Initial Management of Complicated Pancreatitis
The initial management of complicated pancreatitis should focus on goal-directed fluid resuscitation, early oral feeding as tolerated, avoiding prophylactic antibiotics, and management in a high dependency or intensive care unit with full monitoring and systems support. 1, 2
Severity Assessment and Triage
- All patients with complicated pancreatitis require thorough assessment for severity to guide appropriate level of care and management 1
- Patients with persisting organ failure, signs of sepsis, or deterioration in clinical status 6-10 days after admission require computed tomography (CT) to assess for complications and necrosis 3
- Laboratory markers including hematocrit, blood urea nitrogen, creatinine, and lactate should be monitored as indicators of adequate volume status and tissue perfusion 1, 2
Initial Resuscitation
- Goal-directed fluid therapy is recommended for initial management to optimize tissue perfusion without waiting for hemodynamic worsening 3, 1
- Hydroxyethyl starch (HES) fluids should be avoided in fluid resuscitation 3, 1
- Oxygen saturation should be measured continuously and supplemental oxygen administered to maintain arterial saturation greater than 95% 2
Pain Management
- Pain control is a clinical priority and should be addressed promptly using a multimodal approach 1
- Hydromorphone is preferred over morphine or fentanyl in non-intubated patients 1
- NSAIDs should be avoided in patients with acute kidney injury 1
- Epidural analgesia should be considered for patients with severe pancreatitis requiring high doses of opioids for extended periods 1
Nutritional Support
- Early oral feeding (within 24 hours) is strongly recommended rather than keeping patients nil per os 3, 1, 2
- For patients unable to tolerate oral intake, enteral nutrition is recommended over parenteral nutrition 3, 1
- Both nasogastric and nasojejunal feeding routes can be safely utilized 3, 1
- Total parenteral nutrition should be avoided but partial parenteral nutrition can be considered if enteral route is not completely tolerated 1
Antibiotic Management
- Prophylactic antibiotics are not recommended in complicated pancreatitis, including in predicted severe and necrotizing pancreatitis 3, 1, 2
- Antibiotics should be administered only when specific infections occur (respiratory, urinary, biliary, or catheter-related) 1
- In cases with evidence of infection, appropriate antibiotic coverage should be provided based on culture results 1
Management Based on Etiology
Gallstone Pancreatitis
- Urgent therapeutic endoscopic retrograde cholangiopancreatography (ERCP) should be performed in patients with acute biliary pancreatitis who have concomitant cholangitis, jaundice, or a dilated common bile duct 3, 1
- The procedure is best carried out within the first 72 hours after the onset of pain 3
- Cholecystectomy during the initial admission is recommended for patients with biliary pancreatitis 3, 1
Alcoholic Pancreatitis
- Brief alcohol intervention during admission is recommended for patients with alcohol-induced pancreatitis 3, 1
Management of Necrosis
- All patients with persistent symptoms and greater than 30% pancreatic necrosis, and those with smaller areas of necrosis and clinical suspicion of sepsis, should undergo image-guided fine needle aspiration to obtain samples for culture 3
- Patients with infected necrosis will require intervention to completely debride all cavities containing necrotic material 3
- The choice of surgical technique for necrosectomy depends on individual features and locally available expertise 3
Level of Care
- All patients with severe acute pancreatitis should be managed in a high dependency unit or intensive therapy unit with full monitoring and systems support 3, 2
- Management in, or referral to, a specialist unit is necessary for patients with extensive necrotizing pancreatitis or with other complications who may require intensive therapy unit care, or interventional radiological, endoscopic, or surgical procedures 3