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Protsenko DN, Tsvetkov DS, Shifman EМ. Tactics of infusion therapy in patients with acute destructive pancreatitis: a narrative review. ANNALS OF CRITICAL CARE 2024:94-106. [DOI: 10.21320/1818-474x-2024-2-94-106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2025]
Abstract
INTRODUCTION: Infusion therapy is the main method of correcting pathological changes that occur during the phase of “aseptic” inflammation in acute pancreatitis. OBJECTIVE: Summarize current data on infusion therapy regimens in patients with acute destructive pancreatitis, the advisability of using various infusion solutions and options for monitoring the effectiveness of therapy. MATERIALS AND METHODS: The study was carried out in accordance with international reporting requirements for reviews (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). The search was carried out in the following Internet search engines Pubmed and Cochrane Controlled Clinical Trials Register. To select articles, a literature reference search method was also used. The search strategy did not include restrictions on language, article type, or date. RESULTS: The analysis of literature data revealed two approaches to infusion therapy. The initial interest in “aggressive (4 liters per day or more)” infusion therapy regimens in the first 24 hours of the disease has now been replaced by a trend towards less “aggressive” regimens due to the publication of works on the high incidence of various complications (progression of organ dysfunction, local complications). When considering the qualitative composition of infusion therapy, preference should certainly be given to crystalloids. Basic monitoring of infusion therapy should include non-invasive methods: heart rate, blood pressure, diuresis rate. CONCLUSIONS: The analysis demonstrated different approaches to the tactics of infusion therapy in this category of patients. further research into the effectiveness and safety of infusion therapy, taking into account the varying severity of acute pancreatitis, the possibility of the influence of the qualitative composition of the infusion on the course of this disease and the formation of recommendations for initial and maintenance infusion therapy based on the principles of personalized medicine.
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Affiliation(s)
- D. N. Protsenko
- Pirogov Russian National Research Medical University (RNRMU), Moscow, Russia; Moscow Multidisciplinary Clinical Center “Kommunarka”, Moscow, Russia
| | | | - E. М. Shifman
- Odintsovo Regional Hospital, Odintsovo, Russia; Moscow Regional Research and Clinical Institute, Moscow, Russia
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Yang AL, Vege SS. Fluid resuscitation in acute pancreatitis. Curr Opin Gastroenterol 2023:00001574-990000000-00086. [PMID: 37421393 DOI: 10.1097/mog.0000000000000959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/10/2023]
Abstract
PURPOSE OF REVIEW The purpose of the review is to critically evaluate the evidence from the literature to establish the current perspective on fluid resuscitation (FR) in acute pancreatitis (AP). We will review the rationale, type of fluid, rate of administration, total volume, duration, monitoring, ideal outcomes to be studied in clinical trials and recommendations for future studies. RECENT FINDINGS FR remains the key component of supportive therapy in AP. The paradigm has shifted from administration of aggressive fluid resuscitation towards more moderate FR strategies. Lactated Ringer's remains the preferred fluid for resuscitation. There remain critical gaps in knowledge regarding the end point(s) to indicate adequate resuscitation, and accurate assessments of fluid sequestration and intravascular volume deficit in AP. SUMMARY There is insufficient evidence to state that goal-directed therapy, using any of the parameters to guide fluid administration, reduces the risk of persistent organ failure, infected pancreatic necrosis, or mortality in AP, as well as the most appropriate method for the same.
