›Fluid strategy
›Lactated Ringer solution
›Initiate 250-500 ml/hour for most patients with early disease
›Reassess every 2-4 hours
›Urine output target >=0.5 ml/kg/hour
›MAP target >=65 mmHg
›BUN and hematocrit trend down or stable
›If hypovolemia or shock
›Initiate bolus 10-20 ml/kg
›Repeat bolus based on response and lung exam
›Stop escalation if pulmonary edema signs
›Over resuscitation avoidance
›Lung crackles or ultrasound B lines
›Reduce rate
›Consider diuresis only after hemodynamic stability
›Increasing abdominal distension with rising bladder pressure concern
›ICU escalation for abdominal compartment syndrome pathway
›Vasopressors
›Norepinephrine infusion for persistent hypotension after fluids
›Titrate to MAP >=65 mmHg
›Central access when feasible
Analgesia and symptom control
›Pain and nausea control
›Opioid analgesia
›Hydromorphone IV 0.2-0.5 mg every 10-15 minutes as needed
›Transition to oral when tolerating
›Avoid excessive sedation and hypoventilation
›Morphine IV 2-4 mg every 10-15 minutes as needed
›Caution in hypotension
›Smaller titrated doses
›Fentanyl IV 25-50 mcg every 5-10 minutes as needed
›Prefer in hemodynamic instability
›Short duration supports titration
›Non opioid adjuncts
›Acetaminophen 650-1000 mg PO or IV every 6 hours
›Max daily dose adjustment for liver disease
›Use lower limits in chronic alcohol use
›Antiemetics
›Ondansetron IV 4-8 mg every 8 hours as needed
›QT prolongation risk review
›Avoid with significant baseline QT prolongation
›Metoclopramide IV 10 mg every 6-8 hours as needed
›Extrapyramidal risk
›Avoid in Parkinson disease
›Droperidol IV 0.625-1.25 mg as needed
›QT prolongation monitoring
›ECG when risk factors present
›Feeding strategy
›Early oral feeding as tolerated within 24 hours
›Low fat solid or soft diet acceptable when pain improving
›No routine prolonged NPO for mild disease
›Enteral nutrition when unable to feed orally
›Nasogastric tube feeding acceptable
›Nasojejunal option when gastric intolerance
›Prefer enteral over parenteral
›Parenteral nutrition
›Reserve for inability to tolerate enteral route
›Central line infection risk mitigation
Etiology directed interventions
›Biliary pancreatitis
›Suspected cholangitis
›Initiate broad spectrum antibiotics
›Piperacillin tazobactam IV 4.5 g every 6 hours
›Renal adjustment required
›Urgent ERCP within 24 hours
›Source control priority
›Biliary decompression
›Biliary pancreatitis without cholangitis
›No routine urgent ERCP
›ERCP for persistent obstruction evidence
›Rising bilirubin
›Dilated duct with stone on imaging
›Cholecystectomy planning
›Same admission cholecystectomy for mild biliary pancreatitis
›Prevent recurrence
›Delay if severe necrotizing disease
›Hypertriglyceridemia pancreatitis
›Triglycerides >=11.3 mmol/l
›Insulin infusion consideration for rapid lowering
›ICU pathway when infusion used
›Glucose monitoring hourly initially
›Plasmapheresis consideration in refractory severe cases
›Specialist consultation required
›Evidence mixed
›Alcohol associated pancreatitis
›Withdrawal risk pathway
›CIWA based management
›Thiamine prior to glucose containing fluids
›Prevent Wernicke encephalopathy
›Drug induced pancreatitis
›Stop offending agent when suspected
›Pharmacovigilance report consideration
›Alternative therapy planning
Antibiotics and infection management
›Infection strategy
›No prophylactic antibiotics for sterile necrosis
›Guideline based recommendation Class I
›Harms include fungal infection and resistance
›Infected necrosis suspicion
›Clinical triggers
›Persistent fever after initial course
›Worsening leukocytosis
›Sepsis physiology
›Rising lactate
›Gas in collection on CT
›Strongly suggestive
›Antibiotic choices with pancreatic penetration
›Carbapenem option when severe sepsis
›Meropenem IV 1 g every 8 hours
›Renal adjustment required
›Piperacillin tazobactam option
›4.5 g IV every 6 hours
›Renal adjustment required
›Avoid routine fluoroquinolone when resistance concern
›Local antibiogram consideration
›Step up intervention pathway for necrosis
›Delay intervention when possible
›Prefer after about 4 weeks when walled off
›Lower morbidity
›Percutaneous drainage first
›Endoscopic drainage as alternative
›Surgery reserved for failures or complications
VTE and ulcer prophylaxis
›Supportive prevention
›VTE prophylaxis when admitted
›Enoxaparin 40 mg SC daily
›Renal adjustment to 30 mg daily if eGFR low
›Mechanical prophylaxis when anticoagulation contraindicated
›Sequential compression devices
›Stress ulcer prophylaxis in ICU
›PPI or H2 blocker when high risk
›Ventilated patients
›Coagulopathy