1
|
Crosignani A, Spina S, Marrazzo F, Cimbanassi S, Malbrain MLNG, Van Regenemortel N, Fumagalli R, Langer T. Intravenous fluid therapy in patients with severe acute pancreatitis admitted to the intensive care unit: a narrative review. Ann Intensive Care 2022; 12:98. [PMID: 36251136 PMCID: PMC9576837 DOI: 10.1186/s13613-022-01072-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 10/11/2022] [Indexed: 11/26/2022] Open
Abstract
Patients with acute pancreatitis (AP) often require ICU admission, especially when signs of multiorgan failure are present, a condition that defines AP as severe. This disease is characterized by a massive pancreatic release of pro-inflammatory cytokines that causes a systemic inflammatory response syndrome and a profound intravascular fluid loss. This leads to a mixed hypovolemic and distributive shock and ultimately to multiorgan failure. Aggressive fluid resuscitation is traditionally considered the mainstay treatment of AP. In fact, all available guidelines underline the importance of fluid therapy, particularly in the first 24–48 h after disease onset. However, there is currently no consensus neither about the type, nor about the optimal fluid rate, total volume, or goal of fluid administration. In general, a starting fluid rate of 5–10 ml/kg/h of Ringer’s lactate solution for the first 24 h has been recommended. Fluid administration should be aggressive in the first hours, and continued only for the appropriate time frame, being usually discontinued, or significantly reduced after the first 24–48 h after admission. Close clinical and hemodynamic monitoring along with the definition of clear resuscitation goals are fundamental. Generally accepted targets are urinary output, reversal of tachycardia and hypotension, and improvement of laboratory markers. However, the usefulness of different endpoints to guide fluid therapy is highly debated. The importance of close monitoring of fluid infusion and balance is acknowledged by most available guidelines to avoid the deleterious effect of fluid overload. Fluid therapy should be carefully tailored in patients with severe AP, as for other conditions frequently managed in the ICU requiring large fluid amounts, such as septic shock and burn injury. A combination of both noninvasive clinical and invasive hemodynamic parameters, and laboratory markers should guide clinicians in the early phase of severe AP to meet organ perfusion requirements with the proper administration of fluids while avoiding fluid overload. In this narrative review the most recent evidence about fluid therapy in severe AP is discussed and an operative algorithm for fluid administration based on an individualized approach is proposed.
Collapse
Affiliation(s)
- Andrea Crosignani
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy.,Department of Anaesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Stefano Spina
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy.,Department of Anaesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Francesco Marrazzo
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy.,Department of Anaesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Stefania Cimbanassi
- General Surgery and Trauma Team, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Manu L N G Malbrain
- First Department of Anaesthesia and Intensive Therapy, Medical University of Lublin, Lublin, Poland.,International Fluid Academy, Lovenjoel, Belgium
| | - Niels Van Regenemortel
- Department of Intensive Care Medicine, Antwerp University Hospital, Antwerp, Belgium.,Department of Intensive Care Medicine, Ziekenhuis Netwerk Antwerpen Campus Stuivenberg, Antwerp, Belgium
| | - Roberto Fumagalli
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy.,Department of Anaesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Thomas Langer
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy. .,Department of Anaesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.
| |
Collapse
|
2
|
Yan F, Wang P, Xiong Z, Yang F, Cai W, Wang GX, Tan YH, Zhang J, Yang L. Pulmonary Artery Catheter in Patients with Severe Acute Pancreatitis: A Single-Center Retrospective Study. Dig Dis Sci 2022; 67:667-675. [PMID: 33570682 DOI: 10.1007/s10620-021-06881-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 01/26/2021] [Indexed: 02/07/2023]
Abstract
OBJECTIVE It is still uncertain what effects pulmonary artery catheter (PAC)-guided resuscitation has on outcomes for patients with severe acute pancreatitis (SAP). Therefore, we aimed to investigate the effect of PAC on hospital mortality in patients with SAP. METHODS We collected the data of patients with a diagnosis of SAP from January 10, 2017, to July 30, 2019. Patients were divided into a PAC group and a control group. The primary outcome measured was the day-28 mortality. Secondary outcomes included day-90 mortality, duration of ICU and hospital stay, ventilation days, usage of renal support and vasoactive agents, incidences of acute abdominal compartment syndrome, infusion volumes, and fluid balance and hemodynamic characteristics measured by the PAC. Kaplan-Meier analysis was applied to estimate survival outcomes. Complications related to PAC were also analyzed. RESULTS There was no significant difference between the PAC group and the control group for day-28 mortality (22.7% vs. 30%, odds ratio, 0.69; 95% CI 0.31-1.52; P = 0.35). The duration of ICU stay in the PAC group was shorter (P = 0.00), and the rate of dependence on renal support treatment was lower in the PAC group than in the control group (P = 0.03). There was no difference in other secondary outcomes and no significant difference in the survival curve between the two groups (log-rank P = 0.72, X2 = 0.13). However, SAP patients inserted PAC within 24 h ICU admission showed that duration of renal support therapy in PAC patients within 24 h ICU admission (mean days, 1.60; standard deviation, 0.14) was shorter than those with 24-72 h ICU admission (mean days, 2.94; standard deviation, 0.73; P = 0.03). The organ failure rates (1 organ, 2 organs and 3 organs) were all lower in PAC patients within 24 h ICU admission than with 24-72 h ICU admission (P = 0.02, P = 0.02, P = 0.048, respectively). CONCLUSION In patients with severe acute pancreatitis, PAC-guided fluid resuscitation shortened the duration of ICU stay, and patients in the PAC group had a lower rate of dependence on renal support, while no benefit in terms of mortality was observed. However, SAP patients inserted PAC within 24 h ICU admission showed shorter duration of renal support therapy and lower organ failure rates than those with 24-72 h ICU admission, indicating that early use of PAC, especially within 24 h, might be better for SAP patients.
