How do you manage the patient with severe acute pancreatitis?

Key Principles

  • Aggressive fluid resuscitation and pain management
  • Early ERCP if indicated
  • Early enteral feeding (preferably via NG route)
  • Avoid early surgical intervention for necrotic pancreatitis
  • Vigilant supportive care to avoid complications
Initial Resuscitation & Supportive Care
  • ABCDE approach treating abnormalities as found
  • Manage airway and breathing:
    • If intubation may be required, aspiration a major risk
    • Multifactorial causes for respiratory failure (ARDS, diaphragmatic splinting (pain, intra-abdominal oedema or fluid collections) or pleural effusions)
  • Optimise haemodynamics:
    • Early and aggressive fluid resuscitation
    • May require vasopressor support if severe systemic inflammatory response
    • Maintain UO >0.5 ml/Kg
  • Manage electrolyte abnormalities:
    • Vigilance over hypocalcaemia and arrhythmias
  • Ensure optimal analgesia:
    • PCA usually required
    • Some support use of thoracic epidural
    • Aim to prevent further atelectasis
  • Correct coagulopathy in the setting of VTE
  • Optimise nutrition:
    • Early enteral feeding (within 72 hours):
      • Nasogastric - effective in 80%
      • Nasojejunal second line
    • No advantages for early TPN - only after 7 days if enteral fails
  • Vigilance to good supportive care - often long stays and prone to complications
    • Strict glycaemic control
    • DVT prophylaxis (balance against risk of intrabdominal haemorrhage)
    • Stress ulcer prophylaxis
    • VAP bundles
    • Aseptic precautions
Specific Management
  • Management of biliary obstruction
    • Early ERCP indicated to remove gallstone (within 72 hours)
    • Coagulation should be corrected
    • Surgical management of gallstones during same hospital admission or within 2 weeks
  • Management of infected collection / necrosis
    • Prophylactic antibiotics not routinely recommended
    • If clinical sepsis ensure blood cultures taken and treat as per surviving sepsis
    • If >30% pancreatic necrosis, should undergo FNA to obtain material for culture 7–14 days after the onset of the pancreatitis
    • If infected abscess confirmed post-needle aspiration prescribed according to local guidelines
    • If infected will require definitive intervention (Ideally delay until 4 weeks):
      • Radiological drainage first line - successful in 50%
      • Endoscopic drainage
      • Surgical drainage (delay until clear demarcation)
  • If evidence of retroperitoneal gas on CT:
    • Broad spectrum antibiotics
    • Surgical drainage or debridement
    • Delayed surgery (>2 weeks):
      • Associated with increased survival
      • Allows demarcation of necrotic and preserved tissue
Referral & Deposition
  • All patients with sever acute pancreatitis should be manages on HDU
  • Refer all with persisting organ failure or requiring intervention to regional centre