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Affiliation(s)
- Allison L Yang
- Division of Gastroenterology & Hepatology, Weill Cornell Medicine, New York, New York
| | - Santhi Swaroop Vege
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Crosignani A, Spina S, Marrazzo F, Cimbanassi S, Malbrain MLNG, Van Regenemortel N, Fumagalli R, Langer T. Intravenous fluid therapy in patients with severe acute pancreatitis admitted to the intensive care unit: a narrative review. Ann Intensive Care 2022; 12:98. [PMID: 36251136 PMCID: PMC9576837 DOI: 10.1186/s13613-022-01072-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 10/11/2022] [Indexed: 11/26/2022] Open
Abstract
Patients with acute pancreatitis (AP) often require ICU admission, especially when signs of multiorgan failure are present, a condition that defines AP as severe. This disease is characterized by a massive pancreatic release of pro-inflammatory cytokines that causes a systemic inflammatory response syndrome and a profound intravascular fluid loss. This leads to a mixed hypovolemic and distributive shock and ultimately to multiorgan failure. Aggressive fluid resuscitation is traditionally considered the mainstay treatment of AP. In fact, all available guidelines underline the importance of fluid therapy, particularly in the first 24–48 h after disease onset. However, there is currently no consensus neither about the type, nor about the optimal fluid rate, total volume, or goal of fluid administration. In general, a starting fluid rate of 5–10 ml/kg/h of Ringer’s lactate solution for the first 24 h has been recommended. Fluid administration should be aggressive in the first hours, and continued only for the appropriate time frame, being usually discontinued, or significantly reduced after the first 24–48 h after admission. Close clinical and hemodynamic monitoring along with the definition of clear resuscitation goals are fundamental. Generally accepted targets are urinary output, reversal of tachycardia and hypotension, and improvement of laboratory markers. However, the usefulness of different endpoints to guide fluid therapy is highly debated. The importance of close monitoring of fluid infusion and balance is acknowledged by most available guidelines to avoid the deleterious effect of fluid overload. Fluid therapy should be carefully tailored in patients with severe AP, as for other conditions frequently managed in the ICU requiring large fluid amounts, such as septic shock and burn injury. A combination of both noninvasive clinical and invasive hemodynamic parameters, and laboratory markers should guide clinicians in the early phase of severe AP to meet organ perfusion requirements with the proper administration of fluids while avoiding fluid overload. In this narrative review the most recent evidence about fluid therapy in severe AP is discussed and an operative algorithm for fluid administration based on an individualized approach is proposed.
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Affiliation(s)
- Andrea Crosignani
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy.,Department of Anaesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Stefano Spina
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy.,Department of Anaesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Francesco Marrazzo
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy.,Department of Anaesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Stefania Cimbanassi
- General Surgery and Trauma Team, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Manu L N G Malbrain
- First Department of Anaesthesia and Intensive Therapy, Medical University of Lublin, Lublin, Poland.,International Fluid Academy, Lovenjoel, Belgium
| | - Niels Van Regenemortel
- Department of Intensive Care Medicine, Antwerp University Hospital, Antwerp, Belgium.,Department of Intensive Care Medicine, Ziekenhuis Netwerk Antwerpen Campus Stuivenberg, Antwerp, Belgium
| | - Roberto Fumagalli
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy.,Department of Anaesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Thomas Langer
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy. .,Department of Anaesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.
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Management of Acute Pancreatitis in the Pediatric Population: A Clinical Report From the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition Pancreas Committee. J Pediatr Gastroenterol Nutr 2018; 66:159-176. [PMID: 29280782 PMCID: PMC5755713 DOI: 10.1097/mpg.0000000000001715] [Citation(s) in RCA: 149] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although the incidence of acute pancreatitis (AP) in children is increasing, management recommendations rely on adult published guidelines. Pediatric-specific recommendations are needed. METHODS The North American Society for Pediatric Gastroenterology, Hepatology and Nutrition Pancreas committee performed a MEDLINE review using several preselected key terms relating to management considerations in adult and pediatric AP. The literature was summarized, quality of evidence reviewed, and statements of recommendations developed. The authorship met to discuss the evidence, statements, and voted on recommendations. A consensus of at least 75% was required to approve a recommendation. RESULTS The diagnosis of pediatric AP should follow the published INternational Study Group of Pediatric Pancreatitis: In Search for a CuRE definitions (by meeting at least 2 out of 3 criteria: (1) abdominal pain compatible with AP, (2) serum amylase and/or lipase values ≥3 times upper limits of normal, (3) imaging findings consistent with AP). Adequate fluid resuscitation with crystalloid appears key especially within the first 24 hours. Analgesia may include opioid medications when opioid-sparing measures are inadequate. Pulmonary, cardiovascular, and renal status should be closely monitored particularly within the first 48 hours. Enteral nutrition should be started as early as tolerated, whether through oral, gastric, or jejunal route. Little evidence supports the use of prophylactic antibiotics, antioxidants, probiotics, and protease inhibitors. Esophago-gastro-duodenoscopy, endoscopic retrograde cholangiopancreatography, and endoscopic ultrasonography have limited roles in diagnosis and management. Children should be carefully followed for development of early or late complications and recurrent attacks of AP. CONCLUSIONS This clinical report represents the first English-language recommendations for the management of pediatric AP. Future aims should include prospective multicenter pediatric studies to further validate these recommendations and optimize care for children with AP.
