Overcoming barriers while teaching and being humble as a consultant Tackling the expertise bias < Back Overcoming barriers while teaching and being humble as a consultant Why is it so hard to remember what it was like before you knew the things that you now consider fundamental, basic knowledge? If you are a teacher, which includes school teachers as well as everyone responsible for passing knowledge to others, self-reflection on how you relay information and assess comprehension is paramount. One common challenge is overcoming the "curse of knowledge". The curse of knowledge takes hold and becomes a hurdle when the teacher/ instructor assumes that their audience has the same background knowledge and should be "up to speed" without significant delay. In other words, there are many things you do every day that you consider obvious and second nature. It is exceedingly easy to be quick to judge your trainees for not recalling or readily grasping those concepts. How has this manifested itself in my experience as a teacher in the ICU? Caring for patients with a wide breadth of physiologic derangements is a rich environment for interactive real-time learning. Invasive mechanical ventilation is a perfect opportunity to learn about respiratory physiology. Learning how to pick the right mode/ settings and how to make adjustments to optimize each patient's oxygenation and ventilation (while avoiding further lung injury) is key to good critical care for the patient that requires respiratory support. My understanding of mechanical ventilation was the culmination of many hours and long months/ years spent reading, preparing lectures, tinkering bedside with ventilators, engaging in dialogue with experts, and just immersing myself in the weeds. At some point, and I have no idea when it was precisely, it finally clicked. I didn't become an omniscient guru. But after enough practice, the fundamental concepts finally became solidified in my mind, and managing ventilators has become second nature. Ventilator management is a cornerstone of ICU care. Whenever there are patients that require ventilation beyond perioperative indications, I capitalize on the opportunity to teach. Even though I'm acutely aware of how much work (seemingly endless hours of work) went into learning the finer points of ventilators, it's still hard to remember what it was like before I understood. Please note- this phenomenon is NOT limited to in-person teaching. This barrier can infiltrate lectures, manuscript writing, and a variety of other forms of communication and interaction. Another situation relevant to the medical profession- the consultation with a specialist. If you're on the receiving end of the consult, it can be easy to fall into the trap of assuming everyone should have the same knowledge you have. It's crucial to remember that you are an expert in YOUR field- if the physician calling you had the same knowledge, you would be obsolete. So how do you overcome this hurdle? Here are my suggestions 1. The first step is to acknowledge that your interactions can be impacted by your bias. You know more than your students, or the person that's calling you for a consult. More specifically, you know more about what you're teaching your student and you know more about the clinical situation than the person consulting you. That's why you're the teacher and the consultant. 2. Take time to reflect on how you interact when teaching- do you rapidly become impatient, roll your eyes, reply with condescension or snark, or simply look at your students like they're idiots? Pause in real-time: it doesn't have to be awkward, and I'm sure your audience will appreciate a moment to pause and think. 3. Take the opportunity to put the shoe on the other foot. Reflect on what it was like when you were learning- as an intern struggling to remember how to replete electrolytes, a young resident in the ICU struggling to understand ventilators, or even a young attending struggling in a high-stress operative case. How would you want to be approached/ treated? Previous Next

