Fluid in pancreatitis final

Department of Surgery , Kathmandu Medical college

1. Fluid Resuscitation in Acute Pancreatitis Dr. Uttam Laudari

2. objective Pathphysiology of fluid sequestration Role of fluid resuscitation Choice of fluid with scientific reason Measuring response to fluid resuscitation

3. Acute pancreatitis Acute pancreatitis is an inflammatory process of the pancreas that leads to approximately 210,000 hospital admissions annually ( USA based) Many of these admissions are associated with significant morbidity, leading to prolonged hospitalizations, and often require ICU admission . The estimated mortality rate for all patients with acute pancreatitis is approximately 5%

4. The standard treatment of acute pancreatitis focuses on general supportive management intravenous fluid resuscitation pain control correction of electrolyte disturbances, and provision of nutrition if prolonged fasting is expected .

5. Pathophysiology INCREASED IN Pancreatic proteases bacterial endotoxin systemic toxicity activates compliment system (C5 and Kinins ) Granulocytic aggregation and accumulation in pulmonary capillary and other body parts increased elastase,superoxides , H2O2 Local toxic efffects in pulmonary and other parts increasing permeability

6. Fluid loss Marked hemoconcentration Hypovolemia inadequate fluid resuscitation worsens severity External loss Repeated vomiting Internal loss (sequestration) and decreased intake due to nausea Hypochloremic alkalosis

7. Internal fluid sequestration Internal fluid sequestration is greater than external Sequestration to area of inflammation Peripancreatic Retroperitoneum Pulmonary capillary due to capillary leak Soft tissue Decresed perfusion and hypovolemia Metabolic acidosis

8. Most patient of chronic pancreatitis are alcoholic Usually have hypoalbuminemia and hypomagnesemia before presentation Which is exacerbated by losses of pancreatitis Albumin measurement can be much low due to albumin free crystalloid infusion Attributable to low serum calcium Calcium supplement only required only when carpopedal spasm and tetany

9. Just the single finding of fluid sequestration ( ie , fluid administered minus urine output) exceeding 2 L/d for more than 2 days is a reasonably accurate dividing line between severe (life-threatening) and mild-to-moderate disease. The minimal intravenous fluid requirements of a 70 kg person during the first 48 hours after admission is already 6 liters without considering intravascular fluid sequestration loss Tenner S. Initial management of acute pancreatitis: critical issues during the first 72 hours.American Journal of Gastroenterology. 2004

10. Fluid Resuscitation Fluid resuscitation is integral to the acute management of patients with AP There is limited evidence to inform a specific fluid resuscitation regimen with regard to the optimum rate, volume and fluid type Gardner et al. have recently reported that patients who receive timely early fluid therapy in acute pancreatitis (more than 33% of the first 72 h total volume delivered in the first 24 h) have lower mortality

11. Early Fluid Resuscitation Reduces Morbidity Among Patientswith Acute Pancreatitis Matthew G. Warndorf , MD, Jane T et.all Dartmouth-Hitchcock Medical Center, Lebanon , 701 patients were admitted to our medical center from 1985 to 2009 with a primary diagnosis of acute pancreatitis at 0–24, 24–48, and 48–72 hours there was less SIRS in the early resuscitation group compared to the late resuscitation group Additionally, there was no difference in the presence of organ failure between the two groups at time of admission but at 72 hours less organ failure was observed in the early resuscitation group , as compared to the late resuscitation group

12. Measuring the response to fluid resuscitation IAP/APA evidence-based guidelines for the management of acute pancreatitis Pancreatology 13 (2013) e1ee15 The preferred approach to assessing the response to fluid resuscitation should be based on one or more of the following: non-invasive clinical targets of heart rate < 120/min mean arterial pressure between 65 and 85 mmHg and urinary output >0.5-1 ml/kg/h invasive clinical targets of stroke volume variation and intrathoracic blood volume determination, biochemical targets of hematocrit 35-44%

13. Fluid of choice???

14. Fluid of choice??? Ringer lactate One litre of Ringers Lactate solution contains: 130  mEq  of  sodium   ion   109 mEq of  chloride  ion 28 mEq of  lactate   4 mEq of  potassium  ion 3 mEq of  calcium  ion Normal saline One litre of 0.9% Saline contains: 154  mEq  of  sodium   ion   154  mEq  of  chloride   ion

15. The 2 most widely available crystalloid solutions used in routine clinical practice are NS and RL More pH-balanced solution such as RL might dampen systemic inflammation compared with resuscitation with NS The development of hyperchloremic metabolic acidosis is a well-documented phenomenon associated with large-volume saline infusion

