THE PANCREAS AND ANESTHESIAMartha Richter, MSN, CRNA

THE PANCREAS

THE PANCREASEXOCRINE FUNCTIONSPancreatic digestive enzymes secreted by pancreatic aciniNaBicarb secreted by ducts & ductulesCombined, they flow thru pancreatic ductjoin hepatic ductenter duodenum thru papilla of vater, surrounded by sphincter of Oddi

THE PANCREASENDOCRINE FUNCTIONSInvolved with metabolism carbohydrates and blood sugar regulationInsulin secreted directly into bloodIslets of Langerhans patches throughout glandComposed ofAlpha cells =25%GlucagonBeta cells=60%insulin and amylinDelta cells=10%somatostatinPP cellspancreatic polypeptides

THE PANCREASConditions for this lecturePancreatitis-acute & chronicPancreatic cyst/psuedocystPancreatic CADiabetesInsulinoma

ACUTE PANCREATITISThe acute inflammatory process-autodigestion60-80% caused by ETOH and cholelithiasisAlso seen in patients withAIDSHyperparathyroidism (inc Ca++)Blunt abdominal traumaPostoperative abdominal surgeryThorac surgery postop, CABG1-2% post ERCP

ACUTE PANCREATITISS&SSevere epigastric pain radiating to backN&VAbdominal distentionDyspnea b/o pleural effusions, ascitesFeverShockTetany b/o hypocalcemiaObtundedpsychosesWithdrawal in alcoholics

ACUTE PANCREATITISRemember the comorbiditiesETOH abuseMalnourishmentETOH withdrawal

ACUTE PANCREATITISDiagnosisElevated serum amylaseCT scanERCP to localize site of trauma, existence of obstructionDifferential includes:Perforated duodenal ulcerAcute cholecystitisMesenteric ischemiaBowel obstructionAcute MIpneumonia

ACUTE PANCREATITISComplications=25%Shock early=major cause of death b/o sequestration fld in peripancreat sp, hemorrhage, dec SVRARDS=20%arterial hypoxemiaRenal failure=25%poor prognosisGI hemorrhageDICPseudocyst formation=10-15%(b/o hemorrhage & resolution)Pancreatic infection=50% mortality when strictures develop

ACUTE PANCREATITISRX=supportiveAggressive IV fld adminIf hemorrhagiccolloids, blood productsNPON/G for persist vomiting/ileusOpioidsProphylactic antibiotics if necrotizingEndoscopic removal of stonesParenteral nutrition

ACUTE PANCREATITISRXSurgery may be required for complicationsSurgical debride for necrotic pancreasHemorrhagic panc. Unresponsive to blood prod resusc and correction coagulopathiesDrainage pseudocysts

ACUTE PANCREATITISERCPEndoscopic Retrograde CholangiopancreatographyAllows dx re: liver, GB, pancreas, bile ductspresence of jaundice, abdominal pain, unexplained wt loss

ERCPMACThroat sprayedloss airway protectionLLD positionSedationWhen ducts reached, patient positioned supineDye injected into ductsvisualized with xrays. If obstr=stones, removed. If obstr = tumor, bx may be taken

ERCPPt experiences pain when: duodenum insufflated with air and dye injected

If stone is removedovernight observation in hospital

Need to know: Iodine allergy?

ERCPComplicationsPancreatitisInfectionBleedingDuodenal perforation (uncommon)

ACUTE PANCREATITIS AND SURGERYPOSTOP COURSE-ICU probableb/o activation of inflammatory mediators, may seeSepsisMulti organ dysfunctionFld resuscitationPPVpressors

CHRONIC PANCREATITISChronic inflammationirreversible damage of pancreasPain may be attributed to other causesMay have recurrent attacksSymptoms may be progressive

CHRONIC PANCREATITIS35-45 yr males80-90% ETOH associatedConcurrent high protein diets

CHRONIC PANCREATITISIdiopathicSecond most commonMay be seen with cystic fibrosis, hyperparathyroidism, hereditary (autosomal dominant)

CHRONIC OBSTRUCTION PANCRATIC DUCT

CHRONIC PANCREATITISPRESENTATIONPostprandial epigastric pain radiating to back10-30% painlessSteatorrhea when 90% pancreas destroyedEventually develop DMCalcifications develop in ETOH induced

CHRONIC PANCREATITISDIAGNOSISh/o ETOH, pancreatic calcificationsThin & emaciatedMalabsorp syndromeproteins & Fats not digest when enzymes reaching duodenum=10-20%Normal serum amylaseAbd Xray=calcificationsU/S=identifies fluid filled pseudocysts, enlarged pancreasCT=dilated pancreatic ductsERCP=detects early changes in duct

