ICU · GI and nutrition

Severe acute pancreatitis: fluid resuscitation (WATERFALL), necrosis, and PANTER step-up

Also known as Severe acute pancreatitis · Infected pancreatic necrosis · PANTER trial · WATERFALL trial · Step-up approach · Walled-off necrosis

Severe acute pancreatitis (15-20% of cases) = organ failure 48h (Revised Atlanta classification) — ICU-level care. EARLY PHASE (first week): SYSTEMIC INFLAMMATION (SIRS) + FLUID SEQUESTRATION ('third space' — massive fluid shift into retroperitoneum) - hypovolaemia, haemoconcentration, AKI, shock. MANAGEMENT: GOAL-DIRECTED FLUIDS (WATERFALL trial — AGGRESSIVE fluids HARM — goal-directed preferred), analgesia, EARLY ENTERAL NUTRITION (within 48h — reduces infection/necrosis), antibiotics ONLY if infected (prophylactic antibiotics NOT recommended — meta-analyses no benefit). LATE PHASE (week 2+): NECROSIS (sterile vs infected — the key distinction), INFECTION (infected necrosis — 30% — needs antibiotics + drainage), PSEUDOCYST/WALLED-OFF NECROSIS. INFECTED NECROSIS: PANTER trial — STEP-UP approach (percutaneous/endoscopic drainage FIRST, then minimally-invasive necrosectomy if needed) SUPERIOR to open necrosectomy (less complications, fewer deaths). DELAY intervention 4 weeks (let necrosis become walled-off - safer drainage).