Is aggressive intravenous fluid resuscitation beneficial in acute pancreatitis? A meta-analysis of randomized control trials and cohort studies

Evaluating the efficacy of different volume resuscitation strategies in acute pancreatitis patients: a systematic review and meta-analysis

INTRODUCTION

Acute pancreatitis poses a significant health risk due to the potential for pancreatic necrosis and multi-organ failure. Fluid resuscitation has demonstrated positive effects; however, consensus on the ideal intravenous fluid type and infusion rate for optimal patient outcomes remains elusive.

METHODS

A comprehensive literature search was conducted using PubMed, Embase, the Cochrane Library, Scopus, and Google Scholar for studies published between 2005 and January 2023. Reference lists of potential studies were manually searched to identify additional relevant articles. Randomized controlled trials and retrospective studies comparing high (≥ 20 ml/kg/h), moderate (≥ 10 to < 20 ml/kg/h), and low (5 to < 10 ml/kg/h) fluid therapy in acute pancreatitis were considered.

RESULTS

Twelve studies met our inclusion criteria. Results indicated improved clinical outcomes with low versus moderate fluid therapy (OR = 0.73; 95% CI [0.13, 4.03]; p = 0.71) but higher mortality rates with low compared to moderate (OR = 0.80; 95% CI [0.37, 1.70]; p = 0.55), moderate compared to high (OR = 0.58; 95% CI [0.41, 0.81], p = 0.001), and low compared to high fluids (OR = 0.42; 95% CI [0.16, 1.10]; P = 0.08). Systematic complications improved with moderate versus low fluid therapy (OR = 1.22; 95% CI [0.84, 1.78]; p = 0.29), but no difference was found between moderate and high fluid therapy (OR = 0.59; 95% CI [0.41, 0.86]; p = 0.006).

DISCUSSION

This meta-analysis revealed differences in the clinical outcomes of patients with AP receiving low, moderate, and high fluid resuscitation. Low fluid infusion demonstrated better clinical outcomes but higher mortality, systemic complications, and SIRS persistence than moderate or high fluid therapy. Early fluid administration yielded better results than rapid fluid resuscitation.

A Nationwide Analysis of Fluid Resuscitation Outcomes in Patients With Acute Pancreatitis

BACKGROUND

Traditionally, fluid resuscitation has been the foundation of effective acute pancreatitis (AP) treatment. Experts advocate for aggressive intravenous fluid (IVF) resuscitation, especially within the first 24 hours. Research suggests limited efficacy of this approach; in fact, some studies show there may be a risk of increased complications. The aim of this study was to assess outcomes of aggressive IVF resuscitation in patients with AP.

METHODS

We queried the TriNetX Research Network (Cambridge, Massachusetts, United States) for patients admitted between January 1, 2010, and December 31, 2020, with a diagnosis of AP and who had received IVF on admission for at least 24 hours. We compared two cohorts; cohort 1 consisted of patients receiving aggressive IVF resuscitation (>3 ml/kg/hr), and cohort 2 was comprised of patients receiving non-aggressive (≤1.5 ml/kg/hr) IVF resuscitation. We compared mortality during index hospitalization, hospital length of stay (HLS), mechanical ventilation rates, acute kidney injury (AKI), and severe sepsis between the cohorts with propensity scoring matched (PSM) pairs of patients. A sub-analysis of patients with severe AP was performed.

RESULTS

After comparing the two well-matched PSM cohorts (3,680/3,680), we found no significant differences in mortality, HLS, mechanical ventilation rates, AKI, or severe sepsis. We found similar results after conducting the sub-analysis of patients with severe pancreatitis.

CONCLUSIONS

We found no significant differences in mortality and HLS when comparing rates of IVF resuscitation.

Fluid resuscitation in the early management of acute pancreatitis - evidence from a systematic review and meta-analysis

BACKGROUND

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).

METHODS

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.

RESULTS

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).

CONCLUSIONS

Current evidence appears to support moderate intravenous resuscitation (level of evidence, low) with RL (level of evidence, moderate) in the early management of AP.

Development of a predictive nomogram for acute respiratory distress syndrome in patients with acute pancreatitis complicated with acute kidney injury

BACKGROUND

Acute respiratory distress syndrome (ARDS) is a common complication in patients with acute pancreatitis (AP), especially when patients complicated with acute kidney injury (AKI), resulting in increased duration of hospitalization and mortality. It is of potential clinical significance to develop a predictive model to identify the the high-risk patients.

METHOD

AP patients complicated with AKI from January 2019 to March 2022 were enrolled in this study and randomly divided into training cohort and validation cohort at a ratio of 2:1. The Least absolute shrinkage and selection operator(LASSO) regression and machine learning algorithms were applied to select features. A nomogram was developed based on the multivariate logistic regression. The performance of the nomogram was evaluated by AUC, calibration curves, and decision curve analysis.

