24 Oct 2025

The Fire Within: A Battle Against Pancreatic Storm — When Pancreatitis Turns Multiorgan

01) Diagnosis

  • Primary Diagnosis: Severe Acute Pancreatitis
  • Complicating Conditions: Septic Shock, Acute Kidney Injury (AKI), Acute Respiratory Distress Syndrome (ARDS)

02) History of Present Illness (HPI)

  • Chief Complaints:
    • Severe epigastric pain radiating to the back for 2 days
    • Recurrent vomiting and abdominal distension
    • Shortness of breath, oliguria, and fever for 1 day
  • Progression: Pain worsened over 48 hours; patient became drowsy and hypotensive on arrival.
  • Associated Symptoms: Fever, nausea, vomiting, breathlessness, and decreased urine output
  • Negative History: No history of trauma, gallstones, alcohol binge, or drug overdose

03) Past Medical History

  • Hypertension (HTN) – on Amlodipine 5 mg OD
  • Type 2 Diabetes Mellitus (T2DM) – on Metformin 500 mg BD
  • No past ICU admissions or surgeries
  • No known allergies
  • Relevance: Both HTN and DM increase risk for multiorgan dysfunction and worsen prognosis in sepsis.

04) Physical Examination

  • General:
    • Toxic appearance, anxious, in distress
    • Pallor +, Icterus +, Pedal edema mild, Cyanosis + (peripheral)
  • Systemic Examination:
    • CVS :- Tachycardia, no murmur, normal S1S2
    • RS :- Bilateral coarse crepitations (suggestive of early ARDS)
    • CNS :- Drowsy but arousable (GCS 10/15)
    • Abdomen :- Diffuse tenderness, guarding, sluggish bowel sounds

05) Vitals on Admission

  • HR: 126 bpm
  • BP: 78/48 mm Hg
  • RR: 32/min
  • Temp: 101.8 °F
  • SpO₂: 88 % on 10 L O₂
  • GCS: E2 V3 M5 = 10/15

06) Echocardiography (ECHO)

  • LV size: Normal, EF 60 %
  • No RWMA
  • No valvular pathology
  • No pericardial effusion

07) Investigations (Baseline – Day 0)

TestResultInterpretation
CBC Hb 10.8 g/dL, WBC
21,800/mm³, Plt 160k		Infection
RFT Urea 86 mg/dL, Cr 3.1 mg/dL AKI
Na⁺ 132 mEq/LMild hyponatremia
K⁺ 4.9 mEq/LNormal
Ca²⁺ 7.5 mg/dL Hypocalcemia (poor prognostic sign)
LFT AST/ALT 88/91 IU, TB 2.3 mg/dL Hepatic stress
ABG pH 7.28, pCO₂ 28, HCO₃ 16 Metabolic acidosis
Lactate 4.8 mmol/L Severe sepsis
Amylase/Lipase 600 U/L / 1200 U/L Diagnostic for pancreatitis
PCT9.1 ng/mL Severe bacterial sepsis
CRP 210 mg/L Inflammatory marker
INR 1.4 Mild coagulopathy

    08) Imaging

    • USG Abdomen: Bulky pancreas with peripancreatic fluid collection
    • CT Abdomen (CECT): Balthazar Grade E pancreatitis
    • Chest X-ray: Bilateral diffuse infiltrates — ARDS pattern

    09) ECG & RBS

    • ECG: Sinus tachycardia, no ST-T changes
    • RBS: 220 mg/dL (stress hyperglycemia)

    10) Emergency Stabilization (Day 0 – ER)

    • Airway: Intubated and placed on Volume Control Ventilation (VT 6 mL/kg, FiO₂ 0.6, PEEP 10)
    • Breathing: ARDS protocol initiated
    • Circulation:
      • Noradrenaline 0.1 µg/kg/min → titrated to maintain MAP ≥ 65 mm Hg
      • IV Ringer’s Lactate 20 mL/kg in first 2 h (goal-directed fluid resuscitation)
      • Central & Arterial line inserted
    • Drugs:
      • Inj. Meropenem 1 g IV TDS
      • Inj. Pantoprazole 40 mg IV OD
      • Inj. Paracetamol 1 g IV TDS
      • Inj. Fentanyl infusion 1 µg/kg/h
      • Insulin infusion 1 U/h (target 140–180 mg/dL)
      • IV Calcium gluconate 10 mL slow IV if Ca²⁺ < 7 mg/dL

