HTG-Panc – Don’t Pan(i)c!

Today we discussed a case of hypertriglyceridemia-induced pancreatitis (TG >4k). We first utilized this case as an opportunity to provide a comprehensive overview of acute and chronic pancreatitis:

 

We then discussed the management strategy:

General Pancreatitis Management

  1. Assess severity of pancreatitis with SIRS
  • Mild – absence of organ failure and local systemic complications
  • moderate – local complications and +/- transient organ failure (<48hrs)
  • Severe – persistent organ failure (>48hrs)
  1. Aggressive hydration at 5-10mls/kg/hr
  • Adjust based on vital signs, exam, urine output BUN, HCT
  1. Pain Control
  2. Nutrition
  • Mild
    • initiate PO intake within 48 hours (based on symptoms, NOT lipase reduction)
    • Go straight to low residue, low fat, soft diet
  • Moderate – Severe
    • If unable to tolerate PO, consider NJ vs. NG tube after 3-4 days
  • Enteral nutrition >>> parenteral nutrition
  1. Antibiotics?
  • not recommended regardless of pancreatitis severity or type (i.e interstitial or necrotitizing) unless extrapancreatic infection suspected (blood stream, PNA, UTI etc.) OR necrotizing fluid collection suspected to be secondarily infected (systemic infection OR radiographic evidence of infection)

HTG-Pancreatitis Management

  • Insulin Therapy
  • Lipid Lowering Therapy
  • Plasmapheresis (controversial)
    • invasive
    • expensive
    • requires AC
    • Despite that – UTD recommends apheresis in patients with any of the following (hypocalcemia, lactic acidosis, two or more signs of worsening inflammation, worsening organ dysfunction)
    • Two studies of note that discuss this
      • 1) Head-to-head RCT showed quicker time to TG reduction compared to insulin but worse clinical outcomes
      • 2) Addition of apheresis to patients already receiving insulin showed no clinically significant differences in outcome
    • Bottom Line: based on the limited data above, some experts favor an insulin only approach
    • For an in-depth analysis of this topic – please see this fantastic PulmCrit blog post: https://emcrit.org/pulmcrit/hypertriglyceridemic-pancreatitis/

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