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Therapeutic Plasma Exchange in the Management of a Patient With Hyperlipidemic Pancreatitis
Critical Care SESSION TITLE: Fellow Case Report Poster - Critical Care II SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM
Therapeutic Plasma Exchange in the Management of a Patient With Hyperlipidemic Pancreatitis Zeron Ghazarian MD Michael Hanna MD Raminderjit Sekhon MD Tapan Pandya MD*; and Mourad Ismail MD St Joseph’s Regional Medical Center/New York Medical College, Paterson, NJ INTRODUCTION: Hypertriglyceridemia (HTG) is rare of acute pancreatitis (AP). Multiple studies on hypertriglyceridemic pancreatitis (HTP) management have evaluated the use of insulin, heparin, or both. Some series have also reported use of plasmapheresis to reduce triglyceride (TG) levels and halt the progression of HTP. However, no management guidelines are available. We present a case of severe complicated HTP required plasmapheresis to reduce TG level rapidly. CASE PRESENTATION: 31-year-old male with history of alcohol abuse, presented with complaint of epigastric abdominal pain, associated with nausea and vomiting for one day duration. On physical examination, he was afebrile and had moderate epigastric tenderness. Laboratory data revealed WBC 8,500 /mL, Na 109 meq/L, Cl 82 meq/L, bicarbonate 13 meq/L, BUN 18 mg/dL, creatinine 3.46 mg/dL, an anion gap of 14. Glucose was 137 mg/dL and lipase was 1,348 U/L. The patient was admitted to medical intensive care unit where his clinical status rapidly deteriorated requiring intubation and mechanical ventilation. His lipid profile showed TG level of 12,730 mg/dL. One-volume plasmapheresis performed which reduced the TG level to 1883mg/dL. The patient was then placed on heparin and insulin infusion. Subsequent TG levels were 610, 354, 124 mg/dL. His AP was complicated with acute respiratory distress syndrome required mechanical ventilation for 11 days, pleural effusion required thoracentesis, sepsis treated with antibiotics and large pancreatic pseudocyst formation. He survived a complicated and prolonged hospitalization and was discharged home on oral gemfibrozil.
CRITICAL CARE
DISCUSSION: Plasmapheresis has been claimed to reduce TG level rapidly and is believed to halt the progression of HTP. Experiences of plamapheresis in HTP are limited only to sporadic cases. There are also conflicting data regarding mortality benefit of the plasmapheresis in the treatment of HTP. The time of plasma exchange might be the critical point. If patients with HTP can receive plasma exchange early, better results may be predicted. However, large multicenter studies are needed to optimize future management guidelines for patients with HTP. CONCLUSIONS: We presented a case of severe HTG resulting in acute complicated pancreatitis, managed with immediate initiation of plasmapheresis and appropriate supportive care leading to complete recovery as an ideal outcome of a critically ill patient. Reference #1: Hypertriglyceridemic Pancreatitis: Presentation and Management; W. Tsuang et al; Am J Gastroenterol 2009; 104:984-991 DISCLOSURE: The following authors have nothing to disclose: Zeron Ghazarian, Michael Hanna, Raminderjit Sekhon, Tapan Pandya, Mourad Ismail No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2016.08.259
Copyright ª 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
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Therapeutic Plasma Exchange in the Management of a Patient With Hyperlipidemic Pancreatitis Zeron Ghazarian MD Michael Hanna MD Raminderjit Sekhon MD Tapan Pandya MD*; and Mourad Ismail MD St Joseph’s Regional Medical Center/New York Medical College, Paterson, NJ INTRODUCTION: Hypertriglyceridemia (HTG) is rare of acute pancreatitis (AP). Multiple studies on hypertriglyceridemic pancreatitis (HTP) management have evaluated the use of insulin, heparin, or both. Some series have also reported use of plasmapheresis to reduce triglyceride (TG) levels and halt the progression of HTP. However, no management guidelines are available. We present a case of severe complicated HTP required plasmapheresis to reduce TG level rapidly. CASE PRESENTATION: 31-year-old male with history of alcohol abuse, presented with complaint of epigastric abdominal pain, associated with nausea and vomiting for one day duration. On physical examination, he was afebrile and had moderate epigastric tenderness. Laboratory data revealed WBC 8,500 /mL, Na 109 meq/L, Cl 82 meq/L, bicarbonate 13 meq/L, BUN 18 mg/dL, creatinine 3.46 mg/dL, an anion gap of 14. Glucose was 137 mg/dL and lipase was 1,348 U/L. The patient was admitted to medical intensive care unit where his clinical status rapidly deteriorated requiring intubation and mechanical ventilation. His lipid profile showed TG level of 12,730 mg/dL. One-volume plasmapheresis performed which reduced the TG level to 1883mg/dL. The patient was then placed on heparin and insulin infusion. Subsequent TG levels were 610, 354, 124 mg/dL. His AP was complicated with acute respiratory distress syndrome required mechanical ventilation for 11 days, pleural effusion required thoracentesis, sepsis treated with antibiotics and large pancreatic pseudocyst formation. He survived a complicated and prolonged hospitalization and was discharged home on oral gemfibrozil.
CRITICAL CARE
DISCUSSION: Plasmapheresis has been claimed to reduce TG level rapidly and is believed to halt the progression of HTP. Experiences of plamapheresis in HTP are limited only to sporadic cases. There are also conflicting data regarding mortality benefit of the plasmapheresis in the treatment of HTP. The time of plasma exchange might be the critical point. If patients with HTP can receive plasma exchange early, better results may be predicted. However, large multicenter studies are needed to optimize future management guidelines for patients with HTP. CONCLUSIONS: We presented a case of severe HTG resulting in acute complicated pancreatitis, managed with immediate initiation of plasmapheresis and appropriate supportive care leading to complete recovery as an ideal outcome of a critically ill patient. Reference #1: Hypertriglyceridemic Pancreatitis: Presentation and Management; W. Tsuang et al; Am J Gastroenterol 2009; 104:984-991 DISCLOSURE: The following authors have nothing to disclose: Zeron Ghazarian, Michael Hanna, Raminderjit Sekhon, Tapan Pandya, Mourad Ismail No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2016.08.259
Copyright ª 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
246A
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150#4S CHEST OCTOBER 2016
]