Collapse
Affiliation(s)
- Fang Yan
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, No.37 Guoxue Alley, Wuhou District, Chengdu, 610041, Sichuan, China.,Department of Intensive Care Medicine, Chengdu Fifth People's Hospital, Chengdu, 611130, Sichuan, China
| | - Ping Wang
- Department of Intensive Care Medicine, Chengdu Fifth People's Hospital, Chengdu, 611130, Sichuan, China
| | - Zhen Xiong
- Department of Intensive Care Medicine, Chengdu Fifth People's Hospital, Chengdu, 611130, Sichuan, China
| | - Fang Yang
- Department of Intensive Care Medicine, Chengdu Fifth People's Hospital, Chengdu, 611130, Sichuan, China
| | - Wei Cai
- Department of Intensive Care Medicine, Chengdu Fifth People's Hospital, Chengdu, 611130, Sichuan, China
| | - Guo-Xiang Wang
- Department of Intensive Care Medicine, Chengdu Fifth People's Hospital, Chengdu, 611130, Sichuan, China
| | - Yun-Hui Tan
- Department of Intensive Care Medicine, Chengdu Fifth People's Hospital, Chengdu, 611130, Sichuan, China
| | - Jing Zhang
- Department of Intensive Care Medicine, Chengdu Fifth People's Hospital, Chengdu, 611130, Sichuan, China
| | - Li Yang
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, No.37 Guoxue Alley, Wuhou District, Chengdu, 610041, Sichuan, China.
| |
Collapse
|
3
|
Di Martino M, Van Laarhoven S, Ielpo B, Ramia JM, Manuel-Vázquez A, Martínez-Pérez A, Pavel M, Beltran Miranda P, Orti-Rodríguez R, de la Serna S, Ortega Rabbione GJ, Sanz-Garcia A, Martín-Pérez E. Systematic review and meta-analysis of fluid therapy protocols in acute pancreatitis: type, rate and route. HPB (Oxford) 2021; 23:1629-1638. [PMID: 34325967 DOI: 10.1016/j.hpb.2021.06.426] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 06/21/2021] [Accepted: 06/25/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Adequate fluid resuscitation is paramount in the management of acute pancreatitis (AP). The aim of this study is to assess benefits and harms of fluid therapy protocols in patients with AP. METHODS MEDLINE, Embase, Science Citation Index and clinical trial registries were searched for randomised clinical trials published before May 2020, assessing types of fluids, routes and rates of administration. RESULTS A total 15 trials (1073 participants) were included. Age ranged from 38 to 73 years; follow-up period ranged from 0.5 to 6 months. Ringer lactate (RL) showed a reduced number of severe adverse events (SAE) when compared to normal saline (NS) (OR 0.48; 95%CI 0.29-0.81, p = 0.006); additionally, NS showed reduced SAE (RR 0.38; 95%IC 0.27-0.54, p < 0.001) and organ failure (RR 0.30; 95%CI 0.21-0.44, p < 0.001) in comparison with hydroxyethyl starch (HES). High fluid rate fluid infusion showed increased mortality (OR 2.88; 95%CI 1.41-5.88, p = 0.004), increased number of SAE (RR 1.42; 95%CI 1.04-1.93, p = 0.030) and higher incidence of sepsis (RR 2.80; 95%CI 1.51-5.19, p = 0.001) compared to moderate fluid rate infusion. CONCLUSIONS In patients with AP, RL should be preferred over NS and HES should not be recommended. Based on low-certainty evidence, moderate-rate fluid infusion should be preferred over high-rate infusion.
Collapse
Affiliation(s)
- Marcello Di Martino
- HPB Unit, Department of General and Digestive Surgery, Hospital Universitario La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid (UAM), Madrid, Spain.
| | - Stijn Van Laarhoven
- Department of HPB Surgery University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Benedetto Ielpo
- HPB Unit, University Mar Hospital, Parc Salut, Barcelona, Spain
| | - Jose M Ramia
- Faculty of Health Sciences, Valencian International University (VIU), 46002, Valencia, Spain; Department of Surgery, Hospital General Universitario de Alicante, ISABIALAlicante (Spain)
| | - Alba Manuel-Vázquez
- Department of General and Digestive Surgery, Hospital Universitario de Getafe, Madrid, Spain
| | - Aleix Martínez-Pérez
- Faculty of Health Sciences, Valencian International University (VIU), 46002, Valencia, Spain
| | - Mihai Pavel
- HPB Unit, Department of General Surgery, Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain, Universitat Rovira i Virgili, Departament de Medicina i Cirugia, Reus, Spain, Universitat Rovira i Virgili, Departament de Medicina i Cirugia, Reus, Spain
| | - Pablo Beltran Miranda
- Unidad de Cirugía Hepato-Bilio-Pancreática, Hospital Universitario Juan Ramón Jiménez, Huelva, Spain
| | - Rafael Orti-Rodríguez
- Department of General and Digestive Surgery, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - Sofía de la Serna
- HPB Surgery Unit, Department of General and Digestive Surgery, Hospital Universitario Clínico San Carlos, Instituto de Investigación Sanitaria Hospital Clínico San Carlos (IdISSC), Universidad Complutense de Madrid, Spain
| | - Guillermo J Ortega Rabbione
- Data Analysis Unit, Hospital Universitario La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Madrid, Spain
| | - Ancor Sanz-Garcia
- Data Analysis Unit, Hospital Universitario La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Madrid, Spain
| | - Elena Martín-Pérez
- HPB Unit, Department of General and Digestive Surgery, Hospital Universitario La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid (UAM), Madrid, Spain
| |
Collapse
|
4
|
Trikudanathan G, Wolbrink DRJ, van Santvoort HC, Mallery S, Freeman M, Besselink MG. Current Concepts in Severe Acute and Necrotizing Pancreatitis: An Evidence-Based Approach. Gastroenterology 2019; 156:1994-2007.e3. [PMID: 30776347 DOI: 10.1053/j.gastro.2019.01.269] [Citation(s) in RCA: 194] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 01/01/2019] [Accepted: 01/15/2019] [Indexed: 02/07/2023]
Abstract
The incidence of acute pancreatitis continues to rise, inducing substantial medical and social burden, with annual costs exceeding $2 billion in the United States alone. Although most patients develop mild pancreatitis, 20% develop severe and/or necrotizing pancreatitis, requiring advanced medical and interventional care. Morbidity resulting from local and systemic complications as well as invasive interventions result in mortality rates historically as high as 30%. There has been substantial evolution of strategies for interventions in recent years, from open surgery to minimally invasive surgical and endoscopic step-up approaches. In contrast to the advances in invasive procedures for complications, early management still lacks curative options and consists of adequate fluid resuscitation, analgesics, and monitoring. Many challenges remain, including comprehensive management of the entire spectrum of the disease, which requires close involvement of multiple disciplines at specialized centers.
