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Tabla 2

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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:


Early Severe Criteria: PSAP.

Systemic complications: “Persistente” organ failure = ≥ 1 FO

  1. Hypotension: SAP < 90 mm Hg despite a correct contribution of oxygen; or > 40 mmHg of basal SAP in ATH..

  2. Respiratory failure: PaO2 < 60 mm Hg; or PaO2/FiO2 < 250 mmHg

  3. 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.

  1. Medical intervention; ICU. Diagnosis:

    1. Application of Recommendations and

    2. Guidelines for Pancreatitis


"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)


  1. Assessing SAP:

  • SOFA: > 2 in 48 hours

  • APACHE II: ≥ 8

  • PCR: > 15 mg/dl ó 150 mg/L

  • BISAP


Vital signs; History / physical examination; Calculus of Atlanta Severity Criteria + PCR ≥15mg/dl + Biliary ultrasound scan; + (dynamic) basal abdomenTC

PVC/hour


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)


Monitor vital signs; monitor organ functions

If PIA >20 mmHg= HIA and/or SCA: Surgery


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

4. Imaging tests

Thorax Rx; Abdominal TAC ultrasound scan: Assess as diagnosis and severity


Thorax Rx; Repeat dynamic TC-if the previous one was “early”, <72 h from the onset of symptoms);


Thorax Rx; dynamic-TCfrom 72h after onset of pancreatic crisis

Thorax Rx ; Abdominal ultrasound; dynamic-TC from 72h after onset of pancreatic crisis

5. Probes / Monitoring / Vigilance

Foley probe

Place SNG and/or SNY

Invasive monitoring whenever necessary

Central venous catheter


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

6. Medication / Treatments


Optimize: "Measure bundles” “PANCREAS” (See below)

Assess treatment of external cleansing (TDE) (“cherry picking”)


TVP prophylaxis (HBPM) y ulcus (IBPs) (H2 blockers)

No antibiotic prophylaxis

IOT and VM if necessary


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


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



Continue with Nutritional Support; IV fluids

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

9. Biliary AP Treat:

    1. Colangitis

    2. 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

  1. 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

  1. Discharge Plan

Not applicable (N/A)

N/A

N/A

N/A

  1. Medical Objectives / Nursing

Maintain the vital signs.

Goals or objectives: "measure bundles”: Acronym: PANCREAS

Vital signs; Pain control.

Nutritional contribution

Maintain vital functions


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

Eight” therapeutic measures that are easy to remember with the acronym “PANCREAS”:


Acronym “PANCREAS”:


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  1. Final AP Classification – In accordance with the new nomenclature, the classification can evolve and could be:

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.

Severity category

Local complications

 

Systemic complicationss

Mild Acute Pancreatitis

No (peri)pancreatic complications

and

No organ failure

Moderate Acute Pancreatitis

Sterile (peri)pancreatic complication

or

TRANSIENT organ failure

Severe Acute Pancreatitis

Infectious (peri)pancreatic complication

or

PERSISTENT organ failure

Critical Acute Pancreatitis

Infectious (peri)pancreatic complication

and

PERSISTENT organ failure






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