Pancreatitis Clinical Pathway — Emergency Department and Inpatient

Clinical Pathways Home Emergency ICU Inpatient Outpatient Specialty Care Primary Care

Goals and Metrics

Patient Education

Provider Resources

Related Orders
Behavioral Health Order
Integrated Health
Clinical Nutrition

Child with Suspected or Known Pancreatitis

Exclusions

FLOC/RN Team Assessment
History and Physical
- Pain Assessment
- Duration of Symptoms
IV Access, Laboratory Studies
Fluid Resuscitation, NPO
Analgesia
Child Life Consult, Non-Pharmacological Treatment
Imaging Studies
- Complete Abdominal US

Suspected Sepsis

Sepsis Pathway ED, Inpatient and PICU, N/IICU or CICU
- Severe Pancreatitis with Multisystem Organ Failure
- Admit to PICU as indicated
- GI Consult

Traumatic Pancreatitis

General Surgery Consult

Known or Strongly Suspected
Metabolic Disorder

Metabolism Consult

Findings c/w Pancreatitis
- Reassess MS, VS, need for continued IVF
- Review labs, imaging studies
- Determine Severity of Disease
- GI Consult
- Admission Considerations

Diagnostic Criteria for Acute Pancreatitis
Requires at least 2 of the following:
1. Abdominal pain compatible with AP
2. Serum amylase and/or lipase ≥ 3 times upper limit of normal
3. Imaging c/w pancreatitis
INSPPIRE 2012

Review Differential Diagnosis

Mild

Moderate

Severe

Inpatient Treatment Considerations

Fluid	Following NS or LR resuscitation Initiate D5LR or D5NS with electrolytes Rate 1.5 – 2 times maintenance Follow urine output BUN
Nutrition	As soon as clinically stable, start oral feeds Consider NG feeds if oral not tolerated
Analgesia	Acetaminophen, NSAIDS, nalbuphine
Monitoring	Recommendations for lab, Radiology Considerations for additional Evaluation

Assess Treatment Response at 24-48 Hours

Pain controlled
PO hydration, nutrition adequate

Persistent pain
Inadequate PO intake

Discharge

Pain Team Consult, Consider BHIP,
review Nutrition options
- NG, NJ, PICC
Additional Evaluation

Pain Controlled.
Adequate hydration, nutrition.

Follow-up GI 24-48 hrs

Goals of Treatment
- Early fluid resuscitation
- Pain Control
- Early enteral feeds

Additional Consideration
- Classification of Pancreatitis: Types
  - Acute (First episode)
  - Acute Recurrent
  - Chronic Recurrent
- Considerations for Outpatient Management
- Assess signs of shock, organ dysfunction/failure
- Complications
- Consults
- Additional Evaluation
- Treatment Failures
  - Trauma-related pancreatitis with pancreatic duct disruption
  - GI service

Posted: September 2020
Revised: June 2022
Authors: A. Maqbool, MD; N. Tangrea, RN; J. Brownell, MD; S. Irving, PhD, CRNP; A. Grachen, PharmD; W. Kraemer, MD; T. DiMaggio; J. Driggers, RD; M. Mascarenhas, MD; S. Anupindi, MD; S. Mayer-Brown, PhD; M. Kraenbring-Comerford, PsyD; S. Lee, CCLS; J. Allen, CCLS; M. Acord, MD; G. Nace, MD; P. Laje, MD

Evidence and References

Diagnosis and Classification, Management, Medications and Risk for Pancreatitis

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.

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