Dr. Houston
Clinical question: Does early, aggressive, fluid resuscitation improve clinical outcomes in acute pancreatitis when compared to moderate fluid resuscitation?
Background: Studies comparing different volumes of intravenous fluid resuscitation in acute pancreatitis have provided conflicting results.
Study design: Multicenter, open-label, randomized, controlled trial, including patients with mild-moderate acute pancreatitis based on the Revised Atlanta Classification
Setting: 18 centers across four countries (India, Italy, Mexico, and Spain)
Synopsis: Of 249 total patients with mild to moderate acute pancreatitis, 122 received aggressive resuscitation (20 mL/kg bolus of lactated Ringer’s over two hours followed by 3mL/kg/hr) while 127 received moderate resuscitation (1.5 mL/kg/hr lactated Ringer’s, with 10 mL/kg bolus over first two hours if hypovolemic).
No significant difference in the development of moderately severe or severe acute pancreatitis during hospitalization (22.1% in the aggressive group versus 17.3% in the moderate group, adjusted relative risk, 1.30; 95% CI, 0.78 to 2.18; P=0.32). Fluid overload occurred more often with aggressive resuscitation (20.5% versus 6.3%, adjusted relative risk, 2.85; 95% CI, 1.36 to 5.94; P=0.004). The aggressive-resuscitation group received a median of 7.98 L during the first 48 hours, compared to 5.5 L.
Of note, the majority of the patients were diagnosed with biliary pancreatitis and had less than two of the four SIRS criteria. Patients were also reevaluated at 12, 24, 48, and 72 hours and fluids were adjusted as needed. Some of the many exclusion criteria included hyponatremia, hypercalcemia, chronic renal failure, decompensated cirrhosis, and heart failure (NYHA class II or greater).
Bottom line: Early aggressive fluid resuscitation in mild-moderate acute pancreatitis resulted in a higher incidence of fluid overload without improvement in clinical outcomes when compared to moderate resuscitation.
Citation: de-Madaria E, et al. Aggressive or moderate fluid resuscitation in acute pancreatitis. N Engl J Med. 2022;387(11):989-1000.
Dr. Houston is an internal medicine resident at Virginia Commonwealth University in Richmond, Va.