Early Fluid Resuscitation Reduces Morbidity Among Patients With Acute Pancreatitis

doi:10.1016/j.cgh.2011.03.032

Clinical Gastroenterology and Hepatology

Volume 9, Issue 8, August 2011, Pages 705-709

https://doi.org/10.1016/j.cgh.2011.03.032 Get rights and content

Background & Aims

Early fluid resuscitation is recommended to reduce morbidity and mortality among patients with acute pancreatitis, although the impact of this intervention has not been quantified. We investigated the association between early fluid resuscitation and outcome of patients admitted to the hospital with acute pancreatitis.

Methods

Nontransfer patients admitted to our center with acute pancreatitis from 1985–2009 were identified retrospectively. Patients were stratified into groups on the basis of early (n = 340) or late resuscitation (n = 94). Early resuscitation was defined as receiving ≥one-third of the total 72-hour fluid volume within 24 hours of presentation, whereas late resuscitation was defined as receiving ≤one-third of the total 72-hour fluid volume within 24 hours of presentation. The primary outcomes were frequency of systemic inflammatory response syndrome (SIRS), organ failure, and death.

Results

Early resuscitation was associated with decreased SIRS, compared with late resuscitation, at 24 hours (15% vs 32%, P = .001), 48 hours (14% vs 33%, P = .001), and 72 hours (10% vs 23%, P = .01), as well as reduced organ failure at 72 hours (5% vs 10%, P < .05), a lower rate of admission to the intensive care unit (6% vs 17%, P < .001), and a reduced length of hospital stay (8 vs 11 days, P = .01). Subgroup analysis demonstrated that these benefits were more pronounced in patients with interstitial rather than severe pancreatitis at admission.

Conclusions

In patients with acute pancreatitis, early fluid resuscitation was associated with reduced incidence of SIRS and organ failure at 72 hours. These effects were most pronounced in patients admitted with interstitial rather than severe disease.

Section snippets

Methods

The study was approved by the Committee for the Protection of Human Subjects #21847. Patients presenting directly to Dartmouth-Hitchcock Medical Center, an academic tertiary care hospital in Lebanon, NH, from 1985–2009 with the diagnosis of acute pancreatitis were identified retrospectively by using International Classification of Diseases, Ninth Revision, codes. Only nontransferred patients were included in this study, and the primary diagnosis at admission had to be acute pancreatitis to be

Results

Seven hundred one patients were admitted to our medical center from 1985–2009 with a primary diagnosis of acute pancreatitis. Two hundred twenty-two patients were admitted in transfer, and 45 had incomplete or missing fluid administration data, leaving 434 nontransferred patients who were included in the study. Three hundred forty patients were identified as early resuscitation, and 94 patients were identified as late resuscitation. As shown in Table 1, there were no meaningful differences in

Discussion

This study demonstrates that patients admitted with acute pancreatitis receiving early fluid resuscitation have lower rates of SIRS and organ failure, shorter hospitalizations, and less need for ICU admission than do patients who are not resuscitated as aggressively. This effect is observed only in patients with interstitial disease at admission, suggesting that in patients with severe disease, early IV fluid resuscitation is unlikely to substantially alter the patient's clinical course. This