    11) Day-by-Day ICU Care

    • Day 1: Resuscitation Phase
      • On VCV with PEEP 10, FiO₂ 0.6
      • Noradrenaline + Vasopressin support
      • Fentanyl sedation + Midazolam 1 mg/h
      • Meropenem 1 g IV TDS + Metronidazole 500 mg IV TDS
      • Fluid target: 3 L/24 h balanced crystalloids
      • Urine output: 0.2 mL/kg/h → started furosemide 20 mg IV BD
      • Electrolyte correction: Mg²⁺ and Ca²⁺ replaced
      • RRT planned if Cr > 3.5 or anuria > 12 h
    • Day 2: Organ Support Escalation
      • Persistent oliguric AKI → started CRRT (CVVH mode)
      • FiO₂ decreased to 0.5, PEEP 10
      • Vasopressors tapered slowly
      • Meropenem continued, cultures sent (blood, urine, ET aspirate)
      • Started Enteral Nutrition via NJ tube (trickle feeds 20 mL/hr)
      • Monitored RFT, ABG, lactate, I/O hourly
    • Day 3: Clinical Turning Point
      • Urine output improving (0.8 mL/kg/h)
      • CRRT paused
      • FiO₂ down to 0.4, PEEP 8 → PaO₂/FiO₂ = 180
      • Noradrenaline reduced to 0.02 µg/kg/min
      • Pain managed with Paracetamol 1 g IV TDS
      • Insulin infusion → SC insulin sliding scale
      • Physiotherapy: Passive limb movement + chest physiotherapy BD
    • Day 4: Stability Achieved
      • Off vasopressors, hemodynamically stable
      • PEEP 8 → 6, FiO₂ 0.35
      • Meropenem 1 g IV TDS (day 4 of 7)
      • DVT prophylaxis: Enoxaparin 40 mg SC OD
      • Stress ulcer prophylaxis: Pantoprazole 40 mg IV OD
      • Cremaffin 20 mL HS for bowel movement
      • Nutrition: Peptamen 50 mL/hr continuous feed
    • Day 5: Recovery & Diuresis
      • On PSV mode ventilation, alert and following commands
      • Analgesia: Paracetamol 1 g IV TDS
      • Meropenem continued (day 5/7)
      • Furosemide 20 mg IV OD – achieved negative balance
      • Electrolytes normalized
      • DVT prophylaxis & limb physiotherapy continued
    • Day 6: Extubation Day
      • Successfully extubated to HFNC → nasal cannula 2 L/min
      • Antibiotic course (Meropenem) completed
      • Switched to oral Pantoprazole 40 mg OD
      • Oral feeding initiated (soft diet + supplement BD)
      • Mobilization with physiotherapy BD
    • Day 7: Ward Transfer
      • Stable vitals on room air
      • Creatinine 1.1 mg/dL, urine output 2 mL/kg/h
      • Off sedation, fully conscious
      • Pantoprazole 40 mg PO OD, Paracetamol 1 g PO TDS PRN, Thiamine 100 mg BD

        12) Pathophysiology

        • Initiation
          • Trigger (e.g., alcohol, gallstones) → Premature activation of trypsinogen inside acinar cells.
          • Leads to autodigestion of pancreatic tissue.
        • Inflammation Cascade
          • Activated trypsin, elastase, and phospholipase A₂ damage acini, ducts, and surrounding fat.
          • Release of cytokines (TNF-α, IL-1, IL-6) causes Systemic Inflammatory Response Syndrome (SIRS).
        • Vascular Leak & Shock
          • Massive capillary leak → third spacing of fluids → hypovolemia.
          • Cytokines cause vasodilation → distributive + hypovolemic shock.
        • Acute Kidney Injury (AKI)
          • Renal hypoperfusion from shock and cytokine storm.
          • Acute tubular necrosis develops → ↑ Creatinine, oliguria.
        • Septic Shock
          • Necrotic pancreatic tissue gets infected (gram-negative bacteria).
          • Endotoxin release → refractory hypotension despite fluids → needs vasopressors.
        • ARDS
          • Cytokines and enzymes enter pulmonary circulation → alveolar-capillary damage, → ↑ permeability, non-cardiogenic pulmonary edema, ↓ compliance → ARDS.
        • Multiorgan Dysfunction
          • Worsening hypoxia, renal shutdown, metabolic acidosis, encephalopathy, and coagulopathy follow if untreated.

        13) Discharge Medicines

        DrugDose Mechanism Purpose
        Pantoprazole 40 mg OD PPI Stress ulcer prevention
        Paracetamol 500 mg TDS PRN COX inhibition Analgesic
        Thiamine 100 mg BD B1 coenzyme Prevent Wernicke, energy metabolism
        Multivitamin 1 ODNutritional
        Peptamen supplement1 scoop BD Protein supportNutrition
        Cremaffin 20 mL HS Osmotic laxative Bowel regularity

        14) Key Notes / Clinical Pearls

        • Early aggressive fluid resuscitation (first 24 h) saves organs.
        • Avoid over-resuscitation — may worsen ARDS.
        • Enteral > Parenteral feeding once gut functional.
        • Monitor Ca²⁺ and TG levels daily in severe cases.
        • Sterile vs infected pancreatitis differentiation is crucial (guided by PCT/culture).

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