109 Persistent Hemoconcentration After Initial Resuscitation Is Associated With Increased Need for Opiates in the ED in Patients Presenting With Acute Pancreatitis

Abstract

INTRODUCTION: Opiates are commonly used in the management of abdominal pain in acute pancreatitis (AP). The factors associated with increased need for opiates during the initial management are unknown. METHODS: Medical records of adults presenting to the ED from 9/1/2013 to 8/31/2016 with AP were identified retrospectively. AP was diagnosed, and severity stratified using the revised Atlanta Classification (2012). Total quantity of opiates required during ED phase of care was converted to morphine equivalents (ME) and divided by number of hours in the ED to get mean ME per hour in the ED (MME). Log-linear multivariable regression analysis was performed to identify factors associated with MME. Hemoconcentration was defined as hematocrit ≥44%. RESULTS: 318 AP patients were identified. 248 received opiates in the ED. Baseline characteristics are shown in Table 1. At ED presentation, 75 (30.65%) had at least 2 SIRS criteria and 46 (18.55%) had hemoconcentration. On the second set of labs (still within 24 hours of ED arrival), 11/46 (23.9%) remained hemoconcentrated and 2 developed hemoconcentration despite resuscitation. The distribution of mean ME per hour in the ED (MME) ranged from 0.12 mg to 24.81 mg. Mean MME was 2.15 mg (SD = 2.54). Simple linear and multivariable regression analyses are shown in Table 2. Age and first episode of AP were independently associated with less MME. After exponentiation, for every 1-year increase in age, a 1% decrease in MME was observed. Patients with the first episode of AP required 34.9% less MME compared to those with prior AP. On subgroup analysis of patients who were opiate naïve at presentation (N = 193), first episode of AP was still associated with less MME (b-coefficient −0.4024, P = 0.0025); they required 33.1% less MME compared to those with prior AP. Hemoconcentration after initial resuscitation (but within 24 hours of presentation) was associated with increased MME. Patients with hemoconcentration on the second set of labs required 95% higher MME compared to those without hemoconcentration. Increasing number of SIRS criteria was also associated with increased MME; one additional SIRS criteria was associated with a 15% increase in MME. CONCLUSION: Persistent or new hemoconcentration within 24 hours of presentation is associated with increased opiate requirement in the ED in patients with AP. This suggests that inadequacy of initial fluid resuscitation to correct intravascular fluid losses may lead to increased pain and need for opiate medications.