Management protocol for acute pancreatitis

Management Protocol for Acute Pancreatitis (Treatment Summary)

St. Paul’s Hospital Millennium Medical College
Department of Surgery
Maheteme Bekele, MD, Assistant professor of surgery, Girmaye Tamirat, MD, Assistant
Professor of Surgery & Kirubel Abebe, General surgery Resident

o Initial measure is to determine the severity as per definition by Atlanta Symposium.

If one of the following criteria is met it is considered as severe pancreatitis
 A Ranson's score of 3 or more
 An APACHE II score of 8 or more within the first 48 hours
 Organ failure
 Local complications (pancreatic necrosis, abscess, or pseudocyst).
o Criteria for ICU care
 Severe pancreatitis
 Mild pancreatitis which progressed to severe form
 Sustained hypoxemia, hypotension refractory to a bolus of IV fluids, and
possibly renal insufficiency that does not respond to a fluid bolus
o Components of treatment

Oxygen Infection
supplementation control

Nutrition Rx of
pancreatic
necrosis

Pain Control Rx of
associated
conditions

Treatment Correct
Componants electrolyte &
Fluid
Metabolic
Replacement of Acute abnormalitie
Pancreatitis s

Department of surgery
Management protocol for acute pancreatitis

1. Fluid replacement
 Type of fluid
 Ringer lactate is the preferred fluid
 Use normal saline in the face of hypercalcemia
 Amount to give
 2oml/Kg over 1-2 hrs then 250-300 ml/hr over 48 hrs. (fluid can
be adjusted according to patient condition & responses)
 Follow up –see at the end
2. Oxygen supplementation
 Maintain arterial oxygen saturation above 95%
 If below 95% start supplementation
 Nasal Catheter (2L/min-5L/min) either continuous or intermittently
depending on response
 Facemask from 5L/min-15L/min continuous( if no response with
nasal catheter)
 Mechanical ventilation if there is
 Persistent or progressive hypoxia
 Respiratory failure
3. Correct electrolyte & Metabolic abnormalities
 Hypocalcium- correct if ionized calcium is low (<4.65mg/dl) or
symptomatic
o Calcium gluconate 10% 1 to 2 g in 50 mL of 5 percent
dextrose infused over 10 to 20 minutes then 11g in 1000ml of
normal saline or 5 percent dextrose water over 24 hr
 Hypercalcemia
 Serum glucose level should be controlled with sliding scale
insulin(follow the hospital recommendation)
4. Pain Control
 No evidence to suggest an advantage of any particular type of
medication
 Start with NSAIDs Diclofenac 75mg IM daily or BID depending on
patients response
 If no response add Tramadol 50-100mg IV TID or QID

Department of surgery
Management protocol for acute pancreatitis

 Still if no response to the above combination switch to pethidine 50mg -

100mg IM or IV TID Or QID
 Doses should be adjusted if there is renal function impairment
5. Nutritional Support
 In Mild pancreatitis Intravenous hydration alone is enough (Maintenance
fluid & Estimated loss)
 Normal saline, Ringer lactate & D5NS each 1L every 8 hr
alternatively & add 2o MEq potassium in each liter
 Early Nutritional support (24 to 48 hours)- Enteral feeding
 Sever pancreatitis
 In those who are unlikely to resume oral intake for more than five
to seven days
 Endoscopic placement of a jejunal feeding (Nasojejunal) tube
beyond the ligament of Treitz (if not possible nasogastric feeding
is alternative).
 Start with 25ml|hr & advance as tolerated to at least 30% of the
calculated daily requirement (25 kcal/kg ideal body weight)
 Type of diet
 High protein & low fat
 BMD-1ml=lcal
 Initiation of oral feeding
 In Mild acute pancreatitis in the absence of ileus, nausea,
vomiting, or as soon as pain starts improving ( 24 to 48 hours)
 In Sever acute pancreatitis when the local complications start
improving
 Advance from a clear liquid diet to solid food as tolerated
6. Infection control
 Prophylactic antibiotics
 Indication
 Necrotizing pancreatitis involving >30% of the pancreases
 Drugs
 Meropenem 1g IV QID (Drug of choice)

