IAP/APA evidence-based guidelines for the management of acute pancreatitis Flashcards
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What is the definition of acute pancreatitis (regardless of etiology)?
The definition of acute pancreatitis is based on the fulfillment of ‘2 out of 3’ of the following criteria: clinical (upper abdominal pain), laboratory (serum amylase or lipase >3 upper limit of normal) and/or imaging (computed tomography, magnetic resonance (MR), ultrasonography) criteria. (GRADE 1B, strong agreement)
On admission, what should be done to determine the etiology of acute pancreatitis?
On admission, the etiology of acute pancreatitis should be determined using detailed personal (i.e. previous acute pancreatitis, known gallstone disease, alcohol intake, medication and drug intake, known hyperlipidemia, trauma, recent invasive procedures such as endoscopic retrograde cholangiopancreatography (ERCP)) and family history of pancreatic disease, physical examination, laboratory serum tests (i.e. liver enzymes, calcium, triglycerides), and imaging (i.e. right upper quadrant ultrasonography). (GRADE 1B, strong agreement)
What further investigations are indicated in patients after a first or second attack of idiopathic acute pancreatitis?
In patients considered to have idiopathic acute pancreatitis, after negative routine work-up for biliary etiology (e.g. repeated right upper quadrant ultrasonography), endoscopic ultrasonography (EUS) is recommended as the first step to assess for occult microlithiasis, neoplasms and chronic pancreatitis. If EUS is negative, (secretin-stimulated) magnetic resonance chol- angiopancreatography (MRCP) is advised as a second step to identify rare morphologic abnormalities. CT of the abdomen should be performed (i.e. if not performed before). If etiology remains unidentified, especially after a second attack of idiopathic pancreatitis, genetic counseling (not necessarily genetic testing) should be considered.(GRADE 2C, weak agreement)
What is the best score/marker (including cut-off value) to predict severe acute pancreatitis on admission and at 48 h?
Systemic inflammatory response syndrome (SIRS) is advised to predict severe acute pancreatitis at admission and persistent SIRS at 48 h. (GRADE 2B, weak agreement)
What is the best strategy to predict outcome of acute
pancreatitis during admission?
During admission, a 3-dimension approach is advised to predict outcome of acute pancreatitis combining
- host risk factors (e.g. age, co-morbidity, body mass index)
- clinical risk stratification (e.g. persistent SIRS)
- monitoring response to initial therapy (e.g. persistent SIRS, blood urea nitrogen, creatinine)
(GRADE 2B, strong agreement).
What is the indication for and timing of the initial CT
assessment in acute pancreatitis?
The indication for initial CT assessment in acute pancreatitis can be:
(1) diagnostic uncertainty,
(2) confirmation of severity based on clinical predictors of severe acute pancreatitis, or
(3) failure to respond to conservative treatment or in the setting of clinical deterioration.
Optimal timing for initial CT assessment is at least 72-96 h after onset of symptoms.
(GRADE 1C, strong agreement).
What is the indication for follow-up scanning (CT/MR)?
Follow-up CT or MR in acute pancreatitis is indicated when there is a lack of clinical improvement, clinical deterioration, or especially when invasive intervention is considered.
(GRADE 1C, strong agreement).
What is the optimal CT and MR protocol to detect
necrosis?
It is recommended to perform multidetector CT with thin collimation and slice thickness (i.e. 5 mm or less), 100e150 ml of non-ionic intravenous contrast material at a rate of 3 ml/s, during the pancreatic and/or portal venous phase (i.e. 50e70 s delay). During follow-up only a portal venous phase (mono-phasic) is generally sufficient. For MR, the recommendation is to perform axial FS-T2 and FS-T1 scanning before and after intravenous gadolinium contrast administration.
(GRADE 1C, strong agreement).
What is the best fluid to use for initial fluid resuscitation
in acute pancreatitis?
Ringer’s lactate is recommended for initial fluid resuscitation in acute pancreatitis.
(GRADE 1B, strong agreement).
What is the optimal fluid infusion rate and response
measurement for initial fluid resuscitation?
Optimal infusion rate for initial fluid resuscitation: goal directedintravenousfluid therapywith 5e10ml/kg/h should be used initially until resuscitation goals are reached. (GRADE 1B, weak agreement).
Measuring the response to fluid resuscitation: the preferred approach to assessing the response tofluid resuscitation should be based on one or more of the following:
(1) non-invasive clinical targets of heart rate <120/min, mean arterial pressure between 65 and 85 mmHg (8.7e11.3 kPa), and urinary output >0.5e1 ml/kg/h,
(2) invasive clinical targets of stroke volume variation, and intrathoracic blood volume determination,
(3) biochemical targets of hematocrit 35-44%.
(GRADE 2B, weak agreement).
What are the indications for admission to an intensive
care unit in acute pancreatitis?
A patient diagnosed with acute pancreatitis and one or more of the following parameters identified at admission as defined by the guidelines of the Society of Critical Care Medicine (SCCM) should be transferred immediately to an intensive care setting:
(1) pulse <40 or >150 beats/min
(2) systolic arterial pressure <80 mmHg (<10.7 kPa) or mean arterial pressure <60 mmHg or diastolic arterial pressure >120 mmHg
(3) respiratory rate >35 breaths/min
(4) serum sodium <110 mmol/l or >170 mmol/l
(5) serum potassium <2.0 mmol/l or >7.0 mmol/l
(6) paO2 <50 mmHg;
(7) pH < 7.1 or >7.7
8) serum glucose >800 mg/dl
(9) serum calcium > 15 mg/dl (>3.75 mmol/L)
(10) anuria
(11) coma.
Furthermore, a patient with severe acute pancreatitis as defined by the revised Atlanta Classification (i.e. persistent organ failure) should be treated in an intensive care setting.
(GRADE 1C, strong agreement).
What are the indications for referral to a specialist
center?
Management in, or referral to, a specialist center is necessary for patients with severe acute pancreatitis and for those who may need interventional radiologic, endoscopic, or surgical intervention.
(GRADE 1C, strong agreement).
What are the minimal requirements for a specialist
center?
A specialist center in the management of acute pancreatitis is defined as a high volume center with up-to-date intensive care facilities including options for organ replacement therapy, and with daily (i.e. 7 days per week) access to interventional radiology, interventional endoscopy with EUS and ERCP assistance as well as surgical expertise in managing necrotizing pancreatitis. Patients should be enrolled in prospective audits for quality control issues and into clinical trials whenever possible.
(GRADE 2C, weak agreement).
Can persistent SIRS/organ failure be prevented?
Early fluid resuscitation within the first 24 h of admission for acute pancreatitis is associated with decreased rates of persistent SIRS and organ failure.
(GRADE 1C, strong agreement).
What is the definition of abdominal compartment
syndrome?
Intra-abdominal pressure is the steady-state pressure within the abdominal cavity. Abdominal compartment syndrome (ACS) is defined as a sustained intra-abdominal pressure > 20 mmHg (with or without abdominal arterial perfusion pressure <60 mmHg) that is associated with new onset organ failure.
(GRADE 2B, strong agreement).