RESULTS

A total of 292 patients were enrolled in the study, with 206 in the training cohort and 86 in the validation cohort. Multivariate logistic analysis showed that IAP (Odds Ratio (OR)=4.60, 95%CI:1.23-18.24, p = 0.02), shock (OR = 12.99, 95%CI:3.47-64.04, p < 0.001), CRP(OR= 26.19, 95%CI:9.37-85.57, p < 0.001), LDH (OR = 13.13, 95%CI:4.76-40.42, p < 0.001) were independent predictors of ARDS. The nomogram was developed based on IAP, shock, CRP and LDH. The nomogram showed good discriminative ability with an AUC value of 0.954 and 0.995 in the training and validation cohort, respectively. The calibration curve indicating good concordance between the predicted and observed values. The DCA showed favorable net clinical benefit.

CONCLUSION

This study developed a simple model for predicting ARDS in AP patients complicated with AKI. The nomogram can help clinicians identify high-risk patients and optimize therapeutic strategies.

Comparison of early aggressive versus nonaggressive fluid resuscitation in acute pancreatitis: a meta-analysis

Background

Early fluid resuscitation is one of the main therapeutic strategies for acute pancreatitis (AP). This study investigated the effects of early aggressive and nonaggressive hydration on AP.

Objectives

The aim of this meta-analysis is to investigate the differences between aggressive and nonaggressive intravenous fluid resuscitation in AP.

Design

This study was based on publicly available data, all of which have been extracted from previous ethically approved studies.

Data sources and methods

Two authors systematically searched PubMed, Embase (via OVID), Web of Science, and Cochrane Library to find all published research before February 2023. In-hospital mortality were set as primary endpoints.

Results

This meta-analysis included seven randomized controlled trials (RCTs) and eight cohort studies with 4072 individuals in nonaggressive (n = 2419) and aggressive (n = 1653) hydration groups. The results showed that patients in the nonaggressive group had a lower mortality rate than those in the aggressive hydration group [relative risks (RR), 0.66; p = 0.02]. Subgroup analysis results showed that patients in the nonaggressive hydration group had lower mortality rates in RCTs (RR, 0.39; p = 0.001), studies conducted in Eastern countries (RR, 0.63; p = 0.002), and studies with severe pancreatitis (RR, 0.65; p = 0.02). In addition, the nonaggressive hydration group had lower rates of infection (RR, 0.62; p < 0.001), organ failure (RR, 0.65; p = 0.02), and shock (RR, 0.21; p = 0.02), as well as a shorter hospital stay (weighted mean difference, -1.63; p = 0.001) than the aggressive hydration group.

Conclusions

Early nonaggressive fluid resuscitation is associated with lower mortality, lower risk of organ failure and infection, and shorter hospital stays than aggressive fluid resuscitation.

Registration prospero registration number

CRD42023396388.

Aggressive versus controlled fluid resuscitation in acute pancreatitis: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Early fluid resuscitation is one of the fundamental treatments for acute pancreatitis (AP), but there is no consensus on the optimal fluid rate. This systematic review and meta-analysis aimed to compare the efficacy and safety of aggressive vs. controlled fluid resuscitation (CFR) in AP.

METHODS

The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and Web of Science databases were searched up to September 30, 2022, for randomized controlled trials (RCTs) comparing aggressive with controlled rates of early fluid resuscitation in AP patients without organ failure on admission. The following keywords were used in the search strategy: "pancreatitis," "fluid therapy,""fluid resuscitation,"and "randomized controlled trial." There was no language restriction. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework was used to assess the certainty of evidence. Trial sequential analysis (TSA) was used to control the risk of random errors and assess the conclusions.

RESULTS

A total of five RCTs, involving 481 participants, were included in this study. For primary outcomes, there was no significant difference in the development of severe AP (relative risk [RR]: 1.87, 95% confidence interval [CI] 0.95-3.68; P = 0.07; n = 437; moderate quality of evidence) or hypovolemia (RR: 0.98, 95% CI: 0.32-2.97; P = 0.97; n = 437; moderate quality of evidence) between the aggressive and CFR groups. A significantly higher risk of fluid overload (RR: 3.25, 95% CI: 1.53-6.93; P <0.01; n = 249; low quality of evidence) was observed in the aggressive fluid resuscitation (AFR) group than the controlled group. Additionally, the risk of intensive care unit admission ( P = 0.02) and the length of hospital stay ( P <0.01) as partial secondary outcomes were higher in the AFR group. TSA suggested that more studies were required to draw precise conclusions.

CONCLUSION

For AP patients without organ failure on admission, CFR may be superior to AFR with respect to both efficacy and safety outcomes.

REGISTRATION

PROSPERO; https://www.crd.york.ac.uk/PROSPERO/ ; CRD 42022363945.

Current trends in acute pancreatitis: Diagnostic and therapeutic challenges

Acute pancreatitis (AP) is an inflammatory disease of the pancreas, which can progress to severe AP, with a high risk of death. It is one of the most complicated and clinically challenging of all disorders affecting the abdomen. The main causes of AP are gallstone migration and alcohol abuse. Other causes are uncommon, controversial and insufficiently explained. The disease is primarily characterized by inappropriate activation of trypsinogen, infiltration of inflammatory cells, and destruction of secretory cells. According to the revised Atlanta classification, severity of the disease is categorized into three levels: Mild, moderately severe and severe, depending upon organ failure and local as well as systemic complications. Various methods have been used for predicting the severity of AP and its outcome, such as clinical evaluation, imaging evaluation and testing of various biochemical markers. However, AP is a very complex disease and despite the fact that there are of several clinical, biochemical and imaging criteria for assessment of severity of AP, it is not an easy task to predict its subsequent course. Therefore, there are existing controversies regarding diagnostic and therapeutic modalities, their effectiveness and complications in the treatment of AP. The main reason being the fact, that the pathophysiologic mechanisms of AP have not been fully elucidated and need to be studied further. In this editorial article, we discuss the efficacy of the existing diagnostic and therapeutic modalities, complications and treatment failure in the management of AP.