< Back Chronic Upper Abdominal Pain A 65-year-old female with chronic non-specific abdominal pain develops acute severe pain in her epigastrium. She presents to the ED for evaluation. What's on the differential diagnosis? Perforated hollow viscus Gastritis Peptic ulcer disease Pancreatitis Biliary pathology- cholecystitis, choledocholithiasis, hepatitis Pneumonia Myocardial ischemia What are the relevant clinical questions and what is included in a focused physical exam? Further details about the abdominal pain- prior similar episodes, onset/ duration, aggravating/ alleviating factors, constant or intermittent, radiating pain, severity, quality of pain (burning, stabbing, cramps). Associated symptoms- systemic symptoms. Fevers/ chills. Nausea/ vomiting. Change in color of urine or stool? Any prior medical or surgical history? Any medications? Smoker? Exam- abdominal palpation- identify tenderness and presence of peritonitis. The pain is stabbing and constant, and she's never had this pain before. She occasionally has right shoulder pain. She reports nausea and loss of appetite, but denies fevers/ chills/ vomiting. She had tea-colored urine and pale white stool a couple days ago. She has no medical or surgical history and is a non-smoker. On exam, she is afebrile, heart rate in the 90s. She is tender in the right upper quadrant with minimal palpation. What is the initial diagnostic workup? Labs: CBC, amylase/ lipase, hepatic enzymes, bilirubin Right upper quadrant ultrasound Possible computed tomography What ultrasound findings are consistent with cholelithiasis? Masses in the gallbladder that are echogenic (reflect on the anterior surface) with a posterior shadow and mobile/ dependent (move with changes in patient position). What ultrasound findings are consistent with acute calculous cholecystitis? Gallstones + gallbladder wall thickening + pericholecystic fluid +/- positive sonographic Murphys sign. What radiographic and laboratory findings are consistent with choledocholithiasis? Dilated common bile duct, stones visualized in the common bile duct, elevated bilirubin. What clinical/ radiologic/ laboratory findings are consistent with acute calculous cholecystitis? Criteria are based on Tokyo guidelines.[1] Local signs of inflammation- Murphy’s sign, RUQ mass/pain/tenderness Systemic signs of inflammation- fever, elevated CRP, elevated WBC count Imaging findings characteristic of acute cholecystitis Suspected diagnosis- one local sign + one systemic sign Definite diagnosis- one local sign + one systemic sign + imaging findings An ultrasound reveals gallstones, gallbladder wall thickening, and a dilated common bile duct. Her bilirubin is 2. Diagnosis? Cholecystitis with high risk for choledocholithiasis. Right Upper Quadrant Ultrasound- Gallstones Case courtesy of Maulik S Patel, Radiopaedia.org . From the case rID: 20542 Right Upper Quadrant Ultrasound- Gallbladder Wall Thickening Case courtesy of RMH Core Conditions, Radiopaedia.org . From the case rID: 3802 Patient was taken to the OR and underwent uncomplicated laparoscopic cholecystectomy. Intraoperative cholangiogram revealed multiple stones in the distal common bile duct. Despite multiple attempts, stone retrieval was unsuccessful. She underwent a postoperative endoscopic retrograde cholangiopancreatography (ERCP) with successful stone extraction. SAGES Guidelines on Diagnosis and Management of Choledocholithiasis Cholelithiasis, Predicting Likelihood of Choledocholithiasis Choledocholithiasis Management Algorithm Evaluation and Management of Acute Cholecystitis Diagnosis History- right upper quadrant/ epigastric pain, nausea/ vomiting. Labs- CBC, renal panel, LFTs. Radiology- right upper quadrant ultrasound. - Cholelithiasis: echogenic masses in the gallbladder with a posterior shadow that are mobile (move with changes in patient position). - Acute calculous cholecystitis: gallstones + gallbladder wall thickening + pericholecystic fluid +/- positive sonographic Murphys sign. Diagnostic Criteria for Acute Cholecystitis- Tokyo 2018 Guidelines[1] Local signs of inflammation- Murphy’s sign, RUQ mass/pain/tenderness Systemic signs of inflammation- fever, elevated CRP, elevated WBC count Imaging findings characteristic of acute cholecystitis Suspected diagnosis- one local sign + one systemic sign Definite diagnosis - one local sign + one systemic sign + imaging findings Management Cholecystitis is managed with early laparoscopic cholecystectomy unless the patient is too ill to tolerate surgery.[2] A percutaneous cholecystostomy is a minimally-invasive option for high-risk patients, avoiding the risk of general anesthesia. However, in a recent study of high-risk patients, cholecystectomy was associated with fewer complications than percutaneous cholecystostomy.[3] Evaluation and Management of Choledocholithiasis Diagnosis- dilated common bile duct, stones visualized in the common bile duct, elevated bilirubin. Management- common bile duct stones are managed with endoscopic or operative stone extraction.[4,5] References Yokoe M et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis. J Hepatobiliary Pancreat Sci. 2018;25(1):41-54. Okamoto K et al. Tokyo Guidelines 2018: Flowchart for the management of acute cholecystitis. J Hepatobiliary Pancreat Sci. 2018;25(1):55-72. Loozen CS et al. Laparoscopic cholecystectomy versus percutaneous catheter drainage for acute cholecystitis in high risk patients (CHOCOLATE): multicentre randomised clinical trial. BMJ. 2018;363:k3965 . Manning A et al. Protocol-Driven Management of Suspected Common Duct Stones. J Am Coll Surg. 2017;224(4):645-649. Clinical Spotlight Review: Management of Choledocholithiasis - A SAGES Publication. SAGES. Accessed July 13, 2022. Previous Next

