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An arterial catheter for frequent blood gas determinations and a Foley catheter for monitoring urine output are essential in all critically ill patients discount levitra plus 400 mg on line erectile dysfunction treatment costs. Parameters requiring serial monitoring include arterial blood gas; hematocrit; serum electrolytes; and renal 400mg levitra plus free shipping erectile dysfunction natural foods, hepatic levitra plus 400mg amex impotence underwear, and blood coagulation panels. The frequency of these determinations depends on previous results and the patient’s clinical condition and response to therapy. Acute renal failure may be a consequence of shock or deferoxamine therapy in the setting of hypovolemia [32]. Hemodialysis may be required in such situations, especially if deferoxamine therapy is continued, to remove the toxic chelate, ferrioxamine. Coagulopathy during the first few hours after overdose is related to serum iron concentration and is transient. Deferoxamine, the specific treatment of choice for acute iron poisoning [15,19], is a naturally occurring siderophore isolated from Streptomyces pilosus. It is capable of removing iron from ferritin and hemosiderin and, to a very minor degree, from transferrin, but not at all from cytochromes, hemoglobin, or myoglobin. Although deferoxamine is regarded as the treatment of choice, its effectiveness has been questioned because it has limited chelating capacity and only small amounts of iron are recovered in the urine after its administration to iron-poisoned patients [45]. The manufacturer’s recommended daily deferoxamine dosage of 6 g is capable of chelating 510 mg of iron or 8. Although this would seem to be insignificant in the patient who has ingested 50 tablets, the poor absorption of iron and the body’s large storage capacity for it result in only a relatively small amount being responsible for toxicity. Alternatively, 510 mg of iron is approximately 10% of the total amount of iron and approximately 35% of the nonheme iron in a 70-kg man [46]. Historically, therapy was based on the deferoxamine chelation challenge test and relied on visual detection of a change in urine color to rusty orange (vin rosé) caused by the presence of ferrioxamine after intramuscular administration of deferoxamine. The therapy has been recommended for those with peak serum iron concentrations ranging from 300 to 500 μg per dL (55 to 90 μmol per L) [47]. Significant morbidity is unlikely with peak concentrations of less than 500 μg per dL (90 μmol per L). Hence, a serum iron concentration of 500 μg per dL (90 μmol per L) or greater is recommended as an indication for deferoxamine therapy in an otherwise asymptomatic patient. Deferoxamine therapy is indicated when symptoms and signs of severe iron poisoning are present, regardless of the serum iron concentration. Although some toxicologists also advocate deferoxamine therapy for those with recurrent vomiting or diarrhea, these symptoms can be seen in patients who do not develop systemic toxicity. A continuous infusion protocol of 15 mg per kg per hour until 24 hours after the urine returns to its normal color has also been recommended [15]. Only two patients treated with 15 mg per kg per hour over a prolonged course have been well described in the literature [49,50]. Four patients with mild-to-moderate iron poisoning without evidence of shock, acidosis, or sepsis who received 15 mg per kg per hour of deferoxamine intravenously for 2 to 3 days died of noncardiogenic pulmonary edema [51]. If prolonged chelation therapy is deemed necessary, interrupting therapy for 12 of every 24 hours to allow excretion of ferrioxamine can be considered. Deferoxamine therapy is rarely needed beyond 24 hours and should be used with caution for periods longer than this. Those who have required deferoxamine therapy should have a follow-up