Moderate Versus Aggressive Fluid Therapy in Patient With Mild to Moderate Acute Pancratitis

TITLE: Moderate Versus Aggressive Fluid Therapy in Patients with Mild to Moderate Acute Pancreatitis

BACKGROUND AND HYPOTHESES In the United States, acute pancreatitis results in more than 200,000 hospital admissions each year and has an associated mortality of 5%. While protease inhibitors, platelet activating factor inhibitors, and somatostatin have been studied, no pharmacologic agents have been shown to impact the course of acute pancreatitis and the treatment remains supportive. Fluid resuscitation has been recommended based on animal data, however, until recently very limited clinical studies were available to assess its impact. Animal studies using rats, dogs, and pigs suggest that acute pancreatitis compromises splanchnic perfusion and the pancreatic microcirculation. Work by Banks et al demonstrated that hemoconcentration is associated with necrosis and inadequate resuscitation in those with elevated hematocrit was associated with markedly increased rates of necrosis. Blood urea nitrogen and creatinine levels also appear to correlate with mortality in acute pancreatitis.

Nonetheless, recent studies have yielded contradictory results regarding whether fluids should be used judiciously or liberally. Retrospective work by Gardner suggests that early resuscitation is beneficial. Other recent studies however including the work by De Madaria et al suggest that those were received more than 4.1L of fluids during the first 24 hours were more likely to develop organ failure than those who received less. In the only randomized controlled trial of fluids in acute pancreatitis 76 patients with severe pancreatitis, including those with renal failure, were randomized to massive 10-15cc/kg/hr (mean of 545 cc/hour) versus less aggressive resuscitation, 5-10cc/kg/hr. Rates of mechanical ventilation, abdominal compartment syndrome, sepsis, and mortality were higher in the massive resuscitation group In a well done prospective study by Wu et al 40 patients with acute pancreatitis were randomized to goal directed management according to protocol versus standard therapy and also randomized patients lactated ringers (LR) versus normal saline (NS). They were unable to measure a difference between goal directed management and standard therapy arm because the patients were managed very similarly in terms of volume of resuscitation. The rates of systemic inflammatory response syndrome (SIRS) were lower in both groups, 25%, than the predicted level of 50%. It was demonstrated that those who were treated with LR were much less likely to develop systemic inflammatory response syndrome (SIRS) than those with NS. LR will be used in this study based on these results. The current study also employs the system of checkpoints used by Wu et al with the intent to compare moderate versus aggressive fluid resuscitation.

OBJECTIVES AND PURPOSE: Precise fluid management strategy in patients with acute pancreatitis is unclear. The investigators principal aim is to perform a well done randomized trial to assess the hypothesis that aggressive fluids benefits those with mild to moderate acute pancreatitis and help standardize the treatment of these patients. An additional goal of this pilot study will be to determine the effect size of the difference between clinical improvement in those receiving agressive versus moderate fluids with the aim of estimating sample size for larger trials.

STUDY DESIGN: Patients presenting to the Los Angeles County Hospital with mild to moderate pancreatitis are the focus population of this study. Pancreatitis will be diagnosed using 2 of 3 criterion; amylase or lipase greater than 3 times the upper limit of normal, epigastric abdominal pain, and imaging consistent with acute pancreatitis. Available data suggest that in those with severe pancreatitis aggressive fluid rescusctiation may be harmful and these patients will be excluded.Patients will be randomized to aggressive versus moderate fluids within 4 hours of diagnosis of pancreatitis. The inclusion and exclusion criterion will be assessed. Randomization will be performed using a computer program with concealed allocation. The amount of fluids and intervention performed in the emergency department prior to randomization will be recorded but not affect randomization strategy.