Controversies in the management of acute pancreatitis: An update

This review summarized the current controversies in the management of acute pancreatitis (AP). The controversies in management range from issues involving fluid resuscitation, nutrition, the role of antibiotics and antifungals, which analgesic to use, role of anticoagulation and intervention for complications in AP. The interventions vary from percutaneous drainage, endoscopy or surgery. Active research and emerging data are helping to formulate better guidelines. The available evidence favors crystalloids, although the choice and type of fluid resuscitation is an area of dynamic research. The nutrition aspect does not have controversy as of now as early enteral feeding is preferred most often than not. The empirical use of antibiotics and antifungals are gray zones, and more data is needed for conclusive guidelines. The choice of analgesic is being studied, and the recommendations are still evolving. The position of using anticoagulation is still awaiting consensus. The role of intervention is well established, although the modality is constantly changing and favoring endoscopy or percutaneous drainage rather than surgery. It is evident that more multicenter randomized controlled trials are required for establishing the standard of care in these crucial management issues of AP to improve the morbidity and mortality worldwide.

Comparison of clinical outcomes between aggressive and non-aggressive intravenous hydration for acute pancreatitis: a systematic review and meta-analysis

BACKGROUND

Current practice guidelines for optimal infusion rates during early intravenous hydration in patients with acute pancreatitis (AP) remain inconsistent. This systematic review and meta-analysis aimed to compare treatment outcomes between aggressive and non-aggressive intravenous hydration in severe and non-severe AP.

METHODS

This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We systematically searched PubMed, Embase and Cochrane Library for randomized controlled trials (RCTs) on November 23, 2022, and hand-searched the reference lists of included RCTs, relevant review articles and clinical guidelines. We included RCTs that compared clinical outcomes from aggressive and non-aggressive intravenous hydration in AP. Meta-analysis was performed using a random-effects model for participants with severe AP and non-severe AP. Our primary outcome was all-cause mortality, and several secondary outcomes included fluid-related complications, clinical improvement and APACHE II scores within 48 h.

RESULTS

We included a total of 9 RCTs with 953 participants. The meta-analysis indicated that, compared to non-aggressive intravenous hydration, aggressive intravenous hydration significantly increased mortality risk in severe AP (pooled RR: 2.45, 95% CI: 1.37, 4.40), while the result in non-severe AP was inconclusive (pooled RR: 2.26, 95% CI: 0.54, 9.44). However, aggressive intravenous hydration significantly increased fluid-related complication risk in both severe (pooled RR: 2.22, 95% CI 1.36, 3.63) and non-severe AP (pooled RR: 3.25, 95% CI: 1.53, 6.93). The meta-analysis indicated worse APACHE II scores (pooled mean difference: 3.31, 95% CI: 1.79, 4.84) in severe AP, and no increased likelihood of clinical improvement (pooled RR:1.20, 95% CI: 0.63, 2.29) in non-severe AP. Sensitivity analyses including only RCTs with goal-directed fluid therapy after initial fluid resuscitation therapy yielded consistent results.

CONCLUSIONS

Aggressive intravenous hydration increased the mortality risk in severe AP, and fluid-related complication risk in both severe and non-severe AP. More conservative intravenous fluid resuscitation protocols for AP are suggested.

Prospective evaluation of an emergency department protocol to prevent hospitalization in mild acute pancreatitis: Outcomes and predictors of discharge

BACKGROUND

While acute pancreatitis (AP) contributes significantly to hospitalizations and costs, most cases are mild with minimal complications. In 2016, we piloted an observation pathway in the emergency department (ED) for mild AP and showed reduced admissions and length of stay (LOS) without increased readmissions or mortality. After 5 years of implementation, we evaluated outcomes of the ED pathway and identified predictors of successful discharge.

METHODS

We reviewed a prospectively enrolled cohort of patients with mild AP presenting to a tertiary care center ED between 10/2016 and 9/2021, evaluating LOS, charges, imaging, and 30-day readmission, and assessed predictors of successful ED discharge. Patients were divided into two main groups: successfully discharged via the ED pathway ("ED cohort") and admitted to the hospital ("admission cohort"), with subgroups to compare outcomes, and multivariate analysis to determine predictors of discharge.