< Back AKI...pending Management of Acute Kidney Injury Previous Next

Surgery trainee education. Trauma surgeon. Acute Care Surgery. FAQs Why did you make this website? Over these years of learning about the practice of surgery, I've also learned a lot about myself. I am not an expert, and I did not follow a typical pathway- but I have some knowledge and resources to share. As I transition into my new Acute Care Surgeon role after 17 years in training, I'm pausing to share my experience, tips for success, and random nuggets of wisdom. This will be a work in progress, and I look forward to seeing how it evolves. My goal is to share my experience and knowledge in the hopes of helping those who desire to follow this path. But why do we need another medical education website? There are so many good resources already... There are endless ways to explain clinical concepts- pictures, text, analogies, clinical cases, podcast discussions of cases or principles, review articles, etc. There are also different learning styles. When I was trying to grasp advanced ventilator management, I read basic critical care textbooks, a book dedicated solely to ventilator management, and various websites and journal articles. This website is another way to interact with the information. Hopefully you will understand some of the concepts in a new way that helps you remember and apply them in clinical scenarios. In addition, I have also tried to create a comprehensive collection of all the useful resources I know, like apps and open access medical education resources (websites, clinical guidelines, etc) in one place for trainees to What does Doc on the Run mean? The summer before my last year of medical school was the start of my running career. My focus was enjoying the outdoors, not pace or distance. During my residency, I met someone who helped me refine my running. I started timing myself, training, and racing. Within a year or two, I pushed through personal barriers to become a "runner." My first half marathon was on Thanksgiving in my third year of surgical residency. I am at the end of my formal training, I am now an Acute Care Surgeon. As a surgeon, there are numerous factors that I can't control. It's fast-paced, demanding, and dynamic. I enjoy the organized chaos and high-stakes cases. Running is key to my work-life balance. Unlike in the operating room or the trauma bay, I have control over most aspects of my runs- pace, distance, route, and thoughts. It's not chaotic- it's basically the polar opposite of my work. During the day, my mind is going a million miles an hour. When I run, everything becomes clearer- I can solve problems, mull over ideas, or process dilemmas. And perhaps the most concrete impact is the runner's high that I enjoy after finishing. I have continued to run 10Ks, 10 milers, and the occasional 5K or 15K. I have learned more about the science of running (HR training zones, different paces for tempo/ interval/ long runs/ short runs) and I've learned how to adapt training schedules to fit my life. Unfortunately, I have suffered my share of injuries, including most recently nerve impingement in my foot. While I may have scaled back, running will always be part of my identity. Did you really build this website yourself? Yes, I did. No, I didn't do all the intricate coding by myself. But I did design, format, and create the content. So are you a computer/ technology guru? Whatever I know about technology, I learned from my brother and from spending many hours researching problems online. While my parents might consider me an expert, I literally just search online to solve most issues. When I get to the end of the internet and still haven't found the solution, my next step is Apple tech support (obviously only if the problem is with my iPhone or Mac). What did you learn while making this website? - Formatting the working space on a website - URL redirect - Domains and subdomains - Search engine optimization (SEO) - Establishing custom domains - Which text/ background colors are easiest to read - Anchors If you weren't an Acute Care Surgeon, what would you do? I'd be a chef. I love cooking! Is there anything that is overwhelmingly gross in your job? I have had almost every body fluid on me- stool, urine, blood, etc. So very little grosses me out. But I can't stand oral or nasal secretions (aka saliva, slobber, snot, etc.).