visit approximately 1 month after discharge. He or she should also be advised of the symptoms of gastrointestinal obstruction and to return immediately if they occur. Litovitz T, Manoguerra A: Comparison of pediatric poisoning hazards: an analysis of 38 million exposure incidents. Tenenbein M: Unit-dose packaging of iron supplements and reduction of iron poisoning in young children. Rayburn W, Aronow R, DeLancey B, et al: Drug overdose during pregnancy: an overview from a metropolitan poison control center. Tenenbein M: Poisoning in pregnancy, in Koren G (ed): Maternal- Fetal Toxicology: A Clinician’s Guide. Koren G, Bentur Y, Strong D, et al: Acute changes in renal function associated with deferoxamine therapy. Bachrach L, Correa A, Levin R, et al: Iron poisoning: complications of hypertonic phosphate lavage therapy. Deferoxamine in the treatment of acute iron poisoning: clinical observations, experimental studies and theoretical considerations. Moeschlin S, Schnider U: Treatment of primary and secondary hemochromatosis and acute iron poisoning with a new potent iron- eliminating agent (desferrioxamine B). Tenenbein M, Kowalski S, Sienko A, et al: Pulmonary toxic effects of continuous desferrioxamine administration in acute iron poisoning. It is available under a variety of brand names as 50-, 100-, and 300-mg tablets; as an oral syrup (50 mg per 5 mL); as an injectable solution (100 mg per mL); and in powder form. It is rapidly and almost completely absorbed after oral administration, with peak plasma concentrations occurring within 1 to 2 hours [1]. Genetic variation of the enzymes responsible for its metabolism causes significant variations of plasma concentration, elimination half-life, and toxicity. In addition, slow acetylators may have a higher percentage of the dose metabolized to hydrazine, a potential hepatotoxin [5]. In patients with preexisting seizure disorders, convulsions have occurred with therapeutic dosing at doses as low as 14 mg/kg/d; 19 mg/kg/d resulted in seizures in a 7-year-old child [6]. Its metabolism results in metabolites such as hydrazides and hydrazones, which inhibit pyridoxal 5′-phosphate and pyridoxine kinase, respectively [13]. Wallerian degeneration of the myelin sheath and axon with blockade of fast axoplasmic transport is noted, with sensory nerves affected more than motor nerves. Recent work suggests that slow acetylators are more susceptible to antitubercular drug–induced hepatitis and may develop more severe hepatotoxicity than do rapid acetylators [3]. Stupor and coma can develop rapidly, followed by intractable tonic– clonic generalized or localized seizures, hyperreflexia or areflexia, and cyanosis [6,7]. The metabolic alterations are striking and include severe metabolic acidosis, hyperglycemia, glycosuria, ketonuria, and hyperkalemia [6,7,9]. Hepatotoxicity usually presents as elevated serum aspartate aminotransferase values within the first few months of therapy. Other chronic effects include dysarthria, irritability, seizures, dysphoria, and inability to concentrate [17]. Optic neuritis and optic atrophy have also been reported, but their occurrence is often associated with the administration of ethambutol as well. Symptoms include irritability, disorientation, visual and auditory hallucinations, paranoid delusions, and suicidal ideation. Its rare association with isoniazid was first reported in 1956 in a patient also taking prophylactic pyridoxine. This causes a decreased ability to repair cellular damage in tissues with high cellular turnover rates, such as skin and gastrointestinal mucosa, resulting in photosensitivity and gastrointestinal cell damage [27]. Arterial blood gases, electrocardiogram, chest radiograph, head computed tomography, and lumbar puncture should be obtained as clinically indicated. Transient elevations in total bilirubin and alkaline phosphatase, indicating cholestasis, may also be noted.

