High Dependency Unit Care Research Articles

‘The future ain’t what it used to be’– reflections on the evolution of anaesthesia

‘The future ain’t what it used to be’– reflections on the evolution of anaesthesia

Respiratory High-Dependency Care Units for the burden of acute respiratory failure

The burden of acute respiratory failure (ARF) has become one of the greatest epidemiological challenges for the modern health systems. Consistently, the imbalance between the increasing prevalence of acutely de-compensated respiratory diseases and the shortage of high-daily cost ICU beds has stimulated new health cost-effective solutions.Respiratory High-Dependency Care Units (RHDCU) provide a specialised environment for patients who require an “intermediate” level of care between the ICU and the ward, where non-invasive monitoring and assisted ventilation techniques are preferentially applied. Since they are dedicated to the management of “mono-organ” decompensations, treatment of ARF patients in RHDCU avoids the dangerous “under-assistance” in the ward and unnecessary “over-assistance” in ICU. RHDCUs provide a specialised quality of care for ARF with health resources optimisation and their spread throughout health systems has been driven by their high-level of expertise in non-invasive ventilation (NIV), weaning from invasive ventilation, tracheostomy care, and discharging planning for ventilator-dependent patients.

Predicting the Severity of Acute Pancreatitis: Choose the Right Horse Before Hitching the Cart

Prediction of disease severity in patients with acute pancreatitis is an important clinical goal. An accurate predictive tool allows early identification of those patients who would require treatment in a high dependency or intensive care unit and transfer to a referral centre [1]. In addition, it allows the selection of patients who definitely need early enteral tube feeding and possibly other (yet to be determined) early treatments. The research on predictors of severity in acute pancreatitis has traditionally been based on the premise of quest for an ideal predictive tool. The characteristics of such a tool are well established: it would be available on admission to hospital, be easily repeated for monitoring purposes, be quick and reproducible [1]. The pioneering work, which investigated the relationship between 43 early measurements and ‘‘overall morbidity and mortality’’ in 100 patients with acute pancreatitis, was published by Ranson nearly four decades ago [2]. Since then, the scientific framework of the concept of prediction in acute pancreatitis has been unquestionable. Moreover, the number of followers has been constantly growing with the research on predictors of severity being arguably the most prolific area in the literature on acute pancreatitis for many years. A recent systematic review of the literature found 184 original studies that reported on 196 different predictors of severity in acute pancreatitis [3]. Strikingly, 144 of 184 (78%) studies reported a statistically significant result for at least one predictor. It is also worth noting that the search was limited to studies indexed only in MEDLINE and published only in English. Further, it also only focused on novel (non-routine) molecular markers, which effectively means that many routine markers (urea, creatinine, lactate dehydrogenase, C-reactive protein, hematocrit, blood gases, etc.) as well as several modern computer-based predictive tools in acute pancreatitis (artificial neural network, kernel-based modelling, linear discriminant analysis [4–6]) were not counted. Collectively, these indicate that the literature is replete with dozens, if not hundreds, of presumably effective ways to predict the severity of acute pancreatitis, but it appears that very few have entered clinical practice. There are several legitimate reasons for this lack of penetration: the predictive tools are often complex, cumbersome, expensive, and not available commercially [7]. But the most important reason is that they are notoriously inaccurate when it comes to prediction of an individual patient’s severity. In this issue of the journal, Dr. Hong et al. [8] report on a novel computer-based predictive tool in acute pancreatitis—classification and regression tree (CART) analysis. CART is a non-parametric technique that can select from among a large set of variables, those that individually, or in combination, best predict the endpoint of interest by splitting the initial cohort sequentially into smaller subsets. The method has the potential to become a valuable tool in the field of acute pancreatitis because it can not only assess which individual variables are most accurate in predicting the severity but also define their optimal combination and order (so-called ‘‘decision tree’’). The study by Dr. Hong and colleagues advocates three variables for severity prediction, namely blood urea nitrogen, pleural effusion, and serum calcium, and suggests a particular order in which to use them. It is reported that the CART model has a high M. S. Petrov (&) Department of Surgery, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand e-mail: max.petrov@gmail.com

