A middle-aged female patient who was transferred from an outside hospital for more than 20 days with recurrent severe abdominal pain after surgery for severe pancreatitis was recently admitted to our department, and her abdominal pain improved quickly after active treatment. The etiology and management of abdominal pain in severe pancreatitis Patients with severe acute pancreatitis have severe abdominal pain in the early stages of the disease, mostly cutting-like pain, and can be given opioids such as dulcolax for pain relief after the diagnosis of the disease is clear. Most of the pain caused by pancreatitis is completely relieved in these critically ill patients whose condition improves after active anti-shock, surgery and multi-organ function support treatment. In addition to the pain caused by the early stage of puncture and placement of drainage tube, if the abdominal pain appears again it mostly means that the condition is aggravated or new problems appear, such as acute gastric mucosal lesions, secondary hemorrhagic necrosis of the pancreas, mesenteric artery thromboembolism, gastrointestinal perforation, acute cholecystitis, acute appendicitis, etc. It is less common for this patient to have prolonged and severe pain after remission. Several elements of pain interrogation are very important: the time of pain appearance, duration, frequency of attacks, factors of remission or exacerbation, and accompanying symptoms or signs are clinical information that we should know in detail. In this case, one or some of these elements were overlooked during the onset of pain, and the omission of the details of the critical situation could not be compensated for in retrospect, which made the analysis of the etiology of pain difficult. After the patient was transferred to our hospital, after careful physical examination, follow-up history and initial treatment feedback, we concluded that inflammation of the abdominal incision, pulling of the decompression line and psychological dependence on analgesics were the main causes of the patient’s persistent abdominal pain episodes. We used a small size of Lai’s double cannula for continuous suction at the abdominal incision septic area, and the local inflammation was quickly relieved. The hypotonic line was removed to reduce local irritation and a lap band was used to protect the incision; for analgesic drug dependence we used pharmacological and psychological treatment, and the residual abdominal pus cavity was properly drained and flushed, and the patient’s abdominal pain symptoms improved quickly through the above-mentioned treatments and completely disappeared after one week. The traditional comprehensive or specialized ICU has shortcomings in the patient management model. In the SICU, for example, the interface between surgeons and ICU physicians is poor, and there is a “vacuum” in patient management. The early onset of pain in this patient did not attract the attention of ICU doctors, and the implementation of sedation and analgesia was a routine for ICU doctors, and temporary and comforting treatment was a very simple and happy task for ICU doctors and nurses. As for the analysis of the cause of pain, it is easy to put the blame on the surgeon, is there any problem during surgery? Or is there some new postoperative problem that requires surgical intervention? A cursory examination and an over-reliance on imaging may ensue. The surgeon who thinks he did a beautiful job takes it for granted that it is the ICU surgeon’s responsibility and technical strength to address pain, and imaging does not reveal ischemia, intestinal torsion, intestinal obstruction, or other common, pain-related postoperative complications. The patient was still screaming, so more and more fentanyl, dulcolax and other easily addictive analgesics were fed into the patient one after another. So much so that no physician could say exactly when the patient’s initial pain episode occurred, what was checked at that time, and what the patient’s pain was actually characterized as for more than 20 days. The work responsibilities were not fully unified, and there was a fragmentation of time and space in the work mode, and there was a certain interdependence in the ideological understanding and responsibility, resulting in a “vacuum” in the ideology of the lack of in-depth analysis and effective handling of new problems. Academician Li Jieshou told us a short story when he talked about the problem of pain in this patient in the SICU room: about ten years ago, he had consulted a patient in a hospital ICU after open abdominal exploration, and the ventilator condition was very poor. When invited to consult academician Lai, academician Lai noticed that the patient had severe abdominal hypertension and the diaphragm was elevated to compress the thoracic cavity, so the abdominal incision sutures were removed at the bedside and the abdominal cavity was opened, and soon the patient’s ventilator parameters returned to normal ….. The need to integrate the ICU with specialists is evident! 3. ICU specialization and pancreatitis treatment model Under the initiative of Prof. Liu Dawei and Qiu Haibo, former chairmen of the Intensive Care Medicine Branch of the Chinese Medical Association, many domestic experts in intensive care medicine have conducted new exploration on the current management model of ICU in China, and ICU “specialization” has become a new trend in the development of ICU in China. There is a qualitative difference between the ICU and the specialist ICU at the beginning of ICU establishment, which is the initial stage of ICU establishment in each department and is mostly used as a transitional bed for relatively critical patients and post-operative patients, and some ICUs in some hospitals even “hang sheep’s head to sell dog meat” and use ICU as a general ward. ICU specialization is a new management model that is promoted to meet the increasing clinical demand for specialized critical patient care after years of experience accumulation and scientific development, which has higher professionalism and stronger ICU functions. It has higher professionalism and stronger ICU functions, and it also puts forward higher training for specialized ICU