A hemodynamically unstable patient with abdominal penetrating injuries requires no further investigation and immediate laparotomy should be undertaken cheap levitra plus 400 mg on-line doctor for erectile dysfunction in kolkata. Implementation of this protocol decreased the total celiotomy rate from 100% to 24% buy 400mg levitra plus fast delivery erectile dysfunction quran, and the therapeutic celiotomy rate increased from 15% to 80% levitra plus 400mg mastercard erectile dysfunction best medication. Bedside ultrasound evaluation of the abdomen in the pregnant trauma patient is associated with least risk to the woman and to the fetus. The closed percutaneous technique, introduced by Lazarus and Nelson [36] in 1979, is easy to perform, can be done rapidly, is associated with a low complication rate, and is as accurate as the open technique. It should not be used in patients who have had previous abdominal surgery or a history of abdominal adhesions. The open technique entails the placement of the peritoneal lavage catheter into the peritoneal cavity under direct visualization. The semiclosed technique requires a smaller incision than does the open technique and uses a peritoneal lavage catheter with a metal stylet to gain entrance into the peritoneal cavity. It has become less popular, because clinicians have become more familiar and skilled with the closed technique. A catheter is placed into the urinary bladder and a nasogastric tube is inserted into the stomach to prevent iatrogenic bladder or gastric injury. The skin of the anterior abdominal wall is prepared with 2% chlorhexidine solution and sterilely draped, leaving the periumbilical area exposed. Local anesthesia with 1% or 2% lidocaine with 1:200,000 epinephrine is used as necessary throughout the procedure. The infraumbilical site is used unless there is clinical concern of possible pelvic fracture and retroperitoneal or pelvic hematoma, in which case the supraumbilical site is optimal. Closed Percutaneous Technique With the closed percutaneous technique, local anesthesia is infiltrated inferior to the umbilicus and a 5-mm skin incision is made just at the inferior umbilical edge. An 18-gauge needle is inserted through this incision and into the peritoneal cavity, angled toward the pelvis at approximately a 45-degree angle with the skin. If no gross blood returns on aspiration through the catheter, peritoneal lavage is performed using 1 L Ringer’s lactate solution or normal saline that has been previously warmed to prevent hypothermia. The incision is continued sharply down through the subcutaneous tissue and linea alba, and the peritoneum is then visualized. Forceps, hemostats, or Allis clamps are used to grasp the edges of the linea alba and elevate the fascial edges to prevent injury to the underlying abdominal structures. When the lavage is completed, the fascia must be reapproximated with sutures, the skin closed, and a sterile dressing applied. Open Technique After the administration of appropriate local anesthetic, a vertical midline incision approximately 3 to 5 cm long is made. This incision is commonly made in the infraumbilical location, but in patients with presumed pelvic fractures or retroperitoneal hematomas or in pregnant patients, a supraumbilical location is preferred. The vertical midline incision is carried down through the skin, subcutaneous tissue, and linea alba under direct vision. The linea alba is grasped on either side using forceps, hemostats, or Allis clamps; and the fascia is elevated to prevent injury to the underlying abdominal structures. The peritoneum is identified, and a small vertical peritoneal incision is made to gain entrance into the peritoneal cavity. As in the semiclosed technique, the fascia and skin must be reapproximated to prevent dehiscence or evisceration, or both. The closed percutaneous technique was as accurate as the open procedure and was associated with a lower incidence of wound infections and complications. The closed percutaneous technique, using the Seldinger technique, should therefore be used initially in all patients except those who have had previous abdominal surgery or in pregnant patients. The majority (2,409, or 96%) were performed using the closed percutaneous technique, and 92 (4%) were done open because of pelvic fractures, previous scars, or pregnancy. A positive result can be estimated by the inability to read newsprint or typewritten print through the lavage fluid as it returns through clear plastic tubing. The lower the threshold, the more sensitive the test, but the higher the nontherapeutic laparotomy rate. Wound infection, dehiscence, and evisceration are more common with the open technique; therefore, the closed percutaneous technique is recommended in all patients who do not have a contraindication to this technique. Knowledge of all techniques is necessary, however, because the choice of technique should be based on the individual patient’s presentation. Salerno F, Camma C, Enea M, et al: Transjugular intrahepatic portosystemic shunt for refractory ascites: a meta-analysis of individual patient data. Pache I, Bilodeau M: Severe haemorrhage following abdominal paracentesis for ascites in patients with liver disease. Fischer R, Beverlin B, Engrav L, et al: Diagnostic peritoneal lavage 14 years and 2586 patients later. Stengel D, Rademacher G, Ekkernkamp A, et al: Emergency ultrasound-based algorithms for diagnosing blunt abdominal trauma. Sriussadaporn S, Pak-art R, Pattaratiwanon