Preoperative Sleep Studies for Pediatric Adenotonsillectomy

Objective: In 2008, an expert UK panel produced a consensus statement highlighting factors putting children at additional risk of having respiratory complications following adenotonsillectomy for sleep related breathing disorders. This audit, performed at a pediatric teaching hospital, assessed whether at-risk children indicated by the guidelines were having appropriate preoperative investigations. Method: A retrospective study conducted in the Royal Alexandra Children’s Hospital in Brighton over a 6-month period. A total of 49 children having elective day case adenotonsillectomy fulfilled inclusion criteria. Patient notes were analyzed for demographics and past medical history to see if they fit the consensus criteria to undergo sleep studies preoperatively. Results: The audit highlighted that the common indications putting children in the high risk group were weight (<15 kg), age (<2) and significant co-morbidity. Despite 49% fulfilling criteria to have pre-operative sleep studies, only 20% of this high risk group were investigated pre-operatively. The most common complication was postoperative desaturations. Overall 10% of the audit population developed postop complications requiring enhanced level of care. 60% of these complications were in high risk patients who did not have pre-op sleep studies and pre-booked high dependency unit (HDU) provision. A total of 8 days of unplanned HDU care was needed. Conclusion: Standards of preoperative respiratory investigations were not being met, with children being listed for adenotonsillectomy without appropriate risk stratification. Information bulletins were disseminated across relevant specialties and risk chart posters were introduced to ENT consultation rooms. A repeat audit cycle will be completed in 6 months.

Is age a predictor of mortality in a UK medical high dependency unit?

The population aged older than 65 yr is set to increase by 32% by 2033. In resource-limited environments, difficult decisions regarding access to high dependency care for the elderly are increasingly important. The aim of this study was to determine whether age is a predictor of mortality in patients admitted to an open medical high dependency unit (MHDU). Prospective observational cohort study of 100 consecutive patients admitted to an MHDU with a primary medical diagnosis over a 3 month period. The primary endpoint was 30 day mortality. Overall mortality at 30 days was 21% (n=21). Patients aged <65 yr were 41%, 29% were 65-74 yr, and 30% were aged 75 yr and above. There were no significant differences in mortality between groups (12%, 31%, and 23%, respectively). When considering Acute Physiology and Chronic Health Evaluation scores ≥25, there was no significant difference in mortality between age groups [35% <70 yr (7/20) vs. 29% ≥70 yr (4/14), P=1.000]. The final model at multivariable regression analysis identified that ≥2 organ support (odds ratio 10.84, 95% confidence interval 3.28-35.84) and pre-admission moderate/nursing home care [4.44 (1.05-18.70)] were significantly associated with worse outcome. The majority of survivors (88%) were discharged at their pre-admission functional status; those who declined in function were not significantly older than those who did not. Age does not predict the outcome from an MHDU. Those requiring ≥2 organ support, higher levels of pre-admission home support, or both had higher mortality. Selected elderly medical patients should not be denied high dependency unit care.

Respiratory High-Dependency Care Units in Italy

Patients with chronic respiratory failure may require intensive care unit (ICU) admission to overcome severe episodes of acute-on-chronic respiratory failure with ventilatory assistance.[1][1] However, ICUs are expensive resources.[2][2] A high proportion of patients with acute-on-chronic

Increased Number and Expertise of Italian Respiratory High-Dependency Care Units: The Second National Survey

The imbalance between the increasing prevalence of acutely decompensated respiratory diseases and the shortage of intensive care unit beds has stimulated the growth of respiratory high-dependence care units (RHDCUs). We conducted a national survey to analyze the changes, in the past 10 years, in the number, structures, staff, procedures, diagnoses, and outcomes in Italian RHDCUs that satisfy the European Respiratory Society's criteria (modified according to the Italian Association of Hospital Pneumologists) for high level (respiratory intensive care unit), intermediate level (respiratory intermediate intensive care unit), and low level (respiratory monitoring unit) RHDCU care. The number of RHDCUs increased from 26 to 44. The relative prevalence among all the RHDCUs increased only for the low-level units (P = .03). Compared to 1997, in 2007 a higher percentage of Italian RHDCUs were located within respiratory wards than located outside of respiratory wards (P = .03), and the physician-to-patient mean ratio and the nurse-to-patient mean ratio per shift were lower (P = .001 and P = .002, respectively). Admissions for only monitoring decreased (P < .001), and admissions for active interventions increased: noninvasive ventilation (P = .002), invasive ventilation (P < .001), weaning from invasive ventilation (P < .001), and tracheal decannulation (P < .001). The complexity of RHDCU patients' conditions increased: there was a reduction in the percentage of COPD patients (P < .001) and an increase in the percentage of patients with neuromyopathies (P < .001) and de novo hypoxemia (P = .006). Between 1997 and 2007 there was an increase in the number and expertise of Italian RHDCUs, with a shift toward less expensive care, and greater complexity of interventions and patient dysfunctions. These findings support the crucial role of RHDCUs in the management of respiratory critical patients.

