Fluid Therapy In Acute Pancreatitis Research Articles

Balanced Solution versus Normal Saline in Predicted Severe Acute Pancreatitis: A Stepped Wedge Cluster Randomized Trial.

To compare the effect of balanced multielectrolyte solutions(BMES) versus normal saline(NS) for intravenous fluid on chloride levels and clinical outcomes.in patients with predicted severe acute pancreatitis (pSAP). Isotonic crystalloids are recommended for initial fluid therapy in acute pancreatitis, but whether the use of BMES in preference to NS confers clinical benefits is unknown. In this multicenter, stepped-wedge, cluster-randomized trial, we enrolled patients with pSAP (APACHE II score ≥8 and C-reactive protein >150mg/L) admitted within 72 hours of the advent of symptoms. The study sites were randomly assigned to staggered start dates for one-way crossover from the NS phase (NS for intravenous fluid) to the BMES phase(Sterofudin for intravenous fluid). The primary endpoint was the serum chloride concentration on trial day3. Secondary endpoints included a composite of clinical and laboratory measures. Overall, 259 patients were enrolled from eleven sites to receive NS(n=147) or BMES(n=112). On trial day3, the mean chloride level was significantly lower in patients who received BMES(101.8mmol/L(SD4.8) versus 105.8mmol/L(SD5.9), difference -4.3mmol/L [95%CI -5.6 to -3.0mmol/L];P<0.001). For secondary endpoints, patients who received BMES had less systemic inflammatory response syndrome(19/112,17.0% versus 43/147,29.3%, P=0.024) and increased organ failure-free days (3.9d(SD2.7) versus 3.5days(SD2.7), P<0.001) by trial day7. They also spent more time alive and out of ICU(26.4d(SD5.2) versus 25.0days(SD6.4), P=0.009) and hospital(19.8d(SD6.1) versus16.3days(SD7.2), P<0.001) by trial day30. Among patients with pSAP, using BMES in preference to NS resulted in a significantly more physiological serum chloride level, which was associated with multiple clinical benefits(Trial registration number: ChiCTR2100044432).

Evaluating the efficacy of different volume resuscitation strategies in acute pancreatitis patients: a systematic review and meta-analysis

IntroductionAcute pancreatitis poses a significant health risk due to the potential for pancreatic necrosis and multi-organ failure. Fluid resuscitation has demonstrated positive effects; however, consensus on the ideal intravenous fluid type and infusion rate for optimal patient outcomes remains elusive.MethodsA comprehensive literature search was conducted using PubMed, Embase, the Cochrane Library, Scopus, and Google Scholar for studies published between 2005 and January 2023. Reference lists of potential studies were manually searched to identify additional relevant articles. Randomized controlled trials and retrospective studies comparing high (≥ 20 ml/kg/h), moderate (≥ 10 to < 20 ml/kg/h), and low (5 to < 10 ml/kg/h) fluid therapy in acute pancreatitis were considered.ResultsTwelve studies met our inclusion criteria. Results indicated improved clinical outcomes with low versus moderate fluid therapy (OR = 0.73; 95% CI [0.13, 4.03]; p = 0.71) but higher mortality rates with low compared to moderate (OR = 0.80; 95% CI [0.37, 1.70]; p = 0.55), moderate compared to high (OR = 0.58; 95% CI [0.41, 0.81], p = 0.001), and low compared to high fluids (OR = 0.42; 95% CI [0.16, 1.10]; P = 0.08). Systematic complications improved with moderate versus low fluid therapy (OR = 1.22; 95% CI [0.84, 1.78]; p = 0.29), but no difference was found between moderate and high fluid therapy (OR = 0.59; 95% CI [0.41, 0.86]; p = 0.006).DiscussionThis meta-analysis revealed differences in the clinical outcomes of patients with AP receiving low, moderate, and high fluid resuscitation. Low fluid infusion demonstrated better clinical outcomes but higher mortality, systemic complications, and SIRS persistence than moderate or high fluid therapy. Early fluid administration yielded better results than rapid fluid resuscitation.

