▪️︎Imp: acute pancreatitis
▪️︎Cond: emergency
▪️︎Diet: NPO(temporary) then early refeeding within 24h in mild to moderate pancreatitis (low-residue, low-fat, and soft diet, provided there is no evidence of ileus or signifiant nausea and/or vomiting.)
*Early refeeding may decrease length of stay and costs without increasing adverse events in mild to moderate.
▪️︎Act: CBR bed sides up
▪️︎CVS
▪️︎CM and POM
▪️︎oxygen with if sat<90
*to maintain sat>95%
▪️︎IV line fix
▪️︎IV fluid ringer lactate 10mg/kg bolus then 1.5mg/kg/h
▫️goal: HR <120, 65 < MAP <85 , Urine Output >0.5 - 1 CC/kg/hour, Decrease in HCT (goal: 35-44%), Decrease in BUN
▫️reassessed at frequent intervals in the first six hours of admission and for the next 24 to 48 hours. particularly important in older adults and those with a history of cardiac and/or renal disease.
▫️Increased fluid resuscitation should be considered in patients whose BUN levels stay the same or increase.
▫️So monitor BUN BD or TDS.
▫️In rare patients with acute pancreatitis due to hypercalcemia, lactated Ringer's is contraindicated.
▪️︎ECG
▪️︎Check CBC(diff), lipase, amylase, BS, Na, K, Cl, Ca,Mg, BUN, Cr, TG, AST, ALT, ALP, Bill, Alb, CRP, U/A, VBG, lactate, pregnancy test.
*اگر در یک مرکز لیپاز دارد،دیگه نیاز به چک آمیلاز نیست
▪️︎Foley catheter and I/O chart
▪️︎NG tube(not routinely)
*in patients with moderately severe and severe acute pancreatitis who cannot tolerate oral feeding.
▪️︎Abd CT w and w/o contrast as necessary
▫️In patients with abdominal pain that is not characteristic for acute pancreatitis or a serum amylase
and/or lipase activity that is less than three times the upper limit of normal, early CT is appropriate.
▫️Patients with predicted or established moderately severe or severe acute pancreatitis, signs of sepsis, or clinical deterioration 72 hours after initial presentation. for assessing severity and complications, it is optimal to wait until at least 72-96 hours after symptom onset.
▪️︎Abdominal and chest radiography(r/o the perforation and other complications)
▪️︎abdominal ultrasound (کبد، کیسه و مجاری صفراوی، پانکراس
▪️︎Pain Control with M.S or Fentanyl or Meperidine
▫️Amp Fentanyl 25 to 50 mcg IV for moderate and severe pain, respectively; repeat every 2 to 5 minutes as needed.
▫️Amp morphine 1-4mg IV slowly q1-4h as needed in severe pain
*studies showed that morphine caused an increase in sphincter of Oddi pressure. However, there are no
clinical studies to suggest that morphine can aggravate or cause pancreatitis or cholecystitis.
▫️Amp meperidine (pethidine) 50-150mg IM OR SC Q4hr
▪️︎Amp ondansetrone 4-8mg q4-8h if needed
▪️︎monitor serum glucose q1h in severe pancreatitis
*hyperglycemia (BS>180) should be treated
▪️︎monitor electrolytes first 48-72h esp in aggressive fluid resuscitation
*Hypocalcemia should be corrected if ionized calcium is low or if there are Chvostek's or Trousseau's sign.
▪️︎urgent ERCP in <24h (if cholangitis)
▪️︎in hyperTG pancreatitis, consider regimen, medication(fenofibrate), plasmpheresis and insulin based on the condition to goal TG<500
▪️︎consider antibiotics(carbapenem alone; or a quinolone, ceftazidime, or cefepime combined with an anaerobic agent such as metronidazole) only in 2 important complications:
*acute cholangitis (fever + icter + RUQ pain)
*INFECTIOUS necrotizing pancreatitis (which is diagnosed by FNA).
▫️Infected necrosis should be suspected in patients with necrosis who deteriorate (clinical instability or sepsis physiology, increasing white blood cell count, fevers) or fail to improve after 7 to 10 days of hospitalization.
▫️antibiotics should be initiated in the presence of strongly suspected sepsis in acute pancreatitis, but should be discontinued if infection is not confirmed by cultures.
▪️︎Be careful about compartment syndrome!
▪️︎ICU:
PR<40 or PR>150 beat/min
SBP<80 or MAP<60 or Diastolic pressure>120
RR>35 breaths/min
Na<110 or Na>170 mmol/L
K<2 or K>7 mmol/L
PaO2<50 or PH<7/1 or >7/7
BS > 800 mg/dl
Ca > 15 mg/dl
anuria
coma
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