Necrotizing pancreatitis: A review for the acute care surgeon.

BACKGROUND: Necrotizing pancreatitis is a common condition with high mortality; the acute care surgeon is frequently consulted for management recommendations. Furthermore, there has been substantial change in the timing, approach, and frequency of surgical intervention for this group of patients. METHODS: In this article we summarize key clinical and research developments regarding necrotizing pancreatitis, including current recommendations for treatment of patients requiring intensive care and those with common complications. Articles from all years were considered to provide proper historical context, and most recent management recommendations are identified. RESULTS: Epidemiology, diagnosis, treatment in the acute phase, and complications (both short-term and long-term) are discussed. Images of surgical interventions are included from our institutional experience. CONCLUSION: Necrotizing pancreatitis management remains heavily based on clinical judgement, although technological advances and clinical trials have made decision making more straightforward.

PADUA score as a predictor for pulmonary embolism: a potential strategy for reducing unnecessary imaging.

An objective tool that is easy to integrate with an electronic medical record may help reduce unnecessary imaging for diagnosing a pulmonary embolism (PE). In this study, we assess the PADUA score in stratifying patients based on their risk of a PE. We reviewed charts of patients that underwent a computed tomography pulmonary angiogram (CT-PA) between January 2014 and September 2015 at our institution. Patient demographics including gender, age, race, and variables of the PADUA score were collected. The primary outcome was a positive CT-PA for a PE. Univariate and multivariate analysis was performed to derive predictors for a positive CT-PA. A receiver operator curve was calculated for the PADUA score and an optimal cutoff was calculated. Diagnostic test statistics were performed. Our study included 1067 patients. Of these, 185 (17.3%) had a PE. These patients tended to be older (64.3 SD 15.9 vs. 59.7 years SD 17.4, p < 0.01), have a higher proportion of Black patients (38.9% vs. 31.9%, p = 0.03), have a higher median [IQR] PADUA score (4.0 [3-6] vs. 3.0 [1-4], p < 0.01), and a higher rate of a DVT/PE history (30.3% vs. 5.2%, p < 0.01). Independent predictors included a DVT/PE history (OR: 7.65, 95% CI 4.89-12.0, p < 0.01), limited mobility (OR: 1.47, 95% CI 1.01-2.14, p = 0.046), and age 70 or greater (OR: 1.47, 95% CI 1.03-2.11, p = 0.03). The PADUA score had an AUC of 0.64 (95% CI 0.60-0.69, p = 0.046). The optimal cutoff was 4 and the sensitivity and specificity were 57.3% and 66.8%, respectively. The positive predictive and negative predictive values were 22.6% and 88.2%, respectively. The PADUA is a possible tool to stratify patients prior to performing a CT-PA. By using the score to guide management, we may be able to reduce unnecessary imaging through the implementation of the score in an EMR system. Further prospective research is warranted.

Protocolized care for early shock resuscitation.

PURPOSE OF REVIEW: Protocolized care for early shock resuscitation (PCESR) has been intensely examined over the last decade. The purpose is to review the pathophysiologic basis, historical origin, clinical applications, components and outcome implications of PCESR. RECENT FINDINGS: PCESR is a multifaceted systems-based approach that includes early detection of high-risk patients and interventions to rapidly reverse hemodynamic perturbations that result in global or regional tissue hypoxia. It has been applied to perioperative surgery, trauma, cardiology (heart failure and acute myocardial infarction), pulmonary embolus, cardiac arrest, undifferentiated shock, postoperative cardiac surgery and pediatric septic shock. When this approach is used for adult septic shock, in particular, it is associated with a mortality reduction from 46.5 to less than 30% over the last 2 decades. Challenges to these findings are seen when repeated trials contain enrollment, diagnostic and therapeutic methodological differences. SUMMARY: PCESR is more than a hemodynamic optimization procedure. It also provides an educational framework for the less experienced and objective recognition of clinical improvement or deterioration. It further minimizes practices' variation and provides objective measures that can be audited, evaluated and amendable to continuous quality improvement. As a result, morbidity and mortality are improved.