The training of physicians in the specialty ICU has also raised higher requirements. The seamless integration of specialists and ICU is one of the main purposes of ICU specialization, and it is also the way to promote ICU maturity and perfection. I still remember some time ago when the hospital met the national tertiary hospital accreditation activities, everyone in the hospital was mobilized and busy, and one of the department directors once said something that impressed me very much: “Everyone is busy, and everyone wants to finish what they should do as soon as possible. The overload of the hospital and the overload of doctors in many hospitals, especially large hospitals, has long existed, and it is not easy for the doctors who are more serious and responsible to stay on the level of completing the work within their own responsibilities, but the burden on their shoulders is indeed too heavy. In this case, the existence of “two teams” of specialists and ICU doctors directly leads to the “semi-detachment” of critically ill patients in a certain field. Both specialists and ICU physicians use their best expertise in their respective fields, and both have their own treatment plans, but there is always only one patient, and there may be conflicts and a vacuum between the two plans. Some of the conflicts can be resolved by negotiation, while others are persistently antagonistic, and the vacuum cannot be filled by the joint efforts of both parties. We are dealing with precious lives that can be lost at any time and never recovered, and any prevarication or adventurism on the part of either side can have disastrous consequences. Armed with the theories of critical care medicine, the specialist ICU doctors, who have a solid theoretical and practical foundation for both specialist treatment and critical care management, can make the most prudent, comprehensive, scientific and responsible treatment decisions at the most critical and difficult time when facing critical patients with various contradictions in treatment. The success of famous hospitals and departments in China lies, in one way or another, in the “three packages” – that is, the comprehensive responsibility for the patient. Dare to “three packages” reflects the strength, is a responsibility, is a kind of bear. ICU doctors and specialists alike should have the positive attitude of “three packages”, and the specialization of ICU is more helpful to realize the comprehensive responsibility of doctors for patients. It is more conducive to the organic combination of specialist skills and critical care medicine, which is a powerful driving force for the development of critical care medicine nowadays. Under the leadership of Academician Li Jieshou and Professor Li Weiqin, the Pancreatitis Treatment Center of the National Institute of General Surgery of Nanjing General Hospital of Nanjing Military Region is the first in China to propose ICU-centered, multidisciplinary, multi-pronged and comprehensive treatment of severe acute pancreatitis, which organically integrates critical care medicine and specialty treatment. CRRT, early enteral nutrition, early regional perfusion, stepwise drainage of abdominal necrotic tissues and other means have been used to reduce the morbidity and mortality rate of severe acute pancreatitis to less than 5%, and significant progress has been made in the treatment of severe acute pancreatitis, an extremely critical disease. The Pancreatitis Treatment Center of the General Hospital of Nanjing Military Region All-Army General Surgery Institute consists of the surgical care ward at the hospital headquarters, the transition ward and the slow critical care center in Tangshan, which are closely connected organizationally and complement each other functionally, with distinctive features of the three functional areas and orderly patient turnover, thus enabling pancreatitis patients referred to our hospital from all over the country to receive a complete set of seamless This enables pancreatitis patients referred to our hospital from all over the country to receive a set of seamless treatment measures in our center. It is under the guidance of Academician Li’s concept of “internal and external training”, and thanks to the help of the communication platform of this famous domestic doctor-patient network, our pancreatitis treatment center team integrates comprehensive medical treatment, surgery, critical management, slow critical state rehabilitation treatment and post-discharge rehabilitation guidance, which is a model of seamless integration between specialists and ICU. It is a model of seamless integration between specialists and ICU. We sincerely hope that with the joint efforts of our colleagues in critical care medicine, gastroenterology and general surgery, the treatment model for pancreatitis in China can be improved and the death and disability rate of severe acute pancreatitis can be continuously reduced. A little thinking, the level and height of the limitations, inevitably error, welcome colleagues to discuss each other, criticism and correction!