Collapse
Affiliation(s)
- Guru Trikudanathan
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota.
| | | | - Hjalmar C van Santvoort
- Department of Surgery, the University Medical Center Utrecht and the St. Antonius Hospital Nieuwegein, the Netherlands
| | - Shawn Mallery
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota
| | - Martin Freeman
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota
| | - Marc G Besselink
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, the Netherlands
| |
Collapse
|
5
|
Takeda T, Nakai Y, Mizuno S, Suzuki T, Sato T, Hakuta R, Ishigaki K, Saito K, Saito T, Watanabe T, Takahara N, Mouri D, Kogure H, Ito Y, Hirano K, Tada M, Isayama H, Koike K. Fluid sequestration is a useful parameter in the early identification of severe disease of acute pancreatitis. J Gastroenterol 2019; 54:359-366. [PMID: 30478723 DOI: 10.1007/s00535-018-1531-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 11/21/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND Early identification of severe disease of acute pancreatitis (AP) is of critical importance to improve the prognosis. Fluid sequestration (FS), calculated from administrated fluid and fluid output, is a simple prognostic parameter. We examined its utility in the early phase of AP. METHODS We retrospectively investigated AP patients between January 2009 and April 2017. We compared FS in the first 24 h (FS24) with FS in the first 48 h (FS48) and administrated fluid volume within the first 24 h (FV24). Diagnostic yield for predicting intensive care unit (ICU) admission and persistent organ failure (POF) was assessed using receiver operating characteristic curves. We also evaluated risk factors for developing severe disease of AP. RESULTS A total of 400 AP patients were included in the analysis (median age 64 years; male 60%). According to the Japanese severity criteria, 158 patients (40%) were diagnosed as severe disease. The rates of mortality, ICU admission and POF were 0.8%, 4.5% and 7.3%, respectively. FS24 showed a similar predictive accuracy in comparison with FS48 and was superior to FV24 in predicting ICU admission and POF. FS24 ≥ 1.6 L, male sex, presence of systemic inflammatory response syndrome and computed tomography severity index ≥ 3 on admission were independent risk factors for disease progression in AP in the multivariate analysis. CONCLUSIONS FS24 was a simple and easily calculated parameter with high predictive accuracy for discriminating patients who needed intensive care. Patients with FS24 ≥ 1.6 L had an increased risk of developing severe disease.
Collapse
Affiliation(s)
- Tsuyoshi Takeda
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Suguru Mizuno
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Tatsunori Suzuki
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Tatsuya Sato
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Ryunosuke Hakuta
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Kazunaga Ishigaki
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Kei Saito
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Tomotaka Saito
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Takeo Watanabe
- Department of Gastroenterology, Tokyo Takanawa Hospital, Tokyo, Japan
| | - Naminatsu Takahara
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Dai Mouri
- Department of Gastroenterology, JR Tokyo General Hospital, Tokyo, Japan
| | - Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Yukiko Ito
- Department of Gastroenterology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Kenji Hirano
- Department of Gastroenterology, Tokyo Takanawa Hospital, Tokyo, Japan
| | - Minoru Tada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| |
Collapse
|
6
|
Ye B, Mao W, Chen Y, Tong Z, Li G, Zhou J, Ke L, Li W. Aggressive Resuscitation Is Associated with the Development of Acute Kidney Injury in Acute Pancreatitis. Dig Dis Sci 2019; 64:544-552. [PMID: 30327961 DOI: 10.1007/s10620-018-5328-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 10/09/2018] [Indexed: 12/11/2022]
Abstract
INTRODUCTION The association between early resuscitation volume and clinical outcomes remains controversial in acute pancreatitis. In the present study, we aimed to identify the association between resuscitation volume and the development of acute kidney injury (AKI) and other clinical outcome metrics. METHODS Patients admitted to our center with moderately severe acute pancreatitis (MSAP) and severe acute pancreatitis (SAP) from January 2009 to December 2013 were reviewed retrospectively. Patients were stratified into two groups on the basis of the volume of fluid infused during the first 24 h. The primary clinical endpoint was incidence of AKI. Moreover, AKI lasting time, utilization of continuous renal replacement therapy and lasting time, creatinine increase, and other clinical metrics were also compared. The potential risk factors of new-onset AKI were also analyzed. RESULTS A total of 179 patients were included, and aggressive fluid resuscitation (≥ 4 l) was associated with increased incidence of AKI compared with nonaggressive group (53.12% vs. 25.64%, p = 0.008), longer AKI lasting time (p = 0.038), and increased creatinine increase (p < 0.001) during hospitalization. Moreover, utilization of continuous renal replacement therapy was more frequent in aggressive group (40.63% vs. 24.36%, p = 0.108), and the lasting time of continuous renal replacement therapy was also longer (p = 0.181), though both not statistically different. Moreover, in multivariate analysis, aggressive resuscitation [OR 4.36 (1.52-13.62); p = 0.001] and chloride exposure [OR 2.53 (1.26-5.21); p = 0.012] in the first 24 h were risk factors of new-onset AKI. CONCLUSION In patients with MSAP and SAP, aggressive fluid resuscitation was associated with increased incidence and longer duration of AKI. Moreover, aggressive resuscitation and chloride exposure in the first 24 h were risk factors of new-onset AKI.
Collapse
Affiliation(s)
- Bo Ye
- Department of SICU, Research Institute of General Surgery, Jinling Hospital, Nanjing University School of Medicine, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu Province, China
| | - Wenjian Mao
- Department of SICU, Research Institute of General Surgery, Jinling Hospital, Nanjing University School of Medicine, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu Province, China
| | - Yuhui Chen
- Department of SICU, Research Institute of General Surgery, Jinling Hospital, Nanjing University School of Medicine, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu Province, China
| | - Zhihui Tong
- Department of SICU, Research Institute of General Surgery, Jinling Hospital, Nanjing University School of Medicine, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu Province, China
| | - Gang Li
- Department of SICU, Research Institute of General Surgery, Jinling Hospital, Nanjing University School of Medicine, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu Province, China
| | - Jing Zhou
- Department of SICU, Research Institute of General Surgery, Jinling Hospital, Nanjing University School of Medicine, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu Province, China
| | - Lu Ke
- Department of SICU, Research Institute of General Surgery, Jinling Hospital, Nanjing University School of Medicine, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu Province, China.
| | - Weiqin Li
- Department of SICU, Research Institute of General Surgery, Jinling Hospital, Nanjing University School of Medicine, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu Province, China.
| |
Collapse
|
7
|
Kumar P, Gupta P, Rana S. Thoracic complications of pancreatitis. JGH OPEN 2018; 3:71-79. [PMID: 30834344 PMCID: PMC6386740 DOI: 10.1002/jgh3.12099] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 09/12/2018] [Accepted: 09/17/2018] [Indexed: 12/14/2022]
Abstract
Acute pancreatitis in its severe form may lead to systemic inflammatory response syndrome and multisystem organ dysfunction. Acute lung injury is an important cause of mortality in the setting of severe acute pancreatitis. Besides lung involvement, acute and chronic pancreatitis may also lead to the involvement of other thoracic compartments, including mediastinum, pleura, and vascular structures. These manifestations are an important cause of morbidity and may pose diagnostic and therapeutic challenges. These manifestations have not been discussed in detail in the available literature. In this review, we discuss the thoracic complications of pancreatitis, including lung, pleural, mediastinal, and vascular manifestations.
