ARE YOUR ACUTE PANCREATITIS TREATMENT PROTOCOLS UP-TO-DATE WITH THE LATEST GUIDELINES? Make sure your hospital is moving away from old treatment strategies, such as keeping patients NPO (nothing by mouth) to "rest the pancreas". Incorporate updated strategies into your protocol...
ANTIBIOTIC THERAPY. Acute pancreatitis is most often a “sterile inflammation” not requiring antibiotic therapy. Avoid routine use of prophylactic antibiotics in patients with acute pancreatitis, regardless of severity (e.g., mild, severe, necrotizing). Antibiotic use without documented benefit increases the risk of developing antibiotic resistance or adverse events (e.g., Clostridium difficile). Antibiotics are appropriate for patients with confirmed infected necrosis or when sepsis is suspected. Start with broad-spectrum antibiotics that penetrate pancreatic tissue (e.g., carbapenems, metronidazole, piperacillin/tazobactam, quinolones). Once results are available, streamline antibiotics based on culture and sensitivities.
FLUID RESUSCITATION. Consider aggressively hydrating most patients in the first 24 hours, such as using 5 to 10 mL/kg/hr. This is linked to reduced mortality. Consider less aggressive fluids in patients with certain coexisting conditions (e.g., heart failure, pulmonary disease). Avoid hydroxyethyl starch (HES) fluids (e.g., Voluven). Lean toward Lactated Ringer's, it may cause less kidney injury than normal saline. But use saline if needed during a shortage or in patients with hypercalcemia, since there's calcium in Lactated Ringer's. Titrate fluids to blood pressure (e.g., mean arterial pressure of 65 mmHg to 85 mmHg), HR (< 120 beats/minute), urine output (> 0.5 to 1 mL/kg/hour), similar to sepsis. Also consider titrating fluids for elevated hematocrit (35% to 44%) and BUN, since high values in pancreatitis are linked to increased mortality.
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Elevated hematocrit on admission or failure of hematocrit to return to normal within 24 to 48 hours of admission may be predictors of severe disease (e.g., pancreatic necrosis).
NUTRITION SUPPORT. Initiate early oral feeding with a regular or low-fat diet as tolerated, within 24 hours of admission as pain begins to resolve. Order a regular or low-fat diet when pain starts resolving. Avoid bowel rest or starting clear liquid diets. This isn't needed and may prolong hospitalization. Consider enteral nutrition in noncritically ill patients unable to tolerate a diet after 4 days, but start enteral feeds within 48 hours in critically ill patients. Start with the NG (nasogastric ã…¡ into stomach) route, since NJ (nasojejunal ã…¡ into intestine) placement is harder and isn't often needed. And use standard enteral formulations. But if patients aren't tolerating these, try an NJ tube or a semi-elemental formulation before switching to parenteral nutrition.
REFERENCES
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Crockett SD, Wani S, Gardner TB, Falck-Ytter Y, Barkun AN; American Gastroenterological Association Institute Clinical Guidelines Committee. American Gastroenterological Association Institute Guideline on Initial Management of Acute Pancreatitis. Gastroenterology. 2018 Mar;154(4):1096-1101. Available at: https://www.gastrojournal.org/article/S0016-5085(18)30076-3/fulltext?referrer=https%3A%2F%2Fpubmed.ncbi.nlm.nih.gov%2F
Forsmark CE, Vege SS, Wilcox CM. Acute Pancreatitis. N Engl J Med. 2016 Nov 17;375(20):1972-1981. Available at: https://www.nejm.org/doi/10.1056/nejmra1505202
Dick JF 3rd, Gardner TB, Merrens EJ. Acute pancreatitis: New developments and strategies for the hospitalist. J Hosp Med. 2016 Oct;11(10):724-729. Available at: https://pubmed.ncbi.nlm.nih.gov/27240854