Influence of Fluid Therapy on the Prognosis of Acute Pancreatitis: A Prospective Cohort Study
Although aggressive fluid therapy during the first days of hospitalization is recommended by most guidelines and reviews on acute pancreatitis (AP), this recommendation is not supported by any direct evidence. We aimed to evaluate the association between the amount of fluid administered during the initial 24 h of hospitalization and the incidence of organ failure (OF), local complications, and mortality.
This was a prospective cohort study. We included consecutive adult patients admitted with AP. Local complications and OF were defined according to the Atlanta Classification. Persistent OF was defined as OF of >48-h duration. Patients were divided into three groups according to the amount of fluid administered during the initial 24 h: group A: <3.1 l (less than the first quartile), group B: 3.1-4.1 l (between the first and third quartiles), and group C: >4.1 l (more than the third quartile).
A total of 247 patients were analyzed. Administration of >4.1 l during the initial 24 h was significantly and independently associated with persistent OF, acute collections, respiratory insufficiency, and renal insufficiency. Administration of <3.1 l during the initial 24 h was not associated with OF, local complications, or mortality. Patients who received between 3.1 and 4.1 l during the initial 24 h had an excellent outcome.
In our study, administration of a small amount of fluid during the initial 24 h was not associated with a poor outcome. The need for a great amount of fluid during the initial 24 h was associated with a poor outcome; therefore, this group of patients must be carefully monitored.
Available from: Vincenzo Neri
- "The severity of the disease can also be established by multifactorial scores (Ranson , Glasgow , Apache II ) at the point of admission and in the first 24-48 hours, by unifactorial markers (PCR, TAP , Procalcitonin , Hct), and subsequently by means of imaging (Balthazar score and CTSI). In severe or early severe acute pancreatitis the initial therapeutic approach, as mentioned, is based on aggressive fluid resuscitation, invasive hemodynamic monitoring, intensive care, correction of hypoxaemia, and enteral nutrition . Next, the cornerstone of the therapeutic programme required, in the opinion of many authors           , an urgent ERCP with endoscopic sphincterotomy. "
Available from: PubMed Central
- "This observation is supported by a meta-analysis which demonstrated in both RCTs and cohort studies that a conservative fluid strategy was associated with a lower mortality in trauma patients . Similarly, an aggressive fluid strategy in the resuscitation of patients with acute pancreatitis has been associated with an increased risk of complications . "
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ABSTRACT: Current teaching and guidelines suggest that aggressive fluid resuscitation is the best initial approach to the patient with hemodynamic instability. The source of this wisdom is difficult to discern, however, Early Goal Directed therapy (EGDT) as championed by Rivers et al. and the Surviving Sepsis Campaign Guidelines appears to have established this as the irrefutable truth. However, over the last decade it has become clear that aggressive fluid resuscitation leading to fluid overload is associated with increased morbidity and mortality across a diverse group of patients, including patients with severe sepsis as well as elective surgical and trauma patients and those with pancreatitis. Excessive fluid administration results in increased interstitial fluid in vital organs leading to impaired renal, hepatic and cardiac function. Increased extra-vascular lung water (EVLW) is particularly lethal, leading to iatrogenic salt water drowning. EGDT and the Surviving Sepsis Campaign Guidelines recommend targeting a central venous pressure (CVP) > 8 mmHg. A CVP > 8 mmHg has been demonstrated to decrease microcirculatory flow, as well as renal blood flow and is associated with an increased risk of renal failure and death. Normal saline (0.9% salt solution) as compared to balanced electrolyte solutions is associated with a greater risk of acute kidney injury and death. This paper reviews the adverse effects of large volume resuscitation, a high CVP and the excessive use of normal saline.
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ABSTRACT: Die akute Pankreatitis ist ein häufiges und klinisch eindrucksvolles Krankheitsbild. Eine spezifische Therapie existiert nicht. Ziel der ärztlichen Maßnahmen ist die Linderung der Symptome und die Verhinderung von Komplikationen. In den letzten Jahren gab es einen erheblichen Zugewinn an Wissen über die korrekte Behandlung der Erkrankung. Neben einer Spezifizierung der Empfehlungen zur Flüssigkeitstherapie betrifft das vor allem die Ernährungstherapie, die Ökonomisierung der Bildgebung, den Einsatz von Antibiotika bei Komplikationen und vor allem Maßnahmen zur Entlastung von großen oder infizierten Nekrosen. Der derzeitige Stand der Erkenntnisse wird im Beitrag zusammengefasst.
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