Collapse
Affiliation(s)
- Prem Kumar
- Department of Radiodiagnosis and Imaging Postgraduate Institute of Medical Education and Research Chandigarh India
| | - Pankaj Gupta
- Department of Gastroenterology Postgraduate Institute of Medical Education and Research Chandigarh India
| | - Surinder Rana
- Department of Gastroenterology Postgraduate Institute of Medical Education and Research Chandigarh India
| |
Collapse
|
8
|
Fu J, Liu Q, Liu GX, Xu XD. Diagnosis and treatment of severe acute pancreatitis: Current status and main problems. Shijie Huaren Xiaohua Zazhi 2017; 25:2851-2857. [DOI: 10.11569/wcjd.v25.i32.2851] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Acute pancreatitis (AP) is a disease of various causes, characterized by pancreatic enzyme activation and local pancreatic inflammatory response. Serious cases may develop systemic inflammatory response syndrome and even organ dysfunction. Severe AP (SAP) as a category of AP associated with persistent organ failure (>48 h) has an acute onset and high fatality rate. SAP accounts for about 5%-10% of all AP cases, with 30%-50% mortality rate. In this paper, we discuss the current status and main problems on the diagnosis and treatment of SAP based on the literature and our experience.
Collapse
Affiliation(s)
- Jie Fu
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, The Second Xiangya Hospital of Central South University;Hunan Provincial Key Laboratory of Hepatobiliary Disease Research. Changsha 410011, Hunan Province, China
| | - Qiang Liu
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, The Second Xiangya Hospital of Central South University;Hunan Provincial Key Laboratory of Hepatobiliary Disease Research. Changsha 410011, Hunan Province, China
| | - Guo-Xing Liu
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, The Second Xiangya Hospital of Central South University;Hunan Provincial Key Laboratory of Hepatobiliary Disease Research. Changsha 410011, Hunan Province, China
| | - Xun-Di Xu
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, The Second Xiangya Hospital of Central South University;Hunan Provincial Key Laboratory of Hepatobiliary Disease Research. Changsha 410011, Hunan Province, China
| |
Collapse
|
9
|
Effect of Intravenous Fluids and Analgesia on Dysmotility in Patients With Acute Pancreatitis: A Prospective Cohort Study. Pancreas 2017; 46:858-866. [PMID: 28697124 DOI: 10.1097/mpa.0000000000000864] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Analgesia and intravenous fluid resuscitation are cornerstones of initial patient management in acute pancreatitis (AP). The aim was to investigate the effect of intravenous fluids and analgesia on gastrointestinal motility in the early course of AP. METHODS Gastrointestinal dysmotility was assessed using the Gastroparesis Cardinal Symptom Index (GCSI). One-way analysis of variance and analysis of covariance were conducted, adjusting for age, sex, body mass index, severity of AP, preexisting diabetes mellitus, and time from first symptom onset to hospital admission. RESULTS A total of 108 patients with AP were prospectively enrolled. Opioid analgesia, when compared with nonopioid analgesia, was significantly associated with increase in total GCSI score in both unadjusted and adjusted analyses. There was no significant difference between aggressive and nonaggressive fluid resuscitation in both unadjusted and adjusted analyses. A combination of opioids and any intravenous fluids was associated with a significantly increased total GCSI score compared with opioids and no intravenous fluids in both unadjusted and adjusted analyses. Duration of symptoms was the confounder that significantly affected 6 of 9 studied associations. CONCLUSIONS Intravenous fluids and analgesia significantly affect motility independent of severity and other covariates. Guidelines on prudent use of opioids and fluids in AP need to be developed, particularly taking into account duration of symptoms from onset to hospitalization.
Collapse
|
10
|
Srinivasan G, Venkatakrishnan L, Sambandam S, Singh G, Kaur M, Janarthan K, John BJ. Current concepts in the management of acute pancreatitis. J Family Med Prim Care 2016; 5:752-758. [PMID: 28348985 PMCID: PMC5353808 DOI: 10.4103/2249-4863.201144] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Guidelines for the management of acute pancreatitis (AP) are based on the Western experience, which may be difficult to extrapolate in India due to socioeconomic constraints. Hence, modifications based on the available resources and referral patterns should be introduced so as to ensure appropriate care. We reviewed the current literature on the management of AP available in English on Medline and proposed guidelines locally applicable. Patients of AP presenting with systemic inflammatory response syndrome are at risk of moderate-severe pancreatitis and hence, should be referred to a tertiary center early. The vast majority of patients with AP have mild disease and can be managed at smaller centers. Early aggressive fluid resuscitation with controlled fluid expansion, early enteral nutrition, and culture-directed antibiotics improve outcomes in AP. Infected pancreatic necrosis should be managed in a tertiary care hospital within a multidisciplinary setup. The "step up" approach involving antibiotics, percutaneous drainage, and minimally invasive necrosectomy instituted sequentially based on clinical response has improved the outcomes in this subgroup of patients.
Collapse
Affiliation(s)
- Gautham Srinivasan
- Department of HPB and Liver Transplantation, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India
| | - L Venkatakrishnan
- Department of Gastroenterology, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India
| | - Swaminathan Sambandam
- Department of HPB and Liver Transplantation, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India
| | - Gursharan Singh
- Department of HPB and Liver Transplantation, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India
| | - Maninder Kaur
- Department of Anaesthesiology and Critical Care, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India
| | - Krishnaveni Janarthan
- Department of Gastroenterology, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India
| | - B Joseph John
- Department of HPB and Liver Transplantation, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India
| |
Collapse
|
11
|
DiMagno MJ. Clinical update on fluid therapy and nutritional support in acute pancreatitis. Pancreatology 2015; 15:583-8. [PMID: 26454418 DOI: 10.1016/j.pan.2015.09.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Revised: 09/07/2015] [Accepted: 09/10/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND/OBJECTIVES The aim of this focused review is to provide a valuable and updated source of information for clinical practice on fluid therapy (FT) and nutritional support in acute pancreatitis (AP). METHODS The review encompasses important new clinical information that has become available for understanding and offering these specific treatments since the 2013 publication of two guidelines, both the joint International Association of Pancreatology and American Pancreatic Association and the American College of Gastroenterology. The 2015 Revised Japanese Guideline is discussed selectively. To this end, the review is divided into 7 sections, including timing and cause of mortality; severity classification systems; predicting severity; response to treatment; nutritional support; fluid therapy and steps for further research. CONCLUSIONS In mild AP, begin oral feeding when nausea, vomiting and abdominal pain are improving. In (predicted) severe AP, feeding decisions should commence by 72 h, offering oral feeding if GI symptoms improve or enteral feeding if patients are symptomatic and/or intolerant to orals. All patients should be offered goal-directed FT during the first 6-12 h of presentation. Cautious FT is advised in those age >55 years or with preexisting organ failure or predictors of developing fluid sequestration.
