Clinical Case Study: Acute Pancreatitis

By Nicole Vantress --- February 2013

BACKGROUND

Medical Presentation• Patient C.P. transferred from Grossmont Hospital for gallstone

pancreatitis• Admitted to UCSD CCU January 13, 2013 with respiratory

distress and sepsis• Length of stay: 1/13/2013- present

Anthropometrics• C.P. 55 year old male• 6 ft. (72”)• 365# (166 kg)• BMI: 49.6• Ideal Body Weight (IBW): 178# (81kg)• Percent IBW (%IBW): 205%• PMH: HLD, HTN, nephrolithiasis, BPH (benign prostatic

hyperplasia), and morbid obesity

Prior to Admission• Symptoms• Back pain upper abdominal pain• Pain worsened with food• Nausea and emesis• Fevers and chills• Decreased urine output

• Social History/ Other History• Gallstones• 2 glasses of wine twice a week• No past history of pancreatitis• Lives with partner and daughter• Good job, no stressors

Medical Status at Admit to CCU• Gallstone pancreatitis with severe sepsis• AKI• Transaminitis• Plural effusion• Atelactasis vs developing PNA• Hyperglycemia• Hemodynamically unstable• NPO

Progress from Admit to Initial Nutrition Assessment

• Pt intubated 1/14• Sedated and started on 3

vasopressors (norepinephrine, phenylephrine, vasopresson)

• Started CRRT 1/14• Coretrack

Coretrack• Imaging note: “Coretrack placed with tip in atrum.”• Not appropriate with pancreatitis

Vasopressors• Patient on norepinephrine, phenylephrine and vasopressin.• Vasoconstriction and decreased oxygenation to the gut and

microvili put the patient at higher risk for nonocclusive bowel ischemia.

• 3 pressors hold• 2 pressors trophic feeds• 1 pressor advance TF slowly

Obesity in the ICU• Hypocaloric feeding when BMI >30• 60-70% of target energy• If over age 65, Penn State Equation already factors this

percentage in. • High protein needs• For ventilated, critically ill patients:

• BMI<30: 1.2-2.0 gm/kg actual weight• BMI 30-40: 2.0 gm/kg IBW• BMI > 40: Greater than or equal to 2.5 gm/kg IBW

• ~2 g/kg might not be indicated in liver and renal impairment• Patient on CRRT so not a concern.

Sepsis• Hypocaloric feeding the first week of sepsis• 55-65% of goal kcal

• Then feed REE x 1.5 for calories• 1.5-2 g/kg protein• Increased needs can reamain elevated for up to 21 days even

when sepsis has been treated.

CRRT (Continuous Renal Replacement Therapy)• CRRT removes water and wastes at a slow and steady rate

(usually over 24 hrs).• Who gets CRRT?

CRRT cont.• Goals of CRRT• To correct electrolyte and metabolic imbalances associated with

renal dysfunction• Maintain optimal fluid balance

• Types/dialysate• SCUF (Slow Continuous Ultrafiltration)• CVVHDF (Continuous Venous-Venous HemoDiaFiltration)• CVVH (Continuous Venous-Venous Hemofiltraition)• CVVHD (Continuous Venous-Venous Hemodialysis

• % glucose in dialysate ranges from 0.1%-2.5%.• UCSD uses 0.1%, which only provides 33 kcals.

CRRT Cont.• Nutrition goals• Oral and enteral diet does not usually need to be restricted for

renal• Protein needs usually range from 1.5-2.5 g/g (more accurate

estimate can be calculated from 24 hour data)• Renal MVI for water-soluble losses• Standard formula is appropriate• Insulin drip

CRRT Calculation for Protein Needs• In lab values, under filtrate tabs, find BUN ultrafiltrate. Start

with lab value from day before and two others previous from that. Add up and take avg.

• Only able to do calculation if all three values are within 10 points of each other.

