Pancreatitis

[riley290]

Ok, I'm giving a presentation to an EMS service next week and would like to know what interventions you would like done on someone with advanced chronic pancreatitis in pre-hospital care.

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[droliver]

Not much needs to be done for chronic pancreatitis. The overwhelming majority of the time they are stright forward admits for pain control. If they having been having limited PO, they may need a little more aggressive fluid resuscitation, but its very simple mgt. @ the the stage you're talking about. This is a very different beast from acute pancreatitis where aggressive care can make a huge difference about how the episode resolves

 

[DrQuinn]

droliver is right. prehospital treatment for chronic pancreatitis is pretty much just basic stuff... BLS stuff really. Acute Pancreatitis = Bowel Rest. So unless you're feeding people in the ambulance, there's not much you do there, either. Except pain control, and hopefully you're giving demerol.

 

[droliver]

QuinnNSU,

actually bowel rest is common b/w both tx. strategies. Acute pancreatitis can have PROFOUND fluid deficits, that if unrecognized, greatly amplify the inflamatory state & quickly kill you. This is an important take-home message for those who will initially triage these patients. Chronic pancreatitis patients are often frequent flyers. Some important info to get from them is whether or not they have a Pain Mgt. Physician they see regularly so you can spread the pain around (pun intended). On a serious note, its important to find out if they've had any instrumentation of their billiary tree (ie. ERCP with or without stenting). Infected or occluded billiary or pancreatic stents can make you quite ill & referral to their GI or Surgical Endoscopist is warranted. Another possibility to consider if they have elevated WBC/Amylase/Lipase is the potential for pseudocysts & you should have a low threshhold for a CT scan.

 

[DrQuinn]

Your point is well taken,

However, pre-hospital care of pancreatitis shouldn't really be any different than say appendicitis or acute cholecystitis. EMS will/should usually start an IV, O2, etc... but whether or not they've had an ERCP in the past has no relevance to pre-hospital treatment of pancreatitis. Once they step through the doors of the ED, though, everything that you said holds true.

 

[riley290]

So what about pumping the stomach of someone with acute pancreatitis? Won't that slow down the pancreatic and digestive activity and help with the problem?

 

[southerndoc]

Originally posted by QuinnNSU
Except pain control, and hopefully you're giving demerol.

Is anyone aware of any research that supports meperidine over morphine for pain control in these patients? I understand that the theory is that meperidine causes less spasm of the sphincter of Oddi when compared to morphine. However, I have yet to locate anything but review articles that make published reference to this. Anyone aware of any clinical evidence of it rather than just anecdotal stuff? Review articles citing other review articles isn't my idea of evidence-based medicine.

 

[DrQuinn]

Ask and ye shall receive.


Narcotic analgesic effects on the sphincter of Oddi: a review of the data and therapeutic implications in treating pancreatitis.
Thompson DR - Am J Gastroenterol - 01-Apr-2001; 96(4): 1266-72
From NIH/NLM MEDLINE


NLM Citation ID:
11316181 (PubMed}
21212800 (MEDLINE)

Full Source Title:
American Journal of Gastroenterology

Publication Type:
Journal Article; Review; Review, Tutorial

Language:
English

Author Affiliation:
Department of Internal Medicine, Baylor University Medical Center, Dallas, Texas 75246, USA.

Authors:
Thompson DR

Number of References:
16

Abstract:
OBJECTIVE: Traditional teaching dictates that morphine induces "spasm" in the sphincter of Oddi (SO) and should not be used in acute pancreatitis and that meperidine is the analgesic of choice because it does not elevate SO pressures. A literature search and review was performed to evaluate this teaching examining the effect of narcotic analgesic's effects on SO. METHODS: A Medline search was performed using keywords and phrases. The manufacturers of meperidine were contacted and their reports and studies were obtained and reviewed. RESULTS: Initial studies measured biliary pressure after narcotic administration in animals, and postoperative and intraoperative cholecystectomy patients. All narcotics increased biliary pressure, but morphine was associated with the largest elevation. Later studies using endoscopic retrograde cholangiopancreatography with direct SO manometry demonstrated that the SO is exquisitely sensitive to all narcotics including meperidine and that a small increase in biliary sphincter pressure is seen with higher doses of morphine. All narcotics increase SO phasic wave frequency and interfere with SO peristalsis. CONCLUSIONS: Narcotic-induced increases in phasic wave frequency interfere with SO filling and are responsible for the increase in bile duct pressure seen on the initial studies. No studies directly compare the effects of meperidine or morphine on SO manometry and no comparative studies exist in patients with acute pancreatitis. No outcome-based studies comparing these drugs have been performed in patients with acute pancreatitis. Morphine may be of more benefit than meperidine by offering longer pain relief with less risk of seizures. No studies or evidence exist to indicate morphine is contraindicated for use in acute pancreatitis.

 

[spyderdoc]

I do not give meperidine to ANYONE! It has no additional benefits over morphine other than a good "high". It causes a euphoria, whereas other pain meds take care of the pain just fine, but don't provide a great high...Meperidine does nothing but promote addictive behavior. The patients that you give this medicine to will come back to you time and time again. I finished my residency in a large urban tertiary center, and during my intern year we stocked meperidine in our Pixis. We had all of the sickle cell, chronic pain patients, and "migraines" coming to us several times per week for their "fix". During my second year, we removed meperidine from our Pixis. Our chronic visitors tapered off to almost ZERO! People will tell you that they are allergic to every med under the sun, except meperidine. When I tell the patients that I do not prescribe it, PERIOD, they usually will tell me another med they "forgot" they weren't allergic to, like fentanyl, or dilaudid....
I tell patients that I do not prescribe meperidine to anyone, period...It has too many dangerous side effects, such as seizures, etc...
Well, there is my venting. Just say NO!

