I would imagine that every pancreas with a history of -itis remembers the ole good days of bumming around until the pain was over… Lipase 3 times the upper limit of normal was good enough for the pancreas to rest and „self-digest” .
Here, just for you the newest nutritional recs to de-bum the pancreas care:
In mild AP, oral feedings can be started immediately if there is no nausea and vomiting, and the abdominal pain has resolved (conditional recommendation, moderate quality of evidence).
In mild AP, initiation of feeding with a low-fat solid diet appears as safe as a clear liquid diet (conditional recommen- dations, moderate quality of evidence).
In severe AP, enteral nutrition is recommended to prevent infectious complications. Parenteral nutrition should be avoided, unless the enteral route is not available, not tolerated, or not meeting caloric requirements (strong recommendation, high quality of evidence)
Nasogastric delivery and naso-jejunal delivery of enteral feeding appear comparable in efficacy and safety (strong recommendation, moderate quality of evidence).
Have you seen this revelation? ENTERAL FEEDING is recommended to PREVENT INFECTIOUS COMPLICATIONS? Clinical and experimental studies have shown that bowel rest is associated with intestinal mucosal atrophy and increased infectious complications because of bacterial translocation from the gut. Patients provided with oral feeding early in the course of AP have a shorter hospital stay, decreased infectious complications, decreased morbidity, and decreased mortality. Total parenteral nutrition should be avoided in patients with mild and severe AP.
So don’t let the pancreas bum around, at least not too much. Feed enterally as early as you can! And by the way, while we are on it, you can also stop that clear liquid or naso-jejunal nonsense.
Nov 19th, 2013: Now that was a crushing publication… On Nov 17th, 2013 NEJM published the results of an international trial with 950 patient’s which assassinated the concept of therapeutic hypothermia? The study group concluded that „in unconscious survivors of out-of-hospital cardiac arrest of presumed cardiac cause, hypothermia at a targeted temperature of 33°C did not confer a benefit as compared with a targeted temperature of 36°C„.
Therapeutic hypothermia industry must be shivering in fear… Who is going to buy any thermo-suits and likewise devices if all you need is 36 degrees Celsius?
Not a single conscious person likes to shiver… That „brain freeze ache” you get when eating your ice-cream too fast doesn’t feel good at all… Why would those benefit the unconscious? Well, it doesn’t seem like they do! Not that fever does them any good either – golden middle way works best! Who would have thought?
The further we go and the more we know, the more we realize how little we know… To make it even worse, about 50% of what we learn appears not to be true… The caveat is we have no „darn” clue which 50% it is. Additionally, as we travel around the world and look at how things are done in many different corners of the globe, we come to a conclusion there are many ways of doing the right thing and reaching the intended goal.
Our medical knowledge is quite imperfect… There is a significant number of huge gaps in what we know about the human species. That is why I dare saying we aren’t yet at the level of exact science. We are still practicing the art and science of medicine. Some believe it’s a happy marriage while others take it more as the necessary evil. No matter how we look at it, blind faith in the available literature is probably not the smartest thing to do. Evidence based brain farts smell equally bad.
Personally, I take everything with a grain of salt… Every time I read about some novelties I cannot stop wondering when someone is going to disprove them. Don’t get me wrong, I am quite excited to witness progress and advancement, though not all that glitters is gold… Some might accuse me of oversimplifying the sacred medical act, but with increasing complexity of medicine it is quite desirable to filter out all the nonsense. There are no holy grails in our profession. The only certainty we have is that life is a sexually transmitted condition with 100% mortality rate.
I am always quite thrilled to read about studies that question what we do in our clinical reality. I find it incredibly amusing to watch how we jump from A to Z. In my perception there are no studies without conflict of interest… We just decided to agree that lack of industry ties parallels the virtue of purity. Research is „desire-driven”, hence always at risk of betrayal. That is why I’ve abandoned the strategy of quoting study results and percentages to my patients. I don’t like hiding behind potentially misleading or even meaningless numbers. I read, I study, I keep up-to-date, and by the end of each shift I hope to have given my patient the options I would have preferred for myself or my loved one. That’s my „standard of care”!
With this somehow philosophical introduction I’d like to initiate the „brain fart demystified?” series. Occasionally, I’d like to share some articles that made me stop and ponder… It’s not my goal to change the way you think. I am not going to tell you how to practice medicine… I am just hoping to inspire some reflection… The conclusions will remain yours and only yours! Fair enough?
Have you ever watched the population clock? It is quite amazing how fast we are growing in numbers. As of today e.g. the U.S. has over 317 million people! Now, if you imagine the 85 million annual CT scans in this country, I hope you are quite as horrified as I am… The radiation exposure clock runs almost as fast. Thinking mathematically you would have to say that a fourth of the American population gets a yearly CT scan. In reality we have to account for the same individuals getting multiple CTs during one year, but it is still an astronomical number if you are asking me! Millions of lost opportunities to use ultrasound first . What’s even worse, according to a study published recently in JAMA Pediatrics, we are talking about “4 million pediatric CT scans of the head, abdomen/pelvis, chest, or spine performed each year”. Those are projected to cause about 4870 future cancers!
