Nursing S/S of critical pancreatits patient. #5
- Usually SBP <90
- HR >130
- Oliguria <50 mL/h or increasing BUN and creatinine
- Hemorrhagic peritoneal fluid
What are abnormal labs in a pt with pancreatitis? #6
- ^ amylase
- ^ lipase (more specific that amylase)
- ^ glucose (beta cell damage)
- ^ BUN (hypovolemia/dehydration)
- ^WBC (pseudocysts)
- hypokalemia: vomiting
- hypocalcemia <8^billiruben
- ^alkphos indicating stricturing of the common bile duct
- <albumin: movement of fluid into extracellular space
- ABG: hypoxemia r/t resp. failure
1) What are signs & symptoms of hypocalcemia? #7
Muscle twitch, tremor, irritability, broncospasm, tetany & arrythmias
- +Chvosteck's: abnormal reaction to the stimulation of the facial nerve
- +Trousseau's: the wrist and joints flex
Initial nursing tasks (not for ICU patient...see later cards)? #8
- IV, labs, IVF
- Strict NPO; pancreatic rest (approximately 75% of relapses occur within 48 hours of oral refeeding)
- IVF hydration NS or LR (hypovolemia)
- Strict I&O's, Foley
- Labs, Initial ABG
- O2, possible intubation
- PIV, possible central line
What are endocrine and exocrine fuctions of the pancreas? #9
- Endocrine: produces digestive enzymes
- Exocrine: pancreas produces insulin & glucagon
What is a fistula? #10
- Abnormal connection or passageway between two organs that normally do not connect.
- Abnormal connection or passageway between two epithelium-lined organs or vessels that normally do not connect. A disease condition, but may be surgically created for therapeutic reasons.
Diet to prevent work of pancreas? #11
- No alcohol
- Low fat
- High in CHO (unless diabetic)
- Elemental PRO
- Frequent small meals (6 feedings day)
- Elemental PRO (which don't stimulate pancreatic secretions)
- Bland (non-irritating)
- Eating may still be painful
Function of amylase? #12
Function of lipase?
- 1) Digests CHO
- 2) Digests Fats
Meds for pancreatitis? #13
- H2 blockers
- Pancreatic enzymes: effective in treating the malabsorption and steatorrhea
- Insulin (IDDM)
Treatment for tetany #14
According to Wiki what are 2 diagnostic features of pancreatitis? #15
- 1) abdominal pain
- 2) amylase and/or lipase ≥3 times the upper limit of normal
- Two of the following three features:
- 1) abdominal pain
- 2) amylase and/or lipase ≥3 times the upper limit of normal (serum lipase is thought to be more sensitive and specific than serum amylase)
- 3) acute pancreatitis on CT
What are 3 imaging studies regarding Pancreatitis #16
- Abdominal Xrays (for detection of gallstones)
- CT abdomen (no contrast) not a necessary as a primary diagnostic modality (CT abdomen too early <48 h may result in equivocal or normal findings).
- MRI ok
What are 2 functions of Octreotide/Sandostatin. #17
- Reduce secretion of fluids by pancreas.
- Inhibit contraction of the gallbladder.
- Resembles/mimics natural somatostatin physiological activities.
- Inhibits secretion of many hormones, such as gastrin, CCK, glucagon, GH, insulin, secretin, pancreatic polypeptide, TSH, and vasoactive intestinal peptide.
- Reduce secretion of fluids by the intestine and pancreas.
- Reduce gastrointestinal motility and inhibit contraction of the gallbladder.
- Inhibit the action of certain hormones from the anterior pituitary
- Cause vasoconstriction in the blood vessels.
- Reduce portal vessel pressures in bleeding varices
What is third spacing? #18
Fluid from the circulation into the abdominal cavity causing inadequate blood volume
- Fluid loss from vomiting, internal bleeding, or oozing of fluid from the circulation into the abdominal cavity in response to the pancreas inflammation.
- Inadequate blood volume.
What is a pancreatic pseudocyst? #19
Pancreatic secretions walled off by scar and inflammatory tissue
- Late complication, pancreatic secretions walled off by scar and inflammatory tissue.
- Painful & may become infected; may rupture and hemorrhage & pressing/occlucing on bile duct >jaundice
What is a pancreatic abscess? #20
Late complication of pancreatitis; collection of pus on surface of pancreas that can lead to infection.