< Back Sausage Tortellini and Brussels Sprouts Ingredients Sausage Tortellini 2 Tbsp olive oil 2 lbs sausage 2 cloves garlic, minced 1 c vegetable broth 2 c tomato sauce ½ c heavy cream 18 oz tortellini Salt & pepper Brussels Sprouts One package of Brussels Sprouts olive oil black pepper sea salt balsamic vinegar Instructions Sausage Tortellini Heat oil in a large skillet and cook sausage links about 5-7 minutes, until sausages are browned throughout. Add garlic and heat for 30 seconds. Remove sausages from skillet and slice into bite-size pieces. Return sausages to pan along with broth, tomato sauce, cream, and tortellini. Season with salt & pepper. Cover and simmer for 12 minutes. Brussels Sprouts Prepare sprouts by trimming the base and then cutting the sprouts in half or quarters, and then place them in a medium-sized bowl. Drizzle a small amount of olive oil and balsalmic vinegar, and then sprinkle black pepper and sea salt. Toss to coat the sprouts, let sit for at least 30 min. Roast at 400 for 20-30 min, toss halfway through. Sausages cooking Previous Tortellini in Sauce Brussels Sprouts Next

Resolving Patient Concerns Who's my doctor? < Back Resolving Patient Concerns During the course of a day, numerous people walk into a patient's room- nurses, case managers, physicians, APPs, trainees, respiratory therapists, physical therapists, just to name a few. It is easy to see how a patient can lose track of who's who. There are multiple providers on a typical inpatient service, including students, residents, APPs, and an attending physician. Although it's not impossible, it would be a rare occasion for a patient to not be seen by a physician or APP at least once a day (usually more). But multiple times, patients ask their nurse or directly ask their provider why they haven't seen a doctor yet. They may also ask why they hear different plans from different people, or why no one has told them a plan. At first glance, these comments might seem as an indicator that the team caring for the patient isn’t being attentive, isn’t knowledgeable about the patient's current condition or plan, or isn’t a united front. And it's understandable why this would be disconcerting to a patient. So why does it happen and how can you handle it? Some of these comments reveal a misperception (who is my doctor, why does no one come to see me, why is nothing happening), while other comments reveal true instances of confusion or breakdown in communication or that could be avoided (multiple consultants, waiting to talk to the attending, change in plan). Patients can be upset about any of a wide variety of things- untreated pain, prolonged NPO status (nil per os, meaning they can't eat), frustration about prolonged illness or another complication, or restricted activity (patients at risk for falling have to ask for assistance to get out of bed). Patients can also display anger when they are scared. For all of these issues, make sure the patient has the opportunity to verbalize their thoughts and concerns- their initial question may not actually be their real issue. Question #1 Why haven’t I seen my doctor today? When am I going to see the person in charge? A. Background. Patients expect their doctor to be involved in their care. They expect their doctor to examine them, ask them questions, and provide a diagnosis and a plan. They also expect to be able to ask questions and voice concerns to their doctor. B. Why/ how does it happen? Given the wide variety of people who pass through patient rooms, it can be difficult for a patient to identify who their physician is. If the patient feels that nothing is happening or they're still in pain or they haven't had their questions answered, it's natural to ask who the boss is. C. How to respond? Identify your role with the team- whether you're the chief resident, the attending, or even a student or young resident. If you aren't a senior team member, ensure the patient that you will bring their concerns to the attending- and make sure you follow through. If you're the attending or senior resident, your response should be tailored to the patient's demeanor. - If the patient is angry, give them time to express their feelings. - If it's a matter of confusion, it's helpful to take a moment to explain the team structure- the other team members who they see throughout the day are direct extensions of the attending on the service. - If there is a real medical issue that hasn't been resolved, none of the explanations about team structure matter. If you're the attending, convey this to the patient, and make it clear that you will work with them to solve the problem. Question #2 Why does no one know what's going on? Why are you telling me something different than what the other doctor said? A. Background. Patients expect their doctors and nurses to take the best possible care of them, which includes having one unified plan. It would be easy to understand why a patient would be distressed or anxious when they hear conflicting plans or recommendations. B. Why/ how does it happen? Plans are not set in stone in the dynamic field of surgery. - Patients with non-elective surgical issues are at risk of having changes in their plan. New fevers, changes in pain, new laboratory values, or radiographic findings can all lead to an urgent need for intervention, either surgery, a minimally invasive procedure, placing tubes, etc. This doesn't mean that the teammates who spoke to them earlier were wrong- it just means there has been a change. - Patients are often seen by residents, both from the primary team as well as consultant teams. Residents, especially more junior residents, don't have the same authority to tell the patient a definitive plan as the chief resident or attending. They might propose some possibilities, and then tell the patient they'll be back with their boss (common language to refer to their chief resident or attending). Sometimes patients hear one thing and don't understand that it's not the final plan. - In addition, when patients are first seen by the resident, there is often a time delay between the initial patient evaluation and discussion with the attending physician. It can appear that nothing is happening or that the team doesn't know what to do. C. How to respond? - Explaining the team structure and reassuring the patient that they will be updated as soon as possible can alleviate some of the anxiety/ frustration. Explaining a change in plan can be tricky. It's important not to undermine other team members. It's a learning process for trainees- you don't have to make excuses. As the attending, you can reassure that patient that the team members discuss their plans with you and you have the final say in their care. Question #3 Why was my surgery canceled? A. Background. When a patient needs surgery, the operating team makes a plan for their operative day. The patient is made NPO, meaning they can't eat or drink before surgery. They may have their family or friend scheduled to come to be with them on that day. So it's understandable for a patient to be frustrated or angry when they are told their surgery is canceled. B. Why/ how does it happen? Operative cases can get rescheduled or delayed with minimal notice. Even when cases are scheduled, there is always the possibility of another patient needing a more urgent operation. This applies to cases done by the trauma team, as well as cases with subspecialists. The orthopedics team is busier when trauma volume increases, so this puts further strain on OR availability. C. How to respond? The frustration is understandable, so it is helpful to explain why their surgery date has been pushed back (or hasn't been set yet). It's important to NOT "throw them under the bus"- in other words, don't speak ill of other teams. You don't have to go into a big explanation, but it's helpful for the patient to understand because this can alleviate some of their displeasure with the teams, including the consultant teams. It's not a matter of the teams not thinking the patient is important- it's simply triage. Also, try to get a plan as early in the day as possible, so the patient can be allowed to eat if their surgery is postponed. Question #4 Why is nothing happening? A. Background. Patients expect things to happen in a hospital to make them better. B. Why/ how does it happen? A lot of patient care happens away from the patient's bedside. Reviewing labs, imaging, discussing with consultants, performing procedures, phone conversations with nursing and case managers, just to name a few things that happen outside of the patient's room. However, this complaint can be a little more nuanced- sometimes the patient is trying to say they're frustrated by prolonged hospitalization, or they're scared about a complication, or they're worried they won't get back to their life as they had before their injury. C. How to respond? Again, if this is an issue of confusion, sometimes a brief explanation is enough. If there are specific consultant recommendations or a specific test result that is pending, attempting to contact the consultant team or expedite a radiology study in front of the patient is a small way to show the patient that things are happening behind the scenes. But if the patient is frustrated with being hospitalized or scared about surgery or a complication, those explanations won't address their concerns. Those issues require a more tailored response. Question #5 Why can’t I eat? A. Background. Sometimes patients in the hospital are feeling ill enough that they have no interest in eating. But if they still have an appetite, there are sometimes when it’s not safe to eat. B. Why/ how does it happen? Patients can't eat before surgery- specifically, it's dangerous to have food or thick liquids in their stomach when they have sedation medication or paralytics, because there is a risk of the stomach contents coming up into the throat and then going into the airway. So while a patient is awaiting procedural intervention (surgery, minimally invasive procedure that requires sedation), they can't eat. When we are awaiting the recommendations and plan of care from a consultant, we don't allow the patient to eat until we know they don't need a procedure. Besides procedures, patients may have to abstain from eating if they have a problem with their intestines, such as an obstruction or a fistula (abnormal connection from the bowel to the skin). C. How to respond? Apologize, basically. There's not much else to do. Previous Next