Please pardon my Disney fantasies, but we are talking about kids here! Nobody argues the beauty of the CT beast, and we all agree that in certain cases computer tomography is life-saving or inevitable. However, based on daily practice experience, I would say that quite a few of the 4 million CTs could have been ultrasound evaluations… The study authors plead for dose-reduction strategies. I think we all know an excellent one – it’s called “ultrasound first“!
Echoing Resa E Lewiss I would say that the field of pediatric EUS is wide open for disruptive innovations… Ooops, I meant, research inquiries . Let’s get to it – we have a lot of room for improvement and many cancers to prevent!
If you are not really sure where to start, I happen to have some suggestions. A few months ago I had a fascinating FaceTime conversation with Dr. Jason Fischer, Director of Emergency Ultrasound Program at SickKids in Toronto. Emergency medicine (EM), pediatric emergency medicine (PEM) and emergency ultrasound (EUS) trained in this very order. A man with a big heart for the little patients and a soft spot for emergency ultrasound education. Quite a passionate international evangelist of pediatric point-of-care ultrasonography (POCUS)!
Dr. Fischer runs an amazing ultrasound program in Toronto. He has been hiding it a little, but for a very good reason. His initial efforts were rightly focused on training the Canadian physicians. Now his PEM POCUS kingdom has widely opened its doors to international applicants. SickKids is quite unique in that aspect. Their dedication to worldwide education is admirable. They offer an unrivaled wealth of programs for international trainees and established physicians which you can explore at their website. If PEM POCUS is near and dear to your heart, and you want to make a difference for the little patients in your corner of the globe, I would not hesitate to get in touch with Dr. Fischer. I am sure he will think of a training solution quite tailored to your needs. It is your chance to get on board with making history. Without doubt, it is also the moment to embrace POCUS in your pediatric practice or it might hit you when you least expect it! The future is now and tomorrow begins today!
Preventing sternal wound infections in the post operative cardiac surgery patient is an important aspect of post operative care. Sternal infections can increase length of stay, be a substantial financial impact, and increase mortality’ Occurrence of sternal infections is rare and it has been reported as 0.4–4%.
Managing hyperglycemia post-operatively has been one intervention implemented to make a significant impact on reducing sternal infections. It is for this reason we manage such glucose control for these patient and why glucose control <200 mg/dL by POD 1 and POD2 is part of the Surgical Care Improvement Project. Our most recent data has shown that we have met the 100% mark for maintaining glucose control for this patient population. This is excellent work and is a tribute to the excellent post operative nursing care.
Question have come up with the recent changes to the Epinephrine/Insulin glycemic management. Epinephrine is a natural catecholamine produced in our body by the adrenal glands (endocrine gland on top of the kidney). Production of epinephrine and conservation of glucose is a parasympathetic action to prepare our body for “fight” or “flight” stress situations. Epinephrine stimulates the liver to produce glucose by glycogenolysis and gluconeogenesis. Additionally, Glucagon (hyperglycemic hormone) and Cortisol (steroid hormone) are also contributors to hyperglycemia in stress induced states impacted by epinephrine.
Epinephrine interacts with cellular receptors and sends messages from cell to cell to inhibit insulin, elevate glucagon, and manages glucose utilization or conservation.
For these reasons when Epinephrine is infusing, glucose checks are essential. Most likely if the drip continues an insulin drip will follow. The Epinephrine infusion order in Epic indicates checking glucose every 30 minutes to address Hyperglycemia and Hypoglycemia when titrating epinephrine. This frequency of glucose checks is to help us reach goal of <200mgdL.
However, if a patient is on epinephrine and glucose has stabilized within a normal range for a significant amount of time (i.e. 48 hrs with or without insulin infusing) consider revising the frequency of glucose checks. Start at 2 hours. Be sure to get an order so this change in practice is communicated to everyone. From there on, the glucose checks can be modified further.
If situations do progress into an infection state there is potential for opening of the sternum to allow for debridement and dressing changes. Often times patients are intubated and brought into the OR for sternotomy and packing. Sometimes patients are paralyzed for prevention of coughing or major movements by the patient. Abrupt movements or major position changes can create a situation where the separated ribs could puncture the ventricles of the heart. Additionally the ribs and the sternum can become malpositioned and may impact closure of the sternum.
The Z-flo pillow is a perfect option for repositioning patients with open sternums and preventing skin break down. Z-flo pillows are great for microturns and off loading pressure in small areas. Additional things to consider for the open chest patient are:
Log rolling the patient
Minimize coughing (these would create pain and opportunity for piercing the heart)
Promote pain control (PCA)
Optimal Sedation with paralytics
Low air los mattresses
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The effect of tight glycemic control, during and after cardiac surgery, on patient mortality and morbidity: A systematic review and meta analysis. Journal of Cardiothoracic Surgery, 2011;6(3):1-7.
Effect of epinephrine on glucose metabolism in humans: contribution of the liver. American Journal of Physiology Endocrinology and Metabolism. 1984;24(2):E157 -165.
Studies on the mechanism of epinephrine-induced hyperglycemia in man: evidence of participation of pancreatic glucagon secretion. Diabetes 1976;25(1):65-71.