Editing Acute pancreatitis (section)

== '''Initial medical management:''' ==

* Analgaesia:
** Don't give NSAIDs. ?PUD
** Paracetamol probably IV if vomiting
** Initial trial of endone + fluid resus, however often need PCA
** No evidence opioids worsen outcomes, despite supposed sphincter of Oddi contraction
* Antiemetics
* IV PPI - prevent stress ulceration
* Early enteral feeding, unless ileus, pain or intubation
** 20% of severe AP patients get recurrent pain after restarting diet
** Enteral feeding reduces the need for surgery, but TPN can be considered if failing to meet requirements
** NJT feeds if gastric outlet obstruction is present (according to Schein, if gastric aspirates are >250mL/6 hours). Start at 10mL/hr and increase gradually until 40mL/hr is reached)
* Investigate cause
** USS vs MRCP to rule out biliary pathology
** FBE, UEC, LFT, Lipase, CRP, CMP, fasting lipids (don't need to do it unless suspicious this is the cause - see above)
** Consider INR if liver derangement
** Erect CXR - rule out perf ulcer, plus check for ARDS
** CT - only if unclear diagnosis or severe abdominal pain where perforated viscus or bowel ischaemia may be considered
* Strict FB - may need IDC if severe or does not respond to resuscitation
* Supplemental oxygen (to try and optimise perfusion)
* Correct fluids with CSL (vomiting, poor oral intake, increased resp losses, diaphoresis, oedema)
** 5-10ml/kg/hr until HR<120, MAP 65-85, normal lactate and UO 0.5-1ml/kg/hr
** Going to need a lot. Remember pancreatitis pain is worse if dehydrated. Be aggressive.
** CSL better than saline with pancreatitis
* Correct electrolytes
* VTE prophylaxis
* ?Thiamine
* ?ICU if persistent shock for vasopressors after initial resuscitation
* Grade severity - Atlanta - mild/mod/severe - or use SIRS criteria on admission and again at 48/24
* Antibiotics if acute pancreatitis and an active infection (cholangitis, UTI, pneumonia, catheter-related infections, bacteraemia, infected necrosis)