From the Guidelines
The initial fluid resuscitation rate for acute pancreatitis should be 20 ml/kg bolus then 3 ml/kg/hr of isotonic crystalloid solution, such as lactated Ringer's solution, for the first 24 hours, as recommended by recent guidelines and studies 1. This approach is supported by the most recent and highest quality study, which suggests that aggressive intravenous hydration is beneficial in the management of acute pancreatitis, particularly in the first 12-24 hours of admission 1. The goal of fluid resuscitation is to maintain pancreatic microcirculation, prevent pancreatic necrosis, and counteract the third-spacing of fluids that occurs due to increased vascular permeability in acute pancreatitis. Some key points to consider when implementing fluid resuscitation in acute pancreatitis include:
- The use of lactated Ringer's solution, which may be preferred over normal saline as it may reduce the risk of developing systemic inflammatory response syndrome 1
- The importance of adjusting the fluid resuscitation rate based on clinical response, with frequent reassessment of vital signs, urine output (targeting >0.5-1 mL/kg/hour), and markers of hemoconcentration like BUN and hematocrit 1
- The need to consider individual patient factors, such as cardiovascular, renal, or other comorbidities, when determining the optimal fluid resuscitation strategy 1 Overall, the key is to provide aggressive early hydration to all patients with acute pancreatitis, unless contraindicated, and to adjust the fluid resuscitation rate based on clinical response and individual patient factors.
From the Research
Initial Fluid Resuscitation Rate for Acute Pancreatitis
- The initial fluid resuscitation rate for acute pancreatitis is a critical aspect of treatment, with various studies providing insights into the optimal approach 2, 3, 4, 5, 6.
- According to the WATERFALL Trial, aggressive fluid resuscitation consists of a lactated Ringer solution (LR) 20-mL/kg bolus administered over 2 hours, followed by LR 3 mL/kg per hour 3.
- In contrast, moderate fluid resuscitation involves an LR bolus of 10 mL/kg in case of hypovolemia or no bolus in patients with normal volemia, followed by LR 1.5 mL/kg per hour 3.
- A retrospective database analysis found that lactated Ringer's (LR) was associated with lower 1-year mortality compared to normal saline (NS) for initial resuscitation in patients hospitalized with acute pancreatitis 4.
- A prospective cohort study investigated the utility of serum biomarkers of responsiveness to IV fluid resuscitation in patients with acute pancreatitis and systemic inflammatory response syndrome (SIRS), but found no significant differences in biomarkers between responsive and refractory patients 5.
- A nationwide analysis of fluid resuscitation outcomes in patients with acute pancreatitis found no significant differences in mortality, hospital length of stay, mechanical ventilation rates, acute kidney injury, or severe sepsis between patients receiving aggressive and non-aggressive IVF resuscitation 6.
Key Findings
- Aggressive fluid resuscitation may not be associated with improved outcomes in acute pancreatitis 3, 6.
- Lactated Ringer's (LR) may be a better choice than normal saline (NS) for initial resuscitation in patients hospitalized with acute pancreatitis 4.
- Serum biomarkers may not be useful in determining responsiveness to IV fluid resuscitation in patients with acute pancreatitis 5.
- The optimal fluid resuscitation rate for acute pancreatitis remains unclear, with further research needed to determine the best approach 2, 3, 4, 5, 6.