Fever in Travelers Returning from Malaria‐Endemic Areas: Don't Look for Malaria Only

Returning travelers with fever pose challenges for clinicians because of the multitude of diagnostic alternatives. Case data in a Finnish tertiary hospital were analyzed in order to define the causes of fever in returned travelers and to evaluate the current diagnostic approach. A retrospective study of patient records comprised 462 febrile adults who, after traveling in malaria-endemic areas, were admitted to the Helsinki University Central Hospital (HUCH) emergency room from 2005 to 2009. These patients were identified through requests for malaria smear. The most common groups of diagnoses were acute diarrheal disease (126 patients/27%), systemic febrile illness (95/21%), and respiratory illness (69/15%). The most common specific main diagnosis was Campylobacter infection (40/9%). Malaria was diagnosed in 4% (20/462). Blood culture was positive for bacteria in 5% of those tested (21/428). Eight patients were diagnosed with influenza. HIV-antibodies were tested in 174 patients (38%) and proved positive in 3% of them (5/174, 1% of all patients). The cause of fever was noninfectious in 12 (3%), remaining unknown in 116 (25%). Potentially life-threatening illnesses were diagnosed in 118 patients (26%), the strongest risk factors were baseline C-reactive protein (CRP) ≥100 (OR 3.6; 95% CI 2.0-6.4) and platelet count ≤140 (OR 3.8; 95% CI 2.0-7.3). Nine patients (2%) were treated in high dependency or intensive care units; one died of septicemia. Forty-five patients (10%) had more than one diagnosis. The high proportion of patients with more than one diagnosis proves the importance of careful diagnostics. Every fourth returning traveler with fever had a potentially life-threatening illness. Septicemia was as common as malaria. The proportion of HIV cases exceeded the prevalence in population for which Centers for Disease Control and Prevention, USA (CDC) recommends routine HIV testing. Both blood cultures and HIV tests should be considered in febrile travelers.

Pre-Admission Statin Use and In-Hospital Severity of 2009 Pandemic Influenza A(H1N1) Disease

BackgroundStatins are drugs that are used to lower plasma cholesterol levels. Recently, contradictory claims have been made about possible additional effects of statins on progression of a variety of inflammatory disorders, including infections. We therefore examined the clinical course of patients admitted to hospital with 2009 pandemic influenza A(H1N1), who were or weren't taking statins at time of admission.MethodsA retrospective case-control study was performed using the United Kingdom Influenza Clinical Information Network (FLU-CIN) database, containing detailed information on 1,520 patients admitted to participating hospitals with confirmed 2009 pandemic influenza A(H1N1) infection between April 2009 and January 2010. We confined our analysis to those aged over 34 years. Univariate analysis was used to calculate unadjusted odds ratios (OR) and 95 percent confidence intervals (95%CI) for factors affecting progression to severe outcome (high dependency or intensive care unit level support) or death (cases); two multivariable logistic regression models were then established for age and sex, and for age, sex, obesity and “indication for statin” (e.g., heart disease or hypercholesterolaemia).ResultsWe found no statistically significant association between pre-admission statin use and severity of outcome after adjustment for age and sex [adjusted OR: 0.81 (95% CI: 0.46–1.38); n = 571]. After adjustment for age, sex, obesity and indication for statin, the association between pre-admission statin use and severe outcome was not statistically significant; point estimates are compatible with a small but clinically significant protective effect of statin use [adjusted OR: 0.72 (95% CI: 0.38–1.33)].ConclusionsIn this group of patients hospitalized with pandemic influenza, a significant beneficial effect of pre-admission statin use on the in-hospital course of illness was not identified. Although the database from which these observations are derived represents the largest available suitable UK hospital cohort, a larger study would be needed to confirm whether there is any benefit in this setting.

