ReviewFluid Resuscitation in Acute Pancreatitis
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
References (98)
- et al.
Fatal outcome in acute pancreatitis: its occurrence and early prediction
Pancreatology
(2001) - et al.
Management of pancreatic necrosis in severe acute pancreatitis
Clin Gastroenterol Hepatol
(2005) - et al.
The possible role of platelet-activating factor antagonist therapy in the management of severe acute pancreatitis
Baillieres Best Pract Res Clin Gastroenterol
(1999) - et al.
Acute pancreatitis: bench to the bedside
Gastroenterology
(2007) - et al.
Therapy for microcirculatory disorders in severe acute pancreatitis: effectiveness of platelet-activating factor receptor blockade vs. endothelin receptor blockade
J Gastrointestinal Surg
(1999) - et al.
Improvement of impaired microcirculation and tissue oxygenation by hemodilution with hydroxyethyl starch plus cell-free hemoglobin in acute porcine pancreatitis
Pancreatology
(2006) - et al.
Determinants of pancreatic microcirculation in acute pancreatitis in rats
J Surg Res
(1996) - et al.
Microcirculatory dysfunction in acute pancreatitis: a new concept of pathogenesis involving vasomotion-associated arteriolar constriction and dilation
Pancreatology
(2003) - et al.
Expression of activation, adhesion molecules and intracellular cytokines in acute pancreatitis
Immunol Lett
(2001) - et al.
Endoscopic therapy for organized pancreatic necrosis
Gastroenterology
(1996)
Effects of heparin in experimental models of acute pancreatitis and post-ERCP pancreatitis
Surgery
Evolving concepts in the pathophysiology of acute pancreatitis
Surgery
Anti-TNF-a therapy improves survival and ameliorates the pathophysiology sequelae in acute pancreatitis in the rat
Am J Surg
Interleukin-1 receptor antagonist decreases severity of experimental acute pancreatitis
Surgery
Therapeutic regimens in acute experimental hemorrhagic pancreatitisEffects of hydration, oxygenation, peritoneal lavage, and a potent protease inhibitor
Gastroenterology
Pancreatic response to crystalloid resuscitation in experimental pancreatitis
J Surg Res
Low molecular weight dextran in experimental pancreatitis: effects on pancreatic microcirculation
J Surg Res
Hypertonic saline-dextran resuscitation of acute canine bile-induced pancreatitis
Am J Surg
Hemoconcentration as an early risk factor for necrotizing pancreatitis
Am J Gastroenterol
Hemoconcentration: an early marker of severe and/or necrotizing pancreatitis?A critical appraisal
Am J Gastroenterol
Can fluid resuscitation prevent pancreatic necrosis in severe acute pancreatitis?
Pancreatology
Fluid resuscitation and nutritional support during severe acute pancreatitis in the past: what have we learned and how can we do better?
Clin Nutr
AGA Institute technical review on acute pancreatitis
Gastroenterology
National hospital discharge summary: annual summary
2003 National Hospital Discharge Survey: advance data from vital and health statistics
Multicentre audit of death from acute pancreatitis
Br J Surg
Acute pancreatitis: the substantial human and financial costs
Gut
Short and long term outcome of severe acute pancreatitis
Eur J Surg
Acute pancreatitis and the role of histamine-2 receptor antagonists: a meta-analysis of randomized controlled trials of cimetidine
Eur J Gastroenterol Hepatol
Evaluation of atropine in acute pancreatitis
Surg Gynecol Obstet
Octreotide 24-h prophylaxis in patients at high risk for post-ERCP pancreatitis: results of a multicenter, randomized, controlled trial
Aliment Pharmacol Ther
A randomised, double blind, multicentre trial of octreotide in moderate to severe acute pancreatitis
Gut
Essential therapeutic strategies for acute pancreatitis—guidelines for initial treatment and their significance
Nippon Rinsho
Meta-analysis of somatostatin, octreotide and gabexate mesilate in the therapy of acute pancreatitis
Aliment Pharmacol Ther
Evidence-based treatment of acute pancreatitis: a look at established paradigms
Ann Surg
Early ERCP and papillotomy compared with conservative treatment for acute biliary pancreatitis
N Engl J Med
Initial management of acute pancreatitis: critical issues during the first 72 hours
Am J Gastroenterol
An introduction to surgical anatomy and neuroanatomy
Disturbances of the microcirculation in acute pancreatitis
Br J Surg
Vascular anatomy of the pancreas
Pancreatic microvascular permeability in caerulein-induced acute pancreatitis
Am J Physiol
The microvasculature of the pancreas, with emphasis on that of the islet of Langerhans
Microcirculation of the rat pancreas, with special reference to the insulo-acinar portal and insulo-venous drainage systems
Arch Histol Cytol
Effects of somatostatin (SMS) on pancreatic microcirculation
Dig Dis Sci
Pancreatic microcirculatory changes in experimental pancreatitis of graded severity in rat
Surgery
Microcirculatory function and tissue damage is improved after therapeutic injection of bovine hemoglobin in severe acute rodent pancreatitis
Pancreas
Impairment of pancreatic microcirculation correlates with the severity of acute experimental pancreatitis
J Am Coll Surg
Hemolymphomicrocirculatory bed of the pancreas during acute experimental pancreatitis
Bull Exp Biol Med
Therapy for microcirculatory disorders in severe acute pancreatitis: comparison of delayed therapy with ICAM-1 antibodies and a specific endothelin A receptor antagonist
J Gastrointest Surg
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2022, PancreatologyCitation Excerpt :Guidelines recommend aggressive hydration with an infusion rate of 250–500 ml/h or 5–10 ml/kg/h to maintain intravenous volume or stable hemodynamics [2,4]. Nevertheless, these strategies were mainly based on expert opinion [7,8], nonhuman studies [9,10] and limited clinical studies [11,12]. Several studies comparing aggressive hydration and conservative hydration have been reported [12–20], and the advantages of aggressive hydration are difficult to discern due to limited sample sizes and conflicting results.
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The authors disclose no conflicts.