Collapse
Affiliation(s)
- Matthew J DiMagno
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, The University of Michigan School of Medicine, 1150 W. Medical Center Drive, 6520 MSRB 1, Ann Arbor, MI 48109-0682, USA.
| |
Collapse
|
12
|
Lipinski M, Rydzewska-Rosolowska A, Rydzewski A, Rydzewska G. Fluid resuscitation in acute pancreatitis: Normal saline or lactated Ringer's solution? World J Gastroenterol 2015; 21:9367-9372. [PMID: 26309362 PMCID: PMC4541388 DOI: 10.3748/wjg.v21.i31.9367] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Revised: 02/28/2015] [Accepted: 04/28/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate whether administration of Ringer’s solution (RL) could have an impact on the outcome of acute pancreatitis (AP).
METHODS: We conducted a retrospective study on 103 patients [68 men and 35 women, mean age 51.2 years (range, 19-92 years)] hospitalized between 2011 and 2012. All patients admitted to the Department of Gastroenterology of the Central Clinical Hospital of the Ministry of Interior (Poland) with a diagnosis of AP who had disease onset within 48 h of presentation were included in this study. Based on the presence of persistent organ failure (longer than 48 h) as a criterion for the diagnosis of severe AP (SAP) and the presence of local complications [diagnosis of moderately severe AP (MSAP)], patients were classified into 3 groups: mild AP (MAP), MSAP and SAP. Data were compared between the groups in terms of severity (using the revised Atlanta criteria) and outcome. Patients were stratified into 2 groups based on the type of fluid resuscitation: the 1-RL group who underwent standard fluid resuscitation with a RL 1000 mL solution or the 2-NS group who underwent standard fluid resuscitation with 1000 mL normal saline (NS). All patients from both groups received an additional 5% glucose solution (1000-1500 mL) and a multi-electrolyte solution (500-1000 mL).
RESULTS: We observed 64 (62.1%) patients with MAP, 26 (25.24%) patients with MSAP and 13 (12.62%) patients with SAP. No significant difference in the distribution of AP severity between the two groups was found. In the 1-RL group, we identified 22 (55.5%) MAP, 10 (25.5%) MSAP and 8 (20.0%) SAP patients, compared with 42 (66.7%) MAP, 16 (24.4%) MSAP and 5 (7.9%) SAP cases in the 2-NS group (P = 0.187). The volumes of fluid administered during the initial 72-h period of hospitalization were similar among the patients from both the 1-RL and 2-NS groups (mean 3400 mL vs 3000 mL, respectively). No significant differences between the 1-RL and 2-NS groups were found in confirmed pancreatic necrosis [10 patients (25%) vs 12 patients (19%), respectively, P = 0.637]. There were no statistically significant differences between the 1-RL and 2-NS groups in the percentage of patients who required enteral nutrition (23 patients vs 17 patients, respectively, P = 0.534). Logistic regression analysis confirmed these findings (OR = 1.344, 95%CI: 0.595-3.035, P = 0.477). There were no significant differences between the 1-RL and 2-NS groups in mortality and the duration of hospital stay (median of 9 d for both groups, P = 0.776).
CONCLUSION: Our study failed to find any evidence that the administration of RL in the first days of AP leads to improved clinical outcomes.
Collapse
|
13
|
Yokoe M, Takada T, Mayumi T, Yoshida M, Isaji S, Wada K, Itoi T, Sata N, Gabata T, Igarashi H, Kataoka K, Hirota M, Kadoya M, Kitamura N, Kimura Y, Kiriyama S, Shirai K, Hattori T, Takeda K, Takeyama Y, Hirota M, Sekimoto M, Shikata S, Arata S, Hirata K. Japanese guidelines for the management of acute pancreatitis: Japanese Guidelines 2015. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2015; 22:405-32. [PMID: 25973947 DOI: 10.1002/jhbp.259] [Citation(s) in RCA: 267] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 04/10/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND Japanese (JPN) guidelines for the management of acute pancreatitis were published in 2006. The severity assessment criteria for acute pancreatitis were later revised by the Japanese Ministry of Health, Labour and Welfare (MHLW) in 2008, leading to their publication as the JPN Guidelines 2010. Following the 2012 revision of the Atlanta Classifications of Acute Pancreatitis, in which the classifications of regional complications of pancreatitis were revised, the development of a minimally invasive method for local complications of pancreatitis spread, and emerging evidence was gathered and revised into the JPN Guidelines. METHODS A comprehensive evaluation was carried out on the evidence for epidemiology, diagnosis, severity, treatment, post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis and clinical indicators, based on the concepts of the GRADE system (Grading of Recommendations Assessment, Development and Evaluation). With the graded recommendations, where the evidence was unclear, Meta-Analysis team for JPN Guidelines 2015 conducted an additional new meta-analysis, the results of which were included in the guidelines. RESULTS Thirty-nine questions were prepared in 17 subject areas, for which 43 recommendations were made. The 17 subject areas were: Diagnosis, Diagnostic imaging, Etiology, Severity assessment, Transfer indication, Fluid therapy, Nasogastric tube, Pain control, Antibiotics prophylaxis, Protease inhibitor, Nutritional support, Intensive care, management of Biliary Pancreatitis, management of Abdominal Compartment Syndrome, Interventions for the local complications, Post-ERCP pancreatitis and Clinical Indicator (Pancreatitis Bundles 2015). Meta-analysis was conducted in the following four subject areas based on randomized controlled trials: (1) prophylactic antibiotics use; (2) prophylactic pancreatic stent placement for the prevention of post-ERCP pancreatitis; (3) prophylactic non-steroidal anti-inflammatory drugs (NSAIDs) for the prevention of post-ERCP pancreatitis; and (4) peritoneal lavage. Using the results of the meta-analysis, recommendations were graded to create useful information. In addition, a mobile application was developed, which made it possible to diagnose, assess severity and check pancreatitis bundles. CONCLUSIONS The JPN Guidelines 2015 were prepared using the most up-to-date methods, and including the latest recommended medical treatments, and we are confident that this will make them easy for many clinicians to use, and will provide a useful tool in the decision-making process for the treatment of patients, and optimal medical support. The free mobile application and calculator for the JPN Guidelines 2015 is available via http://www.jshbps.jp/en/guideline/jpn-guideline2015.html.