Department of surgery
Management protocol for acute pancreatitis

 Ceftriaxone 1g-2g IV BID & Metronidazole 500mg-1g IV

TID-QID (Alternative)
 Duration
 Discontinue after 7 to 10 days unless infection is confirmed
(CT-guided percutaneous aspiration-Gram's stain or culture
positive) or clinical evidences
 Treatment of Pancreatic Necrosis
 Indications for laparotomy & necrosectomy (Surgical
debridement of pancreatic necrosis)
 Infected pancreatic necrosis
 Sterile symptomatic pancreatic necrosis with chronic low
grade fever, nausea, lethargy, and abdominal pain
preventing oral intake
 Diagnostic uncertainty
 Intra-abdominal catastrophe unrelated to necrotizing
pancreatitis such as perforated viscus
 Timing of debridement
 Optimal timing is at least three to four weeks following the
onset of acute pancreatitis
 Approach
 All patients with pancreatic necrosis undergoing
debridement should have contrast enhanced CT scanning
of the abdomen and pelvis to define the extent and
location of necrotic areas
 Open debridement with external drainage
o Consider cholecystectomy if technically possible
o Send culture for bacteria’s & fungus
o Reserve as much viable tissue as possible
o Place 2 to 4 large size (19 French) drain

Department of surgery
Management protocol for acute pancreatitis

7. Treat of Associated Conditions

 Cholecystectomy
 Indication
 Cholelithiasis
 Biliary sludge
 Timing
 Same admission after 7 days & 3 weeks after recovery from
mild & severe pancreatitis respectively
 Counseling on cessation of alcohol
 Treat associated Hypertriglyceridemia
8. Others
 DVT Prophylaxis
 Heparin (LMW) 500 units subcutaneous QID to BID
 Ulcer (duodenal) prophylaxis
 Indication
 In subtotal or total pancreatic necrosis
 Drugs
 Esomeprazole/omeprazole 20mg IV daily or BID(preferred)
 Cimetidine 200mg-400mg IV daily or BID (alternative)
9. Follow up
 Vital signs including oxygen saturation every 2-4 hr for the first 24-48
hrs. & subsequently based on patients condition
 Strict input & output monitoring(urine output should be (>0.5 ml|Kg|hr)
 Laboratory investigations should be done per this protocol
 For all patient with acute pancreatitis determine severity &
prognosis by using combination of Ranson's score & APACHE II
score ( if CT scan is done include CT severity score)

Department of surgery
Management protocol for acute pancreatitis

 At admission the following investigation should be ordered

Table 8-Lab & Radiologic Evaluations at admission
Laboratory tests Radiologic tests
 Serum Amylase & Lipase  Chest X-ray(PA &Erect)
 CBC  Plain abdominal X-ray(PA &
erect)
 Blood glucose level  Abdominal ultrasound
 Cr. & BUN  CT scan (contrast
enhanced)**
 AST,ALT,ALP & bilirubin
(Total & Indirect)
 Serum calcium, potassium,
sodium, chlorine &
magnesium
 Serum Triglyceride
 LDH
 Arterial blood gas test (PH &
HCO3)
**indicated in patients who are deteriorating or have severe pancreatitis
determined clinically and by APACHE II score & not required on the first
day unless there are other diagnoses are being considered
 Following admission [2,9,10]
o Do CBC(HCT) , RFT (Cr & BUN), LFT (AST,ALP & Bilirubin),serum
electrolyte every 24 hr until adequate resuscitation is obtained
o Repeat Serum amylase & lipase after 48hrs
o Serum glucose level measured per sliding scale protocol
o Other investigations including imaging’s can be done according
to patient’s condition & need

Department of surgery