Update Course Rewind: Management of Acute Pancreatitis 2023
With Dr. Juan Gurria · hosted by Dr. Cecilia Gigena · StayCurrentMD
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Acute pancreatitis could be fatal
Bolus times 2 is adequate fluid resuscitation, with 1.5 times maintenance once past the early phase of acute resuscitation
Pancreatitis is a state of hypoxia requiring re-establishment of intravascular flow to the pancreas to prevent hypoxia, necrosis, and atrophic pancreas insufficiency
Early fluid resuscitation is key in pancreatitis management
Excessive fluid administration worsens outcomes in pancreatitis
There is no reason to give antibiotics for pancreatitis, even in the face of necrosis or necrotizing pancreatitis, unless there are signs of sepsis or infected pancreatitis
The North American Society of Pancreatitis, GI Pathology, and Nutrition published a position paper with guideline recommendations for pancreatitis management
Early fluids lead to better outcomes in pancreatitis
Recommended fluid bolus is 10 to 20 mL per kg, up to 3L in the first 24 hours, with reassessment at the 12-hour mark using urine output and vital signs
Excessive fluid administration can flood the lungs and worsen outcomes
Lactated Ringer's decreases the incidence of inflammatory response and C-reactive protein at 24 hours compared to normal saline in pancreatitis
If albumin is low in pancreatitis patients, albumin should be given
Enrique de Madaria conducted a multi-center worldwide RCT called the Waterfall trial comparing moderate versus aggressive fluid resuscitation in pancreatitis
The Waterfall trial was stopped early because patients receiving too much fluid were developing organ failure
A follow-up Waterland trial is underway to determine whether lactated Ringer's is better than normal saline, expected to be published in one to two years
Patients with pancreatitis should be fed as soon as they are able to tolerate oral intake
Enteral nutrition is significantly better compared to TPN or NPO in pancreatitis
Gastric feeding is preferred over post-pyloric feeding in pancreatitis if the patient can tolerate it
Some vomiting is tolerable during refeeding in pancreatitis, similar to gastroschisis management
If nutrition is lost and the patient loses ground, outcomes will be worse, with dropping albumin and worse inflammatory reaction
Outcomes are dramatically better when the gut is fed in pancreatitis patients
Vitals are the main consideration for deciding whether a pancreatitis patient should go to the floor or ICU
Fluid resuscitation is key in pancreatitis management
Patients should be reassessed at the 12 and 24 hour mark to avoid fluid overload
Current publications suggest lactated Ringer's is better in reducing inflammatory response in pancreatitis
It is important to feed pancreatitis patients as soon as possible, specifically aiming to feed in the stomach