Acute Pancreatitis: Case Report and the Importance of Early Prediction of Severity

INTRODUCTION: Acute Pancreatitis (AP) was the third most common GI diagnosis in 2012, resulting in approximately 275,000 admissions and costing about $2.6 billion. It remains a disease characterized by significant morbidity and mortality, and to this day, there is not a medication to treat it. Most care is supportive. Establishing the severity of the disease accurately is important in order to triage patients to the correct level of care to decrease rate of complications, mortality, and potentially shorten duration of stay. CASE REVIEW: 30yo male with history of alcohol use/abuse, with prior episode of pancreatitis 5mo earlier, presented to the Emergency Department with sudden onset of epigastric pain radiating to the back, nausea, vomiting. Patient’s last drink was 4 days prior, admitting to binging over the weekend. Initial VS: HR in 110s-120s, RR 20. BP 162/105. Initial remarkable labs: WBC 18.3, Na 133, K 3.0, CO2 15, AG 25,BG 149 lipase 2610. On physical exam, patient was uncomfortable with a diffusely tender abdomen. He appeared hypovolemic. He received 2L NS in ED. Patient was admitted to the medical floor and started on 250mL/hrof LR, given Dilaudidfor pain control and placed NPO. 8 hours after admit, patient acutely decompensated. Repeat VS BP 92/60, HR 159, RR 25. Abdomen was taught on exam. Patient was was transferred to the ICU for further management. Repeat labs now showing H&H 21&61, K 5.6, CO2 9, AG 21, Cr 1.35, CA 6.5, Mag 1.6, lactate 8.9. Patient was started on a bicarbonate drip, received calcium gluconate and 10 units of NPH, and D50 injection. A Foley catheter was inserted with an estimated bladder pressure of 12. Despite measures, patient’s acidosis and renal failure worsened and 3 hours later, patient was transferred to PPMC ICU for further management. DISCUSSION: Most authors of past and current guidelines recommend physicians to predict the severity of AP early on to guide the triage of patients. A multitude of predictive models have been developed to predict the severity of AP based upon clinical, laboratory, and radiologic risk factors, various severity grading systems, and serum markers {2] Some of these can be performed on admission to assist in triage of patients, while others can only be obtained after the first 48 to 72 hours or later. However these predictive models have low specificity, which, when coupled with the low prevalence of severe AP, results in low positive predictive values. •A CRP level above 150mg/L at 48 hours is associated with severe pancreatitis with an 80% sensitivity. •A BUN level of 20mg/dLon admission is also associated with an increased risk of death, as is an increase in BUN at 24hrs. •Ranson’scriteria and Apache II scores are 2 scoring tools frequently used in inpatient medicine. •Whilst an Apache II score has a median sensitivity of 100% and can be used on admission and repeated daily, a Ranson‘sscore \u3e 2 has a sensitivity and a specificity in the 80s, and has to be calculated at 48hours. •An Apache II score \u3e 8 and up-trending scores suggest a severe episode5 •Other scoring systems include SIRS, BISAP, CTSI.https://digitalcommons.psjhealth.org/milwaukie_family/1005/thumbnail.jp

Increasing Vaccination Rates of Children up to 24 months old at PMG Milwaukie Family Medicine

Increasing Vaccination Rates of children up to 24 months old at PMG Milwaukie Family Medicine Authors: Justin Ferley DO; Rachel Jackson MD; Aubrey Miller MD; Sebastian Reeve MD; Christelle Serra Van-Brunt DO; Jamie Skreen DO; Jeffrey Sun DO; John Yates MD; Daniel Ruegg MD Introduction: Each year in the US, 42000 adults and 300 children die of vaccine preventable diseases. Yet across the country, clinics – including ours – fall short of the CDC Healthy People 2020 goals of pediatric vaccination rates. This resident-led quality improvement (QI) project aimed to improve our clinic vaccination rates in the under 24mo population. Methods: We identified 3 opportunities for vaccinating children under our clinic current processes: well child visits, medical assistants’ vaccinations visits, and acute care visits. Using a multidisciplinary approach comprising residents, MAs, clinical care coordinators and our nursing quality supervisor, we analyzed our current vaccinations processes and our iterative plan-do-study- cycles (PDSA) included: PDSA #1: standardize our work flow for vaccine reconciliation. PDSA #2: sending personal reminder lebers to patients and overall improving our vaccine recall/ reminder system. PDSA #3: Minimizing provider variation for vaccines given at the 12-18mo WCC. Results: We saw an improvement in our vaccinations rates after personalized reminder letters were sent out, outlining that we do not have a reliable vaccine schedule reminder system. We also noted that different providers created different vaccinations schedules in order to prevent giving 5 vaccines at the same $me – with no system in place to follow on missed vaccination, thus creating missed opportunities and suggesting that we need to implement a clinic-wide vaccine schedule. Conclusion: Our last PDSA cycle was interrupted by current CIVD-19 pandemic. We have however found valuable data to help improve our clinic’s vaccination rates, and plan to continue this project over the next 2 years.https://digitalcommons.psjhealth.org/milwaukie_family/1007/thumbnail.jp