Submitted by Dr LAU Chun Wing Arthur on 12 December 2008
Department of Intensive Care, Pamela Youde Nethersole Eastern Hospital
History of Present Illness
A 22-year-old lady, non-smoker, social drinker
Type I DM diagnosed for one year, started on metformin and insulin
claimed to be using insulin regularly, but recently stopped because of hair loss which she attributed to the insulin, also patient defaulted FU and went to see herbalist
c/o presented this time with vomiting and colicky abd pain
noticed high H’stix with urine ketones ++++. RG 40+
therefore transferred to ICU for close monitoring of DKA
patient alert and stable
clinically dehydrated. not septic looking.
clinically dehydrated. not septic looking.
initially patient was soft
serum amylase 710 with upper abd tenderness
LFT normal
LFT normal
pulse 130, u/o good
no peritoneal sign
no peritoneal sign
Investigations:
CXR no free gas
AXR: no dilated bowel
ABG: metabolic acidosis
LRFT normal
amylase710
AXR: no dilated bowel
ABG: metabolic acidosis
LRFT normal
amylase710
Impression: no peritoneal sign at this moment, abdominal pain can be caused by DKA +/- acute pancreatitis
Ranson’s score 2 (WCC and glu)
What else will you check?
CT abdomen confirmed acute pancreatitis
Triglyceride level was checked, level >19
in view of acute pancreatitis and hyperTG, plasmapheresis was performed
Estimated body weight ~ 55-60kg
Plasmapheresis 2400ml (~40ml/kg) by plasmafiltration method over 4hrs was done
Plasmapheresis 2400ml (~40ml/kg) by plasmafiltration method over 4hrs was done
Appearance of the plasmafiltrate is shown in the figure
Figure. Millky looking plasmafiltrate
TG was reduced to 5 after just one session of plasmafiltration.
Patient remained stable on discharge from ICU.