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Zhang XX, Deng LH, Chen WW, Shi N, Jin T, Lin ZQ, Ma Y, Jiang K, Yang XN, Xia Q. Circulating microRNA 216 as a Marker for the Early Identification of Severe Acute Pancreatitis. Am J Med Sci 2016; 353:178-186. [PMID: 28183420 DOI: 10.1016/j.amjms.2016.12.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Revised: 12/04/2016] [Accepted: 12/08/2016] [Indexed: 02/05/2023]
Abstract
BACKGROUND To study the value of circulating microRNA 216 (miR-216) as a marker for the severity of acute pancreatitis (AP) in both murine models and patients. MATERIALS AND METHODS Mice with AP were induced by intraperitoneal injection of 50μg/kg/hour cerulean either 7 times, sacrificed at 8, 9, 10, 11 or 12 hours after the first injection, or 12 times, sacrificed at 24 hours after the first injection. Plasma samples and data from patients with AP were obtained from a prospective cohort. Quantitative reverse transcription polymerase chain reaction was used to determine the miR-216a and miR-216b level. RESULTS The upregulation of miR-216a and miR-216b in the serum of mice was induced by cerulean injection in both the 7- and 12-injection groups (P < 0.05). The downregulation of miR-216a in pancreatic tissues of mice with AP was detected (P < 0.05), but no difference was observed in pancreatic miR-216b levels among any of the groups (all P > 0.05). The serum miR-216a level was positively correlated with pancreatic histopathology severity scores, and was negatively correlated with pancreatic miR-216a (r = -0.483, P = 0.009). The plasma miR-216a level was significantly upregulated in patients with severe AP (SAP) compared with patients with mild AP (MAP) or moderate severe AP (MSAP) (SAP versus MAP, P = 0.04; SAP versus MSAP, P = 0.00), but no difference was seen between patients with MAP and those with MSAP (P = 0.73). CONCLUSIONS Circulating miR-216a might be a potential biomarker for the early identification of SAP.
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Affiliation(s)
- Xiao-Xin Zhang
- Department of Integrated Traditional Chinese and Western Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Li-Hui Deng
- Department of Integrated Traditional Chinese and Western Medicine, West China Hospital of Sichuan University, Chengdu, China.
| | - Wei-Wei Chen
- Department of Integrated Traditional Chinese and Western Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Na Shi
- Department of Integrated Traditional Chinese and Western Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Tao Jin
- Department of Integrated Traditional Chinese and Western Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Zi-Qi Lin
- Department of Integrated Traditional Chinese and Western Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Yun Ma
- Department of Integrated Traditional Chinese and Western Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Kun Jiang
- Department of Integrated Traditional Chinese and Western Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Xiao-Nan Yang
- Department of Integrated Traditional Chinese and Western Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Qing Xia
- Department of Integrated Traditional Chinese and Western Medicine, West China Hospital of Sichuan University, Chengdu, China.
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6
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Abstract
This article reviews advances in the management of acute pancreatitis. Medical treatment has been primarily supportive for this diagnosis, and despite extensive research efforts, there are no pharmacologic therapies that improve prognosis. The current mainstay of management, notwithstanding the ongoing debate regarding the volume, fluid type, and rate of administration, is aggressive intravenous fluid resuscitation. Although antibiotics were used consistently for prophylaxis in severe acute pancreatitis to prevent infection, they are no longer used unless infection is documented. Enteral nutrition, especially in patients with severe acute pancreatitis, is considered a cornerstone in management of this disease.
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Affiliation(s)
| | - Timothy B Gardner
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA; Section of Gastroenterology and Hepatology, Dartmouth Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756, USA.
