1 Acute Pancreatitis: Initial Management Algorithm 1. Recognition and Initial Severity Assessment Presentation suggestive of acute pancreatitis Medical History Physical Exam Labs to Order Imaging Investigate: Risk Factors/ Etiologies Predictors of severity See section 2.2 in text Epigastric pain, nausea, vomiting Restlessness, fever, tachycardia If severe, may see marked tenderness with guarding, abdominal distension, absent bowel sounds, signs of shock, jaundice, signs of pulmonary involvement CBC (Hct key) Chem10 Amylase, lipase LFTs Lipid panel LDH ABG, lactate if critically illappearing See section 2.3 in text Chest XR and/or Abd XR CT abdomen is not indicated on presentation except in crtically ill patients Acute Pancreatitis is confirmed by these defining characteristics Clinical symptoms of epigastric abdominal pain, nausea, and vomiting and Elevation in amylase and/or lipase 3 times the upper limit of normal CT imaging is not indicated to confirm the diagnosis and should not be performed until hours after symptom onset except in select patients See section 2.4 in text for indications Severity Assessment and Triage Appropriate triage to general floor VS PCU/ICU is essential Acute pancreatitis always warrants admission Severity assessment should be based on the presence of any these factors: Subjects with < 2 factors AND Severity Assessment Model score in the mild range Mild Acute Pancreatitis Presence of multiple comorbidities Presence of SIRS criteria Hct > 44 or failure to decrease by 10% in first 24 hours Elevated BUN or Cr or failure to decrease by 10% in first 24 hours Hypoxia Lactate > 4 mmol Pleural effusion on CXR CT or MRI showing evidence of severe pancreatitis and/or necrosis Severity assessment model score suggesting severe pancreatitis Severity assessment models can also be used: Severity Assessment Ranson Criteria APACHE II BiSAP Scoring System on Admission within 24 hrs Mild Pancreatitis < 3 < 6-8 < 3 Severe Pancreatitis > 3 > 6-8 > 3 Subjects with 2 factors OR Severity Assessment Model score in the severe range Severe Acute Pancreatitis Admission to a general floor is appropriate Serial monitoring for deterioration is essential. Telemetry,SatO2, urine output, frequent vitals and labs Serial Severity Assessment Score calculation Maintain a low threshold to escalate the level of care with any signs of deterioration or lack of improvement Consider admission to PCU/ICU Consideration for pancreatic surgery complications
2 Algorithm 2. Acute Pancreatitis Management 2 Mild Acute Pancreatitis 0-24 hours: Obtain 2 peripheral 18-gauge IVs Control pain and nausea Make NPO Labs: CBC, Chem10, Amylase, lipase, LFTs, Lipid panel, LDH Focus on aggressive rehydration: IVF challenge of 1-2 liters NS if no clinical contraindications IVF at 250 ml/hr of NS or D 5 -½ NS until adequate urine output is achieved Severe Acute Pancreatitis 0-12 hours: Obtain 2 peripheral 18-gauge IVs or central line Make NPO Control pain and nausea Labs: CBC, Chem10, Amylase, lipase, LFTs, Lipid panel, LDH, ABG, lactate Focus on aggressive rehydration: IVF challenge of 1-3 liters NS or LR if acidosis (over min) if no clinical contraindication IVF at ml/hr of NS or LR Calculate severity assessment scores Monitor closely for signs of deterioration: If urine output < 0.5 ml/kg/hr or oxygen requirement increasing, consider CVP placement Failure of Hct/BUN to decrease in 6-12hrs Urine output <0.5 ml/kg/hr Increasing oxygen requirements Altered renal status No Hours Yes Hours Continue aggressive fluid rehydration: IVF at ml/hr of NS or D 5 -½ NS until adequate urine output is achieved Treat supportively and prevent infection, minimize lines, avoid TPN NPO Ensure adequate pain control Prophylactic antibiotic use is not warranted in the absence of biliary sepsis or obvious pancreatic/peri-pancreatic infection (See algorithm #3) Consider Abdominal ultrasound Consider emergent ERCP or MRCP / EUS if evidence of cholangitis (See section 4.3 in text) Consult gastroenterology (hepatobiliary) and general surgery Calculate severity assessment scores Check CRP Continue IV hydration and pain control Hours Severity assessment model labs and RUQ ultrasound If anticipate NPO status for > 7 days, begin jejunal enteral nutrition Do not follow amylase/lipase daily as levels do not correlate with severity See sections 4.2 and 4.3 in text for indications for ERCP, MRCP, and EUS. If scores in severe range OR signs of clinical worsening consider transfer to PCU/ ICU Urine output < 0.5 ml/kg/hr or Oxygen requirement increasing No Yes Consider rapid bolus CT to assess for evidence of pancreatic necrosis (See sections and 4.2 in text) Begin enteral nutritional support within 2-3 days in severe acute pancreatitis; jejunal feeding is preferred TPN is reserved for those unable to tolerate enteral feeds Consider urgent ERCP if evidence of evidence of biliary obstruction (See section 4.3 in text) Calculate severity assessment scores If patient does well after first 48 hrs in PCU/ICU, or recovers from acute illness with no further concern for organ failure, consider transfer out of PCU/ICU 72 Hours If clinically decompensating, suspect infected necrosis (See algorithm #3) Pancreatic Surgery Consultation Guided antibiotics (See section 4.4 in text)
