A 38-year-old woman was admitted to the emergency room with a 12-hour history of abdominal pain in the epigastrium and mesogastrium, radiating to the back, accompanied by biliary emesis, malaise and dyspnea, without fever.
She suffered from high respiratory symptoms 3 weeks prior to consultation and had eaten high fat food 4 days before.
Background: recent diagnosis of untreated hypothyroidism.
Surgical history: mammoplasty, lipectomy, cesarean section.
Upon admission to the emergency department, the patient was anxious, algic, sleepy, absent, TA: 109/60; HR: 109/min; RR: 20/min; T: FiO2: 37.8 oC; SPO
As positive findings, cutaneous warmth, semi-dry oral mucosa, limited thoracic excursion due to pain with biaxial hypoventilation.
The abdomen was distended, blando, noisy, painful to palpation deep epigastric and mesogastric, without irritation.
Initial tests were performed reporting Hb: 18.9; hematocrit: 44.3; leukocytosis 14,000; N: 70%; L: 22%; chlorine: 7%; magnesium: 252,000; calciumUN: 3,372; sodium 124:
Coagulation tests were normal.
Lipemic serum
Abdominal ultrasound: increased periportal echogenicity, enlarged pancreas and diffuse increase in echogenicity, presence of peripancreatic fluid, nonlithiasis.
Acute pancreatitis was diagnosed, studies were initiated to clarify, manage pain and hydration without improvement. There was a persistent tendency to hypotension, drowsiness, urinary volumes, and the decision was made to transfer the patient to the care unit etiology (ICU).
It requires inotropic support with dopamine and norepinephrine, with morphine titration to control pain.
Laboratory reports: CRP: 6.5; total cholesterol: 1.029 mg/dl; triglycerides: 7.508 mg/dl; lipase: 6.660 u/l.
Arterial gas: pH: 7.33; PO2: 77%; PCO2: 26; HCO3: 13; DB: -10.
Hypertriglyceridemia is considered a cause of pancreatitis and insulin infusion is administered at 2 or/hour.
The admission APACHE 19 for severe pancreatitis deteriorated at 24 hours with an APACHE of 38.
Triglyceride control was performed 12 hours after the start of insulin infusion with marked decrease in levels to 2,224 mg/dl and total cholesterol to 674, normalizing their values at day 5 of treatment.
The patient presented deterioration of respiratory mechanics, decreased PaFiO2, requiring endotracheal intubation and initiation of mechanical ventilation.
After 48 hours of development of intra-abdominal hypertension with values of 32 mmHg, acute renal failure and criteria for ARDS, requires laparotomy without emergency pancreas washing edematous aspect, areas of peritoneal necrosis, is performed
Antibiotic coverage was initiated with 1 g of intravenous meropenem every 8 hours and it was decided to start immunomodulatory therapy with human immunoglobulin IGM (5%) Pentaglobin®, 16.8 Ml/1 hour i.e.
The peritoneal cavity washed six times and a continuous abdominal vacuum system (CVA) was placed.
Enteral nutritional support and transfusion of blood products were required.
After the eighth day of admission, paulatin recovery, hemodynamic stabilization, improvement and resolution of multiple organ failure began.
The day of 10 stay is successfully extubated.
A new lavage was performed on the 15th day of hospitalization, taking samples of ascitic fluid, in which growth of S. epidermis orxacillin-resistant was obtained. Management with vancomycin was initiated.
Transfer to floor is ordered after 16 days of ICU stay, where antibiotic management continues until after 159 days of hospital stay HDL, triglycerides levels are 220 mg/dl; total cholesterol:
