Fluid Therapy in Acute Pancreatitis

Abstract

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.

Do Larger Periprocedural Fluid Volumes Reduce the Severity of Post–Endoscopic Retrograde Cholangiopancreatography Pancreatitis?

“…A recent systematic review, entitled, “Fluid therapy in acute pancreatitis: anybody’s guess”, 8 underscores the degree of uncertainty regarding FT in clinical acute pancreatitis. There is insufficient clinical data to determine whether FT has an impact on major outcomes 8 other than preventing early death from hypovolemic shock in acute pancreatitis.…”

“…There is insufficient clinical data to determine whether FT has an impact on major outcomes 8 other than preventing early death from hypovolemic shock in acute pancreatitis. 1-3,5,6 A second major limitation is that clinical studies focus on administering FT after patients present with established acute pancreatitis, which may have little relevance to FT administered before/during the inciting event, before closure of the therapeutic window.…”

“…8 In pigs , 26 FT that was “goal-directed” (using functional hemodynamic parameters) rather than “less restrictive” (using central venous pressure and mean arterial pressure parameters) resulted in a significantly greater 7-day survival (29.4% vs 11.8%). Mean FT administered during the peri-induction period of pancreatitis was 1.0 vs 2.0 L/hour (normalized to 70 kg body mass), respectively.…”

“…1-7 Unfortunately, the optimal timing, the volume and the impact of FT in clinical acute pancreatitis are uncertain. A recent systematic review summarized three specific choices pertaining to FT, including fluid type, fluid rate and assessment of adequate resuscitation, but concluded that the evidence for recommending FT “remains paltry and of poor quality.” 8 Moreover, data are conflicting as to whether administering higher fluid rates prevents or contributes to clinical outcomes in acute pancreatitis. An important limitation of these studies is that FT commences after but not during initiation of clinical acute pancreatitis such that FT only begins when the “therapeutic window” for FT is closing.…”

What guidelines tell us about acute pancreatitis. A review of the last international guidelines

“…Adequacy of fluid resuscitation should include the measuring of clinical parameters such as vital signs and urinary output (>0,5ml/kg body weight), as well as laboratory parameters, especially hematocrit [8].…”