Cleveland Clinic Journal of MedicineWhat Fluids Should I Order for my Patient with Acute Pancreatitis?

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Recent research is refining the approach to fluid management in acute pancreatitis, challenging long-held beliefs about aggressive hydration. A landmark trial and observational study provide new insights into optimal fluid volume and type, potentially improving patient outcomes in this common and costly condition. These findings offer clinicians updated guidance for managing acute pancreatitis, emphasizing a more measured approach to fluid resuscitation.

Key Points:

• Moderate fluid resuscitation (10 mL/kg bolus if clinically hypovolemic, followed by 1.5 mL/kg/hour maintenance) is associated with fewer adverse events compared to aggressive resuscitation in acute pancreatitis.
• The WATERFALL trial demonstrated that aggressive fluid resuscitation led to a higher incidence of fluid overload (20.5% vs 6.3%) compared to moderate resuscitation, with no significant difference in overall health outcomes.
• Lactated Ringer’s solution may be superior to normal saline in acute pancreatitis management, potentially due to better pH homeostasis and reduced risk of hyperchloremic metabolic acidosis.
• An observational study found that lactated Ringer’s administration within the first 24 hours was associated with reduced odds of developing moderately severe or severe acute pancreatitis (adjusted odds ratio 0.52, P = .014).
• Caution is advised when applying these findings to patients with heart failure, cirrhosis, chronic renal failure, or those with moderately severe to severe acute pancreatitis, as they were excluded from the WATERFALL trial.
• Biomarkers such as blood urea nitrogen, creatinine, and hematocrit can be used as surrogate markers of successful hydration, especially within the first 48 hours of treatment.
• The cornerstone of acute pancreatitis treatment remains early fluid resuscitation, analgesia, and nutritional support.

HCN Medical Memo
The shift towards moderate fluid resuscitation and the potential benefits of lactated Ringer’s solution in acute pancreatitis management represent significant changes in clinical practice. Although these findings are promising, clinicians should consider individual patient factors and severity of pancreatitis when applying these strategies, always balancing the risks of under-resuscitation against those of fluid overload.

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