- A late complication of acute necrotizing pancreatitis 4 weeks after the initial attack.
- collection of pus resulting from tissue necrosis, liquefaction, and infection. 3% of the patients will develop an abscess.
What is chronic pancreatitis (easy answer)? #21
Acute inflammation in a previously injured pancreas.
Recurring, alters pancreatic structure and functions.
What is acute pancreatitis? #22
Sudden inflammation of the pancreas can be mild or severe > death.
It is a sudden inflammation of the pancreas, depending on its severity, it can have severe complications and high mortality despite treatment. Severe pancreatitis will need ICU/surgery tx to deal with complications, whereas mild pancreatitis (treated NPO and IV fluid rehydration) can be treated on the common ward.
Why do gallstones cause pancreatitis? #23
Gallstones lodged in the CBD obstruct outflow of pancreatic juices from pancreas into the duodenum. Backflow causes lysis (dissolving) of pancreatic cells and subsequent pancreatitis. Subsequent: occurring or coming later or after.
- Gallstones obstruct outflow of pancreatic juices from pancreas into the duodenum.
1) What is an ERCP? #24
2) What is 1 the indication for early ERCP?
3) What are disadvantages of ERCP?
4) What diagnostic modality is replacing ERCP?
- 1)Endoscopic retrograde cholangiopancreatography (ERCP) Chole-angio-pancrea-graphy
- Endoscopy and fluoroscopy to diagnose and treat problems of the biliary or pancreatic ductal systems.
- 2) ERCP if gallstones are present
- 3) ERCP precipitates pancreatitis
- 4) MRI & US
- 1)Endoscopic retrograde cholangiopancreatography (ERCP)
- Endoscopy and fluoroscopy to diagnose and treat problems of the biliary or pancreatic ductal systems. ERCP can treat conditions of the bile ducts, including gallstones, inflammatory strictures (scars) & leaks (from trauma and surgery). View inside of the stomach and duodenum, and inject dyes into the ducts in the biliary tree and pancreas so they can be seen on x-rays.
- 2) The indications for early ERCP are as follows :
- a) Lack of improvement after 24 hours
- b) ERCP if gallstones are present or
- c) dilated ducts on CT abdomen
- 3)Disadvantages of ERCP are as follows :
- ERCP precipitates pancreatitis, and can introduce infection to sterile pancreatitis
- 4) Safer and relatively non-invasive investigations: such as magnetic resonance
- cholangiopancreatography (MRCP) and endoscopic ultrasound has meant that
- ERCP is now rarely performed without therapeutic intent
When is surgery indicated for chronic pancreatitis (3)? #25
Surgery is divided in which 2 areas?
- 1) Surgery is indicated for complications, diagnostic uncertainty, infection
- 2) Divided into two areas - resectional and drainage procedures
- infection: I&D
- uncertainty: unsure if it is pancreatits causing the pain
Name (3) H2 antagonist drugs (brand name and chemical name)? #26
- Block the action of histamine on parietal cells in the stomach decreasing the production of acid.
- Are surpassed in popularity by the more effective proton pump inhibitors.
1)Give 3 examples of drugs plus trade names.
2) What are Proton pump inhibitors (PPIs) #27
- 2)Irreversibly, long-lasting reduction of gastric acid production
- Pronounced and long-lasting reduction of gastric acid production. They are the most potent inhibitors of acid secretion available today. Irreversibly blocking enzyme system on the gastric proton pump of the gastric parietal cell (enzymes are naturally destroyed then renewed).
Advanced s/s of pancreatits? #28
- Impaired cardiac function:
- Impaired cardiac function:
- Hypovolemia: (low BP, ^HR, Low UO) Ascites;
- High BP r/t pain yet low BP
- SIRS (Systemic inflammatory response syndrome) &
- DIC Disseminated intravascular coagulation
- Decreased bowel sounds
- ARDS: Acute resp distress syndrome
- pleural effusions, hypoxemia atelectasis lungs may collapse as a result of the
- shallow breathing which occurs because of the abdominal pain from Pneumonitis: may occur as a result of pancreatic enzymes directly damaging the lung, pancreatic exudate
- MSOF Multi-system organ failure
- ARF Acute renal failure