New tools for optimizing fluid resuscitation in acute pancreatitis

Abstract

Acute pancreatitis (AP) is a frequent disease with degrees of increasing severity responsible for high morbidity. Despite continuous improvement in care, mortality remains significant. Because hypovolemia, together with microcirculatory dysfunction lead to poor outcome, fluid therapy remains a cornerstone of the supportive treatment. However, poor clinical evidence actually support the aggressive fluid therapy recommended in recent guidelines since available data are controversial. Fluid management remains unclear and leads to current heterogeneous practice. Different strategies may help to improve fluid resuscitation in AP. On one hand, integration of fluid therapy in a global hemodynamic resuscitation has been demonstrated to improve outcome in surgical or septic patients. Tailored fluid administration after early identification of patients with high-risk of poor outcome presenting inadequate tissue oxygenation is a major part of this strategy. On the other hand, new decision parameters have been developed recently to improve safety and efficiency of fluid therapy in critically ill patients. In this review, we propose a personalized strategy integrating these new concepts in the early fluid management of AP. This new approach paves the way to a wide range of clinical studies in the field of AP.

Thoracic complications of pancreatitis

“…Endothelial dysfunction secondary to cytokine storm leads to vasodilation and capillary leakage, which along with vomiting or ileus causes hypovolemia and perfusion failure . The aggressive fluid resuscitation leads to correction of this hypovolemia and thus maintains pancreatic perfusion as well as prevents systemic circulatory dysfunction . The aggressive fluid resuscitation involves the administration of 250–300 mL of intravenous fluid (saline or ringer lactate) per hour, with proposed end‐points for guiding fluid therapy being clinical parameters, such as arterial blood pressure, heart rate, and urinary output; or laboratory parameters, such as blood urea nitrogen, or hematocrit; or invasively monitored parameters, such as central venous pressure (CVP) .…”

“…It was found to be particularly useful when only ultrasound of the nondependent lung (lower lateral and upper quadrants) was performed. 39,43 In pulmonary edema, interstitial fluid progress in a centripetal fashion to affect the peribronchial interstitium initially, and alveoli are affected in the later stages. In ALI/ARDS, the alveolar membrane integrity is compromised early, leading to early flooding of alveolar spaces resulting in heterogeneous areas of ground-glass opacities or consolidations.…”

“…Supportive management, including aggressive fluid resuscitation, remains one of the important pillars of management of acute pancreatitis. 43 Endothelial dysfunction secondary to cytokine storm leads to vasodilation and capillary leakage, which along with vomiting or ileus causes hypovolemia and perfusion failure. 44 The aggressive fluid resuscitation leads to correction of this hypovolemia and thus maintains pancreatic perfusion as well as prevents systemic circulatory dysfunction.…”

“…44 The aggressive fluid resuscitation leads to correction of this hypovolemia and thus maintains pancreatic perfusion as well as prevents systemic circulatory dysfunction. 43 The aggressive fluid resuscitation involves the administration of 250-300 mL of intravenous fluid (saline or ringer lactate) per hour, with proposed end-points for guiding fluid therapy being clinical parameters, such as arterial blood pressure, heart rate, and urinary output; or laboratory parameters, such as blood urea nitrogen, or hematocrit; or invasively monitored parameters, such as central venous pressure (CVP). 45 However, the evidence supporting aggressive fluid resuscitation is not so robust, and there is also evidence to suggest that overzealous fluid resuscitation can lead to various pulmonary complications (pleural effusion, atelectases, and pneumonia) and that rapid and massive hemodilution can lead to tissue hypoxia and consequent multiple organ dysfunctions.…”

Early management of acute pancreatitis: A review of the best evidence

“…The initial goal of fluid resuscitation is to restore circulating blood volume with the aim of improving peripheral tissue oxygenation. Easy clinical markers of adequate hemodynamic function are heart rate, blood pressure, respiratory rate, O 2 saturation and urine output [27,28]. Urine output should be restored at above 0.5 mL/h/kg bodyweight.…”