RESULTS

Of 619 AP patients, 419 had mild AP (109 ED cohort, 310 admission cohort). The ED cohort was younger (age 49.3 vs 56.3,p < 0.001), had lower Charlson Comorbidity Index (CCI) (1.30 vs 2.43, p < 0.001), shorter LOS (12.3 h vs 116 h, p < 0.001), lower charges (mean $6768 vs $19886, p < 0.001) and less imaging, without differences in 30-day readmissions. Increasing age (OR: 0.97; p < 0.001), increasing CCI (OR: 0.75; p < 0.001) and biliary AP (OR: 0.10; p < 0.001) were associated with decreased ED discharge, while idiopathic AP had increased ED discharge (OR: 7.8; p < 0.001).

CONCLUSIONS

After appropriate triage, patients with mild AP (age <50, CCI <2, idiopathic AP) can safely discharge from the ED with improved outcomes and cost savings.

Efficacy and safety of early enteral and intravenous fluid resuscitation in severe acute pancreatitis: a systematic review and meta-analysis

OBJECTIVE

To compare the efficacy and safety of enteral fluid resuscitation (via nasointestinal tube or colorectal tube) and intravenous fluid resuscitation (via intravenous route) in the early treatment of severe acute pancreatitis.

METHODS

In this study, 8 electronic databases (PubMed, Web of Science, Embase, Cochrane Library, Scopus, China HowNet database, Wanfang database, and VIP database) were searched to collect clinical studies from inception to June 12, 2022. After the quality evaluation and data extraction of the included studies, the RevMan 5.3 software was used for analysis.

RESULTS

A total of seven studies including 580 patients were studied in this meta-analysis, in which 291 cases were treated with enteral fluid resuscitation and 289 cases were treated with intravenous fluid resuscitation. Compared with the intravenous route group, the enteral route resuscitation group reduced the incidence of new organ failure (OR = 0.23, 95% CI: 0.12-0.43, P < 0.00001), the incidence of persistent organ failure (OR = 0.38, 95% CI: 0.22-0.64, P = 0.0003), the incidence of mechanical ventilation (OR = 0.15, 95% CI: 0.03-0.69, P = 0.01), the incidence of ICU care (OR = 0.49, 95% CI: 0.27-0.88, P = 0.02), and the incidence of pancreatic infection (OR = 0.38, 95% CI: 0.17-0.83, P = 0.02). There were no statistically significant differences in mortality (OR = 0.77, 95% CI: 0.35-1.66, P = 0.50), surgical intervention rate (OR = 0.47, 95% CI: 0.19-1.18, P = 0.11), and incidence of localized ascites (OR = 0.65, 95% CI: 0.25-1.73, P = 0.39).

CONCLUSION

Early enteral fluid resuscitation is safe and effective for in severe pancreatitis. But this conclusion needs to be verified by more additional multi-centre randomized controlled trials with large samples.

Effect of Aggressive Intravenous Fluid Resuscitation Versus Nonaggressive Fluid Resuscitation in the Treatment of Acute Pancreatitis: A Systematic Review and Meta-Analysis

OBJECTIVES

Despite the need for active fluid therapy, fluid management of most acute pancreatitis (AP) cases is still supportive. The aim of this review is to compare the effect of aggressive versus nonaggressive intravenous (IV) fluid resuscitation in the treatment of acute pancreatitis.

METHODS

A systematic search of medical databases, such as Medline, Google Scholar, Science Direct, Cochrane Central, was conducted for publication until April 2022. We included randomized controlled trials or cohort (prospective and retrospective) studies reporting the outcomes of AP in patients that were managed with aggressive and nonaggressive IV fluid resuscitation. The primary outcome of interest was in-hospital mortality.

RESULTS

Fourteen trials involving 3423 acute pancreatitis patients were included in the review. We did not observe any differences in the risk of mortality, persistent organ failure, and systemic inflammatory response syndrome in both study groups. However, there was an increased risk of development of pancreatic necrosis, renal failure, and respiratory failure in the aggressive fluid therapy group compared with nonaggressive therapy. The funnel plot showed no publication bias.

CONCLUSIONS

Aggressive fluid therapy did not improve mortality rates in acute AP patients and was associated with an increased risk of acute renal failure, and respiratory failure.

[Influence of early surgery and endoscopic interventions on the risk of infection in patients with pancreatic necrosis]

OBJECTIVE

To prevent purulent-septic complications in patients with destructive pancreatitis.

MATERIAL AND METHODS

A cohort study included 488 patients with pancreatic necrosis: group 1 (n=331) - active surgical strategy, group 2 (n=157) - follow-up and therapy. We used binary logistic regression to predict purulent-septic complications.

RESULTS

Original model of independent variables significantly (p<0.001) revealed 5.3 times higher risk of infectious complications after laparotomy within the first week after hospitalization. Incidence of these events increased by 2.8 times in patients biliary pancreatitis compared to alcohol-alimentary pancreatitis. Complication rate was higher in older patients (by 2.1% for each year). Risk of purulent-septic complications decreased by 57.4% in women compared to men. There was no significant correlation between risk of infectious complications and endoscopic procedures. Specificity and sensitivity of the model was 74.2 and 72.6%, respectively.

CONCLUSION

Original model significantly predicts the risk of purulent-septic complications within the first week after hospitalization. Refusal of early active surgical strategy in these patients will significantly reduce the likelihood of purulent-septic complications.

