What are the initial management steps for acute pancreatitis?

Initial Management of Acute Pancreatitis

Adequate prompt fluid resuscitation is crucial in preventing systemic complications of acute pancreatitis and should be initiated immediately upon diagnosis. 1

Severity Assessment

• Severity assessment should be performed immediately using objective criteria to guide appropriate management decisions 1
• Laboratory markers including hematocrit, blood urea nitrogen (BUN), creatinine, and liver function tests should be monitored as indicators of severity and adequate volume status 1
• CT severity index can help stratify patients into mild (scores 0-3% mortality), moderate (scores 4-6% mortality), or severe disease (scores 7-10,17% mortality) 1, 2

Initial Resuscitation

• Intravenous crystalloids (preferably Lactated Ringer's solution) should be administered to maintain urine output >0.5 ml/kg body weight 1, 3
• Oxygen saturation should be measured continuously and supplemental oxygen administered to maintain arterial saturation greater than 95% 1
• An early elevated hematocrit, BUN, or creatinine should prompt more intensive resuscitation measures 4
• Aggressive fluid resuscitation (20 ml/kg bolus followed by 3 ml/kg/h) has been shown to hasten clinical improvement in mild acute pancreatitis compared to standard hydration 5

Management Based on Severity

Mild Acute Pancreatitis (80% of cases, <5% of deaths)

• Can be managed on a general ward with basic monitoring of temperature, pulse, blood pressure, and urine output 2
• Peripheral intravenous line for fluids and possibly a nasogastric tube are required, but indwelling urinary catheters are rarely warranted 2
• Antibiotics should not be administered routinely as there is no evidence that their use in mild cases affects outcomes 2
• Routine CT scanning is unnecessary unless there are clinical signs of deterioration 2
• Early oral feeding (within 24 hours) is recommended rather than keeping patients nil per os 1

Severe Acute Pancreatitis (20% of cases, 95% of deaths)

• Should be managed in an HDU or ITU setting with full monitoring and systems support 2, 1
• Requires peripheral venous access, central venous line (for fluid administration and CVP monitoring), urinary catheter, and nasogastric tube 2
• Strict asepsis should be observed in the placement and care of invasive monitoring equipment as these may serve as a source of subsequent sepsis in the presence of pancreatic necrosis 2
• Regular arterial blood gas analysis is essential as hypoxia and acidosis may be detected late by clinical means alone 2
• Hourly monitoring of pulse, blood pressure, CVP, respiratory rate, oxygen saturation, urine output, and temperature is required 2
• When cardiocirculatory compromise exists, or if initial resuscitation fails to produce clinical improvement, a Swan-Ganz catheter may be required 2

Pain Management

• Pain control is a clinical priority and should be addressed promptly 1
• A multimodal approach to analgesia is recommended, with intravenous opiates generally safe if used judiciously 1
• NSAIDs should be avoided in patients with acute kidney injury 1

Nutritional Support

• For patients unable to tolerate oral intake, enteral nutrition is recommended over parenteral nutrition 1
• Both gastric and jejunal feeding routes can be safely utilized 1
• Total parenteral nutrition should be avoided but partial parenteral nutrition can be considered if enteral route is not completely tolerated 1

Management Based on Etiology

Gallstone Pancreatitis

• Urgent ERCP (within 24 hours) should be performed in patients with concomitant cholangitis 1
• Early ERCP (within 72 hours) is indicated for patients with high suspicion of persistent common bile duct stone, persistently dilated common bile duct, or jaundice 1

Common Pitfalls to Avoid

• Using hydroxyethyl starch (HES) fluids in resuscitation - these should be avoided 1
• Relying on CVP alone as a crude indicator of adequate resuscitation may be unreliable, potentially leading to the use of inotropes/vasopressors in the inadequately filled patient 6
• Routine use of prophylactic antibiotics in mild pancreatitis - only indicated for specific infections 2
• Keeping patients nil per os unnecessarily - early oral feeding is beneficial when tolerated 1
• Relying on specific pharmacological treatments - there is no proven specific drug therapy for the treatment of acute pancreatitis 2, 1
• Inadequate fluid resuscitation - cumulative volume of crystalloid given has been shown to be significantly less at 48h in patients who died in hospital compared to survivors 6