< Back Don't mess with the Pancreas A 47-year-old female with epigastric abdominal pain and nausea presents to the ER for evaluation. She is an otherwise healthy female, with no prior surgical history. On further questioning, her pain started 3 days ago and radiates toward her back. It has persisted and wasn't relieved with over-the-counter Tums, Gas-X, and Pepcid. She has had nausea but no vomiting. She has had minimal appetite over the past few days. Her history is otherwise unremarkable with no prior similar symptoms. On exam, she is uncomfortable but not in acute distress. HR 112, BP 112/63, T 99.1, O2 sat 99% on room air. Her abdominal exam is notable for focal tenderness in the epigastrium. What is on your differential and what is your initial workup? Peptic ulcer disease, esophagitis, hepatobiliary pathology (cholecystitis, hepatitis), pancreatitis, bowel obstruction, GERD, and bowel perforation. Labs- CBC, amylase, lipase, lactate. Imaging- acute abdominal series, possibly CT scan. Her labs are notable for a WBC of 11K, markedly elevated lipase, normal bilirubin and normal renal function. Her acute abdominal series shows non-specific bowel gas pattern with minimally dilated loops of small bowel. Right upper quadrant ultrasound revealed gallstones without evidence of acute cholecystitis. Based on the patients clinical presentation and lab findings, she is diagnosed with acute gallstone pancreatitis and was admitted to the surgical service. What are your initial goals of management? Pain control, IV fluid resuscitation. NPO until pain is improving. NGT if nauseated/ vomiting. Monitor vitals and organ function (urine output, labs). On her second hospital day, she developed worsening nausea/ vomiting, so an NGT was placed to decompress her stomach. Over the next few days, she has ongoing low grade sinus tachycardia, and then she developed intermittent low grade fever and mild leukocytosis. At that point, a CT scan is obtained. CT abdomen and pelvis The scan reveals peripancreatic inflammation with peripancreatic stranding, gland edema and hypoperfusion. There is also simple appearing peripancreatic fluid. Over the next few days, the patient developed worsening pain and an uptrend in her leukocytosis. She is mildly hypotensive and she is urinating less frequently. When a Foley catheter is placed, she has a small volume of concentrated urine in the collection bag. She is transferred to the ICU and a Dobhoff tube was placed for post-pyloric enteral feeding. Over the next two days, she develops fevers, an increasingly oxygen requirement and persistent pain. A repeat CT scan was obtained. Follow-up CT abdomen and pelvis There is evidence of progression of her pancreatitis. There are bilateral pleural effusions as well as worsening intra-abdominal free fluid. There is evidence of non-perfusion of the midportion of her pancreas, consistent with pancreatic necrosis. She remained in the ICU over the next several days. She did not clinically deteriorate and her pain slowly resolved. She had persistent high-volume output from her NGT. Why would she have high volume output in her NGT? Gastric outlet obstruction from peripancreatic fluid collection or necrosis. Ileus from ongoing intra-abdominal inflammation. Her distension improved with NGT decompression, and she continued to have bowel function. She was started on post-pyloric enteral feeds via a nasojejunal tube, and this was continued for the next month, awaiting for the acute necrosis to wall-off and develop a rind. Management of Acute Pancreatitis Etiology Gallstones and alcohol account for the vast majority of cases of pancreatitis. Other causes include hypertriglyceridemia, medication, ERCP, and hypercalcemia. Diagnosis Clinical presentation- epigastric pain, sometimes radiating to the back or shoulder. Nausea/ vomiting. Labs- elevated amylase/ lipase at least 3x normal Radiology- peripancreatic inflammation on contrast CT of abdomen. CT scan is not always mandatory on admission, but its commonly obtained for patients who have significant enough disease that they warrant a surgical consult. CT is also useful to rule out other pathology if the diagnosis is unclear. Clinical Course Most patients (about 80%) with acute pancreatitis suffer only mild disease and have resolution of symptoms without sequalae. The remaining 20% progress to moderate or severe pancreatitis, which is defined by the development of peri-pancreatic fluid collections or necrosis (sterile= moderate, infected= severe), or organ failure (transient= moderate, persistent= severe). Patients with organ dysfunction require ICU admission. Initial management Fluid resuscitation and ensuring adequate pain control. Nutritional support is also important, and patients are allowed to eat. Enteral nutrition should be initiated if the patient doesn't have adequate intake over the first few days. Close monitoring for development of sequalae. Patients are at risk for ARDS, abdominal compartment syndrome and infection. Assessment of Disease Severity Ranson's Criteria: Classic criteria for estimating pancreatitis severity[1] Admit data: WBC >16K, age >55, glucose >200, AST >250, LDH >250 48 hours: ↓Hct >10%, ↑BUN >5, Ca <8, PaO2 <60, Base deficit >4, >6L IVF. CT Severity has also been used to grade pancreatitis- inflammation, fluid collections and necrosis.