Predicting the need for high-dependency care in patients undergoing hip and knee revision surgery

Introduction Revision hip and knee arthroplasty surgery may cause great physiological stress to what is commonly an aged, infirm patient population. In some orthopaedic units, it is routine practice to book high-dependency unit (HDU) beds for postoperative revision arthroplasty surgery patients. If this facility is not available on the day of surgery, the operation may be postponed, leading to increased patient anxiety, wasted theatre time and loss of potential income for the hospital. If the likelihood of a patient needing HDU care could be accurately predicted from their comorbid conditions and type of surgery, it may be possible to safely proceed with surgery, avoiding the above scenario.

Management of Post-Operative Maxillofacial Oncology Patients Without the Routine Use of an Intensive Care Unit

To assess the safety and efficacy of immediate postoperative management of major maxillofacial oncology patients in a High Dependency Unit (HDU). All operated maxillofacial oncology patients were included. Detailed records and clinical parameters were assessed for diagnosis, procedure, diagnosis, American Society of Anaesthiologists (ASA) grade, procedure, type of reconstruction, duration of surgery, post operative location, days of hospitalization risk factors and complications if any. All the patients were placed in a HDU care for 48 h for closed monitoring and thereafter were shifted to the head and neck general ward. Only 7/117 (6%) patients required ICU admission because of development of systemic complications. Of our cases, 108/117 made an uneventful recovery (92.3%) with no serious complications. We noted a correlation between the incidence of perioperative complications and risk factors of ASA status (χ(2)=7.81, P=0.005). Majority of the patients (94%) were managed successfully in the HDU care in the post operative period. Survival of free flaps proved to be extremely reliable with a survival rate of 99.1% (1/15 failed). The routine use of a HDU care for 48 hours followed by shifting the patient to a maxillofacial head and neck general ward is more appropriate for management of post-operative maxillofacial oncology patients. This practice has helped in offering high quality, cost effective and efficient services without having any adverse effect on the quality of care.

Microvascular Anastomoses: A Series of 200 Success Stories

Sir: We read with interest the article by Koizumi et al. entitled “Microvascular Anastomoses: A Series of 200 Success Stories” and congratulate them on their 100 percent microvascular success rate in their most recent series.1 Their strategy for microvascular anastomosis is undoubtedly a very good guide. In our department too, experience has accumulated, and their strategy could be expanded to include the following: Complete preparation of both donor and recipient vessels before disconnecting the flap, to stabilize the vessels and to minimize “flap-off” time. The use of supports (e.g., rolled up theater drapes) to stabilize the hands and to reduce undesirable hand movements. Although the skill and technical knowledge required of the surgeon during surgery is undoubted, we contend that it is not the sole factor for microsurgical success.2,3 The physiologic condition of the patient is vital, and we believe that keeping the patient warm, well perfused, and comfortable throughout the perioperative period is crucial. We advocate that microsurgical cases: Are performed by a dedicated microsurgical team to optimize familiarity with equipment and techniques. Are carried out in a warmed operating room (27°C). Maintain a body core temperature at 38°C and core-peripheral temperature difference less than 1°C. Have regional anesthesia available where appropriate, which can continue postoperatively. Dedicated postoperative care is also essential. In a recent review of all (consecutive and unselected) free flaps (n = 2569) carried out in our unit between 1985 and 2008, 327 free flaps were reexplored on 369 occasions.3 In this series, timing of reexploration was significant, with successful reexplorations taking place at a mean ± SE of 19.4 ± 2.5 hours compared with 56.1 ± 10.5 hours for unsuccessful reexplorations (p < 0.001). Our work concurs with other studies, in that the majority of flaps were reexplored in the first 24 hours, with most of these being carried out within the first 6 hours.4,5 The preoperative clinical diagnosis for cause of the failing free flap was correct in over 90 percent of reexplorations. Therefore, the following are adopted in free-flap patients postoperatively: The patient is cared for in a warmed high-dependency care unit, ideally with continued review by the same anesthetist. Initial flap observations are carried out every 15 minutes by experienced nursing staff and continue with hourly observations until 48 hours has passed. Invasive monitoring is removed when it is safe to do so. Urgent surgical intervention is performed if flap viability is in doubt, rather than waiting until the indication is absolute (in our series, 0.4 percent of flap reexplorations were negative, which we believe is acceptable if overall success rates are high3). We believe that a “microsurgical culture” within a unit and availability of appropriate facilities are pivotal to microsurgical success. Patients and their flap(s) should have a period of very close observation postoperatively, with a clinical model of flap monitoring at its core. We also believe that careful perioperative management of the patient (and flap) is as important as the skill of the surgeon in achieving consistently successful free tissue transfer. Richard M. Pinder, M.R.C.S. Robert I. Winterton, M.R.C.S. Mark I. Liddington, F.R.C.S., F.R.C.S.(Plas.) Simon P. Kay, F.R.C.S., F.R.C.S.(Plas.) Department of Plastic Surgery Leeds General Infirmary Leeds, United Kingdom DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication.