Optimising fluid requirements after initial resuscitation: A pilot study evaluating mini-fluid challenge and passive leg raising test in patients with predicted severe acute pancreatitis

BACKGROUND

The goals and approaches to fluid therapy vary through different stages of resuscitation. This pilot study was designed to test the safety and feasibility of a fluid therapy protocol for the second or optimisation stage of resuscitation in patients with predicted severe acute pancreatitis (SAP).

METHODS

Spontaneously breathing patients with predicted SAP were admitted after initial resuscitation and studied over a 24-h period in a tertiary hospital ward. Objective clinical assessment (OCA; heart rate, mean arterial pressure, urine output, and haematocrit) was done at 0, 4, 8, 12, 18-20, and 24 h. All patients had mini-fluid challenge (MFC; 250 ml intravenous normal saline within 10 min) at 0 h and repeated at 4 and 8 h if OCA score ≥2. Patients who were fluid responsive (>10% change in stroke volume after MFC) received 5-10 ml/kg/h, otherwise 1-3 ml/kg/h until the next time point. Passive leg raising test (PLRT) was done at each time point and compared with OCA for assessing volume status and predicting fluid responsiveness.

RESULTS

This fluid therapy protocol based on OCA, MFC, and PLRT and designed for the second stage of resuscitation was safe and feasible in spontaneously breathing predicted SAP patients. The PLRT was superior to OCA (at 0 and 8 h) for predicting fluid responsiveness and guiding fluid therapy.

CONCLUSIONS

This pilot study found that a protocol for intravenous fluid therapy specifically for the second stage of resuscitation in patients with predicted SAP was safe, feasible, and warrants further investigation.

Intravenous fluid therapy in patients with severe acute pancreatitis admitted to the intensive care unit: a narrative review

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.

The emerging concept of fluid tolerance: A position paper

Fluid resuscitation is a core component of emergency and critical care medicine. While the focus of clinicians has largely been on detecting patients who would respond to fluid therapy, relatively little work has been done on assessing patients' tolerance to this therapy. In this article we seek to review the concept of fluid tolerance, propose a working definition, and introduce relevant clinical signals by which physicians can assess fluid tolerance, hopefully becoming a starting point for further research.

Aggressive intravenous hydration protocol of Lactated Ringer's solution benefits patients with mild acute pancreatitis: A meta-analysis of 5 randomized controlled trials

Objective

The aim of this meta-analysis was to determine the role of an aggressive intravenous hydration protocol of Lactated Ringer's solution in patients with mild acute pancreatitis (MAP).

Methods

A systematic search was conducted in PubMed, EMBASE, Cochrane Library, and China National Knowledge Infrastructure (CNKI) to identify randomized controlled trials (RCTs) published before August 19, 2022. The clinical outcomes were evaluated using the standard mean difference (SMD), mean difference (MD), risk ratio (RR), and 95% confidence interval (CI). The primary outcome was clinical improvement, while the secondary outcomes were the development of systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS), relief of epigastric abdominal pain, and length of hospital stay (LoH). Statistical analysis was performed with RevMan 5.4. Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) Working Group system was used to determine the quality of evidences.

Results

There were five RCTs with 370 MAP patients included, and the overall methodological quality was moderate. Aggressive hydration protocol was comparable to standard hydration protocol in terms of clinical improvement (RR = 1.33, 95%CI = 0.95-1.87, P = 0.10; very low evidence). Fewer events of SIRS (RR = 0.48, 95%CI = 0.31-0.72, P < 0.001; low evidence) and MODS (RR = 0.34, 95%CI = 0.13-0.91, P = 0.03; moderate evidence) were reported in patients receiving aggressive hydration protocol. Meanwhile, aggressive hydration protocol also significantly relieved epigastric abdominal pain (SMD = -0.53, 95%CI = -0.81 to -0.25, P < 0.001; low evidence) and shorten the LoH (MD = -2.36, 95%CI = -3.17 to -1.55, P < 0.001; low evidence) compared with standard hydration protocol.

Conclusion

For patients with MAP, aggressive hydration protocol may be more effective than standard hydration protocol at lowering SIRS and MODS rates, relieving epigastric abdominal pain, and shortening the LoH. Due to the small number of studies that are eligible and poor methodological quality of eligible studies, further studies are required to validate our findings.

Acadesine alleviates acute pancreatitis-related lung injury by mediating the barrier protective function of pulmonary microvascular endothelial cells

Severe acute pancreatitis (SAP) is a condition characterized by highly fatal acute inflammation and is usually associated with multiple organ dysfunction syndrome. Acute lung injury (ALI) is the most common complications of SAP, which is the accelerator of other organ dysfunction caused by SAP and the primary cause of early death due to SAP. Acadesine, an adenosine analog and an AMPK activator, has been discovered to modulate glucose and lipid metabolism, and inhibit the production of pro-inflammatory cytokines and iNOS. However, its role in SAP-ALI and its mechanism remains unclear and need to be explored. Herein, we discovered that acadesine mitigated the generation of reactive oxygen species (ROS) in human pulmonary microvascular endothelial cells (HPMECs), alleviated apoptosis and recovered barrier integrity, thereby contributing to anti-inflammatory effects in vitro and in vivo. Moreover, Nrf2 deficiency partially eliminated the effects of acadesine-induced antioxidant effects and thus weakened the protective effects on cells and Nrf2-knockout (Nrf2^-/-) mice. This study demonstrates that acadesine attenuated SAP-ALI associated inflammation and tissue damage by modulating the Nrf2-dependent antioxidant pathway by triggering AMPK. These findings are of great significance for the treatment of SAP-related lung injury.

