The role of nursing-led support in the successful management of alcohol-related acute pancreatitis: A case report utilizing conservative treatment and continuous renal replacement therapy with an adsorptive Oxiris filter

INTRODUCTION

Acute pancreatitis (AP) is an inflammatory disorder of the pancreas characterized by parenchymal edema and tissue necrosis caused by autodigestion from pancreatic enzymes. In severe cases, it can progress to multi-organ failure or death. This case report highlights the management and recovery of a patient in the liver intensive care unit (LICU) through conservative treatment, continuous renal replacement therapy (CRRT), and focused, nursing-led care.

CASE REPORT

A 32-year-old male with a history of chronic alcohol use (consuming 2-3 bottles of beer 2-3 times per week for the last 05 years) initially presented to the emergency department of a local hospital in Haryana, where he was treated for 4 days. He reported a sudden onset of severe epigastric pain, rated 8/10 on the pain scale, accompanied by multiple episodes of nausea and vomiting. His vital signs were unstable, and imaging revealed bilateral pleural effusion.

As his condition deteriorated, he was transferred to our hospital and was treated in the LICU on 04/04/25. At admission, he was febrile (temperature 101°F), tachycardic (heart rate 112 beats/min), hypertensive (blood pressure 150/110 mmHg), and hypoxic, with an oxygen saturation of 88% on room air, requiring oxygen supplementation at 6 L/min via face mask.

Physical examination revealed marked tenderness in the epigastric region, mild ascites, and bilateral pleural effusion. There was no rebound tenderness, and bowel sounds were present.

Laboratory evaluation revealed findings consistent with alcohol-related AP, complicated by systemic inflammation and early organ dysfunction. His white blood cell count was elevated at 15.78 ×10³/mm³ with a left shift (neutrophils 85.2%); it remained elevated throughout hospitalization, peaking at 25,240 on day 9, indicating persistent infection. Pancreatic enzymes remained markedly elevated (lipase 3548 U/L; amylase 2253 U/L), confirming the diagnosis, and gamma-glutaryl transferase (GGT), alanine amino transferase (ALT), aspartate amino transferase (AST) were significantly elevated, suggesting hepatobiliary involvement, possibly secondary to pancreatitis or alcohol-related liver injury. GGT fluctuated but remained high overall, reaching 385 IU/L by day 6. ALT and AST levels decreased over time but remained elevated. Hemoglobin was elevated at 18.0 g/dL, likely due to haemoconcentration, while serum creatinine was 1.96 mg/dL, suggesting early renal impairment but improved rapidly to normal levels (<1.0 mg/dl) by day 4. Blood urea nitrogen showed fluctuations, rising again by day 12 (33.2 mg/dL), indicating possible renal stress or dehydration. Serum calcium was slightly low at 8.04 mg/dL. Sodium was within normal limits (139 mEq/L), while bicarbonate was elevated (30 mEq/L), likely reflecting metabolic alkalosis secondary to dehydration or fluid shifts. Bilirubin levels remained normal, supporting the absence of significant biliary obstruction, though elevated GGT and transaminase supported alcohol as the underlying etiology. Lipid profile revealed total cholesterol of 250 mg/dL and low-density lipoprotein-cholesterol of 160.4 mg/dL, indicating dyslipidemia. Arterial blood gas analysis showed the Initial metabolic acidosis (pH 7.32), later shifted toward compensated alkalosis (pH ∼7.5). Lactate levels normalized rapidly after day 1, indicating, resolving of tissue hypoperfusion. The lipid profile, triglycerides, and total cholesterol were initially elevated but decreased to near-normal levels over time. Random blood sugar remained elevated initially (148 mg/dL) but stabilized without significant hyperglycemia. The patient received care in the intensive care unit (ICU) from day 1 to day 20, and in the general ward from day 21 to day 22. As the patient was having low oxygen saturation on day 1, he was managed with 6 L/min via face mask. From day 2 to day 6, the patient required mechanical ventilation via tracheostomy (forced inspiratory oxygen (FiO₂) 45-70%). On day 7, the FiO₂ reduced to 40%. On days 8 & 9, he was supported on T-piece (breathing through tracheostomy without full mechanical ventilation), and on days 10 to 20, the tracheostomy was closed, and he was breathing on room air. He showed good respiratory recovery, and the other blood parameters also stabilized. He was shifted to the general ward, where the patients with stable conditions needing monitoring are treated (day 21). He was discharged from the hospital on day 22.

The patient was managed in the LICU with broad-spectrum antibiotics, analgesics, and IV Fluids. Medical treatment included Inj Colistin, Inj Tigecycline, Inj Elores, Inj Aztreonam, and Inj Amphotericin-B. A peripancreatic collection 3.3×3.7×9 cm with bilateral pleural effusion, likely fungal pneumonia, as confirmed by serum galactomannan 1.1 was also present, which added to the respiratory compromise. To treat this, mechanical ventilation, pressure support synchronized mandatory ventilation mode with FiO₂ at 55% (moderate oxygen requirement), respiratory rate, frequency -18 breaths/min, tidal volume VT-480ml, positive end expiratory pressure (PEEP)-5 cm of H₂O (to keep alveoli open), pressure support (PS)-15 cm of H₂O (to assist in spontaneous breaths) was initiated. Tracheostomy was done on 04/04/25. Naso Gastric tube with continuous drainage was put to drain gastric contents, decompress the stomach, and prevent gastric ileus and respiratory compromise. The patient was put on CRRT (20 mL/kg/hr), as, according to his critical condition, he needed slow, continuous dialysis, and an Oxiris filter was initiated, as it specifically helps in removing inflammatory cytokines, which are helpful in sepsis and multi-organ failure. The setup was changed every 48 hours to ensure continued efficacy. During the treatment, the patient showed no adverse outcomes.

