Journal of Surgical Sciences Vol.5, No.3, July – September 2018 166 CLINICAL CASE THERAPEUTIC PLASMAPHERESIS IN PRIMARY PRESENTATION OF DIABETES MELLITUS WITH DIABETIC KETOACIDOSIS, HYPERTRIGLYCERIDEMIA AND ACUTE PANCREATITIS Tonceanu Andra Maria 1,2 , R. Palade 2 , RR Grigorescu 2 , T Trotea 2 , Florentina Mușat 2 1 Department of Anesthesiology and Intensive Care, Emergency University Hospital, Bucharest 2 University of Medicine and Pharmacy “Carol Davila” Bucharest, Romania Corresponding author: Tonceanu Andra Maria Phone no.: 0040758426609 E-mail: tonceanu.a@gmail.com Abstract We present a case of severe hypertriglyceridemia- induced acute pancreatitis associated with diabetic ketoacidosis, managed in intensive care unit. The patient was a 39-year-old woman, with a medical history of Graves-Basedow disease, essential arterial hypertension and morbid obesity (body mass index=31). Firstly, we aggressively corrected hypovolemia and hemodynamic imbalances (administrating fluids and systemic anticoagulant) and then we focused on the infection prevention and control of intra-abodminal pressure, for latter outcome. We decided to start first session of plasma exchange. The patient responded well to the treatment applied. Plasma-exchange was very efficient, reducing TG levels by 60% after the first treatment and achieving a decrease of 77.6% at the third plasmapheresis session. This case was safely and effectively managed with plasmapheresis (three sessions), antibiotics, multimodal analgesia (intravenous and thoracic epidural catether), early jejunal nutrition and forced mobilization. The patient's evolution was significantly favorable, with a reduction of the peripancretic necrosis on computer scan, at day 28 and she was discharged with a normal value of TG and without pain or any clinical signs. Keywords: pancreatitis, plasmapheresi, hypertriglyceridemia Introduction Severe hypertriglyceridemia (HTG), defined as a level of triglycerides (TG) above 1000mg/dl, is the third most common cause of acute pancreatitis, and a potentially life threatening condition. The prognosis depends greatly on our ability to rapidly reduce serum TG concentration [1]–[3]. Plasmapheresis is a procedure where plasma exchange (PE) takes place. During the procedure, the plasma is separated from the blood cells, a large volume of it removed and replaced with a colloid solution in order to maintain oncotic pressure [4]. Poorly controlled diabetes mellitus and diabetic ketoacidosis can trigger (HTG). Acute pancreatitis in diabetic ketoacidosis usually occurs with severe metabolic acidosis characterized by a low serum pH (<7.1) and high anion gap [1], [5]. Marked elevation of serum TG occurs during episodes of acute pancreatitis. Lack of insulin results in lipolysis in adipose tissue with release of free fatty acids. Increased delivery of free fatty acids to the liver leads to high output of very low density