Pain Management

PHASE I: ED & INPATIENT

Inclusion Criteria· All ages

· Confirmed pancreatitis (2 out of 3 criteria)

· Amylase or lipase elevated (> 3x normal)

· Any imaging showing pancreatic

inflammation

· Abdominal pain or clinical symptoms of

pancreatitis (vomiting, feeding refusal)

Exclusion Criteria· Signs and symptoms of shock (use

· Complicated pancreatic fluid collection

· Other diagnosis

- DKA

- TPN dependent

Pancreatitis v2.0: Initial Management

Explanation of Evidence RatingsSummary of Version Changes

Last Updated: March 2018

Next Expected Review: July 2022© 2018 Seattle Children’s Hospital, all rights reserved, Medical Disclaimer

For questions concerning this pathway,

contact: pancreatitis@seattlechildrens.org

Approval & Citation

Fluid Resuscitation· NPO during initial fluid resuscitation

· IVF bolus (20 mL/kg) x1 with LR

· Assess and consider re-bolus as needed

until dehydration improves

· Once dehydration improves, begin 1.5-2.0x

maintenance with D5 NS until enteral feeds

initiated

· Vital signs minimum Q2hrs

Mild

(Pain score 0-3)· Distraction, warm packs

· PO acetaminophen +/-

ibuprofen

Mod – Severe

(Pain score 4-10)· IV opioids (Morphine

preferred)

· If severe pain persists > 4

hours, consult pain

service

Phase Change

Disposition· Admit to GI service unless

patient has established

primary team

· PICU consult if ≥ 3 fluid

boluses during initial

resuscitation

Labs/Imaging(if not already done)

Abdominal Ultrasound

Amylase, Lipase

Lytes (iCa, Mg, Phos), BUN, Cr

AST, ALT, GGT, Bili (conj, unconj)

Triglycerides

CBC

Albumin

CRP

Consult GIEmergent surgical consultation not

required for gallstones

Signs of Dehydration· Urine output (< 1 mL/kg/hr)

· Capillary refill (>2 seconds)

· Skin turgor (tenting)

· BUN/Cr (elevated)

· Hematocrit (elevated)

· Heart Rate (elevated)

· Mean Arterial Pressure (for

SCH only)

!

Antibiotics

not routinely

recommended unless

evidence of infection

Continue Phase I until signs of dehydration resolve (~12-24 hours).

Confirm readiness for phase change with GI.

!

Medically complex/

metabolic disorders:

Use caution – may have

alternate reason for increased

lipase and pain

· IVF bolus (20 mL/kg) x1 with LR

pancreatitis@seattlechildrens.org

(use Septic

Shock pathway)

PHASE II

Pancreatitis v2.0: Subsequent Management

Explanation of Evidence RatingsSummary of Version ChangesApproval & Citation

Nutrition· Nutrition consult, Strict I+O, Daily weights

· If hemodynamically stable and no

contraindications, including upcoming

procedures, begin enteral nutrition within 48

hrs

· Feeding route in order of preference:

1. PO regular diet

2. NG tube feeds

3. NJ tube feeds

4. TPN

· Place feeding tube after 24 hours if patient

starts PO feeds but takes <50% of caloric

goal

Pain Management

!

Antibiotics not

routinely recommended

unless evidence of

infection

Discharge Criteria· Tolerating full enteral feeds

· PO pain meds

· For patients with recurrent/

chronic pancreatitis, consider

follow up in pancreatitis clinic

Last Updated: March 2018

Next Expected Review: July 2022© 2018 Seattle Children’s Hospital, all rights reserved, Medical Disclaimer

For questions concerning this pathway,

contact: pancreatitis@seattlechildrens.org

Specific populations· If triglycerides > 500

- consult endocrinology

- low fat enteral feeds:

PO: <15% calories from fat,

fat free PO supplements (Boost

Breeze, Ensure Clear)

NG/NJ: infant-13yr: Monogen,

>13yr: Vivonex TEN (monitor

essential fatty acids)

· Gallstone pancreatitis

- consult surgery

- due to high recurrence rates, surgery

is generally recommended prior to

discharge

Additional Testing

MRI, exocrine function testing and

genetic testing not routinely

indicated during initial

hospitalization

!

Contraindications

to feeding:· TPN dependent

· Ileus, bowel obstruction

· Hemodynamic instability

Mild

(Pain score 0-3)

For mild pain continue

acetaminophen +/-

Ibuprofen

Mod – Severe

(Pain score 4-10)· If ongoing, consider multi-modal therapy:

- PO > IV Acetaminophen, if tolerated

- IV Ketorolac, if adequate UOP and

surgery not anticipated

· Pain medicine consult if:

- Difficult to manage pain

- Chronic pain

- Chronic opioid use

· Start bowel regimen for those on opioids

· When tolerating enteral nutrition, consider

transition to PO meds.

- PO Acetaminophen

- Oxycodone

pancreatitis@seattlechildrens.org

!

