Fluid Resuscitation for Acute Pancreatitis—When and With What?

Patients that are given fluid resuscitation within 24 hours of developing acute pancreatitis are less likely to experience systemic inflammatory response (SIR) or organ failure, according to a study by Matthew G. Warndorf et al. in the August issue of Clinical Gastroenterology and Hepatology.

Acute pancreatitis is an inflammatory process of the pancreas that leads to approximately 210,000 hospital admissions each year. It is associated with significant morbidity, prolonged hospitalization and frequent admission to the intensive care unit; approximately 20% of patients develop a severe course and suffer from a SIR or pancreatic necrosis. Many physicians believe that fluid resuscitation is an important determinant of outcome, but there is not much evidence to support this concept.

Warndorf et al. compared outcomes of 340 patients admitted to the hospital with acute pancreatitis who were given early fluid resuscitation (in less than 24 hours) with outcomes of 94 who were given the total fluid volume over a longer time period.

Early resuscitation reduced the incidence of SIR and organ failure, compared with late resuscitation, by about 50%. It also reduced the rate of admission to the intensive care unit about 3-fold and reduced length of hospital stay by 3 days. These benefits were more pronounced in patients with interstitial, compared with severe, pancreatitis. Warndorf et al. propose that in patients with severe disease, early intravenous fluid resuscitation is unlikely to substantially alter their course.

These findings are important—there have not been many trials of this subject, so current guidelines for resuscitation are vague and based almost exclusively on expert opinion. The authors state that their findings support the concept that among patients with less-severe disease, early fluid resuscitation prevents progression to severe disease.

Why is adequate fluid resuscitation so important during the early stages of acute pancreatitis? In an accompanying editorial, John Nasr and Georgios Papachristou explain that pancreatic injury activates pancreatic enzymes, proinflammatory cytokines and vasoactive factors that increase capillary permeability. This promotes vascular leakage, intravascular volume depletion and underperfusion of the pancreas and other vital organs; the process is further complicated by the formation of microthrombi. The impaired pancreatic microcirculation contributes to pancreatic tissue ischemia and necrosis, exacerbating SIR and remote organ dysfunction.

Limitations to the study include the fact that it was retrospective, relied on accurate measurements of intravenous fluid administration and analyzed data from a single center. Nasr and Papachristou also pointed out that data were analyzed from a long time period (24 years), during which concepts of fluid resuscitation and intensive care have changed dramatically.

The American Gastroenterological Association recommends early vigorous fluid resuscitation targeted toward correcting hemoconcentration and maintaining adequate urine output in such patients. Nasr and Papachristou warn that the optimal parameters for fluid resuscitation are unclear and that randomized, controlled trials are needed to assess different fluid solutions and infusion rates.

In a video abstract of the article, senior author of the study, Timothy Gardner, discusses remaining questions, such as “What is the optimal type of [intravenous] fluid? What is the optimal volume, and what is the optimal timing of resuscitation?”

Timothy Gardner's Video Abstract

In a separate article in the August issue of Clinical Gastroenterology and Hepatology, Bechien Wu et al. show that patients with acute pancreatitis who were resuscitated with lactated Ringer’s solution have reduced SIR compared with those who received saline. Nasr and Papachristou advocate administration of 1 to 2 L of crystalloids, preferably Lactated Ringer’s (approximately 20 mL/kg), followed by a continuous infusion of 150 to 300 cc/hour (approximately 3 mL/kg/h) for the first 24 hours.

Warndorf et al. state that until more effective therapeutic reagents are developed, optimization of intravenous fluid administration is one of the few interventions can improve outcomes of patients with acute pancreatitis.

More Information on Acute Pancreatitis:

Read the article online.
Warndorf MG, Kurtzman JT, Bartel MJ, et al. Early fluid resuscitation reduces morbidity among patients with acute pancreatitis. Clin Gastroenterol and Hepatol 2011;9:705–709.

Read the related article online.
Wu BU, Hwang JQ, Gardner TH, et al. Lactated ringer’s solution reduces systemic inflammation compared with saline in patients with acute pancreatitis. Clin Gastroenterol and Hepatol 2011;9:710–717.e1.

Read the accompanying editorial.
Nasr JY, Papachristou GI. Early fluid resuscitation in acute pancreatitis: a lot more than just fluids. Clin Gastroenterol and Hepatol 2011;9:633–634.

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About Kristine Novak, PhD, Science Editor

Dr. Kristine Novak is the science editor for Gastroenterology and Clinical Gastroenterology and Hepatology, both published by the American Gastroenterological Association. She has worked as an editor at biomedical research journals and as a science writer for more than 12 years, covering advances in gastroenterology, hepatology, cancer, immunology, biotechnology, molecular genetics, and clinical trials. She has a PhD in cell biology and an interest in all areas of medical research.
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