3 Algorithm 3. Pancreatic Necrosis 3 Suspected Pancreatic Necrosis If < 30% non-enhancement Rapid Bolus Contrast Enhanced CT Scan at hours If 30% non-enhancement or clinically declining Conservative Management IV fluids, aggressive rehydration, and pain control If unable to obtain CT-FNA, and high clinical suspicion of infection Consider starting empiric antibiotics with pancreatic penetration Piperacillin and tazobactam or cefepime + metronidazole, or high-dose cephalosporins Obtain CT-guided FNA (Generally 7-10 days after admission) Send for gram stain and culture Sterile Necrosis Negative Gram Stain or Culture Supportive Care and prevention of infection Minimize IV lines, avoid TPN, NPO, and start enteral nutrition Repeat CT-guided FNA every 5-7 days as clinically indicated Infected Necrosis Positive Gram Stain or Culture Begin empiric antibiotic coverage Tailor antibiotics based on GS/culture Clinically Stable Clinically Unstable Conservative Management Continue IV antibiotics for 2-4 weeks prior to elective surgery (cholecystectomy) Consider prompt surgical debridement Clinical decompensation
4 4 1. Etiologies In Order of Prevalence Biliary (choledocholithiasis, gallstones). Acute alcohol consumption. Medications including: acetaminophen, azathioprine, erythromycin, 6-mercaptopurine, estrogen, exenatide, furosemide, metronidazole, NSAIDs, pentamidine, stavudine, sulindac, tetracycline, and valproic acid. Anatomic or functional disorders (sphincter of Oddi dysfunction, congenital anomalies [e.g., pancreatic divisum], pancreatic or ampullary tumors). Infectious (e.g., viral, bacterial, parasitic, fungal). Traumatic or post-procedure (e.g., post-ercp or abdominal surgery). Autoimmune (e.g., systemic lupus erythematosus). Metabolic derangements: hypercalcemia, hypertriglyceridemia, severe acidosis (DKA). Hypothermia. Genetic: cystic fibrosis (CFTR), trypsinogen gene (PRSS1), pancreatic secretory trypsin inhibitor gene (SPINK1 recurrent disease only). Vascular (e.g., vasculitis, ischemia). Toxins - ethyl alcohol, organophosphates, scorpion bite. Idiopathic. 2. Diagnosis and Workup 2.1 Definition of Acute Pancreatitis: Two of the following: Clinical symptoms of epigastric abdominal pain, nausea, and vomiting. Elevation in amylase and/or lipase 3 times the upper limit of normal. Imaging confirmation of pancreatitis on CT or MRI. 2.2 History and Physical Focus on identifying risk factors such as heavy alcohol use, family history of gallstones or pancreatitis, medications, etc. Focus on identifying predictors of severity such as dehydration, septic appearance, elderly patients, etc. 2.3 Labs to Order On Admission: CBC (hematocrit is key) Elevated levels may indicate higher risk of developing necrotizing pancreatitis. Creatinine (> 2 mg/dl) and blood glucose > 250 mg/dl are significantly correlated with mortality. Amylase, lipase. Liver Functional Panel AST/ALT > 3 times normal, highly suggestive of gallstones as etiology. Calcium -- Levels < 6.6 mg/dl may be suggestive of more severe disease. ABG If patient is critically ill-appearing. At 48 hours: CRP Extremely useful at both 24 hours (if trending upwards) and 48 hours after symptom onset as a predictor of severe disease. o Check if patient not improving with conservative management or if clinically decompensating. o CRP > 150 mg/l suggestive of more severe disease. Check labs for severity assessment model calculations: Chem10, LFTs, CBC w/ diff, LDH, coagulation factors, and ABG 2.4 Imaging Indications for CXR: if ill-appearing or if exam concerning for pleural effusions. o Pleural effusion or infiltrate within 24 hours associated with increased mortality risk, necrotizing pancreatitis, and the development of infected necrosis. Indications for early CT imaging (rapid bolus contrast-enhanced CT): o Generally, CT imaging not indicated until hours after symptom onset except in select patients: If patient is critically ill or questionable diagnosis, if high clinical suspicion but amylase/ lipase less than 3 times the upper limit of normal, or in patients with progressively worsening symptoms. o Advantages of CT: High sensitivity for detection of necrotizing pancreatitis, presence of peri-pancreatic inflammation, and fluid collections. The extent of necrosis may predict disease severity and outcome Allows calculation of CT Severity Index (see appendix for details).
