How do you manage acute pancreatitis in a ward setting?

Step-by-Step Management of Acute Pancreatitis in the Ward Setting

All patients with acute pancreatitis should be managed in a high dependency unit (HDU) or intensive care unit (ICU) with full monitoring and systems support, especially those with severe disease. 1

Initial Assessment and Monitoring

• Establish continuous vital signs monitoring including hourly pulse, blood pressure, central venous pressure, respiratory rate, oxygen saturation, urine output, and temperature 1
• Place peripheral venous access, central venous line (for fluid administration and CVP monitoring), urinary catheter, and nasogastric tube in severe cases 1
• Perform regular arterial blood gas analysis to detect hypoxia and acidosis 1
• Monitor laboratory markers including hematocrit, blood urea nitrogen, creatinine, and lactate as indicators of adequate tissue perfusion 2, 1
• Persistent organ dysfunction despite adequate fluid resuscitation is an indication for ICU admission 2

Fluid Resuscitation

• Initiate early fluid resuscitation to optimize tissue perfusion without waiting for hemodynamic worsening 2
• Use moderate fluid resuscitation at a rate of 1.5 ml/kg/hr following an initial bolus of 10 ml/kg rather than aggressive resuscitation, as aggressive resuscitation has been associated with higher incidence of fluid overload without improvement in clinical outcomes 3
• Prefer isotonic crystalloids, particularly Lactated Ringer's solution over normal saline, as it may reduce systemic inflammation 2, 4
• Guide fluid administration by frequent reassessment of hemodynamic status to avoid fluid overload, which has detrimental effects 2
• Aim to maintain urine output >0.5 ml/kg body weight 1

Pain Management

• Prioritize pain control using a multimodal approach 1
• Consider hydromorphone (Dilaudid) over morphine or fentanyl in non-intubated patients 1
• Avoid NSAIDs in patients with acute kidney injury 1
• Consider epidural analgesia as an alternative or adjunct to intravenous analgesia 1
• Implement patient-controlled analgesia (PCA) when appropriate 1

Nutritional Support

• Initiate early enteral nutrition over total parenteral nutrition (TPN) to prevent gut failure and infectious complications 1
• Both gastric and jejunal feeding can be safely delivered 1
• Start enteral nutrition early, even in severe cases 1
• Consider partial parenteral nutrition integration if enteral route is not completely tolerated 1
• Implement TPN if ileus persists for more than five days 1

Antibiotic Therapy

• Do not administer prophylactic antibiotics in mild cases of acute pancreatitis 1
• Consider prophylactic antibiotics in severe acute pancreatitis with evidence of pancreatic necrosis 1
• Use intravenous cefuroxime as a reasonable balance between efficacy and cost for prophylaxis in severe cases 2
• Administer antibiotics with good pancreatic tissue penetration such as carbapenems or piperacillin/tazobactam when treating confirmed infections 2
• Treat specific infections (chest, urine, bile, or cannula related) with appropriate antibiotics 1

Management of Biliary Causes

• Perform urgent therapeutic ERCP in patients with acute pancreatitis of suspected or proven gallstone etiology who have severe pancreatitis, cholangitis, jaundice, or a dilated common bile duct 1
• Conduct ERCP preferably within the first 72 hours after the onset of pain 1
• Perform endoscopic sphincterotomy in all patients undergoing early ERCP for severe gallstone pancreatitis whether or not stones are found in the bile duct 1
• Always perform ERCP under antibiotic cover 2

Imaging

• Obtain dynamic CT scanning in severe cases within three to ten days of admission to identify pancreatic necrosis and guide management 2, 1
• Use non-ionic contrast for CT scans 2
• Perform follow-up CT only if the patient's clinical status deteriorates or fails to show continued improvement in severe cases 1

Management of Complications

• Monitor for infected necrosis, which is the most serious local complication with a high mortality rate 1
• Consider surgical debridement for infected necrosis 1
• Evaluate minimally invasive approaches for debridement of infected necrosis before open surgical necrosectomy 1
• Address local complications such as pseudocyst and pancreatic abscess with surgical, endoscopic, or radiological intervention as appropriate 1
• Manage each case in an individualized way by a multidisciplinary specialist pancreatic team 1

Specialist Care

• Ensure management by a single nominated clinical team for all patients with acute pancreatitis 1
• Refer patients with extensive necrotizing pancreatitis (>30% necrosis) or with other complications to a specialist unit 1
• Implement a multidisciplinary team approach for optimal management 1

Common Pitfalls to Avoid

• Relying solely on clinical assessment without regular blood gas monitoring, which may lead to delayed recognition of worsening acidosis 5
• Using hydroxyethyl starch fluids for resuscitation, which should be avoided in acute pancreatitis 5
• Administering excessive fluid resuscitation, which can lead to fluid overload and worse outcomes 3
• Delaying enteral nutrition, which may increase the risk of infectious complications 1
• Overuse of prophylactic antibiotics in mild cases, which may lead to antibiotic resistance 1