Collapse
Affiliation(s)
- Masamichi Yokoe
- General Internal Medicine, Japanese Red Cross Nagoya Daini Hospital, Nagoya, Japan
| | - Tadahiro Takada
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Toshihiko Mayumi
- Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, KitaKyushu, Japan
| | - Masahiro Yoshida
- Department of Hemodialysis and Surgery, Chemotherapy Research Institute, International University of Health and Welfare, Ichikawa, Japan
| | - Shuji Isaji
- Hepatobiliary Pancreatic & Transplant Surgery Mie University Graduate School of Medicine, Mie, Japan
| | - Keita Wada
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Naohiro Sata
- Department of Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Toshifumi Gabata
- Department of Radiology, Kanazawa University, School of Medical Science, Kanazawa, Japan
| | - Hisato Igarashi
- Clinical Education Center, Kyushu University Hospital, Fukuoka, Japan
| | - Keisho Kataoka
- Otsu Municipal Hospital, Shiga.,Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masahiko Hirota
- Department of Surgery, Kumamoto Regional Medical Center, Kumamoto, Japan
| | - Masumi Kadoya
- Department of Radiology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Nobuya Kitamura
- Department of Emergency and Critical Care Medicine, Kimitsu Chuo Hospital, Kisarazu, Chiba, Japan
| | - Yasutoshi Kimura
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo, Japan
| | - Seiki Kiriyama
- Department of Gastroenterology, Ogaki Municipal Hospital, Ogaki, Japan
| | - Kunihiro Shirai
- Department of Emergency and Critical Care Medicine, Ichinomiya Municipal Hospital, Ichinomiya, Japan
| | - Takayuki Hattori
- Department of Radiology, Tokyo Metropolitan Health and Medical Treatment Corporation, Ohkubo Hospital, Tokyo, Japan
| | - Kazunori Takeda
- Department of Surgery, National Hospital Organization Sendai Medical Center, Sendai, Japan
| | - Yoshifumi Takeyama
- Department of Surgery, Kinki University Faculty of Medicine, Osaka, Japan
| | - Morihisa Hirota
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Miho Sekimoto
- The University of Tokyo Graduate School of Public Policy, Health Policy Unit, Tokyo
| | - Satoru Shikata
- Department of Family Medicine, Mie Prefectural Ichishi Hospital, Mie, Japan
| | - Shinju Arata
- Gastroenterological Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Koichi Hirata
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo, Japan
| |
Collapse
|
14
|
Feng C, Su X, Zhou X, Wang LL, Li B, Chen LI, Lv FQ, Li TS. Early peritoneal lavage with ulinastatin improves outcome and enhances multi-organ protection in a model of severe acute pancreatitis. Exp Ther Med 2015; 9:1171-1177. [PMID: 25780405 PMCID: PMC4353754 DOI: 10.3892/etm.2015.2251] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Accepted: 01/20/2015] [Indexed: 01/15/2023] Open
Abstract
The aim of this study was to investigate the effect of early peritoneal lavage with ulinastatin on the outcome of a rat model of severe acute pancreatitis (SAP). A total of 80 male Wistar rats were randomly divided into the following groups: Sham-operated (C), SAP model (M), saline lavage (SL), intravenous ulinastatin (IU), early ulinastatin lavage (EUL) and late ulinastatin lavage (LUL). Intraperitoneal lavage or injection were performed immediately subsequent to the establishment of the SAP model in groups SL, IU and EUL and 3 h later in group LUL. Intraperitoneal lavage with or without ulinastatin was performed for 3 h. The survival time of the rats in groups C, M, EUL and LUL was recorded over a 12-h period and the median survival time was calculated. At 3 h after the induction of SAP, histopathological analyses were performed and the biochemical parameters of groups C, M, SL, IU and EUL were assessed. Groups EUL and LUL exhibited an increased median survival time compared with Group M, with the survival time of the rats in group EUL markedly longer than that in the group LUL rats. Group SL, IU and EUL rats were found to have reduced plasma activities of amylase, lipase, aspartate transaminase and alanine transaminase, with the biggest change observed in the group EUL rats. Furthermore, the intervention in groups SL and EUL was more effective at reducing creatinine and urea levels than that in group IU. Rats in group EUL exhibited a greater inhibition of the SAP-induced increase in troponin T levels than rats in groups SL and IU. The pathological severity scores of the pancreas, liver, kidney and lung in group EUL were significantly lower than those in groups M and better than those in groups SL and IU. In conclusion, early intraperitoneal lavage with ulinastatin significantly improves the median survival time and protects multi-organ function in an SAP model.
Collapse
Affiliation(s)
- Cong Feng
- Department of Emergency, General Hospital of the PLA, Beijing 100853, P.R. China ; The Li-Shi Road Outpatient Department of the General Hospital of the Second Artillery, Beijing 100045, P.R. China
| | - Xuan Su
- Department of Hepatology-Immunology, Beijing You An Hospital of the Capital Medical University, Beijing 100069, P.R. China
| | - Xuan Zhou
- Department of Emergency, General Hospital of the PLA, Beijing 100853, P.R. China
| | - Li-Li Wang
- Department of Emergency, General Hospital of the PLA, Beijing 100853, P.R. China
| | - Bei Li
- Department of Emergency, General Hospital of the PLA, Beijing 100853, P.R. China
| | - L I Chen
- Department of Emergency, General Hospital of the PLA, Beijing 100853, P.R. China
| | - Fa-Qin Lv
- Department of Ultrasound, General Hospital of the PLA, Beijing 100853, P.R. China
| | - Tan-Shi Li
- Department of Emergency, General Hospital of the PLA, Beijing 100853, P.R. China
| |
Collapse
|
15
|
Aggarwal A, Manrai M, Kochhar R. Fluid resuscitation in acute pancreatitis. World J Gastroenterol 2014; 20:18092-18103. [PMID: 25561779 PMCID: PMC4277949 DOI: 10.3748/wjg.v20.i48.18092] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Revised: 09/03/2014] [Accepted: 10/15/2014] [Indexed: 02/06/2023] Open
Abstract
Acute pancreatitis remains a clinical challenge, despite an exponential increase in our knowledge of its complex pathophysiological changes. Early fluid therapy is the cornerstone of treatment and is universally recommended; however, there is a lack of consensus regarding the type, rate, amount and end points of fluid replacement. Further confusion is added with the newer studies reporting better results with controlled fluid therapy. This review focuses on the pathophysiology of fluid depletion in acute pancreatitis, as well as the rationale for fluid replacement, the type, optimal amount, rate of infusion and monitoring of such patients. The basic goal of fluid epletion should be to prevent or minimize the systemic response to inflammatory markers. For this review, various studies and reviews were critically evaluated, along with authors’ recommendations, for predicted severe or severe pancreatitis based on the available evidence.
