What is the recommended initial fluid rate for patients with pancreatitis?

From the Guidelines

The recommended initial fluid rate for patients with pancreatitis is 5-10 mL/kg/hour or 250-500 mL/hour in the first 12-24 hours, with adjustments based on clinical response. This aggressive early hydration is crucial during the first 24-48 hours of admission for acute pancreatitis, as it helps to counteract the third-spacing of fluids into the retroperitoneum and systemic inflammatory response that occurs in pancreatitis, which can lead to hypoperfusion and organ dysfunction 1. Lactated Ringer's solution is preferred over normal saline as it may reduce the inflammatory response and risk of systemic complications.

Key Considerations

• Fluid administration should be guided by frequent reassessment of vital signs, urine output (target >0.5-1 mL/kg/hour), and markers of hemoconcentration.
• Patients with heart failure or kidney disease may require lower rates with closer monitoring.
• The goal of aggressive hydration is to prevent hypovolemia and organ hypoperfusion, without waiting for hemodynamic worsening 1.
• After the initial resuscitation period, fluid rates should be reduced to maintenance levels once the patient is hemodynamically stable with adequate urine output.

Recent Evidence

A recent systematic review and meta-analysis compared clinical outcomes between aggressive and non-aggressive intravenous hydration for acute pancreatitis, and found that aggressive hydration may not reduce mortality in AP, and may even increase the risk of fluid overload and mortality in non-severe AP 1. However, the optimal initial rate of fluid resuscitation in AP remains unclear, and more research is needed to determine the best approach.

Clinical Guidelines

The American College of Gastroenterology (ACG) guidelines suggest that aggressive intravenous hydration (250–500 ml/hour) should be given to all patients with AP in the first 12–24 h unless cardiovascular and/or renal comorbidities exist 1. The Italian Association for the Study of the Pancreas (AISP) suggests early aggressive hydration at 2 ml/kg/h, with an initial bolus of 20 ml/kg within 30–45 min in the first 24 h for severe AP 1.

Fluid Protocols

Various fluid protocols have been studied, including aggressive and non-aggressive hydration regimens, with different rates and volumes of fluid administration 1. The choice of fluid protocol should be individualized based on the patient's clinical response and underlying comorbidities.

From the Research

Initial Fluid Rate for Pancreatitis

The recommended initial fluid rate for patients with pancreatitis varies depending on the severity of the condition and the patient's response to treatment.

• According to a study published in 2022 2, patients with predicted severe acute pancreatitis who were fluid responsive received 5-10 ml/kg/h, while those who were not fluid responsive received 1-3 ml/kg/h.
• A review published in 2023 3 suggests that high fluid rate infusion is associated with increased mortality and severe adverse events, and recommends a moderate fluid rate.
• A critical review of randomized trials published in 2018 4 found that initial fluid administration rates varied from 1 to 2 ml/kg/h to 15 ml/kg/h, and that rapid fluid rates were associated with increased morbidity and mortality.
• A clinical update published in 2015 5 recommends goal-directed fluid therapy during the first 6-12 hours of presentation, with cautious fluid therapy advised in patients over 55 years or with preexisting organ failure.
• A systematic review and meta-analysis published in 2024 6 found that aggressive fluid resuscitation increased the risk of all-cause mortality compared to moderate fluid replacement.

Key Considerations

• The type and rate of fluid administration should be tailored to the individual patient's needs and response to treatment.
• Ringer's lactate solution may be superior to normal saline solution in patients with acute pancreatitis 4.
• Colloid administration may be associated with lower morbidity and lower fluid requirements 4.
• The use of passive leg raising test and mini-fluid challenge may help guide fluid therapy and predict fluid responsiveness 2.