M, et al: Clinical uses of diagnostic peritoneal lavage in stab wounds of the anterior abdomen: a prospective study. Menegaux F, Tresallet C, Gosgnach M, et al: Diagnosis of bowel and mesenteric injuries in blunt abdominal trauma: a prospective study. Rapid image localization and percutaneous treatment has played a major role for avoiding the morbidity and mortality associated with surgical exploration [1–4]. Image-guided aspiration or drainage procedures can alleviate symptoms because of mass effect or infection, provide fluid samples for laboratory characterization to refine treatment, and cause reduction in sepsis [5]. Advantages of ultrasound include portability, lack of radiation, relatively low cost, and real-time visualization of needle placement into a collection. Because ultrasound machines all currently have Doppler capability, arterial and venous structures along access routes to fluid are identified and avoided. Limitations of ultrasound include poor visualization of deep collections secondary to large body habitus, bone, overlying bowel gas, or surgical dressings. B: An ultrasound image demonstrating needle placement into the distended gallbladder (arrowhead) during ultrasound-guided cholecystostomy tube placement. Sampling of a presumed infected collection for culture and antibiotic sensitivity, even after broad-spectrum antibiotics have been started, has been found to help tailor therapy in most patients [9]. Although fluid collections regardless of whether they are infected or benign (such as a seroma, lymphocele, or cyst of the kidney or liver) may cause issues for the patient, this is rare. Specific instances do exist and should be considered for critically ill patients, such as large volume ascites or pleural effusions causing continuous ventilator dependence or mass effect causing ureteral, biliary, or venous obstruction. For the critically ill patient, catheter drainage may stabilize the patient’s condition so that a more definitive surgical procedure can be performed at a later time [10,11]. Many patients with abscesses smaller than 4 cm in maximum diameter can be treated conservatively with broad-spectrum antibiotics [12]. When the interventional radiologist believes a collection represents an infected hematoma or a maturing infection, regardless of size, they may request initial conservative management and follow-up imaging to determine when catheter placement will lead to successful drainage. In view of bowel motility and other options such as patient positioning, use of sterile fluid to displace structures temporarily (hydrodissection), inflation or deflation of the stomach or bladder for example, a safe route can often be found. The interventional radiologist should be able to think out of the box and offer a solution, especially in those cases where the only other alternative is surgery.

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Poor-quality readings were found more often in darker skinned patients buy levitra plus 400 mg otc erectile dysfunction treatment in kerala, although this was a rare event (<1% of all patients) [129] buy levitra plus in india erectile dysfunction 19 year old male. Thus order cheap levitra plus on line reflexology erectile dysfunction treatment, dark skin may prevent a measurement from being obtained, but when the oximeter reports an error-free value, the value is generally accurate enough for clinical use [130]. Ambient light that affects absorption in the 660- or 910- nm wavelengths, or both, may affect calculations of saturation and pulse. Xenon arc surgical lights [131], fluorescent lights [132], and fiberoptic light sources [133] have caused falsely elevated saturation but typically are accompanied by obvious dramatic elevations in reported pulse. An infrared heating lamp [134] has produced falsely low saturations and a falsely low pulse, and a standard 15-W fluorescent bulb resulted in falsely low saturation without a change in heart rate [135]. Studies report that ambient lighting has little or no effect on newer generation oximeters [136], although this varies among manufacturers [137]. Bilirubin’s absorbance peak is maximal in the 450-nm range but has tails extending in either direction [138]. Bilirubin, therefore, does not typically affect pulse oximeters that use the standard two-diode system [138,139]. Cooximeters typically use four to six wavelengths of light and measure absolute absorbance to quantify the percentage of all major hemoglobin variants. Serum bilirubin values as high as 44 mg per dL had no effect on the accuracy of pulse oximeters but led to falsely low levels of oxyhemoglobin measured by cooximetry [138]. On the other hand, acquired methemoglobinemia—although uncommon—is seen in routine practice, largely due to the use of methemoglobinemia-inducing drugs such as topical anesthetics [140]. Because methemoglobin absorbs more light at 660 nm than at 990 nm, it affects pulse oximetry readings [141]. Oxygen saturation in smokers, when measured by cooximetry, was on average 5% lower than pulse oximetric values [145]. In dogs, there was no significant degradation in accuracy until the hematocrit was less than 10% [149]. In one study of humans who had hemorrhagic anemia, there appeared to be little effect on pulse oximetry accuracy [150]. Patients with elevated chylomicrons and those receiving lipid infusions may have falsely low SpO because of interference in absorption2 by the lipid [151]. A study of 261 patients with type 2 diabetes