Mild Acute Pancreatitis in Children (< 18 yo)
Last Updated: 6/30/2016 11:48:40 AM
Order Set
  Associated Pathway(s)
 Acute Pancreatitis (<18 years old) - http://www.curbsideup.com/link/2272
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  Inclusion Criteria
Inclusion Criteria ( All criteria are present )
  • Abdominal pain concerning for pancreatitis
Exclusion Criteria
  • Complex history of abdominal surgery
  Admission General Orders
  Admit to Inpatient
Admit to Inpatient - GI
  Vital Signs
Vital signs q4h, O2 spot check with vitals
Cardiorespiratory monitor
  Notify MD (VS Parameters and Bedside Monitor Alarm Limits) as per age-based vital sign parameters specified in the Patient Care Policy
Notify MD - Urine output < 0.5 ml/kg/hr over an 8-hour period
  Activity
Up ad lib
  Nursing Assessments
Admission Measurements
I/O - Strict, q4h
Weight Patient daily
  Wounds/Lines/Drains
PIV insertion/care
  IV Fluids

Learning Points:

  • There is strong evidence for early goal-directed fluid resuscitation in acute pancreatitis of any severity.
  • However, approaches to fluid resuscitation require optimization. Under-resuscitation during the early phase of acute pancreatitis has been associated with increased risk of necrosis and mortality. Over-resuscitation can lead to complications such as pulmonary sequestration.
  • Frequent bedside evaluations (physical exam & VS check) provide key information on fluid status (as opposed to simply relying on numbers in EPIC)
  IV Infusions
D5 and 0.9% NS infusion @ 1.5 x M
  IV Bolus
NS bolus 20 mL/kg
Caution in patients with pre-existing organ failure: watch for signs of pulmonary edema (tachypnea, hypoxia, increased work of breathing)
  NUTRITION

Learning Points:

  • Strong evidence for early enteral nutrition (within 48 hours of admission) in mild acute pancreatitis in pediatric population 
  • In fact, in one large study (Abu-El-Haija et al. 2015), early enteral nutrition was the single most important factor to improved outcomes in pediatric subjects with mild acute pancreatitis.
  • Diet advancement should be patient-driven
  • Pain and nausea should be well-controlled to optimize patient’s ability to eat
  • Diet advance often prolongs admission—we propose making diet advancement part of nursing assessment.
  Diet
NPO
Clear Liquid Diet
Advance Diet Per Protocol
Advance to regular diet if no vomiting and + bowel sounds; abdominal pain should NOT limit diet advance
  Medications

Learning Points:

  • Pain is the primary complaint of many acute pancreatitis patients, however, pain does not correlate well with degree of inflammation.
  • Good pain control early is important.  Begin with scheduled tylenol and NSAIDS (if no AKI) with opiate for breakthrough, escalate as needed.
  • PO pain medications are preferred due to cost, however, IV medications are often better tolerated early in course of pancreatitis.
  • Persistent or worsening pain should prompt the clinician to evaluate complications or reconsider etiology
  • The evidence for opioids in the treatment of pain associated with acute pancreatitis is weak. There is currently no difference in the risk of pancreatitis complications or clinically serious adverse events between opioids.
  Analgesics - Mild/Moderate Pain
acetaminophen PO, 15 mg/kg PO q6h
If no evidence of AKI, add NSAID
ibuprofen 100 mg/5 mL suspension
Caution: use of NSAIDs with pre-existing AKI may worsen kidney function
ibuprofen tablet
Caution: use of NSAIDs with pre-existing AKI may worsen kidney function
ketorolac, 0.5 mg/kg IV q6h
Caution: use of NSAIDs with pre-existing AKI may worsen kidney function
acetaminophen, 15 mg/kg IV q6h
If no evidence of AKI, add NSAID
  Analgesics - Moderate/Severe Pain
hydromorphone injection, 0.01 mg/kg q4h PRN
fentanyl injection, 0.5 mcg/kg IV q2h PRN
morphine injection, 0.05 mg/kg IV q4h pRN
  Nausea and Vomiting
ondansetron 0.1 mg/kg, intravenous
ondansetron, orally disintegrating, 4 mg PO
  Bowel Regimen
      If using > 2 PRN opiates in 24 hours or on ATC opiates
miralax pkt, 17 g PO, daily
  Labs
  Admission Labs
CBC with Diff
Metabolic Panel, Comprehensive
GGT
Lipase, serum
Amylase, serum
Triglyceride
C Reactive Protein
Magnesium, Ser/Plas
Phosphorus, Ser/Plas
  Routine AM Labs while on IV Fluids
Renal function panel
Magnesium, Ser/Plas
  Imaging
  Imaging
US abdomen complete
MRI Abdomen Pelvis With and Without Contrast
  Consults
  Ancillary
Inpatient consult to Nutrition Services
Inpatient consult to Child Life
Inpatient consult to Social Services
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