[2] Management of Complicated Pancreatitis- Fluids Collections, Necrosis, Infection Diagnosis and Classification of peri-pancreatic fluid collections and necrosis [3] Acute interstitial edematous pancreatitis Less than 4 weeks, the fluid collection is an acute peripancreatic fluid collection . After 4 weeks, it becomes walled-off/ encapsulated and is a pancreatic pseudocyst . Acute necrotizing pancreatitis [non-enhancing pancreatic parenchyma] Less than 4 weeks, the fluid collection is an acute necrotic collection . After 4 weeks, it becomes walled-off/ encapsulated and is walled-off necrosis . Infected pancreatic necrosis- diagnosed by air in the necrosis, clinical symptoms consistent with infection and confirmed by aspiration and culture. A negative culture does not definitely rule out infection, so in the appropriate setting of clinical deterioration, there must be a high index of suspicion for infection. Indication for Antibiotics Antibiotics are NOT indicated for severe pancreatitis or pancreatic necrosis as a prophylaxis for infection.[4, 5] They are only indicated in known or highly-suspected infected necrosis. The antibiotics chosen must penetrate pancreatic tissue to be effective- quinolones and carbapenems are both broad-spectrum antibiotics (cover gram positive and gram negative) that penetrate pancreatic tissue. Carbapenems also cover anaerobes. Metronidazole covers gram negatives. Regimen: carbapenem or quinolone + metronidazole. Also consider antifungal coverage in severely ill patients.[6] Diagnosis of Infected Necrotizing Pancreatitis Infected pancreatic necrosis can be a challenging clinical diagnosis because the inflammatory state associated with pancreatitis can present with similar signs and symptoms, including fever, tachycardia, leukocytosis and ileus. CT evidence of air in the pancreatic necrosis is highly suggestive of infection, although absence of air does NOT definitively rule out infection. Fine-needle aspiration (FNA) can be used to obtain a sample for culture. There is a risk of infecting a sterile necrotic collection by performing an FNA, so this requires careful clinical decision-making. Management of Infected Necrotizing Pancreatitis These patients need broad spectrum antibiotics. Some patients may improve with antibiotics alone, but a drainage procedure is often needed. Percutaneous IR drain placement has a low rate of complications, but frequently fails to fully resolve the infection. Upsizing the drain or proceeding to more invasive intervention (see below) is required if that patient deteriorates despite drain placement and antibiotics. Previously, open necrosectomy was the standard. This is a highly morbid procedure, that requires maintaining an open abdomen, repeat washouts, and a prolonged ICU stay. Now, the step up approach is being increasingly utilized to manage these patients less invasively with similar or better outcomes (percutaneous retroperitoneal drainage or endoscopic transgastric drainage, endoscopic necrosectomy, followed by retroperitoneal necrosectomy).[7-10] Management of peri-pancreatic fluid collections [11-13] Enteral nutrition and pain control. A trial of a regular diet is appropriate, but if the patient is able to tolerate a regular diet, supplemental nutrition is required. Enteral nutrition is ideal, as it is associated with improved outcomes compared to TPN. Enteral access distal to the 3rd portion of the duodenum may theoretically avoid stimulation of the pancreas, but there is no evidence that jejunal feeds are superior to gastric feeds. However, depending on the location of the fluid collection, gastric outlet obstruction is a potential complication. Ideally, post-pyloric access would be obtained prior to obstruction, and can be used for long-term feeding while the fluid collection is allowed to resolve/ mature. Most resolve without intervention. As long as the patient is not systemically ill, drainage of pancreatic necrosis should be delayed as long as possible, ideally 6-8 weeks. Goal is to avoid procedural intervention until the fluid/ necrosis have become walled off, and then only intervene if the patient remains symptoms (pain, early satiety). However, if the patient clinically worsens, earlier intervention is necessary. Open pancreatic necrosectomy is associated with significant morbidity and mortality. An algorithm starting with least invasive (percutaneous or endoscopic drainage) and progressing to more invasive if the patient continues to do poorly is associated with decreased morbidity and mortality. References Ranson JH et al. Prognostic signs and the role of operative management in acute pancreatitis. Surg Gynecol Obstet. 