“With the Scientific Guarantee from the Spanish Society of Intensive Care and Coronary Units”
Table 2. CLINICAL PATHWAY FOR Potentially Severe AP in an ICU (PSAP) 2011:
Level of Care / Unit |
Date of Admission to ICU: Day “0” |
Date Day l in ICU: |
Date Day 2 in ICU: |
Date Day 3 in ICU:
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Early Severe Criteria: PSAP. Systemic complications: “Persistente” organ failure = ≥ 1 FO Hypotension: SAP < 90 mm Hg despite a correct contribution of oxygen; or > 40 mmHg of basal SAP in ATH.. Respiratory failure: PaO2 < 60 mm Hg; or PaO2/FiO2 < 250 mmHg Acute renal failure: Cr > 1,2 mg/dl (≥ 171 mmol / L) despite a correct contribution of oxygen; or Oliguria <30 ml in 3 h; or 700 ml in 24h. |
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Medical intervention; ICU. Diagnosis: Application of Recommendations and Guidelines for Pancreatitis
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"Measure bundles” (eight therapeutic measures that are easy to remember) Acronym “PANCREAS” |
Severity Criteria. Promote early enteral nutrition in severe forms of AP, beginning with SNG, and if this is not tolerated, proceed to SNY. |
Identify severity criteria: Organ failure Early support of any FMO Hemodynamic Stability according to the SOFA scale (Cardiological Criteria) |
With severity signs / SIRS, dynamic TC, with or without PAAF for Gram and/or culture (advise Microbiology) PIA > 25 cm H2O optimize renal perfusion pressure (PPR)
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Assessing SAP: SOFA: > 2 in 48 hours APACHE II: ≥ 8 PCR: > 15 mg/dl ó 150 mg/L BISAP
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Vital signs; History / physical examination; Calculus of Atlanta Severity Criteria + PCR ≥15mg/dl + Biliary ultrasound scan; + (dynamic) basal abdomenTC PVC/hour
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Vital signs; evaluate Ranson signs APACHE II: ≥8 points Progessive monitoring of PCR and PCT PIA/8h and SOFA (at the physician’s discretion) PVC/4 hours Respiratory Function; Hemodynamics; Renal and water balance |
Vital signs; PIA/8h y PVC/4 h (If it is pathological evaluate the frequency)
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Monitor vital signs; monitor organ functions If PIA >20 mmHg= HIA and/or SCA: Surgery
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3. Laboratory tests/ techniques. Pancreatic and Nutritional y Profile (discuss with LAB) |
Pancreatic profile and/or nutritional profile Acid-Base “basal” arterial balance with ambient air; thorax Rx; ECG Hemocultures, Uroculure. |
Biochemical panel of functional tests; serum calcium. Monitorized PCR / PCT Pancreatic Panel |
Biochemical panel of functional tests; serum calcium. Monitorized PCR / PCT Pancreatic Panel |
Biochemical panel of functional tests; serum calcium. Monitorized PCR / PCT Acid-Base balance Pancreatic Panel |
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4. Imaging tests |
Thorax Rx; Abdominal TAC ultrasound scan: Assess as diagnosis and severity
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Thorax Rx; Repeat dynamic TC-if the previous one was “early”, <72 h from the onset of symptoms);
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Thorax Rx; dynamic-TCfrom 72h after onset of pancreatic crisis |
Thorax Rx ; Abdominal ultrasound; dynamic-TC from 72h after onset of pancreatic crisis |
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5. Probes / Monitoring / Vigilance |
Foley probe Place SNG and/or SNY Invasive monitoring whenever necessary Central venous catheter
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Central / arterial venous catheter Monitor PVC/4h and PIA/nursing shift. Monitor PIA according to the protocol Intubation (IOT) if VM is |
Central / arterial venous catheter Monitor PVC/4h and PIA/nursing shift. Monitor PIA according to the protocol Intubation (IOT) if VM is necessary |
Central / arterial venous catheter Monitor PVC/4h and PIA/nursing shift. Monitor PIA according to the protocol Intubation (IOT) if VM is necessary |
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6. Medication / Treatments
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Optimize: "Measure bundles” “PANCREAS” (See below) Assess treatment of external cleansing (TDE) (“cherry picking”)
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TVP prophylaxis (HBPM) y ulcus (IBPs) (H2 blockers) No antibiotic prophylaxis IOT and VM if necessary
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Painkillers in perfusion, including opiates. Evaluate TDE, and high volume TDE, if progress is unstable If sepsis is suspected order antibiotics (after culture samples are taken) |
Optimized support based on the FMO If progress is unstable gradual (FMO), and persistent ≥ 3 días = IQ Suitable antibiotics for germs
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7. Nutrition / Fluids |
Energy replacement of IV fluids – volume for maintaining the vital signs (PVC between 7-10 mmHg) |
Begin Nutritional Support “early”, with NE for via jejunal better than gastric, once the vital signs have been stabilized |
IV Fluids; continue with Nutritional Support
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Continue with Nutritional Support; IV fluids |
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8. Activity |
Bed rest with a headrest at more than a 20º angle |
Bed rest with a headrest at more than a 35º angle |
Bed rest with a headrest at more than a 35º angle |
Bed rest with a headrest at more than a 35º angle; have the patient sit in a chair in the morning and afternoon if appropriate |
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9. Biliary AP Treat: Colangitis Biliary Obstrucción |
1º. With Colangitis: Antibiotherapy + Urgent CPRE (24h) SURGERY to urgently remove biliary obstructions when no CPRE is available |
1º. With Colangitis: Antibiotherapy + Urgent CPRE (24h) SURGERY to urgently remove biliary obstructions when no CPRE is available |
2º. With biliary obstructions: evaluate antibiotherapy and early CPRE (<72h) and deferred Colecistectomy SURGERY to urgently remove biliary obstructions when no CPRE is available |
2º. With biliary obstructions: evaluate antibiotherapy and early CPRE (<72h) and deferred Colecistectomy SURGERY to urgently remove biliary obstructions when no CPRE is available |
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Information / Teaching |
Explain the illness, cause and prognosis of Potentially Severe Acute Pancreatitis |
Explain the VM; Early advanced Nutritional Support |
Explain the prognosis again; explain the need for a TC scan |
Progress explanation |
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Discharge Plan |
Not applicable (N/A) |
N/A |
N/A |
N/A |
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Medical Objectives / Nursing |
Maintain the vital signs. Goals or objectives: "measure bundles”: Acronym: PANCREAS |
Vital signs; Pain control. Nutritional contribution Maintain vital functions
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Stable vital signs; correct organ-systematic functions and nutritional control |
Maintain stable vital signs; Optimum oxygenation. Adequate nutrition Gastric aspiration in the event of prolonged ileus |
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“Eight” therapeutic measures that are easy to remember with the acronym “PANCREAS”: |
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Acronym “PANCREAS”:
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Final AP Classification – In accordance with the new nomenclature, the classification can evolve and could be: |
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When a patient arrives at Emergency Services, his/her condition can only be classified into two groups: mild or moderate; in order to be classified as more severe, temporary evolution is required.
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