Chapters authored
Severe Acute Pancreatitis and its Management
Severe acute pancreatitis (SAP) is a severe form of acute pancreatitis, which requires often intensive care therapy. The common aetiology varies with geographic locations. In Middle East, biliary pancreatitis is the commonest type. Initial phase of the disease is due to profound release of the proinflammatory marker, then the organ dysfunction takes over. It mainly divided into three types depending upon the pathological changes that are oedematous, necrotic and haemorrhagic. The common clinical presentation is typical abdominal pain radiating to the back and relieved by typical positioning i.e. sitting or leaning forwards. Raised pancreatic amylase and lipase with imaging will help to diagnose the SAP. The outcome of SAP is dictated by various criteria and scores. The commonly used scoring systems are Ranson’s and Glasgow scores, whereas the local complication is diagnosed and predicted by the Balthazar’s score. The management of SAP is mainly analgesia, prevention of complications and supportive care. Initially, laparotomy was recommended routinely for SAP complicated by necrosis of the pancreas and continuous lavage, but nowadays, minimal invasive image guided drainage is the recommended modality. The most common complications of concern are the abdominal compartment syndrome, Acute respiratory distress syndrome (ARDS), and infection of the pancreatitis necrosis. SAP has a high mortality rate (up to 40%), but initial aggressive supportive management will improve the outcome.
Part of the book: Intensive Care
Fat Embolism Syndrome
Fat embolism syndrome (FES) is a clinical syndrome characterized by signs and symptoms resulting from fat emboli and typically occurs after trauma, orthopaedic surgeries and non-traumatic conditions like acute pancreatitis. Literature reports an incidence of FES of up to 19% in prospective studies. Fat embolism refers to the presence of fat globules in pulmonary microcirculation and is often asymptomatic. The clinical syndrome of FES is characterized by systemic manifestations resulting from fat emboli which may manifest with a triad of lung, brain, and skin involvement in about 24–72 hours of asymptomatic period. The pathophysiology of fat embolism syndrome remains unclear. Two theories have been hypothesized: mechanical(disruptive) and biochemical(production of toxic metabolites). Universal agreement on the definition of FES is lacking. FES presents with nonspecific signs and symptoms;common to other critical illnesses and is often a diagnosis of exclusion. The clinical criteria proposed by Gurd and Wilson are popular. Biochemical tests and imaging may be of value in supporting the diagnosis. Treatment for FES is essentially supportive care in ICU. Principles of treatment include maintenance of adequate oxygenation, ventilation, hemodynamics, and organ perfusion. It may be prevented by early fixation of large bone fractures.
Part of the book: Intensive Care
Acute Pain Management in Intensive Care Patients: Facts and Figures
Pain is an unpleasant experience for all patients including intensive care patients; if it is not treated properly, it has deleterious effects on patients’ acute and chronic well-beings. In ICU patients, it causes sympathetic stimulation leading to adverse hemodynamic effects and after discharge, these patients are at the higher risk for developing chronic pain and post-traumatic stress disorders. Apart from racial and regional factors, sleep deprivation, anxiety, and delirium increase the pain perceptions. Pain assessment is a prerequisite for adequate pain management. The ICU patients are sedated and ventilated, and assessment scales differ depending on whether the patient is able to communicate. There are different pain assessment scales for both groups of patients. The preferred mode of delivery of analgesic medication is intravenous route as intramuscular and subcutaneous route are not reliable for drug delivery in these patients. Patient and nurse controlled analgesia gives better sense of pain control. In the treatment of pain, opioids are the commonly used medications, but paracetamol, dexmedetomidine, and gabapentin are increasingly used. Newer trends are multimodal analgesia, where the combinations of analgesic medications with different mechanism of action are used. Another trend is increasing use of analgosedation; they not only control the pain but also relieve anxiety.
Part of the book: Pain Management in Special Circumstances