Fluid Management in Acute Pancreatitis

Publish date: June 5, 2024

Acute pancreatitis is marked by inflammation of the pancreas, potentially leading to organ failure and pancreatic necrosis. Early management relies heavily on intravenous (IV) fluid resuscitation. Initiating fluid resuscitation at an early stage can enhance pancreatic perfusion and maintain adequate systemic circulation, reducing the risk of pancreatic necrosis, hypovolemic shock, and organ failure.¹

Recently, a series of randomized controlled trials have provided a clearer understanding of the type and rate of fluid administration that is the most beneficial for patients with acute pancreatitis.^2-4 The approach to managing fluids in cases of acute pancreatitis may vary depending on the severity of the condition and individual patient factors. Fluids should be prescribed considering their composition (type of fluid), dosing (rate of administration), goals, potential risks, and contraindications.^2,3 Close monitoring and assessment are essential components of effective fluid management of acute pancreatitis.²

WATERFALL was a recent multinational, open-label, randomized controlled trial comparing early weight-based aggressive vs nonaggressive fluid resuscitation in patients with acute pancreatitis. This landmark study has helped clarify the question of the optimal rate of fluid administration in acute pancreatitis.
The study was terminated after first interim analysis of 249 patients. There was no significant dierence in incidence in moderately severe (MS) or severe acute (SA) pancreatitis by fluid rate.
However, fluid overload was 2.85x greater with an aggressive vs moderate rate of resuscitation.
RCT, randomized controlled trial
CI, confidence interval; LR, lacated ringer; NS, normal saline; RR, risk ratio

References

Tenner S, Baillie J, DeWitt J, Vege SS; American College of Gastroenterology. American College of Gastroenterology guideline: management of acute pancreatitis [published correction appears in Am J Gastroenterol. 2014;109(2):302]. Am J Gastroenterol. 2013;108(9):1400-1415. doi:10.1038/ajg.2013.218

de-Madaria E, Buxbaum JL, Maisonneuve P, et al. Aggressive or moderate fluid resuscitation in acute pancreatitis. N Engl J Med. 2022;387(11):989-1000. doi:10.1056/NEJMoa2202884

Zhao G, Zhang JG, Wu HS, et al. Effects of different resuscitation fluid on severe acute pancreatitis. World J Gastroenterol. 2013;19(13):2044-2052. doi:10.3748/wjg.v19.i13.2044

Guzmán-Calderón E, Diaz-Arocutipa C, Monge E. Lactate Ringer's versus normal saline in the management of acute pancreatitis: a systematic review and meta-analysis of randomized controlled trials. Dig Dis Sci. 2022;67(8):4131-4139. doi:10.1007/s10620-021-07269-8

Hoste EA, Maitland K, Brudney CS, et al; ADQI XII Investigators Group. Four phases of intravenous fluid therapy: a conceptual model. Br J Anaesth. 2014;113(5):740-747. doi:10.1093/bja/aeu300

Working Group IAP/APA Acute Pancreatitis Guidelines. IAP/APA evidence-based guidelines for the management of acute pancreatitis. Pancreatology. 2013;13(4 suppl 2):e1-e15. doi:10.1016/j.pan.2013.07.063

Machicado JD, Papachristou GI. Pharmacologic management and prevention of acute pancreatitis. Curr Opin Gastroenterol. 2019;35(5):460-467. doi:10.1097/MOG.0000000000000563

May 2024 – ICYMI

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Fluid Management in Acute Pancreatitis

References

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