5 5 o Limitations of CT: Early imaging may underestimate the amount of necrosis present. IV contrast may be associated with worse outcomes as it may exacerbate microcirculatory hypoperfusion and worsen necrosis. Notes: These are additional tests that have been studied with data showing utility in predicting disease severity, but not enough clinical data exists to recommend their use at this time: On admission - IL-6 ELISA, cutoff level > 400 pg/ml; IL-8; Trypsinogen activation peptide. At 24 hours - PMN-elastase levels > 300 ug/l suggestive of more severe disease; Phospholipase A 2, Procalcitonin (indicates necrosis if elevated); Urinary T-2 ELISA, cutoff level >35 nmol/l; Urinary trypsinogen activation peptide dipstick, cutoff level >2000 ng/l. 3. Severity Assessment Appropriate triage (to General Floor VS PCU/ICU) is essential in the management of acute pancreatitis. Acute pancreatitis always warrants admission. Acute pancreatitis initially diagnosed as mild or moderate can rapidly progress to severe or even fatal illness: o Prognostic indicators are not reliable in the first 24 hours o In any level of acute pancreatitis appropriate nursing care, continuous monitoring, and serial assessments are essential 3.1 Indications for PCU/ICU Consideration: High risk patients are best cared for in an ICU setting. ICU admission should be considered for subjects with 3 of the following: o Presence of multiple co-morbidities o Presence of SIRS criteria o Hypoxia o Hct > 44 or failure to decrease by 10% in first 24 hours o Elevated BUN or Cr or failure to decrease by 10% in first 24 hours o Presence of multiple comorbidities o Presence of SIRS criteria o Hypoxia o Hct > 44 or failure to decrease by 10% in first 24 hours o Elevated BUN or Cr or failure to decrease by 10% in first 24 hours o Pleural effusions on CXR o CT or MRI showing evidence of severe pancreatitis and/or necrosis o Severity assessment model scores suggesting severe pancreatitis Reversal of organ failure in first 48 hours is critical for improved outcomes. If patient does well after first 48 hours in PCU/ICU with no further concern for organ failure, can consider transfer out. 3.2 Indications for Admission to the General Floor Lack of the above. o Serial monitoring for deterioration is essential Telemetry, continuous pulse oxymetry, frequent vitals and labs, serial assessments. o Maintain a low threshold to escalate the level of care and transfer to PCU/ICU. 3.3 Prognostic Scoring Systems for Acute Pancreatitis and Links to Calculators (see Table 1 in the appendix for details) Ranson Score - BiSAP see appendix APACHE II Score - CT Severity Index see appendix 4. Management 4.1 Resuscitation - On Admission Follow steps above in Diagnosis and Workup. Make patient NPO, and control of nausea and pain. o NSAIDs, IV narcotics, and patientcontrolled administration of analgesia are all acceptable. Use of hydromorphone (Dilaudid ) is acceptable; avoid tramadol due to side effects of nausea/vomiting. No data exist that any one medication is preferred over another.
