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Templeton K, Chan Yuen J, Lenz C, Mann AR, Friedler HS, Yim R, Alfieri M, Starmer AJ, Grover AS. Quality Improvement Initiative to Improve Timing of Enteral Feeds in Pediatric Acute Pancreatitis. Pediatrics 2023; 151:190371. [PMID: 36587014 DOI: 10.1542/peds.2022-056700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/14/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Acute pancreatitis (AP) represents a significant disease burden in the pediatric population. The management of AP includes fluid resuscitation, pain management, and early enteral feeds. Contrary to old dogma, early enteral feeding has been shown to improve outcomes and reduce hospital length of stay (LOS), yet uptake of this approach has not been standardized. Our aim was to standardize the management of AP, increasing the percentage of patients receiving early enteral nutrition from 40% to 65% within 12 months. METHODS Between January 2013 and September 2021, we conducted a quality improvement initiative among patients hospitalized with AP. Interventions included the development of a clinical care pathway, integration of an AP order set, and physician education. Our primary outcome was the percentage of patients receiving enteral nutrition within 48 hours of admission, and our secondary outcome was hospital LOS. Balancing measures included hospital readmission rates. RESULTS A total of 652 patients were admitted for AP during the project, of which 322 (49%) were included after pathway implementation. Before pathway development, the percentage of patients receiving early enteral nutrition was 40%, which increased significantly to 84% after our interventions. This improvement remained stable. Median LOS decreased significantly from 5.5 to 4 days during this timeframe. Our balancing measure of readmission rates did not change during the project period. CONCLUSIONS Through multiple interventions, including the implementation of an AP clinical pathway, we significantly increased the proportion of patients receiving early enteral nutrition and decreased hospital LOS without increasing hospital readmission rates.
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Affiliation(s)
- Kate Templeton
- Department of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts.,Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Jenny Chan Yuen
- Department of Pediatrics Quality Program, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Caitlin Lenz
- Department of Pediatrics Quality Program, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Alison R Mann
- Department of Pediatrics Quality Program, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Haley S Friedler
- Department of Pediatrics Quality Program, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ramy Yim
- Department of Pediatrics Quality Program, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Maria Alfieri
- Department of Pediatrics Quality Program, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Amy J Starmer
- Harvard Medical School, Harvard University, Boston, Massachusetts.,Department of Pediatrics Quality Program, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Amit S Grover
- Department of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts.,Harvard Medical School, Harvard University, Boston, Massachusetts
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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: 0] [Impact Index Per Article: 0] [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.
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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.
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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.
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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
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