Adherance to protocol during the acute management of diabetic ketoacidosis: would specialist involvement lead to better outcomes?

Diabetic ketoacidosis (DKA) is a hyperglycaemic emergency associated with major morbidity and mortality. It has been shown that treating patients admitted with DKA using an integrated care pathway, or protocol, reduces time taken to initiate management thus optimising care. Early input from diabetes specialist services should also be sought. A new protocol for managing DKA was introduced in Sherwood Forest Trust in July 2008. To assess whether the trust DKA protocol is being followed at Kingsmill and Newark District General Hospitals during acute management (first 4 h) of patients. Retrospective case note review of all adult patients coded as DKA from July 2008 to February 2009. Seventy-eight percent of patients were correctly diagnosed according to protocol. Hundred percent of patients had i.v. access and correct blood tests within 1 h of admission. Eighty percent were given appropriate fluid resuscitation within the first hour. Seventy-two percent had correct insulin prescribed and 73% were on the correct sliding scale. Seventy-eight to ninety percent of patients had correct initial investigations ordered. However only 46% of patients requiring High Dependency Unit care were referred appropriately. Between hours 2 and 4 only 38% had repeat electrolytes checked and only 35-60% of patients had the correct fluid prescribed. The findings indicated that there was awareness of the new DKA protocol. It was referred to and placed in clinical notes but not always followed. Management of patients with DKA within the first hour was compliant. However, subsequent fluid management and electrolyte monitoring was poor. It was found that using a protocol does help to standardise initial management of patients but further education is needed and referral criteria need clarifying. Access to 24-hour specialist services may also help to optimise management.

Risk factors for hospitalisation and poor outcome with pandemic A/H1N1 influenza: United Kingdom first wave (May–September 2009)

BackgroundDuring the first wave of pandemic H1N1 influenza in 2009, most cases outside North America occurred in the UK. The clinical characteristics of UK patients hospitalised with pandemic H1N1 infection...

The Glasgow Blatchford scoring system enables accurate risk stratification of patients with upper gastrointestinal haemorrhage

Upper gastrointestinal (UGI) haemorrhage is a frequent cause of hospital admission. Scoring systems have been devised to identify those at risk of adverse outcomes. We evaluated the Glasgow Blatchford score's (GBS) ability to identify the need for clinical and endoscopic intervention in patients with UGI haemorrhage. A retrospective observational study was performed in all patients who attended the A&E department with UGI haemorrhage during a 12-month period. Patients were separated into low and high risk categories. High risk encompassed patients who required blood transfusions, operative or endoscopic interventions, management on high dependency or intensive care units, and those who re-bled, represented with further bleeding, or who died. A total of 174 patients were seen with UGI bleeding. Eight of them self-discharged and were excluded. Of the remaining 166, 94 had a 'low risk' bleed, and 72 'high risk'. The GBS was significantly higher in the high risk (median = 10) than in the low risk group (median 1, p < 0.001). To assess the validity of the GBS at separating low and high risk groups, receiver-operator characteristic (ROC) curves were plotted. The GBS had an area under ROC curve of 0.96 (95% CI 0.95-1.00). When a cut-off value of > or = 3 was used, sensitivity and specificity of GBS for identifying high risk bleeds was 100% and 68%. Thus at a cut-off value of < or = 2 the GBS is useful for distinguishing those patients with a low risk UGI bleed. The GBS accurately identifies low risk patients who could be managed safely as outpatients.