Collapse
|
16
|
Abstract
PURPOSE OF REVIEW To review the changing insights in the pathophysiology and management of acute pancreatitis. RECENT FINDINGS The outdated 1992 Atlanta classification has been replaced by two new classifications, both of which acknowledge the role of organ dysfunction in determining the outcome of acute pancreatitis, and both of which have introduced a new category of 'moderate' pancreatitis. The new classifications will allow fewer patients to be classified as severe, which better reflects the risk of dying of the disease. Intra-abdominal hypertension has emerged as a relevant issue, and strategies to lower intra-abdominal pressure may often be required. Antibiotic prophylaxis has been discontinued for some time, but aggressive fluid resuscitation is also being questioned, and the role of surgery is further reduced as percutaneous drainage of collections has shown to reduce the need for more surgical interventions. If needed, surgery should be as conservative as possible, with minimally invasive strategies preferable. Newer techniques such as endoscopic transgastric drainage are being developed, but their exact role has yet to be defined. SUMMARY Management of severe acute pancreatitis is changing fundamentally. 'Less is more' is the new paradigm in acute pancreatitis - less antibiotics, less fluids, less surgery, which should eventually lead to less morbidity and mortality.
Collapse
|
17
|
Weitz G, Woitalla J, Wellhöner P, Schmidt K, Büning J, Fellermann K. Detrimental effect of high volume fluid administration in acute pancreatitis - a retrospective analysis of 391 patients. Pancreatology 2014; 14:478-83. [PMID: 25451185 DOI: 10.1016/j.pan.2014.07.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Revised: 06/23/2014] [Accepted: 07/09/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND Early fluid resuscitation is recommended for the therapy of acute pancreatitis in order to prevent complications. There are, however, no convincing data supporting this approach. METHODS We reviewed 391 consecutive cases of confirmed acute pancreatitis. Admitting physicians had been advised to administer an aggressive fluid resuscitation in the early phase of disease, if possible. We tested whether disease severity according to the revised Atlanta Classification, local complications, and maximum C-reactive protein levels were predictable by the initial volume therapy in logistic and linear regression models, respectively. We also determined which parameters on admission encouraged a more aggressive fluid resuscitation. RESULTS The recorded fluid administered within the first 24 h was 5300 [3760; 7100] ml (median [1st; 3rd quartile]). More aggressive volume therapy was associated with disease severity and a higher rate of local complications. There was a linear relationship between administered volume and the maximum C-reactive protein. The amount of administered fluid was significantly attributed to age, hematocrit, and white blood cell count on admission. When adjusted for these parameters the impact of administered volume on outcome was still present but attenuated. CONCLUSIONS We found detrimental effects of fluid therapy on major outcome parameters throughout the whole range of administered volume. More volume was administered in younger patients and in patients with evidence of hemoconcentration and inflammation. The adverse effects of volume therapy persisted after elimination of these parameters. Caution should therefore be advised with regards to volume therapy in patients with acute pancreatitis.
Collapse
Affiliation(s)
- Gunther Weitz
- Medical Department I, Gastroenterology, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany.
| | - Julia Woitalla
- Medical Department I, Gastroenterology, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | - Peter Wellhöner
- Medical Department I, Gastroenterology, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | - Klaus Schmidt
- Medical Department I, Gastroenterology, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | - Jürgen Büning
- Medical Department I, Gastroenterology, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | - Klaus Fellermann
- Medical Department I, Gastroenterology, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
| |
Collapse
|
18
|
de-Madaria E, Garg PK. Fluid therapy in acute pancreatitis - aggressive or adequate? Time for reappraisal. Pancreatology 2014; 14:433-5. [PMID: 25455538 DOI: 10.1016/j.pan.2014.09.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Enrique de-Madaria
- Pancreatic Unit, Hospital General Universitario de Alicante, Alicante, Spain.
| | - Pramod K Garg
- All India Institute of Medical Sciences, New Delhi, India.
| |
Collapse
|
19
|
de-Madaria E. [Fluid therapy in acute pancreatitis]. GASTROENTEROLOGIA Y HEPATOLOGIA 2013; 36:631-40. [PMID: 23988650 DOI: 10.1016/j.gastrohep.2013.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2013] [Accepted: 01/15/2013] [Indexed: 10/26/2022]
Abstract
Severe acute pancreatitis (AP) is associated with an increased need for fluids due to fluid sequestration and, in the most severe cases, with decreased peripheral vascular tone. For several decades, clinical practice guidelines have recommended aggressive fluid therapy to improve the prognosis of AP. This recommendation is based on theoretical models, animal studies, and retrospective studies in humans. Recent studies suggest that aggressive fluid administration in all patients with AP could have a neutral or harmful effect. Fluid therapy based on Ringer's lactate could improve the course of the disease, although further studies are needed to confirm this possibility. Most patients with AP do not require invasive monitoring of hemodynamic parameters to guide fluid therapy administration. Moreover, the ability of these parameters to improve prognosis has not been demonstrated.
Collapse
Affiliation(s)
- Enrique de-Madaria
- Unidad de Patología Pancreática, Hospital General Universitario de Alicante, Alicante, España.
| |
Collapse
|
20
|
Contrasts and comparisons between childhood and adult onset acute pancreatitis. Pancreatology 2013; 13:429-35. [PMID: 23890143 DOI: 10.1016/j.pan.2013.06.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2013] [Revised: 06/18/2013] [Accepted: 06/19/2013] [Indexed: 12/11/2022]
Abstract
Acute pancreatitis (AP) in children is an increasingly recognised clinical entity notably different from the adults with respect to incidence, aetiology, severity and outcome. Yet our current understanding and approach to the management of paediatric pancreatitis is based almost entirely on adult studies. Acute recurrent pancreatitis (ARP) in children is more likely associated with various genetic factors, some of which have been relatively well characterised and others are in an evolving phase. The aim of this review is to summarise current knowledge, highlight any recent advances and contrast the paediatric and adult forms of this condition.
