›Balanced crystalloid preferred example lactated Ringer bolus 10 to 20 mL per kg for hypovolemia
›Maintenance example 1.5 mL per kg per hour with frequent reassessment
›Reassessment targets
›HR improvement
›MAP 65 mmHg or higher
›Urine output 0.5 mL per kg per hour or higher
›BUN and creatinine trend improvement
Analgesia and antiemetics
›Symptom control
›Opioid analgesia example hydromorphone IV 0.2 to 0.5 mg every 10 to 15 minutes as needed
›Alternative opioid example fentanyl IV 25 to 50 mcg every 5 to 10 minutes as needed
›Antiemetic example ondansetron IV 4 mg
›If refractory vomiting, add metoclopramide IV 10 mg
Nutrition
›Feeding strategy
›If mild and improving, early oral feeding as tolerated
›If unable to tolerate oral, enteral nutrition preferred over parenteral
›If severe or prolonged intolerance, nasogastric or nasojejunal feed with dietitian support
Etiology specific management
›Biliary pancreatitis pathway
›If cholangitis, urgent ERCP and antibiotics
›If gallstones without cholangitis, cholecystectomy during index admission when clinically stable
›Hypertriglyceridemia pathway
›If very high triglycerides with organ failure, ICU consult for insulin infusion protocol dependent
›Fibrate initiation planning after acute phase
›Alcohol associated pathway
›Withdrawal risk monitoring
›Thiamine replacement if malnutrition risk
Antibiotics and infection
›Antibiotic strategy
›If uncomplicated pancreatitis, no prophylactic antibiotics
›If cholangitis, antibiotics per local protocol and source control
›If suspected infected necrosis, antibiotics and early GI and surgery consult
Monitoring and reassessment loop
›Reassessment loop
›Vital signs and pain reassessment every 30 to 60 minutes early
›Repeat labs within 6 to 12 hours if unstable or severe concern
›Escalate level of care if rising oxygen requirement
›Escalate level of care if worsening renal function
Consultations
›Consultation triggers
›GI consult for cholangitis concern
›GI consult for persistent obstruction concern
›Surgery consult for gallstone pancreatitis and timing of cholecystectomy
›ICU consult for persistent organ failure
17Disposition/dispo29
ICU criteria
›ICU level care criteria
›Vasopressor requirement
›Persistent organ failure 48 hours or more
›Mechanical ventilation requirement
›Lactate rising with shock concern
›Severe metabolic acidosis
Inpatient admission criteria
›Admission criteria
›Uncontrolled pain needing IV opioids
›Persistent vomiting with dehydration
›AKI
›Hypoxemia
›Electrolyte derangements requiring IV replacement
›Biliary obstruction concern
›BISAP 2 or higher
Observation pathway criteria
›Observation criteria
›Mild pancreatitis with improving symptoms
›Stable vitals after initial fluids
›No cholangitis concern
Discharge criteria
›Discharge criteria
›Pain controlled on oral regimen
›Tolerating oral fluids and food
›Stable vitals
›No rising creatinine
›No biliary obstruction concern
›Reliable follow up and return precautions
Transfer criteria
›Transfer considerations
›Need for ERCP not available locally
›Need for ICU bed not available locally
›Suspected necrosis needing advanced multidisciplinary care
18Discharge Instructions/di14
Copy discharge instructions
›You were diagnosed with acute pancreatitis which is inflammation of the pancreas
›Drink fluids frequently to avoid dehydration
›Eat small low fat meals as tolerated
›Avoid alcohol until cleared by your clinician
›Take your prescribed pain medicine only as directed
›Do not drive or drink alcohol when taking opioid pain medicine
›Follow up with your primary care clinician within 2 to 3 days
›If gallstones were suspected, follow up with surgery or GI as arranged
›Return to the emergency department now for worsening abdominal pain
›Return to the emergency department now for repeated vomiting or inability to keep fluids down
›Return to the emergency department now for fever or shaking chills
›Return to the emergency department now for yellowing of the eyes or skin
›Return to the emergency department now for chest pain or trouble breathing
›Return to the emergency department now for fainting or confusion
19References/r6
Guidelines and consensus sources
›Key sources
›American College of Gastroenterology guideline on management of acute pancreatitis 2024
›American Gastroenterological Association Institute guideline on initial management of acute pancreatitis 2018
›Revised Atlanta classification and definitions international consensus 2012 published 2013
›IAP and APA evidence based guidelines for management of acute pancreatitis 2013
›Review on practical management of severe acute pancreatitis 2025
Evidence & Review
Reviewed by SymptomDx Medical Team·Last reviewed
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.