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7
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Srinivasan G, Venkatakrishnan L, Sambandam S, Singh G, Kaur M, Janarthan K, John BJ. Current concepts in the management of acute pancreatitis. J Family Med Prim Care 2016; 5:752-758. [PMID: 28348985 PMCID: PMC5353808 DOI: 10.4103/2249-4863.201144] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Guidelines for the management of acute pancreatitis (AP) are based on the Western experience, which may be difficult to extrapolate in India due to socioeconomic constraints. Hence, modifications based on the available resources and referral patterns should be introduced so as to ensure appropriate care. We reviewed the current literature on the management of AP available in English on Medline and proposed guidelines locally applicable. Patients of AP presenting with systemic inflammatory response syndrome are at risk of moderate-severe pancreatitis and hence, should be referred to a tertiary center early. The vast majority of patients with AP have mild disease and can be managed at smaller centers. Early aggressive fluid resuscitation with controlled fluid expansion, early enteral nutrition, and culture-directed antibiotics improve outcomes in AP. Infected pancreatic necrosis should be managed in a tertiary care hospital within a multidisciplinary setup. The "step up" approach involving antibiotics, percutaneous drainage, and minimally invasive necrosectomy instituted sequentially based on clinical response has improved the outcomes in this subgroup of patients.
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Affiliation(s)
- Gautham Srinivasan
- Department of HPB and Liver Transplantation, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India
| | - L Venkatakrishnan
- Department of Gastroenterology, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India
| | - Swaminathan Sambandam
- Department of HPB and Liver Transplantation, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India
| | - Gursharan Singh
- Department of HPB and Liver Transplantation, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India
| | - Maninder Kaur
- Department of Anaesthesiology and Critical Care, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India
| | - Krishnaveni Janarthan
- Department of Gastroenterology, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India
| | - B Joseph John
- Department of HPB and Liver Transplantation, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India
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8
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Abstract
This article will review the recent advances in managing acute pancreatitis. Supportive care has long been the standard of treatment for this disease despite extensive, but ultimately unsuccessful, efforts to develop disease-specific pharmacologic therapies. The primary interventions center on aggressive fluid resuscitation, initiation of early enteral nutrition, targeted antibiotic therapy, and the management of complications. In this article, we will detail treatment of acute pancreatitis with a focus on intravenous fluid resuscitation, enteral feeding, and the current evidence behind the use of antibiotics and other pharmacologic therapies.
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Affiliation(s)
- Nigeen Janisch
- Department of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Timothy Gardner
- Department of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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9
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Aggarwal A, Manrai M, Kochhar R. Fluid resuscitation in acute pancreatitis. World J Gastroenterol 2014; 20:18092-18103. [PMID: 25561779 PMCID: PMC4277949 DOI: 10.3748/wjg.v20.i48.18092] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Revised: 09/03/2014] [Accepted: 10/14/2014] [Indexed: 02/06/2023] Open
Abstract
Acute pancreatitis remains a clinical challenge, despite an exponential increase in our knowledge of its complex pathophysiological changes. Early fluid therapy is the cornerstone of treatment and is universally recommended; however, there is a lack of consensus regarding the type, rate, amount and end points of fluid replacement. Further confusion is added with the newer studies reporting better results with controlled fluid therapy. This review focuses on the pathophysiology of fluid depletion in acute pancreatitis, as well as the rationale for fluid replacement, the type, optimal amount, rate of infusion and monitoring of such patients. The basic goal of fluid epletion should be to prevent or minimize the systemic response to inflammatory markers. For this review, various studies and reviews were critically evaluated, along with authors' recommendations, for predicted severe or severe pancreatitis based on the available evidence.
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10
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da Costa DW, Boerma D, van Santvoort HC, Horvath KD, Werner J, Carter CR, Bollen TL, Gooszen HG, Besselink MG, Bakker OJ. Staged multidisciplinary step-up management for necrotizing pancreatitis. Br J Surg 2013; 101:e65-79. [DOI: 10.1002/bjs.9346] [Citation(s) in RCA: 119] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2013] [Indexed: 12/16/2022]
Abstract
Abstract
Background
Some 15 per cent of all patients with acute pancreatitis develop necrotizing pancreatitis, with potentially significant consequences for both patients and healthcare services.
Methods
This review summarizes the latest insights into the surgical and medical management of necrotizing pancreatitis. General management strategies for the treatment of complications are discussed in relation to the stage of the disease.
