New tools for optimizing fluid resuscitation in acute pancreatitis

Role of the SARS‑COV2 infection in the evolution of acute pancreatitis (Review)

Acute pancreatitis is characterized as an inflammatory illness that is life-threatening and causes necrosis as well as simple edema when pancreatic enzymes are activated intraglandularly. It is not known whether severe acute respiratory syndrome coronavirus 2 causes acute pancreatitis. Patients with acute pancreatitis who test positive for coronavirus disease 2019 (COVID-19) frequently have biliary or alcoholic causes. It is unclear how common acute pancreatitis is in patients with COVID-19. By contrast with patients without COVID-19, however, COVID-19-positive patients with acute pancreatitis have a higher mortality as well as a higher risk of necrosis and admission to an intensive care unit. The most common cause of mortality in COVID-19-positive individuals with concurrent severe pancreatitis is acute respiratory distress syndrome. The present study discussed research on the link between COVID-19 infection and acute pancreatitis.

Severe Acute Pancreatitis Treated with Negative Pressure Wound Therapy System: Influence of Laboratory Markers

(1) Background: An open abdomen is a serious medical condition that requires prompt and effective treatment to prevent complications and improve patient outcomes. Negative pressure therapy (NPT) has emerged as a viable therapeutic option for temporary closure of the abdomen, offering several benefits over traditional methods. (2) Methods: We included 15 patients with pancreatitis who were hospitalized in the I-II Surgery Clinic of the Emergency County Hospital "St. Spiridon" from Iasi, Romania, between 2011-2018 and received NPT. (3) Results: Preoperatively, the mean IAP level was 28.62 mmHg, decreasing significantly postoperatively to 21.31 mmHg. The mean level of the highest IAP value recorded in pancreatitis patients treated with VAC did not differ significantly by lethality (30.31 vs. 28.50; p = 0.810). In vacuum-treated pancreatitis patients with a IAP level > 12, the probability of survival dropped below 50% during the first 7 days of stay in the ICU, so that after 20 days the probability of survival was approximately 20%. IAP enters the determinism of surgery with a sensitivity of 92.3% and a specificity of 99%, the cut-off value of IAP being 15 mmHg. (4) Conclusions: The timing of surgical decompression in abdominal compartment syndrome is very important. Consequently, it is vital to identify a parameter, easy to measure, within the reach of any clinician, so that the indication for surgical intervention can be made judiciously and without delay.

Update on the strategy for intravenous fluid treatment in acute pancreatitis

Fluid therapy/resuscitation is mandatory in acute pancreatitis due to the pathophysiology of fluid loss as a consequence of the inflammatory process. For many years, without clear evidence, early and aggressive fluid resuscitation with crystalloid solutions (normal saline solution or Ringer lactate solution) was recommended. Recently, many randomized control trials and meta-analyses on fluid therapy have revealed that high fluid rate infusion is associated with increased mortality and severe adverse events compared to those resulting from moderate fluid rates, and this has triggered a paradigm shift in fluid management strategies. Meanwhile, there is evidence to show that Ringer lactate solution is superior to normal saline solutions in this context. The purpose of this review is to provide an update on the strategies for intravenous fluid treatment in acute pancreatitis, including the type, optimal amount, rate of infusion, and monitoring guides. Recommendations from recent guidelines are critically evaluated for this review in order to reach the authors' recommendations based on the available evidence.

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.

SARS-CoV-2 and the pancreas: What do we know about acute pancreatitis in COVID-19 positive patients?

