NMS. Casos Clínicos

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Chapter 7 ♦ Pancreatic and Hepatic Disorders

Figure 7-22: CT scan of the abdomen showing the head and body of the pancreas ( arrows ) severely edematous and inflamed.

such as norepinephrine coupled with appropriate fluid resuscitation can be critical to restore organ perfusion. The patient may need a pulmonary artery catheter if the hemodynamic status cannot be resolved using the central venous pressure (CVP) or echocardiography as a guide to determine how much fluid and what pressor support is best to optimize organ perfusion.

The patient has labored breathing and a pulse oximeter reading of 90%.

Q: What is the best way to assess the patient’s pulmonary status and manage his ventilation? A: This patient warrants immediate physical examination with chest auscultation, an arte- rial blood gas (ABG), and a chest X-ray (radiograph) (CXR). Supplemental oxygen and continuous pulse oximeter monitoring are necessary during this examination. This pa- tient’s problems may be due to pulmonary edema from overhydration, ARDS from a systemic response to the pancreatitis, atelectasis, or pneumonia , which are often dif- ficult to distinguish by CXR. An ABG provides important information on oxygenation (Po 2 ) as well as adequacy of ventilation (Pco 2 ), which helps decide the need for mechan- ical ventilation. Experienced clinicians usually intubate before the patient’s condition be- comes critical. The decision to intubate is usually made based on a combination of ABGs and clinical status. Q: What would you say? A: Amylase levels do not correlate with the severity of pancreatitis or the prognosis. Ranson (Table 7-1) prognostic signs can be used to ascertain the severity of the pancreatitis. You decide that the pulmonary failure in this patient requires intubation and ventilation. Over the next 2 days, signs and symptoms of sepsis develop, with fever, leukocytosis, and septic shock. Q: What is the next step? A: You should be most concerned about the extent of pancreatic necrosis or pancreatic abscess , although other sources of sepsis such as pneumonia, IV access infection, and urinary tract infection (UTI) warrant investigation. To evaluate for pancreatic abscess, a dynamic CT scan is the most reliable examination (Fig. 7-23). This CT scan includes the use of radiographic contrast material timed to determine the vascularity of the pancreas. Your student wants to know the correlation between serumamylase and severity of pancreatitis. SAMPLE

A CT scan shows a peripancreatic collection.