A High-risk Ambulance Transfer and Management of a Critically-ill Patient with Severe Acute Pancreatitis in Oman
Mr. H, a 30 year old gentleman had complaints of severe abdominal pain and was admitted to Ministry Hospital, Nizwa. He was admitted at MOH there with Severe acute pancreatitis and was subsequently intubated and mechanically ventilated since the day of admission due to haemodynamic instability, MODS. He was managed there on ventilator for a whole week.He was found to have severe hypertriglyceridemia. He was also an alcoholic. His CT done there has features of severe necrotizing pancreatitis.Our Gastroenterology team was approached by his family to take over the case since he was deteriorating and after deciding to take over the case our Aster hospital team went to undertake this high risk in ambulance to Aster Al Raffah Hospital, Muscat for further care.On arrival at the hospital of transfer, the ICU patient was on ventilator SIMV mode, sedated with midazolam, fentanyl and propofol. On high dose iontrope support with Dopamine at 15 mcg/kg bodywt/min on flow, barely maintaining a systolic BP of 90/50, tachycardic with a heart rate of over 140/min.His output was maintained with 40mg IV BD Furosemide. He had a central venous catheter (right internal jugular vein) in place (Day 8), on ventilator (Day 8) with paralytic ileus, with hugely dilated abdomen, with pancreatic ascites not tolerating RT feeds, no bowel sounds, started on Day 1 of TPN, empirically initiated on Carbapenem (Day 8) and IV Fluconazole (Day 1) in Moderate ARDS (PaO2/Fio2) -114, able to ventilate. Blood culture results- awaited.
He was thus assessed by our Critical Care Physician and found to be a deteriorating patient. He was jaundiced and diagnosed as severe acute pancreatitis in shock possibly due to Infected abdomen, diaphoretic, spiking high grade fever with Paralytic Ileus, in Moderate ARDS, SIRS. A hemodynamically compromised patient with circulatory collapse due to MODS and in respiratory distress on ventilator, able to ventilate and attain adequate saturation. His last done ABG there had a PH- 7.45, PO2- 80.5, PCO2- 43.5, HCO3- 29.6 with a lactate of 2.5 and FiO2 of 70% O2. He had skin peeling on sacral region and scrotal skin peeling while receiving the case.
Accepting this challenge, the team took over after getting handover from the team in care there. After signing in the register that transfer is done at own risk of the Intensivist they were willing to permit transfer. There was a general sarcasm all round by the staff on duty regarding the transfer to such an extent, that one nursing staff uttered openly that she would refuse the transfer if she was in the receiving team’s shoes as it had a high chance of spiralling down.
The ambulance transfer was initiated at 11:00pm by our team. The team consisted of the Intensivist, OT technician, Male nurse and a ER attender. It was for the first time such a transfer was attempted. It took 1 hour 15 minutes at night for the transfer and it was a adrenaline high experience for the entire team as the risks and consequences involved in such a transfer in a foreign country is huge if things go wrong. Giving no room for errors, after multiple checks and paralyzing the patient on ventilator with Rocuronium, sedation on flow, with an FiO2 of 100%.Dopamine infusion continued on flow at 15 mcg/kgbodywt/min the journey began and the transport went smooth and was uneventful except few runs of Dopamine induced tachyarrhythmia. Since it was night there were no road blocks at signals and it was a straight nonstop run by road to our ICU at Aster Al Raffah Hospital, Muscat.
After receiving at our ICU at 12.30am a new central venous catheter (right sub clavian vein) was immediately secured. CVP was transduced which was 14. Blood cultures were send from peripheral line and the old central line after which it was immediately removed being Day 8 and continued on Dopamine at 10mg/kgbodywt/min maintaining an ideal MAP. A femoral arterial line was secured for invasive hemodynamic monitoring. PETCO2 was 45. His foleys catheter was Day 8 and was changed into silicon catheter and urine routine and cultures were send.
He was toxic, diaphoretic and was spiking fever of 38 C. Meropenem was continued. Metronidazole was initiated alongside considering pancreatic penetration. Fluconazole and TPN was stopped. He was sedated well and continued on volume-controlled mode of ventilation with a tidal volume of 400 and a PEEP of 10, with Fio2 of 70% and a RR of 20/min maintaining a plateau pressure of 22 well below 30 cmH2O thereby optimizing ventilation.
ABG was repeated which had a similar picture as last one with metabolic alkalosis possibly due to diuretic given earlier. SCVO2 was done from CVC which was 71.5% and fluid was optimised. Blood panel was repeated. He was kept NPO until next day. He was suspected to have abdominal compartment syndrome.
On the next day he was reassessed in detail by our gastro team. His WBC was 31.5 x 10^9, CRP-301 mg/L, LFT- Total Bilirubin- 55.4 umol/l and Direct bilirubin- 40.3 umol/l, Hb- was 8.1 g/dL. LDH was elevated 729.71 U/L, Peripheral smear was normal. Other parameters including coagulation profile, PLT count, RFT, serum electrolytes were normal. Ionotrope was changed from Dopamine and a MAP of 65mm Hg was attained using Noradrenaline infusion at 0.3mcg/kgbodywt/min with which his tachycardia settled and better BP control was attained. He continued to be toxic with high grade fever and diaphoresis. His chest X-ray had features suggestive of left pleural effusion. Urine routine had plenty of bacteria and pus cells for which urine culture was sent and awaited. His screening swabs for MRSA were negative. His Lipase level was 135.6 U/L.