CHRONIC PANCREATITISTREATMENTPain treatmentMalabsorption managementDM management(30-40% develop)Drain pancreas: pancreatojejunostomy, stents, stone extractionEnzyme supplements Pseudocyst resect (open/percutaneous)Paracentesis/thoracentesis

CHRONIC PANCREATITIS AND PAINManaged withOpioidsCeliac plexus block

CHRONIC PANCREATITIS & ANESTHESIAEvaluation:Status of ETOHCV complications re: ETOHStatus of DMMethod of pain management (is it working?)Consider state of malnutrition and effect of anesthetic drugs, distributionKeep the patient warmBe alert for withdrawal under anesthesia

PANCREATIC CANCER5th leading cause Cancer death in USFemales60 years+Usually not detected earlyResponds poorly to RXSpreads quickly

PANCREATIC CANCERRisk factorsCigarette smoking accelerates tumor growthFamily historyHereditary syndromes = younger patients

PANCREATIC CANCERS&SJaundice b/o bile duct obstructionN/VLoss of appetiteWt loss (unexplained)Mid abd pain radiating to back (indicates splanchnic & retroperitoneal invasion)Dark urineLight stoolsDM development=rare

PANCREATIC CANCERSTAGING OF MALIGNANCYIvery small tumor, limited to pancreasIIlarger tumors limited to pancreasIIIlymph node spreadIVmetastatic to colon, spleen, stomach and distant organs (liver, lungs)

PANCREATIC CANCER95% begin in ductsUsually adenocarcinomaOccurrence in tail = rare

PANCREATIC CANCERRXBiopsy to confirm (endoscopic/radiologic)Pain managementIf no spread, surgery = best option.Surgical mortality 1-15%Preop chemo and radiation to shrink tumor

PANCREATIC CANCERIf metastatic, goal = palliationERCP to open obstructed ductPain management may include narcotics, celiac plexus blockChemoRadiation

Unresected survival = 5 months

PANCREATIC CANCERSurgeryTotal pancreatectomyPancreaticoduodenectomy (Whipple)

PANCREATIC CANCERTotal PancreatectomySurgically easier to performProduces DM and malabsorption states10% survival = 5 years

PANCREATIC CANCERWHIPPLEMajor morbidity b/o:Cardiopulmonary diseasePancreatic/biliary fistulaHemorrhageinfection

PANCREATIC CANCERWHIPPLEBig procedureshould be done in big hospital setting

Bowel prep = require rehydrationType and crossmatchUsual systems evaluationIf obstructedprepare for RSI (pre treat regimen)

PANCREATIC CANCERWHIPPLEAnesthesia planGAGA/Epi (lumbar/thoracic)Monitors incl CVP, art lineLarge bore IVs-there will be large fld shifts, blood lossRSI in the face of obstructionWarm the patientWarm the fluids

PANCREATIC CANCERWHIPPLEHave the blood in the room and checkedpossibility of portal v or vena cava injuryMay require mesenteric vessel and portal v resectionRemember the comorbiditiesPrepare for postop PPV if massive blood loss/replacement

PANCREATIC CANCERWHIPPLEIn the face of the best planned anesthetic, Plan B must include possibility of open and close

DIABETESChronic diseaseRelative lack/lack of insulinInappropriate hyperglycemia

DIABETESTYPE I or IDDMJuvenile onsetBrittle (more prone to ketosis)Have very low insulin levelsRequire Insulin

DIABETESTYPE II OR NIDDMMakes up 90% of all diabeticsgradual onsetusually overweightnot prone to ketosishave insulin resistanceat inc risk for hyperglycemic hyperosmolar nonketotic coma (HHNK)RX=diet, oral hypoglycemics, occas. insulin

DIABETESWhat else can cause it?Diseases that alter hormone levelsAcromegalyGlucogonomaCushing'sPheochromocytomaALSO:Pancreatic damage/destruction(surgery)Cystic fibrosishemochromatosis

DIABETESManifestationsHyperglycemiaGlycosuriaDegeneration of small blood vessels

DIABETESLong term complications = morbidity, premature mortalityLate complications = HTN, CAD, PVD, cereb vasc dis, retinopathy, nephropathy, peripheral and autonomic neuropathiesLife threatening complications = hypoglycemia, ketoacidosis, HHNK coma

DIABETESKETOACIDOSISCaused by stressInfections, surgery, traumaPoor pt compliance may be implicatedCan be soon post-MI

DIABETES and ketoacidosisPresentationN/VSensorium changesDyspnea (comp for metabol. Acidosis)Abdominal painHyperglycemia (300-500mg/dL)HyperosmolarityIntracellular dehydrationOsmotic diuresisprofound hypovolemiaHyperkalemiahyponatremia