Fluidoterapia en pancreatitis aguda

La pancreatitis aguda es un proceso inflamatorio local causado por activación del tripsinógeno que degrada el parénquima pancreático, se ha estimado cada año 300.000 visitas a sala de emergencias en Estados Unidos; en Ecuador en el 2019 el Instituto Nacional de Estadística y Censos informó 5.478 casos de pancreatitis. El objetivo de este estudio es determinar si el lactato Ringer e hidratación agresiva representan un beneficio en el manejo de pancreatitis aguda. Se realizó una revisión teórica en Pubmed, Scopus y Biomed Central, entre el 2018 al 2022, de revisiones sistemáticas, metaanálisis, ensayos clínicos controlados y estudios retrospectivos. Se incluyeron 17 estudios, 10 corresponden a solución salina versus lactato Ringer, 70 % sustenta el beneficio del uso de lactato, por resultados estadísticamente significativos con relación a menor estancia hospitalaria, menor tasa de ingreso a terapia intensiva y menor progresión a complicaciones. La comparación de hidratación agresiva versus no agresiva incluyó 7 estudios que no recomiendan el uso de hidratación agresiva por riesgo de lesión renal e insuficiencia respiratoria aguda con soporte ventilatorio. Se recomienda la utilización de lactato Ringer en el manejo de pancreatitis aguda, pero no de la hidratación agresiva. En definitiva, es preciso el desarrollo de investigaciones con un diseño más robusto, que aporten evidencia de mayor peso acerca de la efectividad de fluidoterapia en el manejo de pancreatitis aguda.

Hemoconcentration is associated with early faster fluid rate and increased risk of persistent organ failure in acute pancreatitis patients.

BackgroundControversies existed surrounding the use of hematocrit to guide early fluid therapy in acute pancreatitis (AP). The association between hematocrit, early fluid therapy, and clinical outcomes in ward AP patients needs to be investigated.MethodsData from prospectively maintained AP database and retrospectively collected details of fluid therapy were analyzed. Patients were stratified into three groups: Group 1, hematocrit < 44% both at admission and at 24 h thereafter; Group 2: regardless of admission level, hematocrit increased and >44% at 24 h; Group 3: hematocrit >44% on admission and decreased thereafter during first 24 h. “Early” means first 24 h after admission. Baseline characteristics, early fluid rates, and clinical outcomes of the three groups were compared.ResultsAmong the 628 patients, Group 3 had a higher hematocrit level, greater baseline predicted severity, faster fluid rate, and more fluid volume in the first 24 h compared with Group 1 or 2. Group 3 had an increased risk for persistent organ failure (POF; odds ratio 2, 95% confidence interval [1.1–3.8], P = 0.03) compared with Group 1 after adjusting for difference in baseline clinical severity scores, there was no difference between Group 2 and Group 3 or Group 1. Multivariate regression analyses revealed that hemoconcentration and early faster fluid rate were risk factors for POF and mortality (both P < 0.05).ConclusionsHemoconcentration is associated with faster fluid rate and POF in ward AP patients. Randomized trials comparing standardized early fast and slow fluid management is warranted.

Intravenous fluid therapy in acute pancreatitis: a critical review of the randomized trials.

Fluid management is a cornerstone of treatment in acute pancreatitis (AP). Identification of existing randomized prospective trials of patients with AP, in which intravenous fluid management was a significant parameter in the experimental design, was undertaken using the PubMed and ENDOBASE databases. Included patients in the seven studies identified were on the whole very unwell with deaths occurring in six trials. Fluid regimens in AP included crystalloid alone, combinations of crystalloid and colloid and in two studies, plasma. In most studies, patients with premorbid major organ failure and advanced age were excluded. Study entry within 6 h of presentation occurred in three trials. Initial fluid administration rates varied from 1 to 2 mL/kg/h to 15 mL/kg/h. Rapid fluid rates were associated with increased morbidity and mortality except in one study in which a high fluid regimen (20 mL/kg bolus within 4 h of presentation followed by 3 mL/kg) led to a better clinical outcome than a more conservative regimen. Use of Ringer's lactate led to improved surrogate outcome markers compared to that of normal saline in one study. Administration of colloid as part of the fluid management was associated with lower morbidity and lower fluid requirements. Rapid infusion of crystalloid very early in the course of AP may be beneficial but rapid infusion of fluid later in the course of the illness may be deleterious. Colloid administration and the use of Ringer's lactate solution in preference to normal saline may improve outcome.

