How to manage acute Pancreatitis with fluid

This is an updated ppt for how to manage patients with pancreatitis with fluid

1. Fluid Management In Pancreatitis By - Dr. Wondwosen M (IMR2)

2. INTRODUCTION Acute pancreatitis is an acute inflammatory process of the pancreas. Overall mortality rates in acute pancreatitis are approximately 2 % , but can be as high as 30 % in patients with persistent organ failure (severe acute pancreatitis)

3. INITIAL MANAGEMENT Initial management of a patient with acute pancreatitis consists of supportive care with fluid resuscitation , pain control, and nutritional support. While previous guidelines have recommended 250 to 500 mL/hr of NS during the first 24 to 48 hours (5 to 10 m l/kg/hr) IV fluids of RL or NS are initially bolused at 15–20 mL/kg (1050–1400 mL), followed by 2–3 mL/kg /hr (200–250 mL/h), to maintain urine output >0.5 mL/kg per hour. Despite numerous studies that have evaluated intravenous hydration, the timing, the rate, the type of fluid, the duration of treatment, and the appropriate goal to direct such intravenous hydration is unclear

4. Recently, many RCT and meta-analyses on fluid therapy have revealed that high fluid rate infusion is associated with increased mortality and severe adverse events compared to those resulting from moderate fluid rates, and this has triggered a paradigm shift in fluid management strategies Meanwhile, there is evidence to show that Ringer lactate solution is superior to normal saline solutions in this context

5. Fluid Resuscitation Protocol de-Madaria E et al. N Engl J Med2022;387:989-1000

6. Rate Of Fluid Administration - WATERFALL 744 patients were planned to be randomized and assigned to aggressive (20ml/kg bolus, followed by 3ml/kg/hr) or moderate 1.5ml/kg/hr, with a bolus of 10ml/kg only if hypovolemia was present) fluid resuscitation protocols Primary End Point . Detect a difference in the development of moderately severe or severe acute pancreatitis Safety End Point . Evaluate fluid overload based on symptoms, physical signs or imaging evidence of hypervolemia

7. Rate Of Fluid Administration - WATERFALL Iv fluids should be initiated at a moderate rate within 2 hours after the acute pancreatitis diagnosis is made Fluid Rate Aggressive Moderate Incidense of MA 22.1% 17.3% or SA pancreatitis Evidence of fluid overload 20.5% 6.5%

8. - Moderate fluid rate is safer than aggressive fluid resuscitation with similar efficacy - Moderate fluid rate (1.5ml/kg/hr) is recommended for patients with acute pancreatitis of any severity - Fluid boluses of 10ml/kg over 1 to 2 hrs are recommended for patients with hypovolemia Conclusion

9. Fluid Types Crystalloids or colloids? In severe acute pancreatitis in 1 RCT of patients with severe acute pancreatitis, crystalloids showed: Lower rates of adverse events and organ failure Similar survival RL or NS? Reduced risk of ICU admission shortened hospital stay Physioogic and clinical evidence support using balanced crystalloid RL over NS, however a large definitive RCT is needed

10. Assessing Fluid volume status Fluid resuscitation should be guided by specific goals: Maintaining adequate BP, urine output (> 0.5 ml/kg/hr) Normalizing HCT and ELE levels Objective volume assessment should be performed frequently during the first 24 hrs and atleast every day to detect or correct any fluid excess or deficits Continous monitoring is essential to assess f luid status and response to treatment Physical Exam - Urine Out Put Vital signs - Laboratory values