6 First 6-12 hours. Most critical time - Focus on vigorous fluid resuscitation hours: ml/hr NS or D5-1/2NS is the minimum; likely will need more if overall volume depleted. o Bolus 1-2 liters of NS on admission based on clinical presentation. Titrate hydration to decrease Hct by at least 10% and decrease BUN in first 6-12 hours. o Adjust fluid rate q1-4 hours based on serial labs and assessments (urine output, vitals, Hct, BUN). Goal urine output is 0.5 ml/kg/hr. Rate may need to be adjusted in patients with renal, pulmonary, or cardiac co-morbidities. o If unclear ARDS vs volume overload, consider transfer to ICU for intra-cardiac monitoring or intubation. Monitor closely for clinical worsening, failure of Hct/BUN to decrease in first 6-12 hours, or signs of organ failure. o If any of the above develop, consider transfer to PCU or ICU. o Consider imaging hours: If patient clinically worsening, check CRP and labs to calculate severity assessment model scores. If Ranson Score > 3 or APACHE II Score 6-8, consider transfer to PCU/ICU; consult GI (hepatobiliary) / general surgery. 4.2 Indications for ERCP Emergent (within 24 hours): suspicion for ascending cholangitis. Urgent (within hours): severe acute pancreatitis (APACHE II score 8 or persistent illness refractory to supportive care); evidence of biliary obstruction, or elevated bilirubin levels, > 3-fold elevation in AST/ALT, or when patient refractory to conservative management. Late (after 72 hours): sphincterotomy is an alternative to cholecystectomy in non-surgical candidates. 4.3 Indications for MRI / MRCP or EUS To avoid unnecessary ERCP when persistent biliary obstruction is suspected and no radiological (U/S or CT) evidence of CBD abnormalities. Persistently elevated LFTs. To differentiate between pseudocysts and walledoff pancreatic necrosis. 4.4 Severe Pancreatitis with/without Evidence of Necrosis: Patient should be in PCU/ICU. o Continue vigorous fluid ressuscitation ( ml/hr NS). o Obtain imaging to evaluate for severe pancreatitis and/or evidence of pancreatic necrosis. Pancreatic Necrosis: Defined as gross destruction of the pancreatic gland, which is seen in 20% of patients. It is diagnosed by the presence of 30% of non-enhancement on rapid bolus contrast-enhanced CT. o Usually occurs within the first 4 days of the onset of symptoms. o Considered sterile early in course, but can become infected later both can lead to organ failure. Sterile Necrosis. Treat supportively and prevent infection. o Minimize IV lines, avoid TPN, strict NPO and start enteral nutrition. o Prophylactic antibiotic use in the absence of biliary sepsis or obvious pancreatic/peripancreatic infection is not warranted. o Surgery has no proven benefit in sterile necrosis. Infected Necrosis: 33% of those with sterile necrosis develop infection; usually clinically apparent after days of illness. Infected pancreatic necrosis is rare before 14 days. o Look for signs of sepsis and persistent organ failure. o Obtain CT-guided FNA gram stain is 95% sensitive for diagnosis. o Prompt surgical necrosectomy is mandatory for all patients with infected pancreatic necrosis. If strongly suspected: Positive CT guided culture o Emphazematous pancreatitis on imaging Clinical deterioration despite adequate medical therapy. If infected, start pancreatic penetrating antibiotics: piperacillin and tazobactam or cefepime + metronidazole, or high-dose cephalosporins. If unable to obtain CT and strong suspicion of infection, start antibiotics (see algorithm 3 for decision tree). 6
7 4.5 Nutritional Concerns. Critical; pancreatitis leads to a catabolic state and nutritional deterioration. Enteral Nutrition always preferred; Naso-jejunal feeding is preferred; less risk of infection or complications. o Mild Acute Pancreatitis: start enteral nutrition if suspect > 7d NPO status. Nutritional support is usually unnecessary. Resume oral diet when enzymes normalize and symptoms resolve. o Severe Acute Pancreatitis: trial enteral feeds within the first 2-3 days; consider TPN only if patient is unable to tolerate enteral feeding. Consider resuming oral nutrition when clinical improvement is demonstrated by resolving pain the desire to eat. 5. Complications Consider consultation with gastroenterology (hepatobiliary) and pancreatic surgery. o Definitive surgery for biliary pancreatitis (cholecystectomy) should be performed during the same admission if possible. Atlanta classification terminology preferred (see reference). 