mellitus showed that a HbA1c greater than 7% leads to an overestimation of SpO by an average of 2. When good-quality signals could be obtained, SpO differed from cooximetry-measured2 saturation by only 0. Methylene blue, used to treat methemoglobinemia, has a maximal absorption at 670 nm and therefore falsely lowers measured SpO [2 155]. Because of the rapid vascular redistribution of injected dyes, the effect on oximetry readings typically lasts only 5 to 10 minutes [157]. Patent V dye, which is used to visualize lymphatics in sentinel node mapping, confounds pulse oximetry, an effect which may persist for more than 90 minutes [158]. Some oximeters display a warning sign, others stop reporting data, and others display erroneous values. The display of a plethysmographic waveform rather than a signal strength bar helps to indicate to providers that artifact has distorted the pulse signal and lowered the quality of the SpO reading. Newer generation oximeters2 appear to have significantly less susceptibility to motion artifact than earlier models [159]. During a blood pressure cuff inflation model of hypoperfusion, most oximeters remained within 2% of control readings [160]. Increasing systemic vascular resistance and decreasing cardiac output can also make it harder to obtain a good-quality signal. In one series, the lowest cardiac index and highest systemic vascular resistance 2 at which a signal could be detected were 2. Warming the finger [162] or applying a vasodilating cream [161] tended to extend the range of signal detection in individual patients. The oximeter’s ability to display a waveform and detect perfusion degradation of the signal was crucial for determining when the readings obtained were valid [160]. In physiologic states in which venous and capillary flows become pulsatile, the systolic pulse detected by the oximeter may no longer reflect the presence of just arterial blood. In patients with severe tricuspid regurgitation, the measured saturation may be falsely low, especially with ear probes [163]. Sixteen percent of patients not receiving supplemental oxygen in the recovery room following general anesthesia have saturations of less than 90% [165]. In 35% of patients, saturations of less than 90% develop during transfer out of the operating room [166]. Because of the high frequency of hypoxemia among critically ill patients, the frequent need to adjust oxygen flow, and the unreliability of visual inspection to detect mild desaturation, oximeters should be used for most critically ill patients for routine, continuous monitoring. In one study that randomized more than 20,000 operative and perioperative patients to continuous or no oximetric monitoring, the authors concluded that oximetry permitted detection of more hypoxemic events, prompted increases in the fraction of oxygen in inspired gas, and significantly decreased the incidence of myocardial ischemia but did not significantly decrease mortality or complication rates [167]. Once desaturation occurs, attempts to intubate should be postponed until manual ventilation restores saturation. Note, however, that oximetry is not helpful for promptly detecting inadvertent esophageal intubation because desaturation may lag significantly behind apnea in preoxygenated patients [168]. Oximeters can be useful for detecting systolic blood pressure (see arterial pressure monitoring earlier), and have been used in other clinical applications with varying degrees of success. The infrared technique relies on the fact that carbon dioxide has a characteristic absorbance of infrared light, with maximal absorbance near a wavelength of 4. When carbon dioxide passes between a focused beam of light and a semiconductor photodetector, an electronic signal can be generated that, when calibrated, accurately reflects the partial pressure of the tested gas. The ion fragments that are generated can be deflected by a magnetic field to detector plates located in precise positions to detect ions that are characteristic of the molecule being evaluated. The current generated at the detector can be calibrated to be proportional to the partial pressure of the molecule being evaluated. Mass spectrometers can detect the partial pressures of several gases simultaneously and can monitor several patients at once. The calibration and analysis time required for mass spectrometry is significantly longer than with infrared techniques. Infrared systems respond to changes in approximately 100 milliseconds, whereas mass spectrometers take 45 seconds to 5 minutes to respond [170]. Although costs vary widely, mass spectrometers are in general far more expensive and are most frequently purchased to be the central component of a carbon dioxide monitoring system. In the operating room, mass spectrometry has the advantage of being able to measure the partial pressure of anesthetic gases, and the need for a technical specialist to oversee its operation can be more easily justified. Mainstream sampling involves placing the capnometer directly in line in the patient’s respiratory circuit. The sidestream sampling techniques pump 100 to 300 mL expired gas per minute through thin tubing to an adjacent analyzing chamber. The mainstream method can be used only for patients who are intubated or wearing a tight-fitting laryngeal, face, or nose mask. Mainstream sampling offers the advantage of almost instantaneous analysis of sampled air, but it increases the patient’s dead space and adds weight to the endotracheal tube.

