Pancreatitis Clinical Pathway — Emergency Department and Inpatient

Clinical Pathways Home Emergency ICU Inpatient Outpatient Specialty Care Primary Care

Goals and Metrics

Child with Suspected or Known Pancreatitis

Suspected Sepsis
- ED, Inpatient and PICU Sepsis Pathway
- Severe pancreatitis with multisystem organ failure
  - Admit to PICU as indicated
  - GI Consult
- N/IICU Sepsis Pathway
- CICU Sepsis Pathway
Traumatic Pancreatitis
General Surgery Consult
Known or Strongly Suspected Metabolic Disorder
Metabolism Consult

Exclusions

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

ED Team Assessment

History and Physical
- Pain
- Hydration status
- Duration of symptoms
- Prior history of pancreatitis
Initiate treatment bundle while awaiting laboratory and imaging results
Refer to previous pain management plan as applicable for known acute recurrent or chronic pancreatitis

Initial Evaluation
Labs	Amylase/Lipase, CBC w/diff, CMP, GGT Urinalysis
Imaging	Ultrasound right upper quadrant Additional imaging based on clinical status

Initiate Treatment Bundle
IV Fluids	20 mL/kg LR bolus Repeat as needed to restore euvolemia
Analgesia	IV ketorolac IV acetaminophen
Additional Medications	Antiemetics PRN IV pantoprazole or IV Famotodine

Disposition

Initial Inpatient Management Recommendations upon admission based on disease severity
	Mild	Moderate	Severe
IV Fluid Management Goal: Maintain euvolemia without fluid overload Lactated Ringer’s (LR) preferred; if unavailable may use normal saline (NS)	1.25x maintenance rate (IV+PO)	1.5x maintenance rate (IV + PO) Continuous fluids at 1.5x maintenance rate (IV + PO) IV Fluid Pathway	1.5x maintenance rate (IV +PO) If no response after 40 mL/kg in crystalloid, ED, Inpatient, PICU Sepsis Pathway Consider Foley placement for strict I/O monitoring as inpatient IV Fluid Pathway
Nutrition Goal: Early introduction of oral/enteral nutrition PO ad lib as tolerated	Antiemetics PRN PO ad lib	Antiemetics scheduled Consider early enteral feeding tube placement if unable to tolerate PO on admission	Antiemetics scheduled Plan NJ placement at 48-72 hr
Analgesia Goal: Adequate pain control with scheduled medications and non-pharmacological interventions while minimizing opioid use	Acetaminophen PO or IV Ibuprofen or ketorolac IV Acid suppression Famotidine PO or pantoprazole IV	Acetaminophen IV Ketorolac IV Opioid IV PRN Nalbuphine preferred Acid suppression Famotidine PO or pantoprazole IV	Acetaminophen IV Ketorolac IV Opioid IV PRN Nalbuphine preferred Acid suppression Pantoprazole IV

Subsequent Inpatient Management
Lab Monitoring Goal: Decrease BUN and urine specific gravity	At a minimum, BMP and UA q24hr for the first 48 hrs No role for trending lipase or amylase Assess hepatic function panel q24hr in patients with known autoimmune pancreatitis Consider additional labs as needed in recurrent or chronic pancreatitis
IV Fluid Management Goal: Maintain euvolemia without fluid overload	Monitor fluid status with vital signs, physical exam, electrolytes, BUN, urine output, urine specific gravity Fluid overload in first 48 hrs, consider furosemide At 48 hr, decrease IVF to maintenance rate
Nutrition Goal: Early introduction of oral or enteral nutrition	Monitor PO/enteral intake and assess for signs of feeding intolerance If intake poor at 48 hrs, consider: NG IR consult for NJ placement Continue scheduled vs. PRN antiemetics to facilitate PO/enteral tolerance Monitor stool output and consider bowel regimen
Analgesia Goal: Adequate pain control with medication and non-pharmacological interventions while minimizing opioid use	Monitor effectiveness of analgesia and determine whether medication can be de-escalated If no progress at 48 hrs, consider Imaging to screen for complications Acute Pain Service consult

Discharge Criteria

Tolerating oral/enteral feeds
Pain managed with oral medications
Follow-up with Pancreatic Disorders Program

Posted: September 2020
Revised: March 2025

Authors:
- J. Brownell, MD;
- A. Maqbool, MD;
- N. Sierchio, RN;
- S. Irving, CRNP;
- A. Grachen, PharmD;
- W. Kraemer, MD;
- J. Driggers, RD;
- M. Mascarenhas, MD;
- S. Anupindi, MD;
- M. Mason, LCSW;
- M. Rowland, CCLS;
- M. Acord, MD;
- G. Nace, MD;
- P. Laje, MD

Evidence

Evidence

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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.

Children's Hospital of Philadelphia

Emergency Department and Inpatient Clinical Pathway for Treatment and Management of Non-Traumatic Pancreatitis

Evidence

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