emDOCs Videocast: EBM Update – Fluids in Pancreatitis and Hypertriglyceridemic Pancreatitis

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Fluids in Pancreatitis

#1: de-Madaria E, Buxbaum JL, Maisonneuve P, et al; ERICA Consortium. Aggressive or Moderate Fluid Resuscitation in Acute Pancreatitis. N Engl J Med. 2022 Sep 15;387(11):989-1000.

• Question:In adults with acute pancreatitis, does moderate fluid resuscitation compared to aggressive resuscitation reduce the development of moderately severe or severe pancreatitis?
  • Multicenter, open-label, parallel-group, randomized, controlled, superiority trial
    • 18 centers; 4 countries
  • Included patients > 18 years with mild/moderate pancreatitis within 24 hours
  • Diagnosed using Revised Atlanta Classification (2 of 3): Pain characteristic of pancreatitis, amylase/lipase > 3X ULN, imaging findings characteristic of pancreatitis
  • Intervention: LR Bolus of 10 cc/kg in patients with hypovolemia or no bolus in those with normovolemia followed by 1.5 cc/kg/hour of LR
  • Control: LR Bolus of 20 cc/kg (regardless of fluid status) followed by 3.0 cc/kg/hour of LR
  • Primary outcome: Progression to moderately severe or severe acute pancreatitis
  • Primary Safety Endpoint: Fluid Overload defined by 2 of the following 3
    • Criterion 1: non-invasive evidence of heart failure (ie echo), radiographic evidence of pulmonary congestion, invasive cardiac Cath suggesting heart failure.
    • Criterion 2: Dyspnea
    • Criterion 3: Heart failure signs: peripheral edema, pulmonary rales, increased JVP or hepatojugular reflex
  • Secondary Outcomes: Organ failure, Local Complications, Persistent Organ Failure, Respiratory Failure, Hospital LOS, ICU Admission, ICU LOS
  • 676 patients assessed for enrollment; 249 patients included
    • Primary Outcome: All-cause mortality at 28 days
    • Hydrocortisone 6.2% vs. Placebo 11.9%, NNT 18
  • Median Fluid Received:
    • Aggressive: 7.8L (Range 6.5 to 9.8L)
    • Moderate: 5.5L (Range 4.0 to 6.8L)
  • Progression to mod/sevpancreatitis: 22.1% vs. 17.3%, aRR1.30 (0.78-2.18)
  • Fluid Overload: 20.5% vs. 6.3%, aRR 2.85 (1.36-5.94)
  • Trial stopped early due to harm, potentially overinflated results
  • Author Takeaway: In patients with mild/moderate pancreatitis, aggressive fluid resuscitation can lead to volume overload.

#2: Li XW, Wang CH, Dai JW, et al. Comparison of clinical outcomes between aggressive and non-aggressive intravenous hydration for acute pancreatitis: a systematic review and meta-analysis. Crit Care. 2023 Mar 22;27(1):122.

• Question: What are the outcomes between aggressive and non-aggressive intravenous hydration in severe and non-severe AP?
  • Systematic review and meta-analysis.
  • Included 9 studies, 953 patients
  • Aggressive IV hydration significantly increased mortality risk in severe AP (pooled RR: 2.45, 95% CI: 1.37, 4.40), but the result in non-severe AP was inconclusive (pooled RR: 2.26, 95% CI: 0.54, 9.44).
  • Aggressive IV hydration increased fluid-related complication risk in severe (pooled RR: 2.22, 95% CI 1.36, 3.63) and non-severe AP (pooled RR: 3.25, 95% CI: 1.53, 6.93).
  • NNH 20 for increased mortality; NNH 7 for fluid-related complications

Hypertriglycidemic pancreatitis

• Uncommon but not rare; accounts for up to 10% of all cases of pancreatitis.
• Defined by pancreatitis + triglyceride love > 1000 mg/dL + no other cause (must exclude other causes).
• Triglyceride is 3 fatty acids attached to glycerol molecule.
• Unsure exact pathophysiology, but free fatty acids may lead to pancreatic inflammation.
• Medications (furosemide, estrogen, chemotherapies), diabetes, pregnancy, alcohol, hypothyroidism increase free fatty acid.
• Management: 1) Discontinue meds causing hypertriglyceridemia, 2) Gemfibrozil 600 mg BID, 3) Electrolyte repletion, 4) Gentle dextrose/insulin infusion, 5) Nutritional support.