Patient safety and quality: Am J Crit Care. Bright J, Long B.
During the early phase of the disease within the first weekdeath occurs as a result of the development, persistence, and progressive nature of organ dysfunction 75, The development of organ failure appears to be related to the development and persistence of SIRS.
The reversal of and early organ failure has been shown to be important in preventing morbidity and mortality in patients with AP 77, The lack of specificity is due to the fact that the presence of SIRS is not as important as its persistence.
Initial Management Recommendations Aggressive hydration, defined as — ml per hour of isotonic crystalloid solution should be provided to all patients, unless cardiovascular, renal, or other related comorbid factors exist. Early aggressive intravenous hydration is most beneficial during the first 12—24 h, and may have little benefit beyond this time period strong recommendation, moderate quality of evidence.
In a patient with severe volume depletion, manifest as hypotension and tachycardia, more rapid repletion bolus may be needed conditional recommendation, moderate quality of evidence. Fluid requirements should be reassessed at frequent intervals within 6 h of admission and for the next 24—48 h.
The goal of aggressive hydration should be to decrease the BUN strong recommendation, moderate quality of evidence. Early aggressive intravenous hydration Despite dozens of randomized trials, no medication has been shown to be effective in treating AP 32, However, an effective intervention has been well described: Recommendations regarding aggressive hydration are based on expert opinion 10,52,53laboratory experiments 79,80indirect clinical evidence 62,63,81,82epidemiologic studies 59and Management information systems rosenbluth retrospective and prospective clinical trials 9, The rationale for early aggressive hydration in AP arises from observation of the frequent hypovolemia that occurs from multiple factors affecting patients with AP, including vomiting, reduced oral intake, third spacing of fluids, increased respiratory losses, and diaphoresis.
In addition, researchers hypothesize that a combination of microangiopathic effects and edema of the inflamed pancreas decreases blood flow, leading to increased cellular death, necrosis, and ongoing release of pancreatic enzymes activating numerous cascades. Inflammation also increases vascular permeability, leading to increased third space fluid losses and worsening of pancreatic hypoperfusion that leads to increased pancreatic parenchymal necrosis and cell death Early aggressive intravenous fluid resuscitation provides micro- and macrocirculatory support to prevent serious complications such as pancreatic necrosis Although no firm recommendations regarding absolute numbers can be made at this time, the goal to decrease hematocrit demonstrating hemodilution and BUN increasing renal perfusion and maintain a normal creatinine during the first day of hospitalization cannot be overemphasized.
Although some human trials have shown a clear benefit to aggressive hydration 9,85,86other studies have suggested that aggressive hydration may be associated with an increased morbidity and mortality 87, These variable study findings may be partly explained by critical differences in study design.
Although these studies raise concerns about the continuous use of aggressive hydration over 48 h, the role of early hydration within the first 6—12 h was not addressed in these negative studies.
In addition, these negative studies included sicker patients who would have required large volumes of hydration by the 48 h time point 87, Consistently, the human studies in AP that focused on the initial rate of hydration early in the course of treatment within the first 24 h demonstrated a decrease in both morbidity and mortality 9,85, Although the total volume of hydration at 48 h after admission appears to have little or no impact on patient outcome, early aggressive intravenous hydration, during the first 12—24 h, with close monitoring is of paramount importance.
Low pH activates the trypsinogen, makes the acinar cells more susceptible to injury and increases the severity of established AP in experimental studies. Although both are isotonic crystalloid solutions, normal saline given in large volumes may lead to the development of a non-anion gap, hyperchloremic metabolic acidosis Measurement of the central venous pressure via a centrally placed catheter is most commonly used to determine volume status in this setting.
However, data indicate that the intrathoracic blood volume index may have a better correlation with cardiac index than central venous pressure.
Measurement of intrathoracic blood volume index may therefore allow more accurate assessment of volume status for patients managed in the intensive care unit. Patients not responding to intravenous hydration early within 6—12 h may not benefit from continued aggressive hydration.
Although ERCP can be used to identify pancreatic ductal disruption in patients with severe AP, possibly leading to interventions for the so-called dislocated duct syndrome, a consensus has never emerged that ERCP should be performed routinely for this purpose Recommendations Patients with AP and concurrent acute cholangitis should undergo ERCP within 24 h of admission strong recommendation, moderate quality of evidence.
ERCP is not needed early in most patients with gallstone pancreatitis who lack laboratory or clinical evidence of ongoing biliary obstruction strong recommendation, moderate quality of evidence.
Removal of obstructing gallstones from the biliary tree in patients with AP should reduce the risk of developing these complications. There have been several clinical trials performed to answer the question: The trial was performed in a single center in the United Kingdom.
Mortality was not significantly different in the two groups. Patients in the study group underwent ERCP within 24 h of admission and those in the control group were offered conservative management. The control group was offered ERCP if acute cholangitis developed.
Based on these studies, it was unclear whether patients with severe AP in the absence of acute cholangitis benefit from early ERCP. Therefore, Folsch et al.
This study focused on determining the benefit of early ERCP in preventing severe AP in the absence of biliary obstruction.What is MIS? | Management Information Systems. Management Information Systems (MIS) is the study of people, technology, organizations, and the relationships among them.
MIS professionals help firms realize maximum benefit from investment in personnel, equipment, and business processes. MIS is a people-oriented field with an emphasis . Kelly Johnson was born in the remote mining town of Ishpeming, initiativeblog.com parents were Swedish, from the city of Malmö, county of initiativeblog.com father ran a construction company.
Johnson was 13 years old when he won a prize for his first aircraft design. Clinical Guidelines. Authored by a talented group of GI experts, the College is devoted to the development of new ACG guidelines on gastrointestinal and liver diseases.
When using selected information from a table or diagram, or reproducing an entire table or diagram, a reference must be made to the source.
In the following example, information is from a table found on p of the book Management in the media: decision makers by Robert Brown published in Travel Weekly In , Fareportal won a Gold Travel Weekly Magellan Award for the CheapOair Mobile App and a Silver Award for the CheapOair Website.
Fareportal has been awarded a total of 19 Magellan Awards since Magellan Awards. MIS Case Studies. Case 1 is a worldwide telecommunications network through which the airline reservation systems are accessible.
All Rosenbluth agents are connected to GDN as most of the company’s travel software applications. References: 1. Management Information Systems – Managing the Digital Firm, 9th Edition, K C 5/5(1).