1974 Jul;139(1):69-81. Balthazar EJ et al. Acute pancreatitis: value of CT in establishing prognosis. Radiology. 1990;174(2):331-336. Banks PA et al. Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013 Jan;62(1):102-11. Dellinger EP et al. Early antibiotic treatment for severe acute necrotizing pancreatitis: a randomized, double-blind, placebo-controlled study. Ann Surg. 2007 May;245(5):674-83. Leppanieme A et al. Executive summary: WSES Guidelines for the management of severe acute pancreatitis. J Trauma Acute Care Surg. 2020 Jun;88(6):888-890. Howard TJ. The role of antimicrobial therapy in severe acute pancreatitis. Surg Clin North Am. 2013 Jun;93(3):585-93. van Santvoort HC et al. A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med. 2010 Apr 22;362(16):1491-502. van Brunschot S et al. Endoscopic or surgical step-up approach for infected necrotising pancreatitis: a multicentre randomised trial. Lancet. 2018 Jan 6;391(10115):51-58. Luckhurst CM et al. Improved Mortality in Necrotizing Pancreatitis with a Multidisciplinary Minimally Invasive Step-Up Approach: Comparison with a Modern Open Necrosectomy Cohort. J Am Coll Surg. 2020 Jun;230(6):873-883. Boxhoorn L et al. Immediate versus Postponed Intervention for Infected Necrotizing Pancreatitis. N Engl J Med. 2021;385(15):1372-1381. Tyberg A et al. Management of pancreatic fluid collections: A comprehensive review of the literature. World J Gastroenterol. 2016 Feb 21;22(7):2256-70. van Dijk SM et al. Acute pancreatitis: recent advances through randomised trials. Gut. 2017 Nov;66(11):2024-2032. Maurer LR et al. Contemporary Surgical Management of Pancreatic Necrosis. JAMA Surg. 2023;158(1):81. Previous Next

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Lectures and References Trauma Lectures General Surgery Lectures Critical Care References Critical Care Lectures Trauma References Note Templates

Clinical Vignettes Gunshot Wound to the Leg Trauma Guts on the Floor and Exposed Spine Trauma Blast- Multiple Penetrating Injuries Trauma Machete Attack- Neck Trauma Trauma Free Fluid in the Abdomen Trauma Chronic Upper Abdominal Pain EGS Just Cellulitis...or something worse.... EGS Abdominal Pain- Renal Disease ICU Delirium...what's going on? ICU Respiratory Failure- it hurts to breathe ICU Thoracoabdominal Wound Trauma Stabbed in the Right Thigh Trauma Shot in the Chest- Aortic Occlusion Trauma Mangled Extremity- Keep or Cut? Trauma Abdominal Pain- Mesenteric Ischemia EGS Unusual Case of Peritonitis EGS Don't mess with the Pancreas EGS Postoperative hypotension ICU Intracranial Hypertension ICU

Patient Education Anorectal Disease Hemorrhoids GERD Gallbladder Disease Appendicitis Before Surgery ICU Anal Fissure Pruritis Ani Stomach Ulcers Pancreatitis Colorectal Disease Wound Care Disclaimer This website is provided for educational and informational purposes only and although every effort has been made to present accurate information, this is not a substitute for professional advice. Always seek guidance from a qualified healthcare provider or physician for inquiries regarding medical conditions, treatments, or before embarking on any new healthcare regimen. Never disregard professional medical advice or delay in seeking it due to information found here. If you think you may have a medical emergency, call 911 or go to the nearest emergency room immediately. No physician-patient relationship is created by use of this website. This website is based on my interpretation of medical literature and best clinical practices. It is my attempt to compile the information I share with my patients. This information does not replace the clinical expertise of a physician. Every effort has been made to ensure the accuracy and validity of the information, yet there remains a possibility of inaccuracies or unintended errors in this information presented here. The practice of medicine relies on using the best available evidence, but clinical scenarios often lack clear-cut answers. Every clinical situation is unique, and no single solution applies universally. Clinical guidelines attempt to provide recommendations that apply in most situations, but that are not one-size-fits-all solutions and they do not replace clinical judgment. The infinite variety of patient, disease, and environmental factors influencing clinical decision-making cannot be fully accounted for in medical literature. Therefore, any variance in the approach of physicians from what is presented here does not necessarily signify an error on their part.

Tutorials Vent Mgmt #1: Basics Vent Mgmt #3: Pressures Vent Mgmt #5: Weaning Ultrasound: Trauma E-FAST Ultrasound: Cardiac Exam Cardiac Physiology ICU Rounding: How I Do It Bowel Anastomosis Pack the Guts Vent Mgmt #2: Modes Vent Mgmt #4: All Together Ultrasound: Just The Basics Ultrasound: Thoracic Exam Ultrasound: Misc Interpreting Chest X-Rays Nasogastric Tubes Pre-Peritoneal Packing