Fluid resuscitation in acute pancreatitis

Table 1 Recommendations in various reviews for fluid resuscitation in acute pancreatitis

Ref.	Type	Conclusion
Tenner et al[7], 2004	Review	250-500 mL/h or more for 48 h
Whitcomb et al[79], 2006	Review	Fluid bolus: maintain hemodynamicsLater: 250-500 mL/h
Otsuki et al[91], 2006	Review	60-160 mL/kg per day1/3 to 1/2 to be given in 6 h
Forsmark et al[96], 2007	Review	Use crystalloids first,Use colloids if hematocrit < 25% or albumin < 2 g/dL
Pandol et al[78], 2007	Review	Severe volume depletion: 500-1000 mL/h; reduce later
Nasr et al[8], 2011	Review	20 mL/kg (1-2 L) in emergency; 150-300 mL/h (3 mL/kg per hour) for 24 h
Trikudanathan et al[49], 2012	Review	Aggressive fluid resuscitation in patients with AP needs to be initiated with therapeutic intent
Haydock et al[49], 2013	Review	Lack of quality evidence to guide most basic aspects of FT providing the equipoise necessary for further RCTs
Wu et al[31], 2013	Review	Institutional protocols must be developed to help ensure adequate fluid resuscitation, particularly in initial 24 h

AP: Acute pancreatitis; FT: Fluid therapy; RCT: Randomized controlled trial.

Table 2 Summary of available studies to date on controlled fluid therapy

Ref.	Year	Type of study (sample size)	Conclusion
Mao et al[16]	2010	RCT (n = 155)	Rapid hemodilution increases incidence of sepsis within 28 d and in-hospital mortality. Hematocrit should be maintained between 30% and 40% in acute response stage
Mao et al[17]	2009	RCT (n = 76)	Controlled fluid resuscitation offers better prognosis in patients with severe volume deficit within72 h of severe acute pancreatitis onset
Eckerwall et al[15]	2006	Retrospective cohort (n = 99)	Patients receiving 4000 mL or more of fluid in first 24 h developed more respiratory complications
Madaria et al[14]	2011	Retrospective cohort (n = 247)	Administration of > 4.1 L but not < 3.1 L was significantly associated with more local and systemic complications
Kuwabara et al[75]	2011	Retrospective (n = 9489)	Fluid volume during first 48 h was higher in patients requiring ventilation and higher mortality in acute pancreatitis

RCT: Randomized controlled trial.

Table 3 Authors’ recommendations for fluid replacement in predicted severe or severe acute pancreatitis

Parameter	Recommendation
Fluid resuscitation	Necessary: the earlier the resuscitation, the better the outcome
Type of fluid	Colloids and/or crystalloids: Among crystalloids, lactate Ringer’s better than normal salineUse colloids especially when albumin < 2.0 g/dL or hematocrit < 35%
Amount of fluid	Total fluid in first 24 h: between 3 and 4 L, Not to exceed 4 L
Rate of infusion	Initial bolus 1000 mL over one hour followed by 3 mL/kg per hour (200 mL/h) for 24-48 h
Monitoring	Urine output > 0.5 mL/kg/h, hematocrit = 25% to 35%, drop in BUNCVP: Not good for monitoring due to third space loss and hypoalbuminemia
Duration of resuscitation	24-48 h, until signs of volume depletion disappear

BUN: Blood urea nitrogen; CVP: Central venous pressure.