Management of Severe Pancreatitis in Children
Children with severe acute pancreatitis require immediate ICU-level care with aggressive fluid resuscitation using Lactated Ringer's solution, early enteral nutrition within 24 hours, opioid analgesia preferably with hydromorphone, and close monitoring for organ failure—prophylactic antibiotics should only be used when pancreatic necrosis exceeds 30%. 1, 2, 3
Initial Assessment and Triage
Classify severity immediately upon diagnosis to determine the entire treatment approach. Severe pancreatitis carries 95% of mortality and requires ICU admission, while mild disease has <5% mortality and can be managed on general wards. 1, 2 Use clinical impression, obesity status, APACHE II score in the first 24 hours, C-reactive protein >150 mg/L, or persisting organ failure after 48 hours to predict severity. 1
Admit all severe cases to ICU or high-dependency unit with full invasive monitoring including central venous line for CVP monitoring, arterial line for blood gas analysis, urinary catheter for strict output monitoring, and nasogastric tube. 4, 2 Hypoxia and acidosis may be detected late by clinical assessment alone, making arterial blood gas monitoring essential. 4, 2
Fluid Resuscitation Strategy
Administer a 10 ml/kg bolus of Lactated Ringer's solution immediately in children with hypovolemia evidenced by tachycardia and vomiting. 5 Lactated Ringer's is strongly preferred over normal saline due to anti-inflammatory effects and superior outcomes. 5
Continue maintenance fluids at 1.5 ml/kg/hr for the first 24-48 hours, but keep total crystalloid administration below 4000 ml in 24 hours to prevent fluid overload and intra-abdominal hypertension. 5 Target urine output >0.5 ml/kg body weight as the primary resuscitation endpoint. 1, 5
Monitor hematocrit, blood urea nitrogen, creatinine, and lactate levels to assess tissue perfusion adequacy. 2, 5 In severe cases with vascular leak syndrome, administer intravenous fluids cautiously to prevent intra-abdominal hypertension and volume overload. 6
Monitoring Parameters
Record hourly vital signs including pulse, blood pressure, CVP, respiratory rate, oxygen saturation, urine output, and temperature with accurate charting and cumulative fluid balance calculations. 4, 1, 2 Patients with organ failure persisting >48 hours during the first week face the greatest risk of death. 1
Perform regular arterial blood gas analysis as clinical signs alone may miss early hypoxia and acidosis. 4, 2 When cardiocirculatory compromise exists or initial resuscitation fails, place a Swan-Ganz catheter for pulmonary artery wedge pressure, cardiac output, and systemic resistance measurements. 4
Pain Management
Use hydromorphone (Dilaudid) as the preferred opioid over morphine or fentanyl in non-intubated pediatric patients. 1, 2, 5 Consider epidural analgesia as an adjunct in a multimodal approach for severe pain. 1, 2 Avoid NSAIDs due to acute kidney injury risk. 5
Nutritional Support
Initiate enteral nutrition within 24 hours once pain improves and vomiting is controlled. 5, 3 Attempt oral feeding first, then nasogastric tube feeding (effective in 80% of cases), or nasoenteral tube if oral feeding is not tolerated. 1, 2, 3 Early enteral nutrition through any route (oral, gastric, or jejunal) should be started as early as tolerated. 3
Reserve parenteral nutrition only when enteral nutrition is inadequate or caloric goals cannot be met enterally. 2 Early nasoenteric feeding does not reduce infection or death rates compared to on-demand oral feeding in necrotizing pancreatitis. 4
Antibiotic Strategy
Do not use prophylactic antibiotics routinely in mild pancreatitis or uncomplicated cases, as there is no evidence of benefit. 4, 1, 2, 3 Antibiotics are warranted only when specific infections occur (chest, urine, bile, or line-related). 4
Consider prophylactic antibiotics only in severe acute pancreatitis with pancreatic necrosis exceeding 30%, limiting duration to maximum 14 days. 1, 2 Intravenous cefuroxime represents a reasonable balance between efficacy and cost. 2 Infected necrosis carries 40% mortality. 1
Imaging Strategy
Avoid routine CT scanning unless clinical deterioration occurs or signs of complications develop. 4, 1, 2 In severe cases, perform dynamic contrast-enhanced CT with non-ionic contrast within 3-10 days of admission to identify pancreatic necrosis. 1, 2
Perform image-guided fine needle aspiration 7-14 days after onset for patients with persistent symptoms and >30% pancreatic necrosis, or those with smaller areas and clinical suspicion of sepsis. 1, 2
Management of Gallstone Pancreatitis
Perform urgent therapeutic ERCP within 72 hours in children with severe gallstone pancreatitis accompanied by cholangitis, jaundice, or dilated common bile duct. 1, 2 ERCP with cholangitis is strongly indicated as early routine ERCP significantly reduces mortality and complications. 4
Do not perform routine ERCP for all acute gallstone pancreatitis cases without cholangitis or bile duct obstruction, as there is no evidence of benefit. 4 Always perform ERCP under antibiotic cover. 2
All patients undergoing early ERCP require endoscopic sphincterotomy whether or not stones are found in the bile duct. 1 If the patient fails to improve within 48 hours despite intensive resuscitation, proceed with urgent ERCP and sphincterotomy. 2
Respiratory Support
Institute mechanical ventilation when high-flow nasal oxygen or continuous positive airway pressure becomes ineffective in correcting tachypnea and dyspnea. 4 Invasive ventilation is mandatory when bronchial secretion clearance becomes ineffective or the patient is tiring. 4 Use lung-protective strategies when invasive ventilation is needed. 4
Management of Intra-Abdominal Hypertension
Limit sedation, fluids, and vasoactive drugs to achieve resuscitative goals at lower normal limits. 4 Deep sedation and paralysis may be necessary to limit intra-abdominal hypertension if all other nonoperative treatments including percutaneous drainage of intraperitoneal fluid are insufficient, before performing surgical abdominal decompression. 4
Interventions for Pancreatic Collections
Intervene for clinical deterioration with signs or strong suspicion of infected necrotizing pancreatitis using percutaneous or endoscopic drainage. 4 After 4 weeks, indications include ongoing organ failure without infected necrosis, gastric outlet/biliary/intestinal obstruction from large walled-off necrotic collections, disconnected duct syndrome, or symptomatic/growing pseudocysts. 4
Use a step-up approach with endoscopic transmural drainage followed by necrosectomy as the treatment strategy of choice for symptomatic or infected walled-off pancreatic necrosis. 6 Surgery has an important but limited role in pediatric acute pancreatitis. 7
Pediatric-Specific Considerations
Pediatric acute pancreatitis differs from adult disease with different risk factors and outcomes. 7, 8 The most common risk factors include biliary disease, drugs/toxins, and idiopathic causes. 8 Up to one-third of pediatric patients can have moderate or severe disease or progress to recurrent or chronic pancreatitis. 8 Children should be carefully followed for development of early or late complications and recurrent attacks. 3