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2023, Pancreatology
To examine the predictors and outcomes associated with the development of acute pancreatitis (AP) in patients hospitalized with Coronavirus Disease 2019 (COVID-19).
This is an observational analysis of the 2020 National Inpatient Sample Database. The study includes adult patients who were admitted with a confirmed diagnosis of COVID-19 and stratifies them based on the presence or absence of AP during their hospitalization. Predictors of AP development between the two groups and differences in outcomes are examined. Multivariate logistic regression analysis using Stata/BE 17.0 is conducted, with adjustments made for age, sex, race, and Charlson Comorbidity Index (CCI). Statistical significance is determined at a p-value of <0.05.
Significant factors associated with an increased risk of AP in COVID-19 patients include Hispanic ethnicity, higher Charlson Comorbidity Index (CCI) score, residence in states located in the southern region, history of chronic kidney disease, chronic liver disease, malnutrition, portal hypertension, and alcohol use. COVID-19 patients who developed AP were also found to be at higher risk of adverse outcomes, including mortality, acute coronary syndrome, acute kidney injury, sepsis, septic shock, in-hospital cardiac arrest, invasive mechanical ventilation, upper gastrointestinal bleeding, prolonged length of stay, and increased healthcare cost.
In hospitalized patients with COVID-19, the presence of AP is associated with increased mortality and morbidity. Risk factors for developing AP in this population include Hispanic ethnicity, residence in the southern region, higher Charlson Comorbidity Index (CCI) score, history of chronic kidney disease, chronic liver disease, malnutrition, portal hypertension, and alcohol use.
Fluid resuscitation in the early management of acute pancreatitis – evidence from a systematic review and meta-analysis
2023, HPB
Third space fluid loss is one of the hallmarks of the pathophysiology of acute pancreatitis (AP) contributing to complications, including organ failure and death.
We conducted a systematic review of literature to determine the ideal fluid resuscitation in the early management of AP, primarily comparing aggressive versus moderate intravenous fluid resuscitation (AIR vs MIR).
A systematic review of major reference databases was undertaken. Meta-analysis was performed using random-effects model. Bias was assessed using Cochrane risk of bias and ROBINS-I tools for randomized and non-randomised studies, respectively.
Twenty studies were included in the analysis. Though there was no significant difference in mortality between AIR and MIR groups (8.3% versus 6.0%; p = 0.3), AIR cohort had significantly higher rates of organ failure (p = 0.009), including pulmonary (p = 0.02) and renal (p = 0.01) complications. Similarly, there was no difference in mortality between normal saline (NS) and Ringer's lactate (RL) (3.17% versus 3.01%; p = 0.23), though patients treated with NS had a significantly longer length of hospital stay (LOS) (p = 0.009).
Current evidence appears to support moderate intravenous resuscitation (level of evidence, low) with RL (level of evidence, moderate) in the early management of AP.
American Society for Gastrointestinal Endoscopy guideline on post-ERCP pancreatitis prevention strategies: methodology and review of evidence
2023, Gastrointestinal Endoscopy
Citation Excerpt :
The patient representative on the panel valued the reduction in post-ERCP pancreatitis but expressed a preference to avoid increased length of hospitalization. Aggressive hydration is recommended for the management of acute pancreatitis in general, given cohort studies correlating adequate systemic hydration with reduced necrosis, organ failure, and mortality.76-78 Given the high incidence of pancreatitis after ERCP, prophylactic administration of fluids was proposed as a preventative measure.79,80
Acute pancreatitis secondary to hypercalcemia in a patient with primary hyperparathyroidism: An uncommon association
2022, Annals of Medicine and Surgery
An uncommon cause of acute pancreatitis, primary hyperparathyroidism accounts for less than 1% of cases.
A 41-year-old male with acute pancreatitis and hypercalcemia is described in this case. Primary hyperparathyroidism was discovered during the work-up for hypercalcemia. During the first 24 hours after his hospitalization, the patient was monitored in the intensive care unit, and after a positive outcome, he was discharged.
Pancreatitis is a rare presentation of hyperparathyroidism. The first documented case of this association was by Erdheim in 1903 on a post-mortem study (2). Hyperparathyroidism is often only discovered after two or three episodes of recurrent pancreatitis (5), thankfully, in this case, the patient has been diagnosed from its first episode and eventually treated to prevent any other ones. hypercalcaemia leads to increase calcium in the pancreatic responsible for aggression of the pancreatic parenchyma and ducts, Other authors suggest that the pancreatic secretion in patients with hypercalcaemia is lower than normal, but the enzyme activity remains normal, resulting in the formation of protein plugs in the pancreatic ducts leading to their obstruction and self-digestion.