Continuous Infusion of Fluid Hydration Over 24 Hours Does Not Prevent Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis

BACKGROUND

Aggressive intravenous fluid hydration, by administering 3500 mL of lactated Ringer's solution (LRS) in 9 h with a peri-procedural bolus, reduces post-ERCP pancreatitis (PEP) incidence. A concern of this strategy is adverse events related to volume overload; however, the impact of fluid hydration over an extended period without a bolus on PEP is unknown.

AIM

To assess the effect of continuous infusion of high-volume fluid at a constant rate over 24 h on PEP incidence and severity.

METHODS

Two-hundred patients were randomly assigned (1:1) to receive either 3600 mL of LRS in 24 h starting 2 h before the ERCP (high-volume group) or maintenance fluid hydration calculated by the Holliday-Segar method (control group).

RESULTS

The mean age of the patients was 50.6 ± 11.6 years. The predominant indications were choledocholithiasis (48%) and malignancies (32%). Patient demographics and PEP risk factors were similar in both groups. Patients in the high-volume group received significantly more fluid than the control group (3600 vs. 2413 ml, P < 0.001). PEP incidence was not different between the high-volume and the control group (14% vs. 15%; relative risk 0.93: 95% CI 0.48-1.83, P = 0.84). There were no differences in moderate to severe PEP (3% vs. 4%; relative risk 0.75: 95% CI, 0.17-3.27, P = 1.00). Subgroup analysis did not show a benefit in high-risk patients. Only one patient in the control group developed peripheral edema.

CONCLUSIONS

An infusion of high-volume hydration over 24 h is not sufficient to provide optimal hydration for PEP prevention.

CLINICAL TRIAL REGISTRY NUMBER

No. NCT02821546.

Interventional strategies in infected necrotizing pancreatitis: Indications, timing, and outcomes

Acute pancreatitis (AP) is one of the most common gastrointestinal diseases and remains a life-threatening condition. Although AP resolves to restitutio ad integrum in approximately 80% of patients, it can progress to necrotizing pancreatitis (NP). NP is associated with superinfection in a third of patients, leading to an increase in mortality rate of up to 40%. Accurate and early diagnosis of NP and associated complications, as well as state-of-the-art therapy are essential to improve patient prognoses. The emerging role of endoscopy and recent trials on multidisciplinary management of NP established the “step-up approach”. This approach starts with endoscopic interventions and can be escalated to other interventional and ultimately surgical procedures if required. Studies showed that this approach decreases the incidence of new multiple-organ failure as well as the risk of interventional complications. However, the optimal interventional sequence and timing of interventional procedures remain controversial. This review aims to summarize the indications, timing, and treatment outcomes for infected NP and to provide guidance on multidisciplinary decision-making.

Intra-Abdominal Hypertension: A Systemic Complication of Severe Acute Pancreatitis

Patients with severe acute pancreatitis (SAP) present complications and organ failure, which require treatment in critical care units. These extrapancreatic complications determine the clinical outcome of the disease. Intra-abdominal hypertension (IAH) deteriorates the prognosis of SAP. In this paper, relevant recent literature was reviewed, as well as the authors’ own experiences, concerning the clinical importance of IAH and its treatment in SAP. The principal observations confirmed that IAH is a frequent consequence of SAP but is practically absent in mild disease. Common manifestations of AP such as pain, abdominal distension, and paralytic ileus contribute to increased abdominal pressure, as well as fluid loss in third space and aggressive fluid replacement therapy. A severe increase in IAP can evolve to abdominal compartment syndrome and new onset organ failure. Conservative measures are useful, but invasive interventions are necessary in several cases. Percutaneous drainage of major collections is preferred when possible, but open decompressive laparotomy is the final possibility in some cases in order to definitively reduce abdominal pressure. Intra-abdominal pressure should be measured in all SAP cases that worsen despite adequate treatment in critical care units. Conservative measures must be introduced to treat IAH, including negative fluid balance, digestive decompression by gastric–rectal tube, and prokinetics, including neostigmine. In the case of insufficient responses to these measures, minimally invasive interventions should be preferred.

Guidelines for the management of patients with severe acute pancreatitis, 2021

OBJECTIVE

To provide guidelines for the management of the intensive care patient with severe acute pancreatitis.

DESIGN

A consensus committee of 22 experts was convened. A formal conflict-of-interest (COI) policy was developed at the beginning of the process and enforced throughout. The entire guideline construction process was conducted independently of any industrial funding (i.e. pharmaceutical, medical devices). The authors were required to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised.

METHODS

The most recent SFAR and SNFGE guidelines on the management of the patient with severe pancreatitis were published in 2001. The literature now is sufficient for an update. The committee studied 14 questions within 3 fields. Each question was formulated in a PICO (Patients Intervention Comparison Outcome) format and the relevant evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology.

