What is the recommended fluid management for acute pancreatitis?

From the Guidelines

For patients with acute pancreatitis, aggressive intravenous fluid resuscitation is not recommended, as it may increase the risk of fluid overload and mortality, especially in non-severe cases, and instead, a goal-directed fluid therapy approach should be used, with a typical rate of 1.5-2.5 mL/kg/hour of isotonic crystalloid solution, such as lactated Ringer's, in the first 24 hours, as suggested by the most recent and highest quality study 1.

Key Considerations

• The total volume of fluid administered should be individualized based on the patient's response, with frequent reassessments of fluid status every 6-8 hours using clinical parameters such as heart rate, blood pressure, urine output (goal >0.5 mL/kg/hour), and hematocrit.
• Lactated Ringer's solution is preferred over normal saline as it may reduce the risk of systemic inflammatory response syndrome.
• Overly aggressive fluid administration can lead to complications like pulmonary edema, while inadequate resuscitation may worsen pancreatic necrosis and increase mortality.
• Fluid requirements typically decrease after the initial 24-48 hours as the inflammatory response begins to resolve.

Rationale

The recent systematic review and meta-analysis by 1 compared clinical outcomes between aggressive and non-aggressive intravenous hydration for acute pancreatitis and found that aggressive hydration may increase the risk of fluid overload and mortality, especially in non-severe cases. In contrast, goal-directed fluid therapy approaches have been shown to improve outcomes in patients with acute pancreatitis, as suggested by the American Gastroenterological Association guidelines 1.

Important Outcomes

• Morbidity: reduced risk of fluid overload and pulmonary edema
• Mortality: reduced risk of mortality, especially in non-severe cases
• Quality of Life: improved outcomes and reduced risk of complications, leading to improved quality of life for patients with acute pancreatitis.

From the Research

Fluid Resuscitation in Acute Pancreatitis

• The optimal amount of fluid for resuscitation in acute pancreatitis is a topic of ongoing research, with studies suggesting that moderate fluid resuscitation may be more effective than aggressive fluid resuscitation 2, 3.
• A study published in The New England Journal of Medicine found that aggressive fluid resuscitation resulted in a higher incidence of fluid overload without improvement in clinical outcomes, with 20.5% of patients developing fluid overload compared to 6.3% in the moderate-resuscitation group 2.
• Another study published in JGH Open found that aggressive fluid resuscitation increased the risk of all-cause mortality compared to moderate fluid replacement, with a relative risk of 2.40 (CI: 1.38-4.19) 3.

Type of Fluid for Resuscitation

• Lactated Ringer's solution is widely recommended for fluid resuscitation in acute pancreatitis, with studies suggesting that it may have anti-inflammatory effects and reduce the incidence of systemic inflammatory response syndrome (SIRS) and pancreatic necrosis 4, 5, 6.
• A study published in the United European Gastroenterology Journal found that lactated Ringer's solution inhibited the induction of inflammatory phenotype of macrophages and NF-κB activation, suggesting a direct anti-inflammatory effect of lactate 6.

Monitoring and Adjustment of Fluid Resuscitation

• The optimal rate and duration of fluid resuscitation in acute pancreatitis are not well established, with studies suggesting that goal-directed therapy may not reduce the risk of persistent organ failure, infected pancreatic necrosis, or mortality 5.
• A study published in Current Opinion in Gastroenterology noted that there are critical gaps in knowledge regarding the endpoint(s) to indicate adequate resuscitation, and accurate assessments of fluid sequestration and intravascular volume deficit in acute pancreatitis 5.