Review
Fluid Resuscitation in Acute Pancreatitis

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Acute pancreatitis is a common inflammatory disorder of the pancreas resulting in considerable morbidity and a mortality rate of approximately 5%. Although there are no pharmacologic treatments known to improve important outcomes, aggressive intravenous fluid resuscitation generally is recommended in all patients. However, few human investigations have been performed and several important questions have not been answered. For example, what is the optimal resuscitative fluid? Is there a role for colloid solutions? To what clinical marker should resuscitation be targeted? When is the best time to start such fluids and in which group of patients? This review describes the microcirculation of the pancreas and the pathophysiologic alterations caused by acute pancreatitis. Previous animal experiments are described, as are the limited human studies specifically addressing fluid resuscitation. Finally, current recommendations and goals for further investigation are highlighted. It is our hope that this review will stimulate interest in this often overlooked subject and lead to carefully designed human clinical trials using varying fluid solutions and rates, with an emphasis on patient monitoring and safety, in the near future.

Section snippets

Search Methods

A Medline/Pubmed search was performed with manual cross-referencing (January 1966–July 2007). Search topics included “fluid resuscitation and acute pancreatitis,” “fluids and acute pancreatitis,” “pancreatic microcirculation,” “vascular anatomy of the pancreas,” “pancreatic necrosis,” “hemoconcentration and acute pancreatitis,” and “acute pancreatitis.” Recent technical guidelines from the major gastroenterology societies also were evaluated. Original articles and reviews were included. The

The Pancreatic Microcirculation

The arterial supply to the pancreas is derived from the 2 main proximal trunks of the aorta: the celiac trunk and the superior mesenteric artery. The splenic and common hepatic arteries (as well as the left gastric artery, which does not supply the pancreas) arise from the celiac trunk. The splenic artery gives rise to the penetrating branches of the body and tail of the pancreas, and the common hepatic artery, via its branch the gastroduodenal artery, supplies the pancreatic head through the

Acute Pancreatitis and the Pancreatic Microcirculation

Alteration to the pancreatic microcirculation plays a central role in the pathogenesis of acute pancreatitis. In fact, disturbed pancreatic microcirculation is an important step in the transformation from acute self-limited (interstitial edematous) pancreatitis to severe, necrotizing pancreatitis.25, 26, 27, 28 Alteration in the pancreatic microcirculation can occur from one of several causes including hypovolemia, increasing capillary permeability, and hypercoagulability causing microthrombi,

Fluid Resuscitation and Acute Pancreatitis: Animal Studies

Multiple animal studies have addressed ways to combat increasing capillary permeability, vasospasm, and the formation of microthrombi through a variety of mechanisms including endothelin and platelet activating factor–receptor antagonists, IL-1 antagonists, intercellular adhesion molecule-1 antibodies, somatostatin, bradykinin antagonists, tumor necrosis factor-α antagonists, heparin, and endothelial nitric oxide synthase among others.15, 30, 31, 52, 53, 54, 55, 56, 57, 58, 59, 60 Investigators

Fluid Resuscitation and Acute Pancreatitis: Human Studies

Despite the universally accepted paradigm that aggressive resuscitation is critical for the treatment of acute pancreatitis, very few human studies have ever addressed this issue. Currently, there are no published human studies that evaluate the role of aggressive fluid resuscitation using targeted outcome measures in this disease. Presently, the optimal type of fluid (colloid vs crystalloid vs other), the optimal volume of fluid resuscitation, the optimal timing of resuscitation in the course

Current Clinical Recommendations

There is only one review article in the literature that gives very specific recommendations for the amount of fluid that should be replaced in patients with acute pancreatitis.29 However, these recommendations represent expert opinion only, and do not cite any supporting evidence because virtually no human studies, and very few animal studies, have been performed. The investigators recommend that patients with severe volume depletion should be resuscitated with between 500 and 1000 mL fluids

Conclusions and Future Directions

Aggressive fluid resuscitation in acute pancreatitis is a universally recommended and accepted paradigm. However, as this review highlights, there remains a paucity of data to support current clinical recommendations. Several significant questions remain including the type and amount of fluids, the role of colloid solutions, and issues of patient tolerability.

To further define appropriate recommendations, significant future study needs to address these questions. Continued animal studies into

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