16. studies in animal models indicate that up to 38% of the acid load produced during fluid resuscitation in a septic shock canine model was related to saline infusion Studies in experimental rodent models of septic shock have also shown increased of proinflammatory cytokines such as tumor necrosis factor- in low extracellular pH conditions

17. Data from rodent models of acute pancreatitis indicate that trypsinogen activation a key early step in pathogenesis, is a pH-dependent process that requires a low pH compartment Also, low extracellular pH sensitizes acinar cells to injury and exacerbates severity of disease

18. Early resuscitation with RL dampens the inflammatory response in acute pancreatitis as measured by SIRS and CRP at 24 hours Recent observational studies have linked the persistence of SIRS beyond 48 hours with increased organ failure and death in acute pancreatitis Persistent SIRS was associated with a mortality of 25% compared with 8% for transient SIRS IAP/APA evidence-based guidelines for the management of acute pancreatitis Pancreatology 13 (2013) e1ee15

19. CRP is the most widely used nonspecific marker for inflammatory diseases because of its high prognostic accuracy, widespread availability, and low cost As an acute phase reactant, CRP synthesis is induced from hepatocytes in response to interleukin-1 and interleukin- 6. Numerous studies have determined it to be a useful predictor of severe acute pancreatitis

20. Impact of lactated Ringer’s vs saline resuscitation on serum bicarbonate levels Participants resuscitated with RL will had less metabolic acidosis (as measured by decrease in serum bicarbonate) compared with those resuscitated with NS during the initial 24-hour treatment period Early resuscitation with the more pH-balanced RL solution led to reduced prevalence of SIRS and lower CRP levels when compared with resuscitation with NS Lactated Ringer’s Solution Reduces Systemic Inflammation Compared With Saline in Patients With Acute Pancreatitis. BECHIEN U. WU et.all CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2011;9:710–717

21. O ptimal fluid infusion rate and response measurement for initial fluid resuscitation Goal directed intravenous fluid therapy with 5-10ml/kg/h should be used initially until resuscitation goals are reached In most patients, a total infusion of 2500-4000 ml will suffice to reach the resuscitation goals within the first 24 h Overly aggressive fluid therapy increases morbidity and mortality Age and co-morbidities such as heart failure need an individualization of the fluid management

22. Mao EQ, Tang YQ, Fei J, Qin S, Wu J, Li L, et al. Fluid therapy for severe acute pancreatitis in acute response stage. Chin Med J ( Engl ) 2009;122:169e73. In the first RCT, patients assigned to a fluid infusion rate of 5-10 ml/kg/h experienced less need for mechanical ventilation Less occurance of abdominal compartment syndrome, Less sepsis and mortality as compared to patients assigned to 10-15 ml/kg/h infusion rates In a second RCT patients assigned to slow hemodilution , aiming at a hematocrit >35% within 48 h, had decreased rates of sepsis and mortality as compared to patients assigned to rapid hemodilution , aiming at a hematocrit <35% within 48 hour

23. Historically recommendations for resuscitation have been based on expert opinion that urge “ aggressive resuscitation ,” and rely on clinical decision making to monitor for complications of the disease process or the resuscitation strategy itself. Most guidelines encourage targeting fluid resuscitation toward correcting hypotension, correcting hemoconcentration , and maintaining adequate urine output The goal of fluid resuscitation is to improve patient outcomes, and prevent, or at least minimize, compromise of the microcirculation of the pancreas and prevent necrosis

24. Conclusion Fluid resuscitation most important modality of treatment, more effective if initiated within first 24 hours RL is the fluid of choice Measurement of adequacy by goal directed response Serial SIRS, CRP, BUN, Hematocrit essential paramenters to guide adequacy of fluid response

25. References Sabiston Text book of surgery IAP/APA evidence-based guidelines for the management of acutepancreatitis . Pancreatology 13 (2013) e1ee15 Detailed fluid resuscitation profiles in patients with severe acute pancreatitis Damian J. Mole1, Andrew Hall1, Dermot McKeown , O. James Garden1 & Rowan W. Parks Lactated Ringer’s Solution Reduces Systemic Inflammation Compared With Saline in Patients With Acute Pancreatitis BECHIEN U. WU et. all. CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2011;9:710–717 Fluid Therapy in Acute Pancreatitis-A Systematic Review of Literature. Nicholas S Solanki, Savio George Barreto. Department of Surgery, Royal Adelaide Hospital. Adelaide, South Australia, Australia

26. Thank you