Approach to critical patient
›First 5 minutes workflow
›If hypotension or altered mentation, resuscitation bay
›Cardiac monitor and pulse oximetry
›Two large bore IV access if severe illness
›If SpO2 under 92 percent, oxygen to target 92 to 96 percent
›If MAP under 65 mmHg after fluids, vasopressor and ICU consult
›IV fluids
›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
›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
›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