• Under CRRT flowsheet:• Make sure the is a number for each hour of the day yesterday

0000-2300. • Add up all the numbers from dialysate infused (1B)• Add up all the numbers in the patient fluid removal (3A)

CRRT Calculation Cont…• Take (1B) + (3A) = TOTAL• TOTAL x BUN Avg = XYZ• Take (XYZ/100/1000) + 4 + 1.5 (g of nitrogen lost per 24 hrs) =

g nitrogen• G nitrogen x 6.25 (6.25g nitrogen in 1g protein) = g protein• Can add g nitrogen + 2, then multiply by 6.25 to make a

protein range

INITIAL NUTRITION INTERVENTION

Significant Labs at Initial Assessment

• No prealbumin or CRP• Elevated LFTs• K+/P/Mg WNL

Lipase 2601 2742 U/LBUN 54 mg/dL

Creatinine 4.74 mg/dL

A1C (1/13) 5.7%

POCT 121-202 mg/dL

Lactate 21.5 mEq/L

Ionized Ca 0.96 mmol/L

Nutrition RequirementsEstimated Needs• Energy• REE per Penn State Equation: 3281 x 0.55-0.65 for sepsis/obesity

= 1804-2133 kcal (22-26 kcal/81 kg IBW)• Protein• 162-203 gm protein (2-2.5 g/81 kg IBW)• 24 hr CRRT info not available

• Maintenance Fluids• 500-1000 mL + UOP or per MD given CRRT

Nutrition Care Process• Diagnosis: PT with inadequate nutrient intake R/T NPO status,

hemodynamic instability/sepsis AEB diet Rx and no nutrient intake since admission.

• Intervention Goal: Pt to receive > 75% of estimated nutrient needs with acceptable tolerance.

Nutrition Plan/ Recommendations1. Start senna/colace.• LBM prior to admission

2. D/C coretrack and place NJ tube via IR if/when possible.• pancreatitis

3. REC once on 2 pressors or less, start Peptamen AF @ 10 mL/hr x 24 hrs.• why the low goal rate?

4. Continue calcium gluconate.• Note low ionized Ca

5. REC check prealbumin along with CRP to get baseline, then weekly to trend and to better assess nutrition status.

6. Check weight daily to monitor trends/dry weight.

Acute Pancreatitis

Gallstone Pancreatitis• Gallstone pancreatitis is inflammation of the pancreas that

results from blockage of the pancreatic duct by a gallstone. • 15% of cases of acute pancreatitis are either idiopathic or

from biliary disease. • Progression of disease• Obstruction blocks enzymes• Pancreatic enzymes• Amylase and lipase

LFTs• Obstructed outflow• Elevated alkaline

phosphatase, ALT, AST, and bilirubin

• ALT >150 IU/L• C.P. had these elevated

liver enzymes• Progress note:• MD noted LFTs had begun

to trend down, which suggests the gallstone had passed.

Risk Factors• Female gender• Obesity• Older age• High cholesterol levels• Rapid weight loss• Diabetes• Pregnancy

Severe acute pancreatitis• The mean hospital length of stay is approximately 1 month• Organ failure occurs in at least 16% to 33% of cases, and

infection complicates the disease course in 30% to 50%. • Mortality alone is 19% to 30%, but may range up to as high as

80% if organ failure or sepsis complicates the disease process.

Treatment• Pancreatic Rest• Severe pancreatitis • Nutrition support• Fix underlying cause

PN vs EN• Need for pancreatic rest can still be achieved with EN• EN reduces:• infectious morbidity• hospital length of stay• cost for nutrition support• need for surgical intervention• multiple organ failure and mortality

• Feeding the gut

Early Enteral Feeds• Feeding within 24-48 hours showed the most outcome

benefits• EN should be initiated as soon fluid resuscitation is complete• Less gut permeability• Decreased release of inflammatory cytokines• Overall decrease in infectious morbidity and hospital length of

stay

Tube Feed Placement and Formula• NJ preferred with severe acute pancreatitis• 40 cm or more below the Ligament of Treitz

• Coretrack vs IR placement• Peptide based formula• Peptamen AF• Other options

• Nepro• Standard formula (2 cal)

Nutrition Goals• Increased energy expenditure and protein catabolism• Calories: 22-47 kcal/kg or injury factor of 1.3-1.5 x REE

Protein: 1.4-2 g/kg protein• End goal of low fat PO diet

Patient progress• Gallstone passed• Staged wounds• Stage 2• REC nephrocaps

• Feeding at goal rate• Peptamen @ 65 mL/hr + Prosource TID

• Lipase back to normal

Complications• (1/26) Decreased goal rate to Peptamen @ 40 mL/hr• Diarrhea per MD; improved when tube feeds were held• Placement of FT still not optimal

• (1/24) Imaging showed tip in duodenum, (1/25) imaging showed poorly visualized tip of the feeding tube

• Left in duodenum because lipase, LFTs decreased• REC NJ for best tolerance

• Couldn’t wean off ventilator, vasopressors or CRRT• Sepsis, necrotizing pancreatitis or both.