Hypercalcemia can cause acute pancreatitis. This report describes rare case of a patient with acute pancreatitis caused by hyperparathyroidism.
Impact of abdominal imaging on the diagnosis of acute pancreatitis in patients with painless lipase elevation
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Abdominal pain is considered a cardinal feature of acute pancreatitis (AP), and abdominal imaging is only required to diagnose AP when the pain is atypical, or serum enzyme elevation does not match the clinical picture. While painless lipase elevation is being increasingly associated with worse outcomes in various diseases, the diagnostic approach to such elevation is so-far unclear. We thus aimed to learn the impact of pain on the diagnosis of AP.
All patients presenting to the Mayo Clinic Arizona Hospital emergency department with a serum lipase ≥3x upper limit of normal between April 2016 and January 2020 were prospectively followed. Their charts were reviewed for the nature of pain, serum lipase levels on presentation, abdominal imaging, and whether a diagnosis of AP was made. Chronic pancreatitis was excluded.
Among 320 patients, 85 (26.5%) had painless lipase elevation. These patients had abdominal imaging less often (56/85, 66%) than in those with abdominal pain (201/235, 83%; p = 0.001). The diagnosis of AP increased overall from 31/63 (49%) without imaging to 198/257 (77%) with imaging (P < 0.001). Imaging increased the diagnosis of AP in patients with painless lipase elevation from 2/29 (7%) without imaging to 16/56 (29%; p = 0.025) among those who were imaged.
Painless lipase elevation >3-fold the upper limit of normal is common in emergency department patients. 1/3 to 1/4 of these may have AP. Abdominal imaging increases the diagnosis of AP in patients with painless lipase elevation. Therefore, abdominal imaging in such patients may help detect AP that otherwise eludes diagnosis.
Effect of aggressive versus conservative hydration for early phase of acute pancreatitis in adult patients: A meta-analysis of 3,127 cases
2022, Pancreatology
Citation Excerpt :
Funnel plots were used to screen for potential publication bias. Thirteen included studies [12–20,28–31] published from 2009 to 2020 that enrolled 3127 patients fulfilled the selection criteria (Fig. 1). An expanded search of the reference lists of the included studies and reviews did not yield any additional studies to evaluate.
The advantages of aggressive hydration compared to conservative hydration within 24 h for acute pancreatitis (AP) remain controversial in adult patients. A meta-analysis was undertaken to investigate whether aggressive strategies are more beneficial.
We searched (on February 1, 2021) PubMed, Embase, and the Cochrane Library for eligible trials that assessed the two therapies and performed a meta-analysis. The primary endpoint was in-hospital mortality. Secondary outcomes were adverse events (e.g., renal failure and pancreatic necrosis) within 24 h of treatment.
Five randomized controlled trials and 8 observational trials involving 3127 patients were identified. Patients with severe pancreatitis showed significant difference of in-hospital mortality (OR 1.75; 95% CI 1.32–2.33) in aggressive hydration group, which were less susceptible to study type and age. Patients with severe pancreatitis were likely to develop respiratory failure (OR 5.08; 95% CI 2.31–11.15), persistent SIRS (OR 2.83; 95% CI 1.58–5.04), renal failure (OR 2.58; 95% CI 1.90–3.50) with significant difference. A longer hospital stay was observed in patients with severe pancreatitis (WMD 7.61; 95% CI 5.51–9.71; P < 0.05) in the aggressive hydration group. Higher incidence of pancreatic necrosis (OR 2.34; 95% CI 1.60–3.42; P < 0.05) was major susceptible to observational studies, old patients and mild pancreatitis.
Compared to conservative hydration, aggressive hydration increases in-hospital mortality and the incidence of renal failure, pancreatic necrosis with relatively strong evidence. Further investigation should be designed with a definitive follow-up period and therapeutic goals to address reverse causation bias.

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: Conflicts of interest The authors disclose no conflicts.

: Funding Dr Gardner is supported in part by NIH grant 1K23DK088832-01.

: View this article's video abstract at www.cghjournal.org.

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Original article—liver, pancreas, and biliary tractEarly Fluid Resuscitation Reduces Morbidity Among Patients With Acute Pancreatitis

Background & Aims

Methods

Results

Conclusions

Section snippets

Methods

Results

Discussion

Gastroenterology

Gastroenterology

Clin Gastroenterol Hepatol

Clin Gastroenterol Hepatol

J Chronic Dis

Chest

Am J Gastroenterol

Pancreatology

Clin Nutr

Original article—liver, pancreas, and biliary tract
Early Fluid Resuscitation Reduces Morbidity Among Patients With Acute Pancreatitis