5.1 Infected Necrosis Suspect in patients with preexisting sterile pancreatic necrosis who have persistent or worsening symptoms or who develop signs/ symptoms of infection, typically 7-10 days after illness. Culture and gram stain of fluid should guide antibiotic therapy. 5.2 Vascular Leak Syndrome Complication of SIRS/sepsis that can result in intravascular depletion, hemoconcentration, hypotension, renal insufficiency, pulmonary edema, ARDS, and shock. Multiorgan dysfunction or failure associated with SIRS is a leading cause of morbidity and mortality during the first week of severe acute pancreatitis. 5.3 Hyperglycemia Patients without a history of diabetes may experience moderate hyperglycemia during severe pancreatitis. Administer insulin cautiously because of volatility in the serum glucose level, the potential for a blunted pancreatic release of glucagon in response to hypoglycemia, and the frequently transient nature of the serum glucose abnormalities. 5.4 Hypocalcemia Commonly occurs with severe acute pancreatitis. o Primarily secondary to precipitation of calcium soaps in the abdominal cavity. o Management: Quickly correct symptomatic or severe hypocalcemia with cardiac arrhythmias or tetany with calcium gluconate or calcium chloride. Administer 1-2 ampules 10% calcium gluconate (93 mg/10 ml) in ml of D5W over 5-10 minutes. Calcium chloride10% solution (273 mg/10-ml ampule) delivers higher amounts \of calcium and is advantageous when rapid correction is needed, but it should be administered via central venous access. Measure serum calcium every 4-6 hours to maintain serum calcium levels at 8-9 mg/dl. If low albumin is also present, monitor ionized calcium. If calcium remains low despite calcium supplementation: rule out hypomagnesemia. 5.5 Fluid Collections and Pseudocysts Intraabdominal fluid collections can persist and form a fibrinous wall in 33% of cases. It cannot be called a pseudocyst if identified in the first 2-3 weeks after the onset of symptoms. o The differential diagnosis includes: Walled-Off Pancreatic Necrosis (WOPN): a local complication of acute necrotizing pancreatitis, occurring more than 4 weeks after the initial attack. They represent enzyme-rich fluid that can walled off by granulation tissue or bacterial seeding of pancreatic or peripancreatic tissue Pseudocyst: Peripancreatic fluid encased in a fibrinous capsule. Cystic neoplasm: particularly if no history of chronic pancreatitis. Important to differentiate between walled-off pancreatic necrosis (WOPN; always involves pancreas) and pseudocysts (outside pancreatic parenchyma): o MRI/MRCP or EUS are more sensitive than CT for differentiation. o Treatment of an infected pseudocyst (abscess) is different than pancreatic necrosis. 7
8 8 5.6 Recurrent Pancreatitis Prevention References Order Sets Alcoholic pancreatitis: refer to counseling services and smoking cessation services, if applicable. Gallstone pancreatitis: o If mild pancreatitis: attempt surgery during same admission. o If severe: delay surgery until sufficient resolution of inflammation and clinical recovery. o If non-surgical candidate: endoscopic sphincterotomy is an alternative to cholecystectomy. AGA Institute medical position statement on acute pancreatitis. Gastroenterology (5): Curtis C. and Kudsk KA. Nutrition support in pancreatitis. Surg Clin North Am (6): , viii. Isenmann R, et al. Prophylactic antibiotic treatment in patients with predicted severe acute pancreatitis: a placebo-controlled, double-blind trial. Gastroenterology (4): UK Guidelines for the management of acute pancreatitis. Gut Suppl 3:iii1-9. Papachristou, G. I., V. Muddana, et al. Comparison of BISAP, Ranson's, APACHE-II, and CTSI scores in predicting organ failure, complications, and mortality in acute pancreatitis. Am J Gastroenterol (2):435-41; quiz 442. Uhl W, et al. IAP guidelines for the surgical management of acute pancreatitis. Pancreatology 2002;2: Banks PA, Freeman ML and the Practice Parameters Committee of the American College of Gastroenterology. Practice guidelines in acute pancreatitis. Am J Gastroenterol 2006;101: Revision of the Atlanta Classification of Acute Pancreatitis. Acute Pancreatitis Classification Working Group. April 9, H:/MGSarr/Documents/Atlanta Classification.doc. OSU IP GE: ADM ACUTE PANCREATITIS  OSU IP ED: CDU/OBS PANCREATITIS  Quality Measures Documentation of severity Percent of patients with pancreatitis diagnosis who are transferred to the ICU Percent of patients with a CT within first 48 hours of admission/arrival (non-icu vs. ICU patients) Percent of patients readmitted within 30 days Mortality rate