 

[DocWagner]

First and foremost, few patients that decide to take EMS as their mode of transport to the hospital will say "hurry I have chronic pancreatitis" and it would probably be of benefit for any EMS personnel to treat any abdominal pain with the IV, O2, monitor protocol. I really don't see how anything would change regarding prehospital care.

Regarding the Demerol vs morphine debate...did that article even discuss dosages? It sounds as if this is a dose related issue.
And much like the last poster, I try to never give demerol...never. Rather than true pain control, people get "high"...too many side effects.

 

[jawurheemd]

For some reason it seems that Benadryl is synergistic with Demerol in promoting a high -- I'm not sure about the mechanism exactly, but I know that it gets requested as well.

The pain med that I found these patients most allergic to is Toradol -- they absolutely are always allregic to Toradol. Not that I give it too often, but it seems that somewhere along the line in an effort to provide some analgesia, the patients got Toradol and experienced an awful allergic reaction.

Anyway, Demerol is not a good drug for analgesia as there are so many other drugs work just as well or better for pain without the same side effect profile. I'm beginning to appreciate Dilaudid more and more.

Just me 2 cents.

-James

 

[Stinky T]

I've also had good experiences using Dilaudid. The literature I've seen hasn't described any significant benefits or side effects when compared to equianalgesic doses of Morphine; nonetheless, I prefer it. I'm not sure why it's not used more often, but when I've used it, patients seemed to have slightly less side effects and achieved greater pain control.

 

[DocWagner]

Quite honestly, if I have a patient that tells me they are allergic to Toradol, that sends off a red flag. If they ask for demerol right off the bat, that sends off a red flag.
Personally, I am in the habit to ask patients "what happens to you when you take drug X"...
Dilauded is good, I have just gotten out of the habit of using it. I will have to look into it again.

 

[12R34Y]

Wow! that is interesting stuff about not giving demorol....the er's that i have worked out can't give it out enough.

The ER I currently work in gives demorol for essentially every type of pain. kidney stones, migraines, back pain etc.....they can't give it out enough.

we do have an awful lot of drug seekers. I wonder if that is why?

 

[DocWagner]

I work in some big ED's in town, and I have worked in large ED's in the past, and the trend is to stay away from demerol.
I think most new EM residency trained ED docs tend to stay away from it as well.

For Renal colic I give morphine and toradol (perhaps phenergan also)
For back pain of musculoskeletal origin, there is no excuse to give demerol...there are numerous better things to give or to do.
Sickle cell...morphine or toradol
Migrains? Demerol? Not a chance. DHE and phenergan or Toradol and phenergan...all in a dim room or which a warm towel over their eyes.

The "Priniples of Analgesic Use in the Treatment of Acute Pain and Cancer Pain" by the American Pain Society has served to be a nice guide. It is a small handbook.

Prior to the "black box" warning on Droperidol, it was used FREQUENTLY in academic centers across the country. And it may again make a comeback.

 

[droliver]

Demerol has a very long track record with treating sickle cell crisis pain & is the preferred analgesic for that among many of the hematologists who see it frequently. Demerol is still also the preferred drug for hepato-billiary dz. with the majority of specialists in that area as well.

 

[12R34Y]

I guess i should clarify that ALL of the ER docs i work with that give tons and tons and tons of demorol were all ER residency trained in the mid to late seventies! They have been practicing for almost 30 years.

however, they do give TONS of demorol. it is the most common drug by far that we give out for all types of pain.

and again........we have tons of drug seekers also.

migraines get it, kidney stones definately get it. back pain also gets it whether it be IM or IV it is definately hugely popular there.

interesting..........

mabye they should change?

later

 

[jawurheemd]

We have a huge population of sicklers who come through our hospital, and it seems that the move is to get away from Demerol for analgesia in these patients for the same reasons we're starting to avoid Demerol use in other populations. Unfortunately, we have those sicklers who have been on Demerol before and have come to realize that they are allergic to everything except Demerol.

I don't mind using the drug, but it's important to know what the downsides to the drug are -- it lowers seizure threshold, and may in fact precipitate a seizure (I've witnessed it twice), it's analgesic effects are not very long-lived leading to frequent redosing leading to possibility of seizures, it gives the patient a "high" unparalleled by other narcotics with the exception of heroin (this high seems to be potentiated by Benadryl), it becomes very addicitive -- thus the reason why some patients are allergic to everything except Demerol.

I believe that there are plenty of drugs that are better than Demerol with a more benign side effect profile. That's why it's not one of my first line agents. I can't even use it at one hospital I rotate through because they've take the drug off their formulary. With regard to the whole sphincter of oddi thing, everytime I bring it up, the attending around here laugh saying that it's all based on pig physiology, and there are no clinical trials to date supporting that Demerol doesn't affect the spincter of oddi. So I still go with Dilaudid. It's worked on all my pancreatitis patients that I've given it to so far.

Just ran across this link a little while ago which sums up pretty much what I've learned about Demerol.

http://ruralnet.marshall.edu/pain/demerol.htm

-James