Acute pancreatitis

Manage now— do this, in order

• Fluid replacement is the intervention that most influences outcome and should begin before confirmatory results return. Correct hypovolaemia with Ringer's lactate or Hartmann's solution — balanced crystalloid is preferred to 0.9% sodium chloride, which in volume causes hyperchloraemic acidosis. In a shocked adult give 500 mL over about 15 minutes and reassess immediately, repeating as required, then continue an infusion; in children 10–20 mL/kg of isotonic crystalloid as a bolus, reassessed after each bolus, then weight-appropriate isotonic maintenance.Doctor / Nurse
• Titrate to endpoints, not to a formula: urine output at least 0.5 mL/kg/hour (which requires a catheter), a falling haematocrit, a falling urea, a falling lactate, and normalising heart rate and blood pressure, with haematocrit and urea measured every 8–12 hours. Both under- and over-resuscitation cause harm — high fixed-rate regimens cause fluid overload, pulmonary oedema, worsening hypoxaemia and abdominal compartment syndrome. Never give hypotonic maintenance fluid (plain 5% dextrose or 0.45% sodium chloride) to a sick child — it causes hyponatraemia and cerebral oedema.Not available at your setup — Renal function (creatinine/urea).
• Give opiate analgesia promptly and without rationing: tramadol 50–100 mg IV/IM 6-hourly, or fentanyl 25–50 micrograms IV titrated, or morphine 2.5–5 mg IV slowly repeated every 5–10 minutes to effect; children morphine 0.1 mg/kg IV titrated in increments or fentanyl 1 microgram/kg IV. Do not withhold opiates for fear of the sphincter of Oddi — the concern is theoretical, there are no clinical data supporting it, and if morphine is the available opiate, give it. NSAIDs should generally be avoided.Doctor / Nurse
• Add regular paracetamol as background analgesia: 1 g IV or orally 6-hourly (maximum 4 g/24 h); children 15 mg/kg IV or orally 6-hourly (maximum 60 mg/kg/24 h). Give an antiemetic — ondansetron 4–8 mg IV 8-hourly or metoclopramide 10 mg IV 8-hourly (children ondansetron 0.1–0.15 mg/kg IV, maximum 4 mg/dose) — since nausea and vomiting are near-universal.
• Give oxygen to hypoxic patients, titrated to saturations of 94–98%, and take baseline arterial gases, which are both a resuscitation measurement and a severity criterion; patients who develop SIRS may need ventilatory support.Not available at your setup — Arterial blood gas.
• Prescribe thromboprophylaxis on admission for every patient: enoxaparin 40 mg subcutaneously daily (reduce in renal impairment) or unfractionated heparin 5000 units subcutaneously 12-hourly — these patients are immobile, dehydrated, inflamed and often obese, and splenic and portal vein thrombosis are recognised complications; in children thromboprophylaxis is usually mechanical, pharmacological only on specialist advice.Doctor / Nurse
• Correct symptomatic or severe hypocalcaemia (tetany, Chvostek or Trousseau signs, seizures, prolonged QT) with 10% calcium gluconate 10 mL IV over 10 minutes into a large vein with cardiac monitoring (children 0.5 mL/kg IV over 10 minutes, maximum 20 mL), and measure magnesium at the same time — hypomagnesaemia renders hypocalcaemia refractory to calcium; give magnesium sulfate 2 g (8 mmol) IV over 20 minutes (children 25–50 mg/kg IV over 20 minutes, maximum 2 g) if hypomagnesaemic. In alcohol-related disease give parenteral high-dose thiamine or B-complex before any glucose-containing fluid, document the time of the last drink (withdrawal begins at 6–24 hours) and prescribe a withdrawal regimen pre-emptively; give phytomenadione 10 mg IV for the coagulopathy of obstructive jaundice (children 300 micrograms/kg IV, max 10 mg). Correct hyperglycaemia with a variable-rate insulin infusion in severe disease (soluble insulin 50 units in 50 mL of 0.9% sodium chloride) titrated to hourly capillary glucose; children 0.05–0.1 units/kg/hour.Doctor / NurseNot available at your setup — Serum electrolytes, Infusion pump.
• Do not give prophylactic antibiotics. Reserve them for cholangitis, strongly suspected infected necrosis, or proven extrapancreatic infection, guided by blood cultures: meropenem 1 g IV 8-hourly, or ciprofloxacin 400 mg IV 12-hourly plus metronidazole 500 mg IV 8-hourly, or piperacillin-tazobactam 4.5 g IV 8-hourly; children meropenem 20 mg/kg/dose IV 8-hourly (max 1 g) and metronidazole 7.5 mg/kg/dose IV 8-hourly (max 500 mg). Hospital-acquired infections occur in up to 20% — look for pneumonia, urinary and line infection before blaming a new fever on the pancreas.Doctor / NurseNot available at your setup — Blood culture.
• Feed the patient — in mild disease enteral feeding begins as soon as abdominal pain has settled; in severe disease only after about 48 hours nil by mouth and full resuscitation; nasogastric feeding is as effective as nasojejunal. Insert a nasogastric tube only if paralytic ileus is present — it is not therapeutic and routine insertion is unjustified. Get the CT timing right: do not scan in the first 72 hours merely to confirm the diagnosis; do scan immediately if a surgical catastrophe cannot be excluded; do scan at 48–72 hours or later in any patient with persisting organ failure, sepsis or deterioration — contraindications to contrast are creatinine above 2 mg/dL (about 177 µmol/L) and severe previous reaction, so restore volume first. Cholangitis with severe acute pancreatitis requires urgent ERCP, and cholecystectomy should follow within about two weeks of resolution, preferably during the same admission in mild disease.DoctorNot available at your setup — CT scan, Ultrasound.