He was initiated on Movicol sachet and Dulcholax suppository and he started passing stool and flatus. RT feeds were started at 30cc/hr and slowly uptitrated with IV prokinetics. He tolerated RT feeds. Potassium was always maintained above 4.0 mmol/l. He was initiated on aggressive chest and limb physio. He was started on DVT prophylaxis using mechanical prophylaxis and LMWH. Bedside ultrasound-guided therapeutic paracentesis was done, draining about 1.2 litre from both drains and was send for routine labs and cultures which showed a TC of 980 hence diagnosing Spontaneous Bacterial Peritonitis. Our cardiologist did a bed side echo and his LV function was found to be normal.
He was adequately fluid resuscitated with CVP guidance and serial SCVO2 every day.
Input and Output were optimised. He was transfused one packed red blood cell and Hb was optimised. His urine culture had Staph Haemolyticus and antibiotics were optimised according to sensitivity pattern. His Blood cultures didn’t yield any growth. His CRPs continued to be elevated. He underwent one more USG guided paracentesis for the distended abdomen. His LFT values started coming down and his jaundice regressed. His repeat LFT showed a total bilirubin of 32.4 umol/l and direct bilirubin of 24.4 umol/l. His albumin was low ( 27.4g/L) and was started on albumin as replacement and for volume expansion and continued for 5 days.
He was shifted for CT the next day which showed evidence of necrotic pancreatitis with pancreatic ascites. He had abdominal distention and significant abdominal ascites despite multiple attempts at paracentesis.
That evening under aseptic precaution and USG guidance two pig tail drains were inserted were inserted and peri pancreatic collection and ascitic collection were drained by our Interventional Radiologist bedside. Ascitic fluid was again send for routine and cultures. The total counts came as 3550 & 1250 for peri pancreatic drain and ascitic drain. An add-on agent Levofloxacin 750 mg IV was added. Cultures and gram stain did not yield any growth. He was continued on Meropenem. The pig tail catheters drained about 750ml from peri pancreatic drain and 550ml from ascitic drain on first day.
He continued to be in sepsis-induced encephalopathy. His repeat labs showed total counts have a downward trend to 14.1 x 10^9, LFT has normalized but CRP continued to be 298 mg/L. With time and taking one day at time he started haemodynamically stabilizing and after a week of stay at our hospital the ionotropes were tapered, stopped and arterial was removed.
By now sedation breaks were given and he was initiated in SIMV/VC mode of ventilation. He continued to have high grade fever with diaphoresis. Surveillance cultures were repeated for bacteria and fungus. The drains were regularly draining. The abdominal distension was significantly reduced.
His sensorium improved and he was intiated on weaning. Post multiple drainage his abdominal distension decreased. He tolerated CPAP, T piece trail and was extubated on the 9th day at our hospital. The ET tube tip and non-bronchial lavage was sent for culture. Post extubation he was agitated and pulled out the central venous catheter. A left-sided subclavian line was secured subsequently.
He tolerated extubation for 6 hours and then became tachypneic, developed desaturation despite adequate pain control. He was reintubated and mechanically ventilated again in volume control. His PaO2/FiO2 was 154. Xray had B/L infiltrates. In view of his ascites, abdominal pain and drains he was not an ideal candidate for proning. The family was not in favour of tracheostomy.
He was tolerating RT feeds well by now. He was empirically started on Fluconazole. His Xrays started clearing and haemodynamics stabilised. His sensorium improved. He was transfused one more packed cell. Hb was 9.2. His ET tip culture and Non BAL grew MDR Klebsiella and Stenotrophomonas maltophilia sensitive to Fluroquinolones. By then his total counts were 15.7 X 10^9, CRP has reduced to 47.35mg/L, Chest Xray cleared, and secretions were minimal, with less bouts of fever - so was continued on same antibiotics. His sensorium totally improved. The earlier send fungal culture reports came as negative for 7 days growth- first interim report. A negative balance was attained for next few days.
He was attempted to wean once more after 2 week ventilator stay at our hospital (3 weeks in total) with the plan if weaning failure to come out with a tracheostomy on the same day, after convincing the family with great difficulty and obtaining consent for the same. He tolerated CPAP, 2 hours t-piece trail and was finally extubated and tolerated extubation well. He was active and alert.
His potassium was low in the subsequent days so correction was given along with magnesium and was optimised. He was extubated and was managed with nasojejunal feeds and hydration. His silicon catheter was removed.
MRI done subsequently showed acute pancreatitis with necrosis, moderate loculated inflammatory ascites, bi basal atelectasis with mild left pleural effusion.
His central line was removed after MRI after establishing a peripheral line. Two sets of surveillance cultures were repeated again, one from central line prior to removing and one from peripheral line which did not yield any growth. He was shifted out of the ICU.
He improved clinically and symptomatically then onwards. His bed sores have by now healed well. His antibiotics Metronidazole was discontinued on Day 12, Levoflox after 10 days. Meropenem to be continued till discharge in view of SBP/ Sepsis. Fluconazole discontinued after a week.
He was initiated on peripheral TPN for 4 days after for improving nutritional status along with oral feeds. His repeat albumin was 34.2 g/L.
The drain continued to have high output of around 500 ml from both drains, which persisted despite the nasojejunal feeds. So, he was initiated on Inj. Octreotide as infusion and over a period of time the drain settled down and both pigtail catheters were removed and he was fed orally with recurrence of collection seen.
An MRCP did not reveal any disconnect of the ducts and hence an ERCP was deferred. He was advised that he would require an endoscopic ultrasound and possibly an ERCP if the pancreatic ascites as well as peripancreatic collection persists.
Pancreatitis is a multi-system disease especially a case such as this which had almost all complications of severe pancreatitis. In management of pancreatitis the first few days are extremely critical especially with regards to fluid resuscitation and interventions. This patient had abdominal compartment syndrome which was very effectively managed with pigtail drainage enabling effective ventilation and hydration. He was subsequently discharged after 4 weeks of stay. This case could not have been managed without the excellent teamwork and communication across all the subspecialties concerned.