Nursing management of the patient was carried out based on Roy’s Adaptation Model, developed by sister Callista Roy.^[1] According to Roy’s Adaptation Model, the goal of nursing is to promote the patient’s adaptive responses to physiological and psychosocial stressors. In the context of this patient with alcohol-induced AP, critical illness, and ventilatory dependence, nursing interventions were directed toward supporting adaptation across multiple domains: respiratory, renal, nutritional, emotional, and communicative. By enhancing the patient’s ability to respond effectively to these challenges, nursing care improved the interaction between the patient and the critical care environment, thereby facilitating recovery, restoring function, and contributing to overall health outcomes [Figure 1]. The outcomes are written in terms of the Nursing Outcomes Classification.

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Figure 1:

Nursing care based on Roy’s adaptation model.

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DISCUSSION

AP is an inflammatory condition of the pancreas characterized by abdominal pain and elevated levels of pancreatic enzymes. Several aetiologies are associated with AP. As per a prospective study conducted at King George’s Medical University, Lucknow, the majority (73%) of the participants were males with a mean age of 36.96 ± 13.44 years, and the most common etiology (71%) was alcohol.^[1] In this case also the case was also a 32-year-old male, and the related etiology was alcohol. AP causes acute inflammation and autodigestion by its own glandular enzymes, leading to multiorgan failure and death. The presentation of the case may vary from mild self-limiting to a severe condition.^[2] The present case presented in a severe decompensated stage with high fever, dropping oxygen levels, and signs and symptoms of renal impairment. For this, he was admitted to the LICU and put on ventilatory support and close intensive care monitoring. Chronic alcohol consumption accounts for 17% to 25% of AP cases globally and is the second leading cause after gallstones. It typically occurs in individuals with a history of heavy alcohol use, approximately 4 to 5 drinks per day, for more than 5 years.^[3] The type of alcohol consumed does not affect the risk.^[4] the present case had been consuming Beer on a regular basis, every week two to three times for more than 5 years. Severity is an important indicator of mortality and the need for intensive care, nutritional support, urgent surgical intervention, and antibiotic usage.^[5] In this case, the severity was determined based on Revised Atlanta criteria with Abdominal Pain, Lipase/Amylase levels at least three times the normal, and the high resolution - computed tomography findings. As per the recent guidelines, a moderate fluid resuscitation with preferably Ringer’s Lactate, antibiotics, and a normal diet should be undertaken.^[5] The present case was also initially managed with the same line of treatment.

In this case, on synchronized intermittent mandatory ventilation with an Oxiris filter was initiated early to manage the patient’s severe inflammatory and septic state at admission. By day 4, the development of acute kidney injury (AKI) was evident through deranged renal function parameters.

Endotoxins play an important role in the initiation and propagation of sepsis by inducing the release of cytokines.^[6] This may lead to the development of AKI.^[7,8] Some patients with AKI require RRT to remove toxic metabolites and excessive water. A benefit of CRRT is blood purification from endotoxins and cytokines.^[9] Apart from standard dialysis filters, some membranes are equipped with special adsorption capabilities. An oXiris hemofilter is a high-permeability polyacrylonitrile (AN69)-based membrane, enriched with a positively charged polyethyleneimine surface, which adsorbs negatively charged endotoxins.^[10] It is the only hemofilter to simultaneously provide renal replacement therapy, remove endotoxin molecules, and adsorb cytokines.^[11,12] By removing endotoxins and adsorbing cytokines, one might expect a decreased inflammatory state, a reduction in vasoplegia, capillary leaks, and, eventually, organ improvement. However, the clinical effectiveness of an Oxiris membrane is still being analyzed in the published literature.^[13]

As per a pooled meta-analysis study, use of the Oxiris filter with CRRT was found to be associated with significantly lower 28-day mortality in sepsis patients.^[14] In the present case, the patient was given CRRT with an Oxiris filter for 10 days, and a significant reduction of amylase levels, improvement in renal parameters, and overall general condition were noticed. However, the duration could not be compared with published findings because of a lack of sufficient data. Considering the risk of significant membrane clogging, the Oxiris haemofilter was replaced every 48 hours for this patient.^[15]

Nursing management in this case required close coordination with the medical team due to the severity of the patient’s condition. Nursing interventions were aligned with evidence-based practices, focusing on pain management, fluid resuscitation, and nutritional support. Given the patient’s critical and rapidly deteriorating status, nursing care often overlapped with medical management to ensure timely and comprehensive support.

CONCLUSION

The integration of CRRT with an Oxiris filter into the standard management of AP complicated by AKI may have the potential to enhance patient outcomes. However, given the limited available data, this report does not attribute the improvement in outcome specifically to the use of the Oxiris filter along with CRRT. However, coordinated and dedicated efforts of the medical and nursing teams are considered pivotal in influencing the overall prognosis of patients with severe AP.