What are the guidelines for managing necrotizing pancreatitis?

Management of Necrotizing Pancreatitis

Initial Management and Monitoring

All patients with necrotizing pancreatitis must be managed in a high dependency unit (HDU) or intensive care unit (ICU) with comprehensive hourly monitoring of vital signs including pulse, blood pressure, central venous pressure, respiratory rate, oxygen saturation, urine output, and temperature. 1, 2

Fluid Resuscitation

• Use goal-directed fluid therapy with crystalloid or colloid at 1.5 ml/kg/hr following an initial bolus of 10 ml/kg to maintain urine output >0.5 ml/kg body weight 3, 2
• Avoid aggressive fluid resuscitation protocols as they increase mortality and complications without improving clinical outcomes 1
• Monitor for abdominal compartment syndrome, which requires early intervention if unresponsive to conservative management 1, 2

Respiratory Support

• Provide supplemental oxygen to maintain arterial saturation >95% 3, 2
• Monitor respiratory status continuously for early detection of respiratory failure 1

Pain Management

• Implement a multimodal approach to pain control, with dilaudid as the preferred analgesic 1
• Consider epidural analgesia for patients requiring high doses of opioids for extended periods 1
• Avoid NSAIDs in patients with acute kidney injury 1

Diagnostic Imaging

Dynamic contrast-enhanced CT scanning should be obtained within 3-10 days of admission using non-ionic contrast to assess the extent of necrosis. 1, 2

• Perform follow-up CT scans only if the patient's clinical status deteriorates or fails to show continued improvement 2
• For patients with persistent symptoms and >30% pancreatic necrosis, perform image-guided fine needle aspiration to diagnose infected necrosis (sensitivity 96%) 1, 2, 4

Nutritional Support

Enteral nutrition is strongly preferred over parenteral nutrition and should be initiated early within 24 hours via nasogastric or nasojejunal tube to prevent gut failure and infectious complications. 1, 3, 2

• Nasogastric feeding is effective in approximately 80% of cases and can be used instead of nasojejunal feeding 3
• Both gastric and jejunal feeding routes are delivered safely 1
• Reserve parenteral nutrition only for patients who cannot tolerate enteral nutrition or when enteral nutrition is contraindicated 1
• In patients with intra-abdominal pressure (IAP) >15 mmHg, initiate enteral nutrition via nasojejunal route starting at 20 mL/h with rate increases based on tolerance 1
• Temporarily discontinue enteral nutrition and initiate parenteral nutrition when IAP exceeds 20 mmHg or abdominal compartment syndrome develops 1

Antibiotic Management

Prophylactic antibiotics are not routinely recommended for prevention of pancreatic necrosis infection. 1, 3

• Administer antibiotics only when specific infections are documented, such as infected necrosis, respiratory infections, or urinary infections 1, 3
• If antibiotic prophylaxis is used, limit duration to a maximum of 14 days 1, 3
• When early antibiotic treatment (imipenem/cilastatin) is used, be aware that pancreatic infection characteristics change to predominantly gram-positive and fungal infections 4

Management Based on Infection Status

Sterile Necrosis (Mortality 0-11%)

• Focus on fluid resuscitation, nutritional support, and monitoring for complications 5, 2
• Conservative management without surgery is the treatment of choice, with mortality rates as low as 1.8% 4
• Continue intensive monitoring for development of infection or organ failure 2

Infected Necrosis (Mortality 40% average, up to 70%)

Interventions for infected necrosis should be delayed until at least 4 weeks after disease onset when possible, as this results in lower mortality by allowing time for "walled-off" necrosis to develop. 1, 2, 6, 7

Step-Up Approach

• Start with percutaneous catheter drainage or endoscopic (transgastric/transduodenal) drainage as the initial intervention 6, 7, 8
• Place a second drain if no clinical improvement occurs after initial drainage 6
• Progress to minimally invasive necrosectomy only if no improvement occurs after drainage, using video-assisted retroperitoneal debridement (VARD), minimally invasive retroperitoneal pancreatectomy (MIRP), or transluminal direct endoscopic necrosectomy (DEN) 6, 7
• Reserve open necrosectomy for cases where minimally invasive approaches fail, as it is associated with substantially higher morbidity 6, 8

Indications for Early Intervention (<4 weeks)

• Abdominal compartment syndrome unresponsive to conservative management 1, 2
• Acute ongoing bleeding when endovascular approach is unsuccessful 1, 2
• Bowel ischemia or acute necrotizing cholecystitis 1, 2

Management of Biliary Necrotizing Pancreatitis

Urgent therapeutic ERCP should be performed within 72 hours in patients with necrotizing pancreatitis of suspected or proven gallstone etiology who have cholangitis, jaundice, or a dilated common bile duct. 1, 3, 2

• All patients with biliary pancreatitis should undergo definitive management of gallstones (cholecystectomy) during the same hospital admission, unless a clear plan has been made for definitive treatment within the next two weeks 1, 3, 2

Referral Considerations

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. 1, 2

• Every hospital that receives acute admissions should have a single nominated clinical team to manage all patients with acute pancreatitis 1, 2
• Optimal treatment requires a multi-disciplinary team including interventional radiologists, therapeutic endoscopists, and surgeons 6, 8

Mortality Expectations

• Overall mortality from necrotizing pancreatitis is 30-40% 5
• Target overall mortality should be lower than 30% in those diagnosed with severe disease 5
• Approximately one-third of deaths occur in the early phase from multiple organ failure, while most deaths after the first week are due to infected necrosis 5
• Specialist centers using aggressive surgical debridement for infected necrosis have reported mortality rates between 10-20% 5

Critical Pitfalls to Avoid

• Do not perform early surgical intervention (<4 weeks) for pancreatic necrosis, as this results in higher mortality 3
• Do not use aggressive fluid resuscitation rates that may lead to fluid overload and abdominal compartment syndrome 1, 3
• Do not administer prophylactic antibiotics routinely, as they do not prevent infection of pancreatic necrosis 1, 3
• Do not proceed directly to open necrosectomy without attempting the step-up approach with drainage first 6, 7, 8