Results
Frequent clinical evaluation of the patient's condition remains paramount in the first 24–72 h of the disease. Liberal goal-directed fluid resuscitation and early enteral nutrition should be provided. Urgent endoscopic retrograde cholangiopancreatography is indicated when cholangitis is suspected, but it is unclear whether this is appropriate in patients with predicted severe biliary pancreatitis without cholangitis. Antibiotic prophylaxis does not prevent infection of necrosis and antibiotics are not indicated as part of initial management. Bacteriologically confirmed infections should receive targeted antibiotics. With the more conservative approach to necrotizing pancreatitis currently advocated, fine-needle aspiration culture of pancreatic or extrapancreatic necrosis will less often lead to a change in management and is therefore indicated less frequently. Optimal treatment of infected necrotizing pancreatitis consists of a staged multidisciplinary ‘step-up’ approach. The initial step is drainage, either percutaneous or transluminal, followed by surgical or endoscopic transluminal debridement only if needed. Debridement is delayed until the acute necrotic collection has become ‘walled-off’.
Conclusion
Outcome following necrotizing pancreatitis has improved substantially in recent years as a result of a shift from early surgical debridement to a staged, minimally invasive, multidisciplinary, step-up approach.
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Affiliation(s)
- D W da Costa
- Department of Operating Theatres and Evidence Based Surgery, Radboud University Medical Centre Nijmegen, Nijmegen, The Netherlands
| | - D Boerma
- Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
| | - H C van Santvoort
- Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
| | - K D Horvath
- Department of Surgery, University of Washington Medical Center, Seattle, Washington, USA
| | - J Werner
- Department of Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - C R Carter
- Department of Surgery, Glasgow Royal Infirmary, Glasgow, UK
| | - T L Bollen
- Department of Radiology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - H G Gooszen
- Department of Operating Theatres and Evidence Based Surgery, Radboud University Medical Centre Nijmegen, Nijmegen, The Netherlands
| | - M G Besselink
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - O J Bakker
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
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Contrasts and comparisons between childhood and adult onset acute pancreatitis. Pancreatology 2013; 13:429-35. [PMID: 23890143 DOI: 10.1016/j.pan.2013.06.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2013] [Revised: 06/18/2013] [Accepted: 06/19/2013] [Indexed: 12/11/2022]
Abstract
Acute pancreatitis (AP) in children is an increasingly recognised clinical entity notably different from the adults with respect to incidence, aetiology, severity and outcome. Yet our current understanding and approach to the management of paediatric pancreatitis is based almost entirely on adult studies. Acute recurrent pancreatitis (ARP) in children is more likely associated with various genetic factors, some of which have been relatively well characterised and others are in an evolving phase. The aim of this review is to summarise current knowledge, highlight any recent advances and contrast the paediatric and adult forms of this condition.
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12
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Wu BU, Banks PA. Clinical management of patients with acute pancreatitis. Gastroenterology 2013; 144:1272-81. [PMID: 23622137 DOI: 10.1053/j.gastro.2013.01.075] [Citation(s) in RCA: 125] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2012] [Revised: 12/31/2012] [Accepted: 01/07/2013] [Indexed: 12/14/2022]
Abstract
Acute pancreatitis is the leading cause of hospitalization for gastrointestinal disorders in the United States. As rates of hospitalization for acute pancreatitis continue to increase, so does demand for effective management. We review approaches to best manage patients with acute pancreatitis, covering diagnosis, risk and prognostic factors, treatment, and complications, considering recommendations from current practice guidelines.
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Affiliation(s)
- Bechien U Wu
- Center for Pancreatic Care, Southern California Permanente Medical Group, Department of Gastroenterology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California, USA.
