Early Aggressive Hydration Hastens Clinical Improvement in Mild Acute Pancreatitis
Early Aggressive Hydration Hastens Clinical Improvement in Mild Acute Pancreatitis. Buxbaum, Quezada Michael et. al. American Journal of Gastroenterology 2017; 112:797
Pancreatitis is one of the leading causes of hospitalization due to gastrointestinal disease in the USA. There are no pharmacological agents that have been shown to impact the course of acute pancreatitis and treatment is mainly supportive. Fluid resuscitation is recommended for pancreatitis based on animal models. It is important to note that increased hematocrit (Hct), blood urea nitrogen (BUN) and creatinine levels (Cr) are utilized to guide fluid resuscitation in acute pancreatitis as they are markers of perfusion and correlate with the severity of pancreatitis. There are many conflicting reports/studies on the benefits of fluid resuscitation for acute pancreatitis. Some reports show improvement while others show harm with aggressive hydration and there are few randomized control trials.
The primary aim of this study was to compare aggressive intravenous hydration with standard hydration for the management of acute pancreatitis in a randomized control trial.
Randomized control trial in which eligible patients presenting with acute pancreatitis were randomized within 4hrs. of diagnosis to the aggressive vs. standard hydration arm. The overall exclusion criteria included patients with SIRS, clinical signs of pulmonary edema, end-organ damage, and congestive heart failure. After randomization, patients in the aggressive fluid arm received a 20cc/kg bolus followed by a 3cc/kg/hr. fluid regimen vs. a 10cc/kg/hr. followed by a 1.5cc/kg/hr. fluid regimen in the standard fluid arm. Of note lactated ringers (LR) was utilized as the fluid of choice based on prior studies showing improvement of SIRS in pancreatitis with LR. Patients were assessed at 12-hr intervals where BUN, Cr and Hct were assessed. At each interval, in both groups, if Hct, BUN or Cr was increased a bolus of 20cc/kg followed by 3cc/kg/hr. was given; if labs were decreased and epigastric pain was decreased (measured on a 0-10 scale), hydration was then given at 1.5cc/kg/h and a clear liquid diet was started.
The primary endpoint was clinical improvement within 36hrs, which required a composite outcome of decreased Hct, BUN, Cr and epigastric pain as well as tolerance of oral nutrition.
The secondary outcomes included rate of clinical improvement over the entire hospitalization, development of SIRS, development of severe pancreatitis and volume overload.
A total of 198 patient were enrolled in the study with a n=60 randomized to each treatment arm after exclusion/inclusion criteria. The majority of patients were males, average age 45yrs, with only 23% having comorbidities. A higher proportion of patients treated with aggressive hydration vs. standard hydration showed clinical improvement at 36hrs: 70 vs. 42% (P=0.03) (primary outcome). The rate of clinical improvement was greater with aggressive hydration vs. standard hydration by regression analysis: Adjusted hazards ration =2.32, 95% CI (1.21-1.41). Persistent SIRS occurred less commonly with aggressive hydration (7.4 vs. 21.1%; Adjusted OR = 0.12, 0.02-0.94). No patients developed signs of volume overload (secondary outcomes).
Overall takeaway: Early aggressive intravenous hydration with LRs hastens clinical improvement in patient with mild acute pancreatitis
Pros of study:
One of the first RCTs that showed that intravenous shows clinical benefit in patients with mild acute pancreatitis.
Study defined a set fluid resuscitation goal/initial rate and type of fluid for patients with mild acute pancreatitis
There is no harm in aggressively hydrating patients with mild acute pancreatitis
Cons of study:
Extensive exclusion criteria so that the primary endpoint was assessed in patients with only mild acute pancreatitis with no significant comorbidities and thus the generalizability of this study is limited
Small “N” of study of only 60 patients randomized