Patient Progress Cont.• Moved to SICU and put on surgical team service• Necrotizing pancreatitis• REC pancreatic enzymes-creon for better absorption• REC goal rate @ 65 mL/hr + Prosource TID

• Necrosectomy (1/30) and repeat necrosectomy (1/31)• (2/4) Abdominal washout, debridement of necrotic pancreas,

cholecystectomy, and temporary abdominal closure.

Monitoring/Evaluation• Labs• Prealbumin/CRP

1/16/1

3

1/17/13

1/18/1

3

1/19/1

3

1/20/1

3

1/21/13

1/22/1

3

1/23/1

3

1/24/1

3

1/25/1

3

1/26/1

3

1/27/1

3

1/28/13

1/29/1

30

5

10

15

20

25

30

35

40

45

50Prealbumin/CRP Trends

PAB CRPDate

Monitoring/Evaluation Cont• Labs• Lipase/amylase• Renal labs now switched to iHD

• Wounds • Remains staged 2; improving

• Wt/fluids• D/C CRRT, trending up

Weight and Fluid Trends

15-Jan

16-Jan

17-Jan

18-Jan

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20-Jan

21-Jan

22-Jan

23-Jan

24-Jan

25-Jan

26-Jan

27-Jan

28-Jan

29-Jan

30-Jan

31-Jan

1-Feb

350360370380390400410

Wt (lbs)

Wt (lbs)

15-Jan16-Ja

n17-Ja

n18-Ja

n19-Ja

n20-Ja

n21-Ja

n22-Ja

n23-Ja

n24-Ja

n25-Ja

n26-Ja

n27-Ja

n28-Ja

n29-Ja

n30-Ja

n31-Ja

n1-Fe

b0

2000400060008000

100001200014000160001800020000

Acummulated Fluids (mL) Since Admission

Fluids (mL)

End Nutrition Goals• NJ feeding of Peptamen @ 65 mL/hr x 24 hrs + prosource TID• ADAT to PO low fat diet• Possible need for pancreatic enzymes, regular diet

Questions?

References1. The A.S.P.E.N. nutrition support core curriculum: A case-based approach-The adult patient. ASPEN. 2007.2. Inotropes and vasopressors. Contemporary review in cardiovascular medicine. Circulation 2008. 3. Wells DL. Provision of enteral nutrition during casopressor therapy for hemodynamic instability: An evidence-based review. Nutrition in Clinical Practice. 2012; 27:521-526.4. Choi Y, Silverman WB. Biliary tract disorders, gallbladder disorders, and gallstone pancreatitis. American College of Gastroenterology. 2013.5. Norman JG. New approaches to acute pancreatitis: role of inflammatory mediators. Digestion. 1999;60(suppl 1): 57-60.

References Cont6. Ed. Gottschlich, MM. The A.S.P.E.N nutrition support core curriculum: A case-based approach-The adult patient. ASPEN. 2007.7. Petrov MS, Kukosh MV, Emelyanov NV. A randomized controlled trial of enteral versus parenteral feeding in patients with predicted severe acute pancreatitis shows a significant reduction in mortality and in infected pancreatic complications with total enteral nutrition. Dig Surg. 2006;23:336-344.8. Eckerwall GE, Axelsson JB, Andersson RG. Early nasogastric feeding in predicted severe acute pancreatitis: a clinical, randomized study. Ann Surg. 2006;244:959-967.9. Casas M, Mora J, Fort E, et al. Total enteral nutrition vs. total parenteral nutrition in patients with severe acute pancreatitis. Rev Esp Enferm Dig. 2007;99:264-269.

Thank You!