Update Course Rewind: Management of Acute Pancreatitis 2023

Global Cat MD along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hello pediatric surgery family. I'm Cecilia Jigena, a research fellow from Cincinnati Children's Hospital Medical Center. Our 11th annual update course in pediatric surgery was held this past August. In this video, we are going to talk about treatment for acute pancreatitis, and for that we have Doctor Juan Gurria, a pediatric surgeon from Cincinnati Children's Hospital. And he started with a case. We have a 9 year old female with ALL, uh, comes to the ER with acute severe abdominal pain. You got, you get those, those numbers, uh, with the elevated AST, dropping hematocrit, lipase of 9000, um, a little bit tachycardia, um, that's your CT scan. So, You know, you have a clear acute edematous pancreatitis there, not a lot of free fluid in the pelvis. If you ask. There's no signs of bleeding. So we have a 9-year-old patient with acute pancreatitis, low blood pressure, and tachycardia. What should we do? All right, so the plan is floor. NPO antibiotics being controlled, or ICU with different settings there, or ED and then discharged from ED once they start tolerating PO. What do you guys think? PICU, who would send to the PICU? So I would, cause yeah, heart, heart rate of 160 and a low blood pressure, who would give antibiotics? How much fluid? How much fluid we give? Let's see what people. It's saying out there. The audience did not all agree on the best management for these patients for discharge, ICU, but let's hear what Doctor Gria recommended. So, we're going to the ICU, right? This patient is not humanomically normal, right? Acute pancreatitis could be fatal. So, bolus times 2 is adequate, uh, fluid maintenance.5 once you pass that early phase of acute resuscitation. Remember that pancreatitis is a state of, uh, hypoxia. You need to re-establish the intravascular flow to the pancreas to prevent hypoxia, necrosis, atrophic pancreas insufficiency. So you, you have to stop that right away. So, early fluorociation. It's, it's the key. However, you cannot be too aggressive with fluids. Now, there's no reason to give antibiotics anymore at all for pancreatitis, even in the face of world of necrosis or necrotizing pancreatitis, unless there are signs of sepsis infected pancreatitis, which is a different beast, OK, awesome. So ICU or floor according to vitals, in this case, PQ early resuscitation with IV fluids and no antibiotics. But let's. Let's go deeper. How much fluids should be given? So, uh, there was a position paper from the North American Society of uh Pancreatitis, uh, uh GI Pathology, and Nutrition, um, stating some of the, uh, guideline recommendations. So, when we talk early fluids, better outcomes as a concept. However, how much, so, bowls 1010 to 20 per kilo, up to 3 L the 1st 24 hours, even if you can stop it at the 12-hour mark and reassess with urine output and, and, um, And, and vital signs is always better. You cannot flow these lungs too much because the outcomes are worse. OK, great. 1.5 to 2 times maintenance, reassessing at 12 and 24 hour mark. Is there any specific fluid we should use? There's a lot of work being done right now in which type of fluid is the best for pancreatitis. It's been shown that LR. Decreases the incidence of inflammatory response and C, C-reactive protein at 24 hours compared to NS, right? If there's, uh, if their albumin is low, uh, please give albumin as well. And it was a very, very important, um, RCT by uh one of our wonderful colleagues from Spain, Enri Enrique de Madaria, wonderful guy, and he, they did a multi-center all over the world trial, they call it the waterfall trial. To say, to try to see who, um, who's getting too much fluid, basically. So they gave moderate or, or a lot of fluid. Uh, clearly, of course, uh, they had to stop the trial on, uh, sooner because the patient's getting too much fluid or getting, uh, organ failure. He's following this with a Waterland trial to see whether in fact LR is better than, than NS. So another. Multi-center, multi-country RCT study that is going to come out uh hopefully in a year or two, which is going to be wonderful. Perfect. Fluid resuscitation using LR as the preference. Now, what about refeeding? Feed the pancreas as soon as the patient is able to tolerate PO. Just give in nutrition significantly better compared to TPN or NPO. So we usually prefer to feed the stomach. If you can feed the stomach, feed the stomach. I feel like we still get into this cycle, like, because I know that data, right, but it feels like we still get into the cycle of you start feeding them by mouth, they puke a couple of times, everybody freaks out, you know, we end up, we go NJ, uh, that doesn't work either. Then we go TPN. That's fine. If they cannot tolerate it, it's OK. I mean, but it's like gastroschisis, it's OK to tolerate some, some, some vomiting. If you can feed them, that's fine. If you're losing nutrition and you're losing ground, the patient's gonna have a worse outcome. Their albumin is gonna drop, inflammatory reaction is gonna be worse. So better to feed if you cannot than NPO or TPN, but outcomes are dramatically better when you. The gut. Great. Time to summarize. Acute pancreatitis is an inflammation of the pancreas that can be very severe. To decide if the patient should go to the floor or the ICU, vitals is the main thing we should consider. Fluid resuscitation is key. However, we should be careful to not overload the patient with fluids, making sure to reassessing the patient at the 12 and 24 hour mark. The type of fluid is still undergoing trials, but current publications suggest LR to be better in reducing inflammatory response. Last, it is important to feed the patient as soon as possible, specifically aiming to feed in the stomach. Hope you enjoyed the video and thank you for watching. Don't forget to subscribe to the Stay Current MD YouTube channel. Follow our social media channels and download the Stay Current MD app for tons of content in pediatric surgery. Global Cat MD along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.