What is the initial management of acute pancreatitis?

Initial Management of Acute Pancreatitis

Immediate Severity Assessment and Triage

Begin with immediate severity stratification using objective criteria (BISAP or APACHE II scores) to determine appropriate level of care and guide management intensity. 1

• Monitor laboratory markers including hematocrit, blood urea nitrogen, creatinine, and lactate as indicators of severity and tissue perfusion 1, 2
• Obtain CT severity index if needed for risk stratification (scores 0-3: mild with 3% mortality; scores 4-6: moderate with 6% mortality; scores 7-10: severe with 17% mortality) 1
• Measure oxygen saturation continuously and administer supplemental oxygen to maintain arterial saturation >95% 1, 2

Fluid Resuscitation Strategy

Use goal-directed, non-aggressive fluid resuscitation with Lactated Ringer's solution at 1.5 ml/kg/hr following an initial bolus of 10 ml/kg only if the patient is hypovolemic. 3

Initial Bolus

• Administer 10 ml/kg bolus in hypovolemic patients 3
• No bolus in normovolemic patients 3

Maintenance Rate

• Continue at 1.5 ml/kg/hr for the first 24-48 hours 3
• Keep total crystalloid administration <4000 ml in the first 24 hours 3
• Use Lactated Ringer's solution preferentially over normal saline due to anti-inflammatory effects 3, 4

Monitoring Targets

• Maintain urine output >0.5 ml/kg body weight 1, 3
• Monitor central venous pressure frequently in appropriate patients 1, 3
• Track hematocrit, blood urea nitrogen, creatinine, and lactate levels 3, 2
• Reassess hemodynamic status frequently to avoid fluid overload 3

Critical Pitfall

• Avoid aggressive fluid resuscitation rates (>10 ml/kg/hr or >250-500 ml/hr) as these increase mortality risk in severe pancreatitis and fluid-related complications without improving outcomes 3
• Never use hydroxyethyl starch (HES) fluids 1, 3

Pain Management

Implement multimodal analgesia immediately with hydromorphone as the preferred opioid in non-intubated patients. 2

• Intravenous opiates are generally safe when used judiciously 1, 5
• Avoid NSAIDs in patients with any evidence of acute kidney injury 1, 2

Nutritional Support

Initiate early oral feeding within 24 hours rather than keeping patients nil per os. 1, 2

• For patients unable to tolerate oral intake, use enteral nutrition over parenteral nutrition 1, 2
• Both nasogastric and nasojejunal feeding routes are safe 1, 2
• Total parenteral nutrition should be avoided, but partial parenteral nutrition can be considered if enteral route is not completely tolerated 1

Antibiotic Management

Do not administer prophylactic antibiotics routinely in acute pancreatitis, including in predicted severe and necrotizing pancreatitis. 1, 2

• Use antibiotics only when specific infections are documented (respiratory, urinary, biliary, or catheter-related) 1, 2
• This applies to both mild and severe cases with pancreatic necrosis 1, 2

Level of Care Based on Severity

Mild Acute Pancreatitis

• Manage on general ward with basic monitoring of temperature, pulse, blood pressure, and urine output 1
• Peripheral intravenous line and possibly nasogastric tube are sufficient 1
• Indwelling urinary catheters are rarely warranted 1
• Routine CT scanning is unnecessary unless clinical deterioration occurs 1

Severe Acute Pancreatitis

• Manage in HDU or ICU setting with full monitoring and systems support 1, 2
• Requires peripheral venous access, central venous line, urinary catheter, and nasogastric tube 1
• Hourly monitoring of pulse, blood pressure, CVP, respiratory rate, oxygen saturation, urine output, and temperature 1
• Obtain dynamic CT scanning within 3-10 days of admission using non-ionic contrast 1, 2
• Regular arterial blood gas analysis is essential 1
• Maintain strict asepsis with all invasive monitoring equipment 1, 2

Etiology-Specific Management

Gallstone Pancreatitis

• Perform urgent ERCP within 24 hours in patients with concomitant cholangitis 1, 2
• Early ERCP within 72 hours is indicated for patients with high suspicion of persistent common bile duct stone, persistently dilated common bile duct, or jaundice 1
• Cholecystectomy during initial admission is recommended 2

Alcoholic Pancreatitis

• Provide brief alcohol intervention during admission 2

Discontinuing IV Fluids

Discontinue IV fluids when pain resolves and the patient can tolerate oral intake. 3

• In mild pancreatitis, IV fluids can typically be discontinued within 24-48 hours 3
• Progressively wean IV fluids rather than stopping abruptly to prevent rebound hypoglycemia 3
• Begin oral refeeding with diet rich in carbohydrates and proteins but low in fats when pain has resolved 3

Management of Persistent Hypoperfusion

If lactate remains elevated after 4L of fluid:

• Do not continue aggressive fluid resuscitation 3
• Perform hemodynamic assessment to determine the type of shock 3
• Consider dynamic variables over static variables to predict fluid responsiveness 3
• Reassess for other causes of tissue hypoperfusion 3