Acute pancreatitis is something you should put in your bucket list of things you hope to never experience before you die. Pancreatitis is inflammation of your pancreas. Acute pancreatitis is active, ongoing inflammation of your pancreas. The clinical presentation of acute pancreatitis can be very mild to life ending. I've had patients in the hospital for one day with acute pancreatitis. I've also had patients in the hospital for six months with pancreatitis. As internists, we are taught to manage acute pancreatitis with aggressive fluid resuscitation in order to maintain adequate perfusion of the pancreatic tissue bed. But how much fluid? How much fluid is enough fluid in severe cases of acute pancreatitis. Internist/Hospitalist Dr RW Donnell comments on new data that suggests less is more.
Traditional teaching and guidelines held that we should pour the fluids early on in the treatment of acute pancreatitis. Nobody would say just how much, but a lot. The problem was, these recommendations were not driven by high level data. We had expert opinion, animal data, pathophysiologic rationale and low level studies in patients but nothing more.
A prospective cohort study titled Influence of Fluid Therapy on the Prognosis of Acute Pancreatitis: A Prospective Cohort Study, was recently published in The American Journal Of Gastroenterology (Am J Gastroenterol 2011; 106:1843–1850; doi:10.1038/ajg.2011.236; published online 30 August 2011 ) The results seem to contradict expert driven guidelines. Two-hundred forty-seven consecutive adults with acute pancreatitis participated. Those folks that received more than 4.1 liters of volume in the first 24 hours had a higher rate of persistent organ failure, acute collections, respiratory insufficiency and renal insufficiency. Those that received less than 3.1 liters did not. Those patients that received between 3.1-4.1 liters of volume in the first 24 hours had an excellent outcome as well.
Perhaps less is more. Perhaps. I don't have access to the full data so I don't know how the different volume resuscitation groups faired in their baseline presentation. It does make me wonder, however, if pancreatitis patients who present with a shock like state do better with less volume resuscitation, as I may be correctly or incorrectly assuming from this abstract, then why shouldn't septic patients also do better with less resuscitation. That's exactly what recent data seemed to suggest. With Xigris pulled from the market, and data suggesting a higher mortality in septic shock patients with a 4 L or more positive fluid balance at 12 hours into resuscitation, it might be time to reevaluate the roll of aggressive fluid resuscitation in patients who present with a toxic syndrome, whether it's sepsis or pancreatitis.
For the sepsis study, at 12 hrs, patients with central venous pressure <8 mm Hg had the lowest mortality rate followed by those with central venous pressure 8–12 mm Hg. That's interesting. Maybe we should start therapeutic bleed letting. And I'm not just talking about daily hospital blood draws. Perhaps the Jehovah's folks are really onto something.. All that is old is new again. This data is comforting on a macro political level. With all the drug shortages of late and the restrictive economics of ObamaCare glaring us in the face, perhaps someday soon we can stare our patients in their intubated eye and tell them that normal saline is simply not indicated for their toxic syndrome. We don't have to tell them that we simply ran out or we couldn't afford more or that the company stopped making it. We can just tell them it doesn't work. Halleluiah. The truth shall set you free.