What are the appropriate orders for a patient diagnosed with acute pancreatitis?

Management Orders for Acute Pancreatitis

All patients with acute pancreatitis require hospital admission for diagnosis confirmation within 48 hours, severity stratification, aggressive supportive care, and monitoring for complications. 1, 2

Initial Diagnostic Orders

• Order serum lipase (preferred over amylase) for diagnostic confirmation 1
• Order comprehensive metabolic panel, complete blood count, liver function tests, triglycerides, and calcium 2
• Order right upper quadrant ultrasound to identify gallstone etiology in all patients 1, 2
• Determine etiology in at least 80% of cases—no more than 20% should remain idiopathic 1

Severity Assessment Orders (Within 48 Hours)

• Calculate APACHE II score within first 24 hours of admission 1, 2
• Order C-reactive protein (CRP) at admission and 48 hours—CRP >150 mg/L predicts complications 1, 2
• Calculate Glasgow score—score ≥3 indicates severe disease 1, 2
• Monitor for persistent organ failure beyond 48 hours (defines severe pancreatitis per Atlanta criteria) 1, 2
• Document obesity status as this independently predicts severity 1

Fluid Resuscitation Orders

Order goal-directed fluid resuscitation with Lactated Ringer's solution at 1.5 ml/kg/hr following an initial bolus of 10 ml/kg. 2, 3 This represents a paradigm shift from aggressive hydration with normal saline. 3

• Lactated Ringer's solution reduces systemic inflammatory response syndrome (SIRS) by 84% at 24 hours compared to normal saline 4 and significantly reduces CRP levels (51.5 vs 104 mg/dL, P=0.02) 4
• Avoid hydroxyethyl starch fluids as they increase risk of multiple organ failure 2
• Monitor urine output to maintain >0.5 ml/kg body weight 1
• Order central venous pressure monitoring in appropriate patients to guide fluid rate 1
• Avoid aggressive fluid resuscitation in predicted severe disease as it may be futile and deleterious 5

Oxygenation Orders

• Order continuous pulse oximetry monitoring 2
• Provide supplemental oxygen to maintain arterial saturation >95% 1, 2

Nutrition Orders

Order early oral feeding within 24 hours as tolerated rather than keeping patients nil per os. 2, 3

• If nutritional support is required, order enteral nutrition via nasogastric tube (effective in 80% of cases) rather than parenteral nutrition 1, 2
• Enteral feeding prevents infectious complications compared to parenteral nutrition 2
• Nasogastric feeding is as effective as nasojejunal feeding and easier to implement 1, 2

Pain Management Orders

• Order analgesics for pain control (specific agents not mandated by guidelines, but morphine should be used cautiously) 1, 6
• Monitor patients with pancreatitis receiving morphine for worsening symptoms as opioids may cause sphincter of Oddi spasm and increase serum amylase 7
• If prescribing opioids, routinely order laxatives to prevent opioid-induced constipation 8

Antibiotic Orders

Do not order routine prophylactic antibiotics in predicted severe or necrotizing pancreatitis. 2 The evidence is conflicting and there is no consensus on prophylactic antibiotics. 1

• If antibiotic prophylaxis is used, limit duration to maximum 14 days in the absence of positive cultures 1
• Reserve antibiotics for documented infected necrosis based on fine needle aspiration 1, 2

Imaging Orders for Severe Disease

Order contrast-enhanced CT with dedicated pancreas protocol for patients with:

• Persistent organ failure after 48 hours 1, 2
• Signs of sepsis 6-10 days after admission 1, 2
• Clinical deterioration 1, 2

CT technique: 100 ml non-ionic contrast at 3 ml/s, thin collimation (≤5 mm) at 40 seconds post-injection, with portal venous phase at 65 seconds 1

Orders for Gallstone Pancreatitis

Order urgent ERCP within 72 hours for patients with gallstone pancreatitis AND any of the following: 1, 2, 3

• Cholangitis (urgent ERCP within 24 hours mandatory) 2, 3
• Jaundice 1, 2
• Dilated common bile duct 1, 2
• Predicted or actual severe pancreatitis 1

Do not order urgent ERCP for gallstone pancreatitis without cholangitis or biliary obstruction. 3

• All patients undergoing early ERCP require endoscopic sphincterotomy whether or not stones are found 1
• Schedule cholecystectomy during same hospital admission or within 2 weeks of discharge to prevent recurrence 1, 8, 2

Monitoring Orders

• Order daily or more frequent reassessment to diagnose life-threatening complications early 2
• Continuous vital sign monitoring until danger of organ failure has passed 1
• Repeat severity assessment as condition is unstable especially in early stage 6

Admission Location Orders

For severe acute pancreatitis (persistent organ failure, >30% necrosis, or clinical deterioration), order admission to high dependency unit or intensive care unit with full monitoring and systems support. 1, 8, 2 This is mandatory, not optional. 1

Critical Pitfalls to Avoid

• Never discharge before 48-hour severity assessment is complete as organ failure can develop after initial presentation 8, 2
• Never delay definitive gallstone management beyond 2 weeks as this dramatically increases recurrence risk 8, 2
• Never order CT without intravenous contrast as it provides suboptimal information 1
• Never order aggressive fluid resuscitation in predicted severe disease without careful monitoring as it may worsen outcomes 2, 5

Audit Standards

• Mortality should be <10% overall and <30% in severe pancreatitis 1
• Correct diagnosis made in all patients within 48 hours 1
• Etiology determined in ≥80% of cases 1
• Severity stratification completed in all patients within 48 hours 1