resuscitation to confirm that tissue perfusion and oxygen delivery have been restored adequately in patients with acute pancreatitis. Aggressive fluid resuscitation is often required, and monitoring the response to this relies upon traditional mark­ers, in particular urine output, blood pressure and pulse oximetry. Physiological markers of resuscita­tion, for example acid–base balance from an arte­rial blood gas, may be helpful in detecting clinically occult hypoperfusion. Patients who do not respond to initial resuscitation, or who have evidence of or­gan dysfunction, should be transferred to a critical care environment for more invasive and intensive monitoring with central venous and arterial cath­eters. Respiratory failure should be treated with humidified oxygen, and this will be guided by con­tinuous pulse oximetry and arterial blood gas analy­sis. Deteriorating respiratory function is a sign of disease progression. As many as half of all deaths from acute pancreatitis occur in less than 7 days, and the majority of these occur within 72 h of admission.1 There is evidence that patients managed in specialist institutions have a reduced risk of early death and this may be an indication that manage­ment of early MODS could be improved.