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can cause pancreatic damage, both directly to the pancreas via angiotensin-converting enzyme 2 receptors (the transmembrane proteins required for SARS-CoV-2 entry, which are highly expressed by pancreatic cells) and indirectly through locoregional vasculitis and thrombosis. Despite that, there is no clear evidence that SARS-CoV-2 is an etiological agent of acute pancreatitis. Acute pancreatitis in coronavirus disease 2019 (COVID-19) positive patients often recognizes biliary or alcoholic etiology. The prevalence of acute pancreatitis in COVID-19 positive patients is not exactly known. However, COVID-19 positive patients with acute pancreatitis have a higher mortality and an increased risk of intensive care unit admission and necrosis compared to COVID-19 negative patients. Acute respiratory distress syndrome is the most frequent cause of death in COVID-19 positive patients and concomitant acute pancreatitis. In this article, we reported recent evidence on the correlation between COVID-19 infection and acute pancreatitis.

Ward based goal directed fluid therapy (GDFT) in acute pancreatitis (GAP) trial: A feasibility randomised controlled trial

BACKGROUND

Goal-directed fluid therapy (GDFT) reduces complications in patients undergoing major general surgery. There are no reports of cardiac output evaluation being used to optimise the fluid administration for patients with acute pancreatitis (AP) in a general surgery ward.

METHOD

50 patients with AP were randomised to either ward-based GDFT (n = 25) with intravenous (IV) fluids administered based on stroke volume optimisation protocol or standard care (SC) (n = 25), but with blinded cardiac output evaluation, for 48-h following hospital admission. Primary outcome was feasibility.

RESULTS

50 of 116 eligible patients (43.1%) were recruited over 20 months demonstrating feasibility. 36 (72%) completed the 48-h of GDFT; 10 (20%) discharged within 48-h and 4 withdrawals (3 GDFT, 1 SC). Baseline characteristics were similar with only 3 participants having severe disease (6%, 1 GDFT, 2 SC). Similar volumes of IV fluids were administered in both groups (GDFT 5465 (1839) ml, SC 5211 (1745) ml). GDFT group had a lower heart rate, blood pressure and respiratory rate and improved oxygen saturations. GDFT was not associated with any harms. There was no evidence of difference in complications of AP (GDFT 24%, SC 32%) or in the duration of stay in intensive care (GDFT 0 (0), SC 0.7 [(Van DIjk et al., 2017) 33 days). Length of hospital stay was 5 (2.9) days in GDFT and 6.3 (7.6) in SC groups.

CONCLUSION

Ward-based GDFT is feasible and shows a signal of possible efficacy in AP in this early-stage study. A larger multi-site RCT is required to confirm clinical and cost effectiveness.

Does the Implementation of a Clinical Care Pathway Have an Impact on Early Intravenous Fluid Therapy of Acute Pancreatitis?: A Pilot Quality Improvement Study

OBJECTIVES

Early intravenous fluid (IVF) resuscitation is crucial in the management of acute pancreatitis; variation in IVF prescription practice had been demonstrated. This pilot study aims to assess whether the implementation of an Acute Pancreatitis Care Pathway (APCP) produces a change toward a more adequate IVF regimen in the first 24 hours.

METHODS

Patients with confirmed diagnosis of acute pancreatitis, from July 2015 to February 2016 (group 1) and from September 2017 to March 2018 (group 2), were considered. The APCP was developed between March 2016 and August 2017. Median IVF rate, volume, and type infused in the first 24 hours, were compared between groups. Nonparametric data were analyzed with the Mann-Whitney U test, differences in frequencies with the McNemar test; significance was set at P < 0.05.

RESULTS

Seventy-two patients were included, 36 in each group. In the first 24 hours, the median IVF rate was 177 mL/h vs 225 mL/h (P = 0.004); Ringer lactate infusion was 30% vs 77.8% (P = 0.0003). The median total IVF volume did not differ between groups.

CONCLUSIONS

The implementation of the APCP has the potential to lead to a successful change in early IVF resuscitation practice.

