Numerous severity scoring systems exist for acute pancreatitis.3,7,8 The early recognition of severe acute pancreatitis is important, given the significantly increased mortality and morbidity.2,8,10
Explore This IssueACEP News: Vol 29 – No 12 – December 2010
The traditionally used severity scoring systems, Ranson and APACHE II, have limited value in the emergency department setting. The Ranson score cannot be calculated until 48 hours after admission.7 The APACHE II scoring system is complex and time consuming to calculate.7
Singh and colleagues recently developed a new severity scoring system, the bedside index for severity in acute pancreatitis (BiSAP), which may be more practical for use in the emergency department.22 It is a five-point scoring system that assigns one point each for the following criteria: older than 60 years, pleural effusion, systemic inflammatory response syndrome (SIRS), altered mental status, and blood urea nitrogen greater than 25 mg/dL.22 The presence of three or more points correlates with morbidity and mortality, with similar accuracy to APACHE II.3,7
The Harmless Acute Pancreatitis Score (HAPS) allows the emergency physician to quickly and accurately identify patients who are low risk for the development of severe acute pancreatitis. The absence of rebound tenderness and/or guarding, a normal hematocrit, and a normal serum creatinine predict with 98% accuracy patients who will have a mild course.3 This could have important implications when an emergency physician is considering allocating limited resources, such as intensive care unit beds.
The mainstay of treatment for acute pancreatitis is supportive care. This includes aggressive fluid management, adequate opiate analgesia, early nutrition, and oxygen administration.8 Fluid resuscitation is an especially important aspect of treatment.1,3,19,23 Hypovolemia plays a central role in pancreatic necrosis by compromising pancreatic microcirculation.7 Fluids should be bolused initially to achieve hemodynamic stability, followed by rates of 250-500 cc/hr to replete fluid losses.4,7 Crystalloid is generally preferred. Colloid may be considered in specific situations when hematocrit is less than 25% or albumin is less than 2 g/dL.23,24
The choice of parenteral analgesic should be based on provider comfort and patient relief. Traditional teaching has been to avoid morphine as it causes spasm of the sphincter of Oddi and to favor meperidine, which has no such effect.8,25 Meperidine, however, has fallen out of favor because of its adverse effect profile. No outcomes-based evidence has emerged that morphine is contraindicated in acute pancreatitis.8,25
Acute pancreatitis is a hypercatabolic state and therefore adequate nutrition is critical.3 Oral feeding can be considered in patients as early as 24 hours.3 It is now recognized that enteral nutrition offers advantages over parenteral nutrition.1,4,7 These include preservation of the gut barrier, prevention of bacterial translocation, decreased cost, and avoidance of catheter-related complications.1-4,7