Sa1337 - Guidelines Versus Directed IV Fluid Therapy in Acute Pancreatitis of More than 24 Hours of Clinical Evolution: A Prospective Randomized Clinical Trial

Sa1337 - Guidelines Versus Directed IV Fluid Therapy in Acute Pancreatitis of More than 24 Hours of Clinical Evolution: A Prospective Randomized Clinical Trial

National Survey of Fluid Therapy in Acute Pancreatitis: Current Practice Lacks a Sound Evidence Base

Fluid therapy (FT) is a critical intervention in managing acute pancreatitis (AP). There is a paucity of evidence to guide FT and virtually no data on current prescribing practice. This survey aims to characterize current practice and opinion with regard to FT in AP throughout New Zealand. Information was collected on fluid selection, administration, and goal-directed FT. The survey was distributed online and in print to all doctors employed in General Surgery Departments in New Zealand on 1 May 2012. Monthly email reminders were sent for 6 months. The overall response rate was 47 % (n = 190/408). Crystalloids were the preferred initial fluid for all categories of severity; however, colloid use increased with severity (p < 0.001). Fluid volume also increased with severity (p = 0.001), with 74 % of respondents prescribing >4 L for AP with organ failure (OF). Clinicians treating 26-50 patients per year with AP were less likely to prescribe colloid for AP with OF (8 vs 43 %) (p = 0.001). Rate of fluid administration in AP with OF varied according to physicians' seniority (p = 0.004); consultants prescribed >4 L more than other groups (83 vs 68 %). Only 17 % of respondents reported the use of guidelines. This survey reveals significant variation in prescription of FT for AP, and aggressive FT is commonly prescribed for AP with OF. There is little adherence to published guidelines or best available evidence.

Fluid therapy in acute pancreatitis – Anybody's guess

Objective:The aim of this study was to systematically review and evaluate the quality of current evidence about fluid therapy (FT) in acute pancreatitis (AP).Background:Intravenous FT is thought to be important in the early management of patients with AP. Clinically relevant questions remain regardi

Fluid Therapy in Acute Pancreatitis

The aim of this study was to systematically review and evaluate the quality of current evidence about fluid therapy (FT) in acute pancreatitis (AP). Intravenous FT is thought to be important in the early management of patients with AP. Clinically relevant questions remain regarding the type of fluid, the rate of administration, and the goal of FT. A comprehensive literature search for human studies was performed using online databases (MEDLINE, EMBASE, PubMed, and the Cochrane Library). The quality of the entire body of evidence was then graded according to the Grading of Recommendations Assessment, Development and Evaluation Working Group guidelines in relation to 3 key areas: type of fluid, rate of fluid administration, and goal-directed FT. The initial search yielded 410 studies, of which 15 met the inclusion criteria. Only 2 randomized studies compared types of fluids. Nine studies looked at aggressive versus nonaggressive resuscitation protocols, of which 4 concluded that an aggressive approach yielded better outcomes and 5 concluded that a nonaggressive approach was better. Two studies investigated goal-directed FT, using different goals; one demonstrating benefit and the other none. Analysis of the body of evidence as per the Grading of Recommendations Assessment, Development and Evaluation Working Group revealed that the majority of evidence was of low or very low quality. FT is considered a cornerstone of the early management of patients with AP and yet the evidence on which it is based remains paltry and of poor quality. This systematic review has demonstrated the equipoise necessary for the design of randomized controlled trials to answer pressing questions relating to the type of fluid, the rate of administration, and how FT should be guided.