QI Committee

Are you confused about how much fluid to give for a new pancreatitis diagnosis or if you really need that CT scan to confirm the diagnosis? Well, good news; Dr. Keswani and a multidisciplinary committee have developed an updated evidence-based order set for acute pancreatitis management in Epic. I have addressed four common topics and their updates with this new order set in the post.

Acute pancreatitis is the most common gastrointestinal indication for hospitalization in the United States, resulting in significant morbidity and cost. There is increasing evidence to support a best practice approach to acute pancreatitis to improve patient outcomes. Clinical guidelines have been established at NM, but adherence remains low. Current performance indicates opportunities to improve care for this patient population to reduce hospital length of stay and cost.

• What type of fluid to order and how much?

Recent evidence suggests that hydration with 3 mL/kg/hr might reduce complications of acute pancreatitis. The most important period in the resuscitation of acute pancreatitis is within the first 24 hours. This updated order set includes the use of Lactated Ringers as the only IVF to use for rehydration and in the first 24 hours is goal-directed (initial bolus 20 mL/kg and maintenance fluids 1.5-3 mL/kg/hour). The order set then gives options after 24 hours for IVF boluses and maintenance fluids pending the clinical picture.

• When to get imaging? What modality?

The use of CT/MRI is not required for the diagnosis of pancreatitis if lipase is greater than three times the upper limit of normal and physical exam symptoms are consistent with pancreatitis. There is a link in the order set to clarify the need for imaging under ‘CT imaging guidance’ as listed below. Reasons to consider ordering imaging include diagnostic uncertainty (equivocal labs/history, concern for alternative process (e.g., MRI for choledocholithiasis or CT for intra-abdominal bleeding)), severe disease with instability (unstable vitals, BISAP >3), and failure to improve after > 48-72 hours. In patients with normal renal function, a CT scan with IV contrast of the abdomen can be obtained. If your patient has renal insufficiency, an MRI of the abdomen without intravenous contrast can be obtained.

• When to feed patients? What is the longest we should wait? 

Patients should remain NPO for the first 12-24 hours of presentation to allow for an adequate assessment of symptoms and disease severity. Patients with mild acute pancreatitis or patients who are clinically improving and report feeling “ready” to begin an oral diet, can begin a low-fat solid oral diet as tolerated after 12-24 hours as listed in the order set. Severe pancreatitis should still be NPO initially and providers should monitor their progress with the help of consultation to the Dieticians. The Dieticians can be a great resource to help manage your patients and give support in restarting feeding and management moving forward in patient recovery.

• When to consider ICU admission?

There are no currently available risk calculators that have both high sensitivity and specificity in predicting patients at high risk for severe acute pancreatitis and thus requiring ICU admission. We recommend that BISAP and SIRS scores and relevant comorbidities (renal insufficiency and congestive heart failure, obesity, and elevated triglycerides) be considered and documented on hospital presentation as these will affect resuscitation goals and management. Providers should strongly consider ICU admission for any patient with a BISAP score of at least 3 or > or equal to SIRS 3 as these are predictive of severe acute pancreatitis. In select patients with a BISAP score of 2 or SIRS < 3, it may be appropriate to consider ICU admission as well. These scores can be calculated as below.

BISAP Score; scored 0-5 based on number of positive criteria at admission.

1. Blood Urea Nitrogen > 25
2. Impaired Mental Status
3. > or equal to 2 SIRS criteria
4. Age > 60 years
5. Pleural effusion (on chest x-ray)

SIRS Criteria

1. Temperature < 36C or > 38C
2. Heart rate > 90 bpm
3. Respiratory rate > 20 breaths/minute
4. White blood cell count < 4,000 cells/mm3 or > 12,000 cells/mm3

– Dylan