Follow up

imaging not routinely

recommended unless

worsening clinical

status

Labs (daily until goal

enteral feeds established)

· BUN/Cr

· Lytes

· Hct

· CRP

· LFTs if initially

abnormal

· Do not need to

trend Lipase

Inclusion Criteria· All ages

· Confirmed pancreatitis (2 out of 3 criteria)

· Amylase or lipase elevated (> 3x normal)

· Any imaging showing pancreatic

inflammation

· Abdominal pain or clinical symptoms of

pancreatitis (vomiting, feeding refusal)

Exclusion Criteria· Signs and symptoms of shock (use

· Complicated pancreatic fluid collection

· Other diagnosis

- DKA

- TPN dependent

(use Septic

Shock pathway)

Lactated Ringers

Isotonic fluid type for fluid resuscitation:

Lactated ringers (LR) is recommended as the initial infusion solution for AP

based on 2 randomized controlled trials (pediatrics not specified) favoring

reduction of inflammation versus normal saline (NS). [LOE: Low

quality] (#45 Yokoe 2015) (#152 Working Group IAP/APA 2013)

Conditional recommendation made in favor of LR vs NS given in large volumes

may lead to non-anion gap, hyperchloremic metabolic acidosis. (# 157 Tenner

2013) A Spanish multidisciplinary society guideline commented on benefit of

LR over NS for control of inflammatory states, but did not make a

recommendation. (#178 Poma 2013)

Retrospective pediatric cohort study was not willing to recommend best type of

fluid due to lack of evidence in children. (#62 Szabo 2015).

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Management

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Management

Nutrition

Recommendations:

A nutrition consult should be placed for all patients admitted with pancreatitis.

Enteral nutrition is preferred in patients with pancreatitis and should begin

within 48 hours of hospital admission when the patient is hemodynamically

stable unless there are contraindications such as ileus or bowel obstruction.

Feeding route (in order of preference):

Oral Diet: Advance diet to goal of regular

Nasogastric feeds (NG): If unable to take PO due to pain, poor appetite,

other underlying cause impairing ability to eat, first line treatment should

be NG tube placement with initiation of continuous polymeric formula

unless contraindicated by protein allergy. Conversion to bolus feeds

should be attempted when clinical status allows.

Nasojejunal (NJ): If NG-feeds are poorly tolerated due to vomiting,

diarrhea, post-pyloric tube placement and trial of NJ continuous polymeric

feedings is recommended.

Parenteral nutrition: IV nutrition should be considered if there are

contraindications to enteral feeds or if severe feeding intolerance persists

despite attempts at enteral feeds.

Return to Initial

Management

Return to Subsequent

Management

Empiric Antibiotics for Patients with Pancreatitis

Return to Initial

Management

Return to Subsequent

Management

Use age appropriate pain scale. See pain policy (for SCH only) for more details.

Return to Initial

Management

Return to Subsequent

Management

Pancreatitis Approval & Citation

Approved by the CSW Pancreatitis team for July 26, 2017 go live.

CSW Pancreatitis Team:

Owner, GI Matt Giefer, MD, FAAP

Medical Clinical Nurse Specialist Anjanette Allard, RN

Medical Clinical Nurse Specialist Rebecca Engberg, RN, BSN,CPN

ED Clinical Nurse Specialist Sara Fenstermacher, RN

Clinical Dietitian Kim Leaf Braly, RD

Endocrinology Helen Dichek, MD

Clinical Pharmacy Jennifer Nguyen, PharmD

Pharmacy Informatics Rebecca Ford, PharmD

Anesthesia & Pain See Tham, MD

Clinical Effectiveness Team:

Consultant: Sara Vora, MD, MPH

Consultant: Lori Rutman, MD, MPH

Project Manager: Asa Herrman

CE Analyst: Maria Jerome

CIS Informatician: Carlos Villavicencio, MD, MS-MI

CIS Analyst: James Johnson

Librarian: Sue Groshong, MLIS

Program Coordinator: Kristyn Simmons

Executive Approval:

Sr. VP, Chief Medical Officer Mark Del Beccaro, MD

Sr. VP, Chief Nursing Officer Madlyn Murrey, RN, MN

Surgeon-in-Chief Bob Sawin, MD

Retrieval Website: http://www.seattlechildrens.org/pdf/pancreatitis-pathway.pdf

Please cite as:

Seattle Children’s Hospital, Giefer M, Allard A, Braly K, Dichek H, Fenstermacher S, Herrman A,

Rutman L, Tham S, Vora S, 2017 July. Pancreatitis Diagnosis Pathway. Available from: http://

www.seattlechildrens.org/pdf/pancreatitis-pathway.pdf

Return to Initial

Management

Return to Subsequent

Management

Evidence Ratings

To Bibliography

This pathway was developed through local consensus based on published evidence and expert

opinion as part of Clinical Standard Work at Seattle Children’s. Pathway teams include

representatives from Medical, Subspecialty, and/or Surgical Services, Nursing, Pharmacy, Clinical

Effectiveness, and other services as appropriate.