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The presence of fewer than three of the Ranson criteria is associated with mild pancreatitis purchase cheap levitra plus on line erectile dysfunction after prostate surgery, little morbidity order 400mg levitra plus mastercard erectile dysfunction drugs prostate cancer, and a mortality of less than 1% generic 400 mg levitra plus overnight delivery severe erectile dysfunction causes. In contrast, many patients with three or more of these prognostic signs have severe pancreatitis, with a 34% incidence of septic complications and a mortality that, with seven to eight prognostic signs, may reach 90%. Using the Imrie criteria, severe pancreatitis has been found when three or more of the criteria are present, whereas mild pancreatitis is associated with fewer of the prognostic signs. A cutoff score of 3 during the earlier phase of the disease identifies patients with an increased risk of death [99]. In addition to these scoring systems, other factors characterizing acute pancreatitis may be helpful for predicting the severity and, thus, the outcome after an attack. Most notable in this regard are the presence or onset, shortly after presentation, of evidence suggesting organ failure and/or evidence of extravascular extravasation of normally intravascular fluid [7,101,102]. This fluid loss can result in renal failure, respiratory failure, or both as well as hemoconcentration, and each of these changes is predictive of a poor outcome. In contrast, the absence of hemoconcentration on admission usually suggests that pancreatic necrosis is unlikely [103,104]. In clinical practice, narcotics available on inpatient pharmacy formulary plans are used often via a patient controlled administration pump [37]. Fluid and Electrolyte Replacement the early stage of severe acute pancreatitis is characterized by major fluid and electrolyte losses. External losses, caused by repeated episodes of vomiting and exacerbated by nausea and diminished fluid intake, can lead to hypochloremic alkalosis. Internal losses caused by leakage of intravascular fluid into the inflamed retroperitoneum, pulmonary parenchyma, and soft tissues elsewhere in the body contribute to hypovolemia. Aggressive and adequate fluid resuscitation, instituted during the early stages of acute pancreatitis, is essential. A growing body of evidence indicates that inadequate fluid resuscitation may promote progression of otherwise mild pancreatitis into severe pancreatitis, with its associated major morbidity and high mortality. Recently, studies have suggested the use of ringer’s lactate solution rather than saline to neutralize the development of metabolic acidosis. Nutrition Nutrition is the other most important arm of therapy for patients with severe acute pancreatitis. If provided enterally, it can feed the gut and decrease ischemia and transmigration of organisms into areas of necrosis with improved patient outcomes. A number of studies have demonstrated the benefits of nasojejunal tube feedings that support these contentions [106,107]. Furthermore, recent reports suggest that enteral nutrition can be successfully administered by either the nasogastric or the nasojejunal route and that the benefits of using either route are comparable [108,109]. Current guidelines published by the American College of Gastroenterology, based on a number of studies, recommend against prophylactic antibiotics or antifungals, even in cases of severe pancreatitis (strong recommendation with moderate level of evidence quoted). Three prospectively randomized controlled trials and a recent observational, prospective, multicenter trial have evaluated the benefit of early endoscopic sphincterotomy and stone extraction in the management of patients with gallstone pancreatitis [64,110–112]. Each study concluded that early intervention did not alter the course of mild pancreatitis, but they suggested [64,110,112] that the morbidity of severe pancreatitis, particularly if it was associated with cholestasis, was reduced by early stone removal. Therefore, on the basis of currently available data, it seems most appropriate that patients with mild pancreatitis need not undergo either early surgical or endoscopic intervention. Recurrent attacks of gallstone pancreatitis may develop if stones either in the gallbladder or biliary ducts remain after resolution of the index attack. For that reason, most clinicians recommend