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Maraví Poma E, Zubia Olascoaga F, Petrov M, Navarro Soto S, Laplaza Santos C, Morales Alava F, Darnell Martin A, Gorraiz López B, Bolado Concejo F, Casi Villarroya M, Aizcorbe Garralda M, Albeniz Arbizu E, Sánchez-Izquierdo Riera J, Tirapu León J, Bordejé Laguna L, López Camps V, Marcos Neira P, Regidor Sanz E, Jiménez Mendioroz F. SEMICYUC 2012. Recommendations for intensive care management of acute pancreatitis. ACTA ACUST UNITED AC 2013. [DOI: 10.1016/j.medine.2013.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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SEMICYUC 2012. Recommendations for intensive care management of acute pancreatitis. Med Intensiva 2013; 37:163-79. [PMID: 23541063 DOI: 10.1016/j.medin.2013.01.007] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Accepted: 01/17/2013] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Significant changes in the management of acute pancreatitis have taken place since the 2004 Pamplona Consensus Conference. The objective of this conference has been the revision and updating of the Conference recommendations, in order to unify the integral management of potentially severe acute pancreatitis in an ICU. PARTICIPANTS Spanish and international intensive medicine physicians, radiologists, surgeons, gastroenterologists, emergency care physicians and other physicians involved in the treatment of acute pancreatitis. LEVELS OF EVIDENCE AND GRADES OF RECOMMENDATION: The GRADE method has been used for drawing them up. DRAWING UP THE RECOMMENDATIONS: The selection of the committee members was performed by means of a public announcement. The bibliography has been revised from 2004 to the present day and 16 blocks of questions on acute pancreatitis in a ICU have been drawn up. Firstly, all the questions according to groups have been drawn up in order to prepare one document. This document has been debated and agreed upon by computer at the SEMICYUC Congress and lastly at the Consensus Conference which was held with the sole objective of drawing up these recommendations. CONCLUSIONS Eighty two recommendations for acute pancreatitis management in an ICU have been presented. Of these 84 recommendations, we would emphasize the new determinants-based classification of acute pancreatitis severity, new surgical techniques and nutritional recommendations. Note. This summary only lists the 84 recommendations of the 16 questions blocks except blocks greater relevance and impact of its novelty or because they modify the current management.
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Abstract
OBJECTIVE The aim of this study was to systematically review and evaluate the quality of current evidence about fluid therapy (FT) in acute pancreatitis (AP). BACKGROUND Intravenous FT is thought to be important in the early management of patients with AP. Clinically relevant questions remain regarding the type of fluid, the rate of administration, and the goal of FT. METHODS A comprehensive literature search for human studies was performed using online databases (MEDLINE, EMBASE, PubMed, and the Cochrane Library). The quality of the entire body of evidence was then graded according to the Grading of Recommendations Assessment, Development and Evaluation Working Group guidelines in relation to 3 key areas: type of fluid, rate of fluid administration, and goal-directed FT. RESULTS The initial search yielded 410 studies, of which 15 met the inclusion criteria. Only 2 randomized studies compared types of fluids. Nine studies looked at aggressive versus nonaggressive resuscitation protocols, of which 4 concluded that an aggressive approach yielded better outcomes and 5 concluded that a nonaggressive approach was better. Two studies investigated goal-directed FT, using different goals; one demonstrating benefit and the other none. Analysis of the body of evidence as per the Grading of Recommendations Assessment, Development and Evaluation Working Group revealed that the majority of evidence was of low or very low quality. CONCLUSIONS FT is considered a cornerstone of the early management of patients with AP and yet the evidence on which it is based remains paltry and of poor quality. This systematic review has demonstrated the equipoise necessary for the design of randomized controlled trials to answer pressing questions relating to the type of fluid, the rate of administration, and how FT should be guided.
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Affiliation(s)
- Arvind I Srinath
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center UPMC, Pittsburgh, PA, USA
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17
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Abstract
Acute pancreatitis (AP) is a common inflammatory disorder of the pancreas resulting in considerable morbidity and mortality. Aggressive intravenous fluid resuscitation generally is recommended in all patients with AP and remains the cornerstone of management of these patients. However, the optimal rate, type, and the goal of resuscitation remain unclear. The purpose of this review was to give an insight about the pathophysiologic alterations in the pancreatic microcirculation that occur in AP, the markers for early recognition of severity of pancreatitis, the optimal fluid, and timing and extent of fluid resuscitation. An early elevated hematocrit, blood urea nitrogen, or creatinine should prompt clinicians to institute more intensive early resuscitation measures. Crystalloids are the currently recommended fluids for management of these patients. Current studies are underway to determine the optimal end points of fluid resuscitation that determine outcome.
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