Guideline Author Maher Azzouz, MD Guideline Approved Disclaimer July 24, Second Edition Clinical practice guidelines and algorithms at The Ohio State University Wexner Medical Center (OSUWMC) are standards that are intended to provide general guidance to clinicians. Patient choice and clinician judgment must remain central to the selection of diagnostic tests and therapy. OSUWMC s guidelines and algorithms are reviewed periodically for consistency with new evidence; however, new developments may not be represented. Copyright The Ohio State University Wexner Medical Center. No part of this publication may be reproduced in any form without permission in writing from The Ohio State University Wexner Medical Center
9 Appendix Severity Risk Model Calculations 9 Risk Score Type Ranson Score Notes Scoring Interpretation Link to calculators Five of these signs measured on admission The remaining six are measured at 48 hours into the hospital course At admission or diagnosis: Age > 55 years WBC > 16,000 Blood glucose > 200 mg/dl LDH > 350 U/L AST > 250 U/L During initial 48 hours: Hct decreases > 10% BUN increases > 5 mg/dl Serum Ca < 8mg/dL Base deficit (24 HCO3) > 4 meq/l Fluid needs > 6L within 48h of admission PaO2 < 60 mm Hg 1 point for each criterion met Score 3 at 48 hours: Major complications, severity, organ failure, pancreatic necrosis, mortality, longer hospital stay. Severe pancreatitis is likely. Score < 3: Severe pancreatitis is unlikely. Mortality Risk: Score 0 to 2: 2% mortality Score 3 to 4: 15% mortality Score 5 to 6: 40% mortality Score 7 to 8: 100% mortality Limitations: Can only be completed after 48 hours, though points can be assigned at any time during that 48-hour period. All data points not always obtained. It cannot be repeated on a daily basis. m/ransons-criteriafor-pancreatitismortality APACHE-II The major advantages of the APACHE-II system are the ability to calculate a score on admission and to be updated daily during the hospital course, allowing for monitoring of disease progression and response to therapy. Total score < 8: Morality < 4% Total score 8: Mortality of 11-18% Trajectory of APACHE II score in the first 48 hours is an accurate prognostic indicator as well cores2/apache22.ht ml m/apache-ii-scorefor-icu-mortality BISAP (Bedside Index for Severity in Acute Pancreatitis) A new 5-point scoring system. Compared with APACHE II, BISAP has similar accuracy and is easier to calculate. Blood urea nitrogen level > 25 mg/dl Impaired mental status (GCS < 15) Presence of SIRS Age > 60 years Pleural effusion detected on imaging 1 point is assigned for each variable within 24 hours of presentation for a total score of 0-5. Scores of 3 predict the development of organ failure, persistent organ failure, and necrosis. The higher the score, the higher the mortality rate. Total Score Approximate Mortality 0 0.2% 1 0.6% 2 2% 3 5-8% % % Simple to calculate
10 Appendix 10 Severity Risk Model Calculations (continued) Risk Score Type Notes Scoring Interpretation Link to calculators CT Severity Index Radiological tool that takes into account degree of pancreatic inflammation and the amount of necrosis, the two most important prognostic factors in pancreatitis imaging. A high index of severity is associated with a protracted clinical course, a higher complication rate, and increased mortality. May be more useful after 72 hours, when necrosis becomes more obvious; however, early studies may be indicated if there is uncertainty about the diagnosis or a high degree of clinical suspicion that there may be a significant complication. CT Grade: % Necrosis A 0 0 B 0 1 C < 30% 4 D 30-50% 7 E > 50% 10 Severity Index A score > 5 associated with 8 times risk of death, 17 times more likely to have a prolonged hospital course, and 10 times more likely to require necrosectomy. CT Grade B: 0% necrosis, but shows focal or diffuse enlargement of the pancreas. CTSI of 0-1: No morbidity or mortality CTSI of 2: Morbidity of 4%, no mortality CTSI 7-10%: Mortality 17% Complication rate 92% Advantages of CTSI: Research has shown CTSI of 5 correlated with prolonged hospitalization and higher rates of mortality and morbidity. CTSI 5 associated with a mortality rate 15 times higher than in those with a score of less than 5. No association was found between Ranson s criteria and APACHE II scale scores and mortality or length of hospitalization. Limitations include: Only moderate interobserver correlation, up to 75%. Variable correlation with established clinical scoring systems such as Ranson and APACHE II.