What is the comprehensive management approach for acute pancreatitis?

Comprehensive Management of Acute Pancreatitis: 30-Question Assessment Questionnaire

Section 1: Initial Assessment and Diagnosis (Questions 1-5)

1. What are the three diagnostic criteria for acute pancreatitis, and how many must be present?

• Two of three criteria: upper abdominal pain, serum amylase or lipase elevation ≥3 times upper limit of normal, and characteristic imaging findings 1, 2

2. Within what timeframe must the correct diagnosis of acute pancreatitis be made?

• Within 48 hours of admission 3

3. What percentage of cases should have an identified etiology versus being classified as "idiopathic"?

• At least 80% should have identified etiology; no more than 20% should be idiopathic 3

4. When must severity stratification be completed?

• Within 48 hours of diagnosis using APACHE II, C-reactive protein, Glasgow score, or persistent organ failure (>48 hours) 3, 4

5. What is the target overall mortality rate and severe pancreatitis mortality rate?

• Overall mortality <10%; severe pancreatitis mortality <30% 3, 4, 2

Section 2: Initial Resuscitation and Monitoring (Questions 6-10)

6. What is the single most critical early intervention to prevent organ failure and reduce mortality?

• Aggressive early fluid resuscitation and oxygen supplementation within the first 12-24 hours 1, 2

7. What is the target urine output during fluid resuscitation?

• Greater than 0.5 ml/kg body weight 1, 4, 2

8. What oxygen saturation target should be maintained?

• Arterial saturation greater than 95% with continuous monitoring 2

9. What monitoring equipment is required for severe cases?

• Peripheral venous access, central venous line (for fluid administration and CVP monitoring), urinary catheter, and nasogastric tube 3, 1

10. What vital signs must be monitored hourly in severe cases?

• Pulse, blood pressure, central venous pressure, respiratory rate, oxygen saturation, urine output, and temperature 3, 1

Section 3: Location of Care and Specialist Services (Questions 11-13)

11. Where must all patients with severe acute pancreatitis be managed?

• In a high dependency unit (HDU) or intensive care unit (ICU) with full monitoring and systems support 3, 1, 4, 2

12. What percentage of pancreatic necrosis triggers discussion with or referral to a specialist unit?

• Greater than 30% necrosis 3

13. What are the five essential components of a specialist pancreatic unit?

• Multidisciplinary team (surgery, endoscopy, intensive care, anesthesia, gastroenterology, nutrition); team leader with pancreaticobiliary expertise; HDU/ITU facilities with renal and respiratory support; radiology expertise (dynamic CT, percutaneous procedures); 24-hour ERCP capabilities 3

Section 4: Pain Management (Questions 14-16)

14. What is the preferred opioid analgesic in non-intubated patients?

• Dilaudid is preferred over morphine or fentanyl 1

15. What medication class should be avoided in patients with acute kidney injury?

• NSAIDs should be avoided 1

16. What multimodal pain management approach should be considered?

• Epidural analgesia as alternative or adjunct to IV analgesia, integrated with patient-controlled analgesia (PCA) 1, 2

Section 5: Nutritional Support (Questions 17-20)

17. What is the preferred route of nutritional support and why?

• Enteral nutrition over total parenteral nutrition (TPN) to prevent gut failure and infectious complications 3, 1, 4, 2

18. What are the two safe routes for enteral feeding?

• Both gastric (nasogastric) and jejunal feeding routes are safe; nasogastric route is effective in 80% of cases 1, 2

19. When should enteral nutrition be initiated in severe cases?

• Early enteral feeding should be initiated, even in severe cases 1, 4, 2

20. When is parenteral nutrition indicated?

• If ileus persists for more than five days; partial parenteral nutrition can be considered if enteral route is not completely tolerated 1

Section 6: Antibiotic Therapy (Questions 21-23)

21. Should prophylactic antibiotics be used in mild acute pancreatitis?

• No, prophylactic antibiotics are not recommended in mild cases 3, 1, 2

22. What is the maximum duration of antibiotic prophylaxis in severe pancreatitis with necrosis?

• Maximum 14 days in the absence of positive cultures 3, 4, 2

23. What antibiotic provides reasonable balance between efficacy and cost for prophylaxis?

• Intravenous cefuroxime 1, 2

Section 7: Imaging (Questions 24-25)

24. When is CT scanning indicated in mild pancreatitis?

• Only if there are clinical signs of deterioration; routine CT is unnecessary 3, 1

25. When must CT scanning be performed in severe cases?

• Within 3-10 days for initial assessment; patients with persistent organ failure, signs of sepsis, or deterioration 6-10 days after admission require immediate CT 3, 4, 2

Section 8: Management of Biliary Pancreatitis (Questions 26-28)

26. Within what timeframe should urgent therapeutic ERCP be performed in severe gallstone pancreatitis?

• Within 24-72 hours after onset of pain in patients with severe pancreatitis, cholangitis, jaundice, or dilated common bile duct 3, 1, 4, 2

27. Is endoscopic sphincterotomy required in all patients undergoing early ERCP for severe gallstone pancreatitis?

• Yes, whether or not stones are found in the bile duct 3, 2

28. When must definitive management of gallstones occur?

• During the same hospital admission, unless a clear plan for definitive treatment within the next two weeks has been made 3, 4, 2

Section 9: Management of Pancreatic Necrosis (Questions 29-30)

29. Which patients require image-guided fine needle aspiration for culture?

• All patients with persistent symptoms and greater than 30% pancreatic necrosis, and those with smaller areas of necrosis and clinical suspicion of sepsis 3, 4, 2

30. What is the preferred approach for managing infected necrosis?

• Step-up approach starting with percutaneous or endoscopic drainage; delay surgical/radiologic/endoscopic drainage for 4 weeks when possible to allow wall formation; minimally invasive techniques preferred over open surgical necrosectomy 3, 1, 2