Ward-based Goal-Directed Fluid Therapy (GDFT) in Acute Pancreatitis (GAP) trial: study protocol for a feasibility randomised controlled trial

INTRODUCTION

Acute pancreatitis is an inflammatory disease of the pancreas with high risk of developing multiorgan failure and death. There are no effective pharmacological interventions used in current clinical practice. Maintaining fluid and electrolyte balance is the mainstay of supportive management. Goal-directed fluid therapy (GDFT) has been shown to decrease morbidity and mortality in surgical conditions with systemic inflammatory response. There is currently no randomised controlled trial (RCT) investigating the role of GDFT based on cardiac output parameters in patients with acute pancreatitis in the ward setting. A feasibility trial was designed to determine patient and clinician support for recruitment into an RCT of ward-based GDFT in acute pancreatitis, adherence to a GDFT protocol, safety, participant withdrawal, and to determine appropriate endpoints for a subsequent larger trial to evaluate efficacy.

METHODS AND ANALYSIS

The GDFT in Acute Pancreatitis trial is a prospective two-centre feasibility RCT. Eligible adults admitted with new onset of acute pancreatitis will be enrolled and randomised into ward-based GDFT (n=25) or standard fluid therapy (n=25) within 6 hours from the diagnosis and continuing for the following 48 hours. Cardiac output parameters will be monitored with a non-invasive device (Cheetah NICOM; Cheetah Medical). The intervention group will consist of a protocolised GDFT approach consisting of stroke volume optimisation with crystalloid fluid boluses, while the control group will receive standard care fluid therapy as advised by the clinical team. The primary endpoint is feasibility. Secondary endpoints will include safety of the intervention, complications, mortality, admission to intensive care unit, cost and quality of life.

ETHICS AND DISSEMINATION

Ethics approval was granted by the London Central Research Ethics Committee (17/LO/1235, project ID: 221872). The results of this trial will be presented to international conference with interest in general surgery and acute care and published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

ISRCTN36077283.

Thoracic complications of pancreatitis

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.

Early management of acute pancreatitis: A review of the best evidence

In the 20th century early management of acute pancreatitis often included surgical intervention, despite overwhelming mortality. The emergence of high-quality evidence (randomized controlled trials and meta-analyses) over the past two decades has notably shifted the treatment paradigm towards predominantly non-surgical management early in the course of acute pancreatitis. The present evidence-based review focuses on contemporary aspects of early management (which include analgesia, fluid resuscitation, antibiotics, nutrition, and endoscopic retrograde cholangiopancreatography) with a view to providing clear and succinct guidelines on early management of patients with acute pancreatitis in 2017 and beyond.

Beneficial effects of fluid resuscitation via the rectum on hemodynamic disorders and multiple organ injuries in an experimental severe acute pancreatitis model

OBJECTIVES

Exaggerated hydration is harmful for patients with severe acute pancreatitis (SAP), and it can increase mortality rate. In this study, we investigated the role of fluid resuscitation via the rectum (FRVR) on the hemodynamic state and compared FRVR with intravenous fluid resuscitation (IVFR) on resuscitation effect and organ function in an early stage of SAP.

METHODS

We studied whether FRVR corrects hemodynamic disorders at an early stage of SAP in Spraque-Dawley (SD) rats and whether it mitigates organ dysfunction and whether FRVR is superior to IVFR.

RESULTS

In both IVFR and FRVR groups, we observed a rebound in the mean arterial pressure (MAP) after 5 h and 6 h of administration (p < 0.05), respectively. MAP of the FRVR group reached the same level as the SHAM group at the end of the treatment, with hematocrit declining compared with the non-fluid resuscitation (NFR) group (p < 0.05). A concomitant increase in abdominal ascites and the lung wet/dry ratio by IVFR was depressed in the FRVR group (p < 0.05). Liver function was ameliorated in both fluid resuscitation groups (p < 0.05), consistent with histopathological improvement. TNF-α in serum and MPO in the lungs and jejunum of the FRVR group were lower than the IVFR group (p < 0.05). Pancreas histopathological injuries were ameliorated by both IVFR and FRVR (p < 0.05).

CONCLUSIONS

Our findings suggested FRVR is a potential supplementary method for fluid management in an early stage of SAP and FRVR should be studied further.