Rita, a 55-yrs-old has been hospitalized due to recurrent pancreatitis, ARDS, prolonged ileus, and need for parenteral nutrition. She demonstrates weakness, lassitude, orthostatic hypotension, nausea, and fever. The most likely accompanying finding is
a. Aggressive fluid and electrolyte repletion is the most important element in the initial management of pancreatitis.
b. Fluid losses can be enormous and can lead to marked hemoconcentration as well as hypovolemia. Inadequate fluid resuscitation during the early stages of pancreatitis can worsen the severity of an attack and lead to subsequent complications.
c. The fluid depletion that occurs in pancreatitis results from the additive effects of losing fluid both externally and internally.
d. The external fluid losses are caused by repeated episodes of vomiting and worsen by nausea that limits fluid intake.Repeated vomiting can result in a hypochloremic alkalosis.
e. Internal fluid losses, which are usually even greater than the external losses, are caused by fluid sequestration into areas of inflammation (i.e., the peripancreatic retroperitoneum) and into the pulmonary parenchyma and soft tissues elsewhere in the body. These latter losses result from the diffuse capillary leak phenomenon that is triggered by proinflammatory factors released during pancreatitis.
f. Total fluid losses may be so great that they lead to hypovolemia and hypoperfusion, and as a result, a metabolic acidosis can develop.
g. Many of the patients with chronic pancreatitis are alcoholics who, even before the onset of pancreatitis, had hypoalbuminemia and hypomagnesemia. Those problems are exacerbated by the losses of pancreatitis.
h. The measured values for serum albumin may be even further depressed as fluid losses are treated with albumin-free crystalloid solutions.
i. Although hypocalcemia is common particularly during a severe attack, the low total serum calcium is usually attributable to the low levels of circulating albumin, and no treatment is needed when ionized calcium is normal.
j. Ionized calcium levels may also be depressed, and tetany as well as carpopedal spasm can occur. Under those circumstances, aggressive calcium repletion is indicated.
k. Hypoxemia can also occur as a result of the combined effects of increased intrapulmonary shunting and a pancreatitis-associated lung injury that closely resembles that seen in other forms of ARDS.
l. Fluid management, although critical, may be particularly difficult when hypovolemia is combined with the respiratory failure of ARDS.
m. Treatment requires meticulous replacement of fluid and electrolyte losses.