that some form of treatment designed to prevent recurrent attacks should be administered before discharge of the patient from the hospital [106]. That might be accomplished by laparoscopic or open cholecystectomy combined with surgical or endoscopic duct clearance if choledocholithiasis is discovered by preoperative magnetic resonance cholangiopancreatography. Alternatively, for patients whose only symptoms are those of ductal disease and who lack symptoms of cholecystolithiasis, endoscopic sphincterotomy and duct clearance may be sufficient, particularly if those patients have high surgical risks. Treatment of Systemic Complications Systemic complications of acute pancreatitis include cardiovascular collapse, respiratory failure, renal failure, metabolic encephalopathy, disseminated intravascular coagulation, and gastrointestinal bleeding (Table 209. For the most part, the pathogenesis and management of these manifestations of acute pancreatitis are identical to those involved when these processes are superimposed on other diseases that result in severe peritonitis and hypovolemic shock. In other words, there may be nothing specific about these systemic complications of pancreatitis, although they may be worsened by circulating vasoactive agents, activated digestive enzymes, and protein breakdown fragments absorbed from the inflamed pancreas. Please refer to the chapters on peritonitis in chapter 51 and management of shock in chapter 37 for the detailed management of these problems. In contrast to morphine, meperidine relaxes the sphincter of Oddi and is thus a favored analgesic in cases of pancreatitis [115,116]. Use of enteral nutrition has shown benefit over parenteral nutrition in terms of duration of hospital stay, infectious morbidity, and need for surgery in meta- analysis [117–119]. Enteral nutrition, because it is associated with fewer complications, may be the better of these two treatment modalities. Antibiotic use remains controversial; meta-analyses have shown utility in preventing infection of pancreatic necrosis [120,121], although a large, randomized, controlled trial failed to demonstrate benefit [122]. In cases of severe necrotizing pancreatitis, conservative management in an intensive care setting trends toward a survival benefit when compared with early surgical intervention [123]. Early endoscopic sphincterotomy and stone extraction are beneficial in preventing sepsis in cases of severe gallstone pancreatitis in patients with jaundice [64,110,124]. At a symposium in Atlanta, an international group of clinicians and scientists attempted to resolve this confusion by proposing the use of the following definitions [113]: 1. Acute pancreatic and peripancreatic fluid collections: Fluid collections in or near the pancreas that occur early in the course of acute pancreatitis and that lack a wall of granulation or fibrous tissue. Pancreatic necrosis: An area of nonviable pancreatic tissue that may be diffuse or focal and that typically is associated with peripancreatic fat necrosis. Pancreatic pseudocyst: A collection of pancreatic juice that usually is rich in digestive enzymes and that is enclosed by a nonepithelialized wall of fibrous or granulation tissue (s. It is usually round or ovoid in shape and not present until 4 to 6 weeks have elapsed from the onset of acute pancreatitis. Before this time, the fluid collection usually lacks a defined wall and may be either an acute fluid collection or a localized area of pancreatic necrosis. Bacteria may be present in a pseudocyst as a result of contamination; but in this setting, clinical signs of infection usually are absent. Leakage of pseudocysts into the peritoneal cavity or chest leads to the development of pancreatic ascites or pancreatic-pleural fistula, respectively. Pancreatic abscess: A circumscribed intra-abdominal collection of pus, usually in proximity to the pancreas, which contains little or no pancreatic necrosis that arises as a consequence of either acute pancreatitis or pancreatic trauma. It is characterized by granulation tissue forming around a collection of enzymes and debris and even bacteria (which can in fact secondarily seed the collection). Diagnosis These types of fluid collections are usually found as a complication of severe acute pancreatitis 7 to 10 days following the onset of symptoms. Usually, patients seem to develop recurrence of their pain in association with fever and leukocytosis.