When possible, we used the GRADE method of rating evidence quality. Evidence is first assessed

as to whether it is from randomized trial or cohort studies. The rating is then adjusted in the

following manner (from: Guyatt G et al. J Clin Epidemiol. 2011;4:383-94.):

Quality ratings are downgraded if studies:

· Have serious limitations

· Have inconsistent results

· If evidence does not directly address clinical questions

· If estimates are imprecise OR

· If it is felt that there is substantial publication bias

Quality ratings are upgraded if it is felt that:

· The effect size is large

· If studies are designed in a way that confounding would likely underreport the magnitude

of the effect OR

· If a dose-response gradient is evident

Guideline – Recommendation is from a published guideline that used methodology deemed

acceptable by the team.

Expert Opinion – Our expert opinion is based on available evidence that does not meet GRADE

criteria (for example, case-control studies).

Return to Initial

Management

Summary of Version Changes

· Version 1.0 (7/26/2017): Go live

· Version 2.0 (3/16/2018): Added feeding tube parameters to algorithm

Return to Initial

Management

Return to Subsequent

Management

Medical Disclaimer

Medicine is an ever-changing science. As new research and clinical experience broaden our

knowledge, changes in treatment and drug therapy are required.

The authors have checked with sources believed to be reliable in their efforts to provide information

that is complete and generally in accord with the standards accepted at the time of publication.

However, in view of the possibility of human error or changes in medical sciences, neither the

authors nor Seattle Children’s Healthcare System nor any other party who has been involved in the

preparation or publication of this work warrants that the information contained herein is in every

respect accurate or complete, and they are not responsible for any errors or omissions or for the

results obtained from the use of such information.

Readers should confirm the information contained herein with other sources and are encouraged to

consult with their health care provider before making any health care decision.

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Management

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Management

Bibliography

Identification

Screening

Eligibility

Included

Flow diagram adapted from Moher D et al. BMJ 2009;339:bmj.b2535

Search Methods, Pancreatitis, Clinical Standard Work

Studies were identified by searching electronic databases using search strategies developed and executed by a medical

librarian, Susan Groshong. Searches were performed in December, 2016. The first search for the concept pancreatitis

was completed in the following databases – on the Ovid platform: Medline and Cochrane Database of Systematic

Reviews; elsewhere: Embase, National Guideline Clearinghouse, TRIP and Cincinnati Children’s Evidence-Based

Recommendations. A second search was completed for the concepts pancreatitis, hypertriglyceridemia, dyslipidemias,

chylomicronemia, lipodystrophy and nutrition therapy in Medline and Cochrane Central Register of Controlled Trials

on the Ovid platform, plus Embase. In Medline and Embase, appropriate Medical Subject Headings (MeSH) and

Emtree headings were used respectively, along with text words, and the search strategy was adapted for other

databases using text words. Retrieval was limited to humans, English or French language, 2007 to current and further

limited to certain evidence categories, such as relevant publication types, index terms for study types and other similar

limits.

Susan Groshong, MLIS

June 29, 2017

To Bibliography, Pg 2

713 records identified

through database searching

0 additional records identified

through other sources

672 records after duplicates removed

672 records screened 470 records excluded

181 full-text articles excluded,

155 did not answer clinical question

23 did not meet quality threshold

3 outdated relative to other included study

202 records assessed for eligibility

21 studies included in pathway

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Management

Bibliography

Basurto Ona X, Rigau Comas D, Urrutia G. Opioids for acute pancreatitis pain. Cochrane Database of

Systematic Reviews [Pancreatitis]. 2013;7.

Carr RA, Rejowski BJ, Cote GA, Pitt HA, Zyromski NJ. Systematic review of hypertriglyceridemia-induced acute

pancreatitis: A more virulent etiology? Pancreatology [Pancreatitis]. 2016;16(4):469-476.

Greenberg JA, Hsu J, Bawazeer M, et al. Clinical practice guideline: Management of acute pancreatitis. Can J

Surg [Pancreatitis]. 2016;59(2):128-140. Accessed 20160324.

Haffar S, Bazerbachi F, Garg S, Lake JR, Freeman ML. Frequency and prognosis of acute pancreatitis

associated with acute hepatitis E: A systematic review. Pancreatology [Pancreatitis]. 2015;15(4):321-326.

Accessed 20150724. http://dx.doi.org/10.1016/j.pan.2015.05.460.

Hoffmeister A, Mayerle J, Beglinger C, et al. English language version of the S3-consensus guidelines on

chronic pancreatitis: Definition, aetiology, diagnostic examinations, medical, endoscopic and surgical

management of chronic pancreatitis. Z Gastroenterol [Pancreatitis]. 2015;53(12):1447-1495. Accessed

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Italian Association for the Study of the Pancreas (AISP), Pezzilli R, Zerbi A, et al. Consensus guidelines on

severe acute pancreatitis. Dig Liver Dis [Pancreatitis]. 2015;47(7):532-543. Accessed 20150622. http://

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literature. J Pediatr (Rio J) [Pancreatitis]. 2012;88(2):101-114. Accessed 20120430. http://dx.doi.org/

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(Edinburgh, Scotland) [Pancreatitis]. 2016.

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Meng W, Yuan J, Zhang C, et al. Parenteral analgesics for pain relief in acute pancreatitis: A systematic review.

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Management