RESULTS

The experts' synthesis work and their application of the GRADE® method resulted in 24 recommendations. Among the formalised recommendations, 8 have high levels of evidence (GRADE 1+/-) and 12 have moderate levels of evidence (GRADE 2+/-). For 4 recommendations, the GRADE method could not be applied, resulting in expert opinions. Four questions did not find any response in the literature. After one round of scoring, strong agreement was reached for all the recommendations.

CONCLUSIONS

There was strong agreement among experts for 24 recommendations to improve practices for the management of intensive care patients with severe acute pancreatitis.

Effect of aggressive versus conservative hydration for early phase of acute pancreatitis in adult patients: A meta-analysis of 3,127 cases

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Comparison of aggressive versus standard intravenous hydration for clinical improvement among patients with mild acute pancreatitis: A randomized controlled trial

BACKGROUND

Controversy remains regarding fluid management strategy, optimal volume and rate of intravenous fluid in mild acute pancreatitis. We performed a randomized controlled trial to compare clinical improvement and inflammatory markers between aggressive and standard fluid management.

METHODS

A single center prospective randomized controlled trial was conducted in a tertiary care hospital. We randomized patients with a diagnosis of mild acute pancreatitis using revised Atlanta classification in two groups, the aggressive (20 ml/kg bolus followed by 3 ml/kg/hr) and standard (10 ml/kg bolus followed by 1.5 ml/kg/hr) intravenous hydration with Lactated Ringer's solution. Primary outcome was clinical improvement at 24 and 36 hours.

RESULTS

The mean age of patients was 46 years and 34 patients (77%) were male. The average volumes of fluid during the first 24 hours in aggressive and standard groups was 4886 ml (71 ml/kg) and 3985 ml (53 ml/kg), respectively; p-value 0.002. Aggressive intravenous hydration did not significantly improve clinical outcome compared with standard intravenous hydration (45.45% vs. 31.82%, respectively; p-value 0.353). However, subgroup analysis between patients with obese and non-obese status, revealed aggressive intravenous hydration significantly improved clinical outcome within the first 24 hours in obese group.

CONCLUSION

Aggressive intravenous hydration with Lactated Ringer's solution did not improve clinical outcome in mild acute pancreatitis but showed statistically significant improvement only in patients with obese status. Future studies should include a larger sample size to confirm these findings.

Heparin-binding protein is significantly increased in acute pancreatitis

Background

Most patients with acute pancreatitis (AP) experience mild, self-limiting disease with little or no need for hospital care. However, 20–25% of patients develop a more severe and potentially life-threatening condition with progressive systemic inflammatory response syndrome (SIRS) and multiorgan failure, resulting in high morbidity and mortality rates. Predicting disease severity at an early stage is important, as immediate supportive care has been demonstrated to reduce the incidence of SIRS and organ failure, improving patient outcome. Several studies have demonstrated elevated levels of heparin-binding protein (HBP) in patients with sepsis and septic shock, and HBP is believed to play a part in endothelial dysfunction leading to vascular leakage. As HBP levels increase prior to other known biomarkers, HBP has emerged as a promising early predictor of severe sepsis with organ dysfunction.

Methods

Patients admitted to Skåne University Hospital in Malmö between 2010 and 2013 fulfilling the criteria for AP were identified in the emergency department and prospectively enrolled in this study. The primary outcome was measured levels of HBP upon hospital admission in patients with confirmed AP. Correlations among HBP concentrations, disease severity and fluid balance were considered secondary endpoints. The correlation between HBP levels and fluid balance were analysed using Pearson correlation, and the ability of HBP to predict moderately severe/severe AP was assessed using a receiver operating characteristic (ROC) curve.

Results

The overall median HBP level in this study was 529 (307–898) ng/ml. There were no significant group differences in HBP levels based on AP severity. Fluid balance differed significantly between patients with mild versus moderately severe and severe pancreatitis, but we found no correlation between HBP concentration and fluid balance.

Conclusions

HBP levels are dramatically increased in patients with AP, and these levels far exceed those previously reported in other conditions. In this study, we did not observe any significant correlation between HBP levels and disease severity or the need for intravenous fluid. Additional studies on HBP are needed to further explore the role of HBP in the pathogenesis of AP and its possible clinical implications.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-021-01910-6.

An investigation on the association between sodium glucose co-transporter 2 inhibitors use and acute pancreatitis: A VigiBase study

PURPOSE

To characterize acute pancreatitis (AP) related to sodium glucose co-transporter 2 inhibitors and to investigate this relationship through disproportionality analysis in an international pharmacovigilance database.

METHODS

We analyzed all AP reports for canagliflozin, dapagliflozin and/or empagliflozin from the WHOs Global adverse drug reactions database VigiBase® up to July 2019. We characterized the patients, reporters, and reactions, and we present the proportional reporting ratio (PRR) and information component (IC) for each of the gliflozins. AP cases were reports containing at least one of 11 previously selected preferred terms. Gliflozin exposure was considered for all reports with at least one gliflozin as suspected/ interacting drug.