Clinician response to Candida organisms in the urine of patients attending hospital

The epidemiology of 54 episodes of candiduria with respect to clinical risk factors, species of Candida and physician response to the isolation of Candida in urine were studied in an observational survey over 3 months. Candida spp. were isolated from 4.7% of positive urine cultures. Common predisposing conditions included antibiotic use (74.1%), urinary drainage devices (57.4%), surgery (51.9%), intensive care unit (ICU) or high-dependency care unit (HDU) admission (42.6%) and urinary tract (UT) disease (18.5%). Upper UT infection was uncommon (n = 3). Of 65 Candida isolates, C. albicans predominated (85.2%), followed by C. glabrata (27.8%) and other Candida spp. (6.2%). All isolates were susceptible to fluconazole, itraconazole, voriconazole, amphotericin and caspofungin. Indwelling urinary catheters were removed in 76.2% of episodes. Antifungal therapy was initiated in 33.3% of cases independently of patient symptoms, underlying disease or Candida colony count. Patients in ICU/HDUs were significantly more likely to receive antifungal agents than those outside these units (p < 0.001). Fluconazole was the most common drug prescribed (77.8%). Clearance of candiduria occurred independently of antifungal therapy (p = 0.60). Physicians often did not follow up a positive urine result for Candida. Efforts to increase clinician awareness of current recommendations for managing candiduria and further study to elucidate specific risk factors in defined patient populations are warranted.

Laparoscopic gastrectomy for gastric cancer: early experience among the elderly

The data are scarce on the outcome for elderly patients presenting with resectable gastric cancer in the West who have been treated with minimally invasive surgery. This report presents the authors' early experience with totally laparoscopic gastric resections for cancer in elderly patients. A total of 20 patients underwent laparoscopic gastrectomy procedures: 14 distal, 5 subtotal, and 1 total gastrectomy. The male-to-female ratio was 15 to 5. The ages ranged from 75 to 88 years (mean, 80 years). All cases were managed laparoscopically with R0 resection. Four patients needed high-dependency unit care postoperatively. There were no perioperative deaths. The median time required for the procedure was 212 min, and time to diet was 4 days. The hospital stay was 8 days. Four patients experienced significant complications, with two patients requiring reoperation. The pathology was adenocarcinoma for 17 patients and high-grade dysplasia for 3 patients. Among elderly patients for whom conventional gastric surgery carries a high morbidity and mortality risk, minimal access surgery may offer equivalent oncologic integrity but with superior safety and economy. The primary aim is to remove the tumor with at least a D1 lymphadenectomy.

High dependency care unit after major cancer surgery: medical and economic impact

High dependency care unit after major cancer surgery: medical and economic impact

An Audit of Intrathecal Morphine Analgesia for Non-Obstetric Postsurgical Patients in an Adult Tertiary Hospital

We conducted a retrospective audit of adult non-obstetric patients who had received a single dose of intrathecal morphine for postoperative analgesia. These patients were predominantly admitted to a regular postsurgical ward with strict hourly nursing observations, treatment protocols in place and supervision by an Acute Pain Service for the first 24 hours after intrathecal morphine administration. A total of 409 cases were examined for sedation score, incidence of respiratory depression and other side-effects, admission to the high dependency or intensive care unit and opioid-tolerance. Respiratory depression was defined as requiring treatment with naloxone (implying a sedation score of 3 irrespective of respiratory rate), or a sedation score of 2 with a respiratory rate less than six breaths per minute. The patients were predominantly elderly (57.2% were over the age of 70 years) and 84.8% had undergone vascular surgery. Of the total of 409 cases, only one case of respiratory depression was observed. A total of 77 patients were admitted to high dependency or intensive care unit for various reasons including management of postsurgical complications and patient co-morbidities. Our findings suggest that elderly patients who receive intrathecal morphine analgesia can be safely managed in a regular postsurgical ward.

Pathophysiology, diagnosis and management of acute pancreatitis

Pancreatitis is an inflammation of the pancreas that can be either acute or chronic in origin and is caused by a varied range of aetiologies. However, in both types of the disease alcohol use may be a major contributor. In acute pancreatitis the symptoms can range from mild, which resolve within a few days, to severe, which is associated with both multi-organ failure and a high mortality necessitating admission to a high dependency or intensive care unit. As the incidence of acute pancreatitis is increasing it is imperative that nurses are familiar with the causes, underlying pathophysiology, diagnostic tests and the potentially vast range of complications that can occur in acute pancreatitis. This article reviews the current medical and nursing management of this condition.