Collapse
|
21
|
Abdo EE, Coelho AMM, Patzina RA, Sampietre SN, Cunha JEM, Machado MCC, D'Albuquerque LAC. Nitric oxide synthase inhibition reduces albumin induced lung damage in acute pancreatitis. Pancreatology 2013; 13:225-9. [PMID: 23719592 DOI: 10.1016/j.pan.2013.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2012] [Revised: 04/03/2013] [Accepted: 04/04/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES Colloid resuscitation in acute pancreatitis (AP) is a matter of controversy due to the possible deleterious effect on lung function. A previous study demonstrates that albumin administration increases lung damage in burns and this effect can be reversed by inducible nitric oxide synthase (iNOS) inhibition. This study evaluates the effects of S-methylisothiourea (SMT), a specific iNOS inhibitor, on lungs and pancreas of rats with AP receiving intravenous albumin. METHODS AP was induced in Wistar rats by intraductal 5% taurocholate injection. To evaluate the effect of albumin on lung damage, animals received IV saline or human albumin immediately after AP (Groups: Saline and Albumin). To evaluate the effect of iNOS inhibition on lung damage, SMT was given immediately after AP (Group Saline+SMT, and Group Albumin+SMT). At 12 h after AP induction, serum amylase activity, lung vascular permeability and myeloperoxidase (MPO) activity were evaluated. Lung and pancreas histological analysis were performed. RESULTS Serum amylase activity, pancreatic edema, lung vascular permeability, MPO activity, and inflammatory infiltration were significantly increased after AP. Albumin administration increased lung vascular permeability, inflammatory infiltration, and pancreatic edema compared to saline administration (p < 0.05). Albumin administration with SMT reduced lung vascular permeability, MPO activity, and inflammatory infiltration compared to albumin administration alone (p < 0.05). CONCLUSION Lung and pancreatic damage induced by albumin administration for restoration of plasma volume in AP are reduced by iNOS inhibition. Awareness of this fact may be useful in high-risk patients who need to receive albumin for volume replacement.
Collapse
Affiliation(s)
- Emilio Elias Abdo
- Department of Gastroenterology (LIM/37), Medical School, University of São Paulo, São Paulo, Brazil
| | | | | | | | | | | | | |
Collapse
|
22
|
Maraví Poma E, Zubia Olascoaga F, Petrov M, Navarro Soto S, Laplaza Santos C, Morales Alava F, Darnell Martin A, Gorraiz López B, Bolado Concejo F, Casi Villarroya M, Aizcorbe Garralda M, Albeniz Arbizu E, Sánchez-Izquierdo Riera J, Tirapu León J, Bordejé Laguna L, López Camps V, Marcos Neira P, Regidor Sanz E, Jiménez Mendioroz F. SEMICYUC 2012. Recommendations for intensive care management of acute pancreatitis. ACTA ACUST UNITED AC 2013. [DOI: 10.1016/j.medine.2013.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
|
23
|
SEMICYUC 2012. Recommendations for intensive care management of acute pancreatitis. Med Intensiva 2013; 37:163-79. [PMID: 23541063 DOI: 10.1016/j.medin.2013.01.007] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Accepted: 01/17/2013] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Significant changes in the management of acute pancreatitis have taken place since the 2004 Pamplona Consensus Conference. The objective of this conference has been the revision and updating of the Conference recommendations, in order to unify the integral management of potentially severe acute pancreatitis in an ICU. PARTICIPANTS Spanish and international intensive medicine physicians, radiologists, surgeons, gastroenterologists, emergency care physicians and other physicians involved in the treatment of acute pancreatitis. LEVELS OF EVIDENCE AND GRADES OF RECOMMENDATION: The GRADE method has been used for drawing them up. DRAWING UP THE RECOMMENDATIONS: The selection of the committee members was performed by means of a public announcement. The bibliography has been revised from 2004 to the present day and 16 blocks of questions on acute pancreatitis in a ICU have been drawn up. Firstly, all the questions according to groups have been drawn up in order to prepare one document. This document has been debated and agreed upon by computer at the SEMICYUC Congress and lastly at the Consensus Conference which was held with the sole objective of drawing up these recommendations. CONCLUSIONS Eighty two recommendations for acute pancreatitis management in an ICU have been presented. Of these 84 recommendations, we would emphasize the new determinants-based classification of acute pancreatitis severity, new surgical techniques and nutritional recommendations. Note. This summary only lists the 84 recommendations of the 16 questions blocks except blocks greater relevance and impact of its novelty or because they modify the current management.
Collapse
|
24
|
Treatment of necrotizing pancreatitis. Clin Gastroenterol Hepatol 2012; 10:1190-201. [PMID: 22610008 DOI: 10.1016/j.cgh.2012.05.005] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2012] [Revised: 04/25/2012] [Accepted: 05/07/2012] [Indexed: 02/07/2023]
Abstract
Acute pancreatitis is a common and potentially lethal disease. It is associated with significant morbidity and consumes enormous health care resources. Over the last 2 decades, the treatment of acute pancreatitis has undergone fundamental changes based on new conceptual insights and evidence from clinical studies. The majority of patients with necrotizing pancreatitis have sterile necrosis, which can be successfully treated conservatively. Emphasis of conservative treatment is on supportive measures and prevention of infection of necrosis and other complications. Patients with infected necrosis generally need to undergo an intervention, which has shifted from primary open necrosectomy in an early disease stage to a step-up approach, starting with catheter drainage if needed, followed by minimally invasive surgical or endoscopic necrosectomy once peripancreatic collections have sufficiently demarcated. This review provides an overview of current standards for conservative and invasive treatment of necrotizing pancreatitis.
Collapse
|
25
|
[Gastrointestinal emergencies - acute pancreatitis]. Med Klin Intensivmed Notfmed 2012; 108:491-6. [PMID: 23076392 DOI: 10.1007/s00063-012-0154-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2012] [Revised: 07/11/2012] [Accepted: 08/07/2012] [Indexed: 10/27/2022]
Abstract
The acute pancreatitis is a frequent event with an impressive clinical presentation. Specific treatment does not exist. The goals of the medical measures are to ameliorate complaints and to prevent complications. During recent years, insights into adequate treatment have significantly increased. Recommendations on volume therapy have now been specified. Moreover, progress has been made in the efficient employment of nutritional support, imaging and antibiotic treatment. In addition, the treatment of large or infected necrosis has significantly improved. The article reviews the current state-of-the-art care of acute pancreatitis.
Collapse
|
26
|
Clinical pathways for acute pancreatitis: Recommendations for early multidisciplinary management. ACTA ACUST UNITED AC 2012. [DOI: 10.1016/j.medine.2012.02.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
|
27
|
Maraví Poma E, Laplaza Santos C, Gorraiz López B, Albeniz Arbizu E, Zubia Olascoaga F, Petrov M, Morales F, Aizcorbe Garralda M, Casi Villaroya M, Sánchez-Izquierdo Riera J, López Camps V, Regidor Sanz E, Loinaz Bordonabe M, do Pico J. Hoja de ruta de los cuidados clínicos para la pancreatitis aguda: recomendaciones para el manejo anticipado multidisciplinar (clinical pathways). Med Intensiva 2012; 36:351-7. [DOI: 10.1016/j.medin.2012.02.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2011] [Revised: 02/16/2012] [Accepted: 02/21/2012] [Indexed: 02/08/2023]
|