RESULTS

Of the 19 834 180 individual case safety reports in VigiBase, in 600 reports containing 618 AP group reactions, gliflozins were suspected/ interacting drugs. Men were affected in 52.3% of the cases and 59.6% of the patients were in the 45-64 years age group. The reporters were in 417 cases healthcare professionals. Most of the reactions were reported for canagliflozin (59.7%), followed by empagliflozin (21%) and dapagliflozin (19.2%) and were serious (98.6%). Most of the reactions' outcomes (84% of the patients) were favorable. Ketoacidosis was frequently associated with the AP (21.3%). Significant PRR and IC were found for pancreatitis and pancreatitis acute for all three gliflozins, pancreatitis necrotizing for canagliflozin and empagliflozin and pancreatitis relapsing for empagliflozin.

CONCLUSIONS

Most of the AP cases were serious and with favorable outcome. We identified possible alternative causes for AP, like concomitant medication, hypertriglyceridemia, and cholelithiasis and a frequent association with ketoacidosis. We found a significant association between AP and the use of canagliflozin, dapagliflozin, and empagliflozin that would need further investigation.

The impact of fluid resuscitation via colon on patients with severe acute pancreatitis

Severe acute pancreatitis (SAP) is a life-threatening disease. Fluid Resuscitation Via Colon (FRVC) may be a complementary therapy for early controlled fluid resuscitation. But its clinical application has not been reported. This study aims to explore the impact of FRVC on SAP. All SAP patients with the first onset within 72 h admitted to the hospital were included from January 2014 to December 2018 through electronic databases of Ruijin hospital and were divided into FRVC group (n = 103) and non-FRVC group (n = 78). The clinical differences before and after the therapy between the two groups were analyzed. Of the 181 patients included in the analysis, the FRVC group received more fluid volume and reached the endpoint of blood volume expansion ahead of the non-FRVC group. After the early fluid resuscitation, the inflammation indicators in the FRVC group were lower. The rate of mechanical ventilation and the incidence of hypernatremia also decreased significantly. Using pure water for FRVC was more helpful to reduce hypernatremia. However, Kaplan–Meier 90-day survival between the two groups showed no difference. These results suggest that the combination of FRVC might benefit SAP patients in the early stage of fluid resuscitation, but there is no difference between the prognosis of SAP patients and that of conventional fluid resuscitation. Further prospective study is needed to evaluate the effect of FRVC on SAP patients.

Early Changes in Blood Urea Nitrogen (BUN) Can Predict Mortality in Acute Pancreatitis: Comparative Study between BISAP Score, APACHE-II, and Other Laboratory Markers-A Prospective Observational Study

BACKGROUND

Changes in BUN have been proposed as a risk factor for complications in acute pancreatitis (AP). Our study aimed to compare changes in BUN versus the Bedside Index for Severity in Acute Pancreatitis (BISAP) score and the Acute Physiology and Chronic Health Evaluation-II score (APACHE-II), as well as other laboratory tests such as haematocrit and its variations over 24 h and C-reactive protein, in order to determine the most accurate test for predicting mortality and severity outcomes in AP.

METHODS

Clinical data of 410 AP patients, prospectively enrolled for study at our institution, were analyzed. We define AP according to Atlanta classification (AC) 2012. The laboratory test's predictive accuracy was measured using area-under-the-curve receiver-operating characteristics (AUC) analysis and sensitivity and specificity tests.

RESULTS

Rise in BUN was the only score related to mortality on the multivariate analysis (p=0.000, OR: 12.7; CI 95%: 4.2-16.6). On the comparative analysis of AUC, the rise in BUN was an accurate test in predicting mortality (AUC: 0.842) and persisting multiorgan failure (AUC: 0.828), similar to the BISAP score (AUC: 0.836 and 0.850) and APACHE-II (AUC: 0.756 and 0.741). The BISAP score outperformed both APACHE-II and rise in BUN at 24 hours in predicting severe AP (AUC: 0.873 vs. 0.761 and 0.756, respectively).

CONCLUSION

Rise in BUN at 24 hours is a quick and reliable test in predicting mortality and persisting multiorgan failure in AP patients.

[Acute kidney injury following acute pancreatitis (AP-AKI): Definition, Pathophysiology, Diagnosis and Therapy]

Acute pancreatitis (AP) is the most frequent gastrointestinal cause for hospitalization and one of the leading causes of in-hospital deaths. Severe acute pancreatitis is often associated with multiorgan failure and especially with acute kidney injury (AKI). AKI can develop early or late in the course of the disease and is a strong determinator of outcome. The mortality in the case of dialysis-dependent AKI and acute pancreatitis raises exponentially in the affected patients. AP-induced AKI (AP-AKI) shows many similarities but also distinct differences to other causes of AKI occurring in the intensive care unit setting. The knowledge of the exact pathophysiology can help to adjust, control and improve therapeutic approaches to the disease. Unfortunately, there are only a few studies dealing with AP and AKI.In this review, we discuss recent data about pathogenesis, causes and management of AP-AKI in patients with severe acute pancreatitis and exploit in this regard the diagnostic and prognostic potential of respective newer serum and urine markers.