Acute pancreatitis — severity, fluids and infected necrosis

Infected necrosis. Clinical timing (second–third week after initial improvement) plus gas within necrosis on CT is treated as infected necrosis. Hasibeder names CT-guided FNA as the technique of choice to differentiate sterile from infected necrosis; it is not a prerequisite before starting antibiotics when the picture is typical.^[11]

Antimicrobials. ACG 2013: antibiotics known to penetrate pancreatic necrosis may be useful in delaying intervention. Do not quote unsourced meropenem 1 g 8-hourly or ciprofloxacin-plus-metronidazole milligram doses. Prophylactic antibiotics earlier would not have prevented this.^[1]

Source control. Delayed step-up approach (PANTER): percutaneous drainage first → minimally invasive retroperitoneal necrosectomy if needed. Composite of major complications or death 40 versus 69 percent (RR 0.57); 35 percent drainage only; new-onset MOF 12 versus 40 percent; death 19 versus 16 percent (not significant); hernias 7 versus 24 percent; new-onset diabetes 16 versus 38 percent. ACG 2013: delay drainage preferably for 4 weeks in stable patients to allow a wall to form.^[6][1]

Day-1 fluids. WATERFALL moderate lactated Ringer's: 10 mL/kg bolus only if hypovolaemic, then 1.5 mL/kg/h, reassessed at 12, 24, 48 and 72 hours. Aggressive 20 mL/kg then 3 mL/kg/h caused overload 20.5 versus 6.3 percent (adjusted RR 2.85) without reducing moderately severe or severe pancreatitis (22.1 versus 17.3 percent).^[4]

Do not use probiotics for prophylaxis — PROPATRIA: death 16 versus 6 percent; bowel ischaemia 9 versus 0; infections 30 versus 28 percent (not significant).^[5]