What is the management plan for complications of pancreatitis?

Management Plan for Complications of Pancreatitis

The management of pancreatitis complications requires a systematic approach focused on early identification and aggressive intervention, with all patients with severe acute pancreatitis requiring management in a high dependency or intensive care unit with full monitoring and systems support. 1

Initial Assessment and Monitoring

• All patients with pancreatitis require ongoing reassessment on a daily or more frequent basis to diagnose life-threatening complications early 1
• Clinical monitoring should include assessment for prolonged ileus, abdominal distension, tenderness, epigastric mass, vomiting, and signs of sepsis 1
• Laboratory monitoring should include leucocyte and platelet counts, clotting studies, APACHE II score, and CRP concentration to detect possible sepsis 1
• Oxygen saturation should be measured continuously with supplemental oxygen administered to maintain arterial saturation greater than 95% 2
• Minimum monitoring should include hourly pulse, blood pressure, CVP, respiratory rate, oxygen saturation, urine output, and temperature 2

Fluid Resuscitation

• Non-aggressive fluid resuscitation at a rate of 1.5 ml/kg/hr following an initial bolus of 10 ml/kg is recommended, with Lactated Ringer's solution preferred 3
• Total crystalloid fluid administration should be less than 4000 ml in the first 24 hours to avoid fluid overload 3
• Fluids should be given intravenously to maintain urine output >0.5 ml/kg body weight 1
• The rate of fluid replacement should be monitored by frequent measurement of central venous pressure in appropriate patients 1

Imaging for Complications

• Dynamic CT should be performed within 3-10 days of admission in severe cases to assess the extent of pancreatic necrosis 2
• CT severity index combines CT grade and necrosis score to predict complications and mortality 1
• Follow-up CT scans are recommended only if the patient's clinical status deteriorates or fails to show continued improvement 1
• Ultrasound is helpful in the evaluation and serial monitoring of fluid collections 1

Management of Specific Complications

Infected Necrosis

• All patients with persistent symptoms and >30% pancreatic necrosis, or smaller areas with clinical suspicion of sepsis, should undergo image-guided fine needle aspiration 1
• Patients with infected necrosis require intervention to completely debride all cavities containing necrotic material 1
• The choice of surgical technique for necrosectomy depends on individual features and locally available expertise 1

Gallstone Pancreatitis

• Urgent ERCP should be performed in patients with acute pancreatitis of suspected or proven gallstone etiology who have severe pancreatitis, cholangitis, jaundice, or a dilated common bile duct 1
• The procedure is best carried out within the first 72 hours after the onset of pain 1
• All patients with biliary pancreatitis should undergo definitive management of gallstones during the same hospital admission or within two weeks 1
• In mild gallstone pancreatitis, cholecystectomy should be performed as soon as the patient has recovered, preferably during the same hospital admission 1
• In severe acute pancreatitis, cholecystectomy should be done later when the inflammatory process has subsided 1

Respiratory Failure

• Mechanical ventilation must be instituted when oxygen supply becomes ineffective in correcting tachypnea and dyspnea 2
• Lung-protective strategies should be used when invasive ventilation is needed 2

Nutritional Support

• If nutritional support is required, the enteral route should be used if it can be tolerated 1
• The nasogastric route for feeding can be used as it appears to be effective in 80% of cases 1
• Enteral nutrition is recommended to prevent gut failure and infectious complications 2

Antibiotic Management

• The evidence regarding antibiotic prophylaxis against infection of pancreatic necrosis is conflicting 1
• If antibiotic prophylaxis is used, it should be given for a maximum of 14 days 1
• Intravenous cefuroxime may be a reasonable balance between efficacy and cost for prophylaxis 2

Pain Management

• Pain control is a clinical priority and should be addressed promptly using a multimodal approach 2
• Dilaudid is preferred over morphine or fentanyl in the non-intubated patient 2

Referral to Specialist Centers

• Management in, or referral to, a specialist unit is necessary for patients with extensive necrotizing pancreatitis or with other complications 1
• Every hospital that receives acute admissions should have a single nominated clinical team to manage all patients with acute pancreatitis 1

Common Pitfalls to Avoid

• Avoid using hydroxyethyl starch fluids in resuscitation 2
• Avoid aggressive fluid resuscitation rates 3
• Do not wait for hemodynamic worsening before initiating fluid resuscitation 3
• Avoid fluid overload, which is associated with worse outcomes and increased mortality 3