Critical care - Acute pancreatitis: Nursing

Acute pancreatitis is an inflammation of the pancreas. Causes include damage to the pancreas from biliary conditions such as gallstones; chronic alcohol use; certain medications like sulfonamides and corticosteroids; certain endoscopic procedures like endoscopic retrograde cholangiopancreatography, or ERCP; and abdominal trauma. As the nurse, you’ll provide patient-centered care for critically ill patients with acute pancreatitis.

So, the pancreas is a large gland located behind the stomach. Its endocrine function involves regulation of glucose by producing hormones like insulin and glucagon, while its exocrine function aids in digestion. As far as its digestive function goes, the acinar cells of the pancreas produce and release inactivated digestive enzymes into the small intestine. Here, they’re activated into amylase, lipase, and protease which break down carbohydrates, fats, and proteins.

Now, in acute pancreatitis, the pancreatic acinar cells are injured, and the inactivated enzymes leak into surrounding pancreatic tissue where they become prematurely activated and begin the process of autodigestion of the tissue. As the pancreatic tissue is damaged by its own enzymes, edema, hemorrhage, fibrosis, and necrosis occurs, along with localized inflammation.

As inflammation progresses, enzymes and inflammatory mediators are released into the systemic circulation, and travel to other organs, like the liver, kidneys, and lungs, causing widespread organ damage. Acute pancreatitis can progress to systemic inflammatory response syndrome, which leads to increased systemic vascular permeability, third-spacing of fluid, loss of circulatory volume and hypovolemic shock, as well as multiple organ failure, and potentially death.

Alright, so, clinical manifestations will depend on the severity of the damage to the pancreas and the degree of systemic complications. Typically, there’s an acute onset of pain that’s often described as a knife-like or twisting sensation located in the epigastric to periumbilical region, that radiates to the back and improves when leaning forward or lying in a semi-fetal position. The pain is also usually associated with nausea and vomiting.

Other clinical manifestations include fever, hypoactive bowel sounds, abdominal distension and tenderness, and guarding. In severe cases there can be ascites, jaundice, palpable abdominal masses, and signs of hypovolemic shock, including tachypnea, hypotension, and tachycardia.

Rarely, signs of retroperitoneal hemorrhage occur, manifested as bluish discoloration of the flanks, known as Grey-Turner sign, or of the umbilical region, called Cullen sign.

In addition, laboratory results will show elevated lipase and amylase levels, white blood cell count, and inflammatory markers like C-reactive protein and procalcitonin. Peritonitis or sepsis may develop due to translocation of intestinal bacteria into the bloodstream. Hyperglycemia may also be present if the pancreatic tissue damage compromises the endocrine function of the pancreas.

When caring for your critically ill patient with acute pancreatitis, your goals of care include correcting fluid, electrolyte, and metabolic imbalances; managing pain; and providing nutritional support.

Begin by assessing their airway, breathing, and circulation, or ABCs, and placing them on a continuous monitor. For any emergent, life-threatening findings, activate emergency protocols as needed.