DIABETES AND KETOACIDOSISRXCorrection dehydration, hyperglycemia, K+ deficiencyIsotonic fluidsInsulin infusionK+ replacement

DIABETES AND HYPOGLYCEMIADEF:excessive insulin relative to carbohydrate intake= bld glucose

DIABETES AND HHNK COMAPlasma hyperosmolarity >330mOm/LHyperglycemia >600mg/dLMarked osmot diuresisloss K, Na, volProfound dehydrationLeads to lactic acidosis, renal failure, predisposition to venous thrombosisAbsence ketoacidosis (pt has enough insulin to avoid ketosis)

DIABETES AND HHNK COMAS&SAltered mental statecomaRXFluid resuscitationSmall doses IV InsulinK+ supplementWhen glu reaches 300mg/dL, Rx slows to prevent cerebral edemaTriggered by: infection, trauma, dehydration; more common in elderlyMay occur in diabetics/nondiabetics

DIABETES AND ANESTHESIAPreop assessmentCorrect glucose abnormalitiesCheck for electrolye abnCorrect ketoacidosis

DIABETES AND ANESTHESIAPeriop morbidity re: end organ damageEval CV, cereb, renal systemsDiabetic neuropathy may manifest:Painless MI (silent)Orthostatic hypotensionResting tachycardiaLack HR variabilityGastroparesisImpotenceDec sensation peripheral

DIABETES AND ANESTHESIAWhen diabetics have neuropathy affecting autonomic function, they are at high risk of aspiration, intraop cardiac instability, sudden cardiac death.

DIABETES AND ANESTHESIAAspiration prophylaxisPreop cocktailRapid sequence inductionInvasive monitoring Strict aseptic technique when placing b/o compromised immune system

DIABETES AND ANESTHESIAINTRAOP GOALSPrevent hypoglycemiaPrevent hyperglycemia and ketoacidosisMaintain bld glu 120-180mg/dL

Monitor blood glucose at intervals approp to case

DIABETES AND ANESTHESIABe familiar with oral hypoglycemia agents, onset and duration. This influences when a patient may become hypoglycemia while under your care.

DIABETES AND ANESTHESIA

DIABETES, INSULIN AND ANESTHESIA3 possible approaches for insulin management during anesthesia

Pt takes -1/2 total a.m. dose in form of intermediate acting insulin. Consider D5 soln to prevent hypoglycemia. If hypoglycemia develops (50-100mg/dL), give 10gms D50will raise bld Glu 30-40mg/dL

DIABETES, INSULIN AND ANESTHESIAA second approach:

IV regular insulin may be given according to a sliding scale.1 Unit regular insulin will decrease bld glucose 25-30mg/dL in an adult

DIABETES, INSULIN AND ANESTHESIAA 3rd approachRun an IV Insulin infusion at 1Unit/hr

No matter what approach is chosen, remember to monitor the blood glucose at regular intervals (preop, intraop, postop)

DIABETES, INSULIN AND ANESTHESIA

DIABETES AND ANESTHESIAAVOID HYPOGLYCEMIAImproved glycemic managementimproved perioperative M&MHbA1c

DIABETES AND ANESTHESIAWhat about insulin pumps?Different philosophies:May continue infusion if not in operative fieldSome will always discontinue; restart in PACUIf continue or d/cremember to monitor the bld glucose levels at frequent intervals

DIABETES AND ANESTHESIAWhat about emergencies?Common for diabetics to require appendectomies, I&Ds, lower extremity amputations (infect/vasc insuff)Evaluate mental status, labsIf presenting with ketoacidosis, Rx 1st with IV Insulin, K+ replace, fluid vol replacement. CVP may be helpful

INSULINOMABeta Islet cell tumorsprofound hypoglycemia b/o excess release InsulinCNS=dizziness to coma

INSULINOMAS&SHypoglycemia (tachycardia, HTN, diaphoresisMay be masked by GA

RX: surgical excision of tumor

INSULINOMAWant to start an Insulin infusion prior to inductionSome recommend bld glu measures q 15 minGlu fluctuates widely with:Tumor manipulation (hypoglycemia)\Tumor excision (hyperglycemia)

The POST-PANCREATIC TRANSPLANT PATIENTThe actual considerations of the transplant surgery will be covered in the transplant lecturesWhat about taking care of these patients after the Tx?The transplant effectively restores glucose metabolismThese patients will not require insulin coverageAlways assume IHD

The PANCREAS AND ANESTHESIA CONSIDERATIONSJust as with most other physiologic issues, this patient population will have comorbidities. It is important to appreciate the influences and interactions that exist so that we may approach the plan of care in a careful, logical, thoughtful way.