Despite progress in recent years in the diagnostics, surgical treatment and intensive care therapy, severe acute pancreatitis remains a major challenge to the medical profession and a serious threat to the patients. In its most severe form, acute pancreatitis is characterised by a profound inflammatory process in the pancreas leading to partial or total necrosis of the parenchyma. Acute pancreatitis also frequently causes dysfunction of remote organs as well as local complications (pancreatic infection, haemorrhage and pseudocysts). The majority of the attacks of acute pancreatitis (85-90%) are, however, mild and can be dealt with by simple routine treatment. It is essential to identify at an early stage those patients who will develop a severe form of the disease, to allow timely vital organ system monitoring and support in an intensive care unit. Early intervention may have a significant influence on the course of the disease. As soon as the pancreatic inflammation has progressed to necrosis, anti-enzyme or anti-inflammatory therapy and/or treatment which may enhance the pancreatic microcirculation is not likely to change the course of the disease and leaves the treating physician with symptomatic measures only. On arrival to the ICU the patients are frequently hypovolaemic, have diminished blood flow to the abdominal organs, resulting not only in more severe local disease, but also frequently causing failure of remote organs such as the lungs (adult respiratory distress syndrome), kidneys, liver and the intestine (possibly encouraging translocation of enteral bacteria). The aim of therapy in severe pancreatitis is obviously to halt the progress of the local disease and to prevent remote organ failure. So far, very limited experimental and clinical research has been performed on the effects of different modes of intensive care therapy on pancreatic blood flow or on the progress of the panceatic necrosis. Based on clinical experience and available research data, the following procedures are currently recommended in the ICU management of severe pancreatitis. (l)Use invasive monitoring. (2) Optimise oxygen transport by maintaining hyperdynamic circulation (at least during the first 3 days), for example by using isovolaemic or hypervolaemic haemodilution, administration of low dose dopexamine and if necessary other cardio-inotropic drugs. (3) Indications for assisted ventilation should be liberal in order to guarantee high blood oxygen content and to decrease energy expenditure. (4) Start nutrition early to minimise negative nitrogen balance, but avoid overfeeding. (5) Use crystalloids for replacement of insensible fluid loss only and synthetic colloids such as pentastarch for plasma substitution. (6) Provide effective pain relief, for example, by continuous epidural or coeliac block. (7) In cases of extensive necrosis, prophylactic antibiotic therapy (imipenem) should be considered. (8) Follow the clinical course of the patient very closely and monitor the degree of necrosis and possible pancreas infection for timely surgical intervention when necessary.