In this episode, I’ll discuss an article about aggressive vs moderate fluid resuscitation in acute pancreatitis.
There has been a trend in research published over the last several years towards demonstrating that aggressive fluid resuscitation in septic patients without consideration to other factors is not necessarily associated with the best possible patient outcomes. A group of authors recently took this concept and applied it to patients with acute pancreatitis and published their results in the New England Journal of Medicine.
The study was a multi-center randomized controlled trial of patients who presented with acute pancreatitis. Patients were evenly split into two groups to receive goal-directed aggressive or moderate resuscitation using crystalloid therapy with lactated Ringer’s solution. The aggressive fluid resuscitation group received a bolus of 20 mL/kg, followed by 3 mL/kg/hr. The moderate fluid resuscitation group received a bolus of 10 mL/kg only if hypovolemia was present – otherwise they received no bolus, followed by 1.5 mL/kg/hr.
The primary efficacy outcome was the development of moderately severe or severe pancreatitis during the hospitalization and the main safety outcome was fluid overload.
After 249 patients were enrolled a pre-planned interim safety analysis was performed and the study was terminated early after only enrolling one-third of the planned study population. While the efficacy outcome was similar between groups, the safety outcome of fluid overload was far more common in the aggressive management group with 20.5% of patients developing fluid overload vs only 6.3% in the moderate fluid resuscitation group.
The authors concluded:
In this randomized trial involving patients with acute pancreatitis, early aggressive fluid resuscitation resulted in a higher incidence of fluid overload without improvement in clinical outcomes.
The editors of the NEJM invited expert commentary to be published along side the study which is usually a sign that the results are considered significant enough to change the way medicine is practiced. The editorialist argues the study was extremely well-designed and it indicates that not only should the rate of resuscitation be slower but the total infused volume should be lower.
Members of my Hospital Pharmacy Academy have access to a review of the practice of deresuscitation and over 200 practical trainings on aspects of hospital pharmacy that cover critical care, emergency medicine, infectious disease, and general hospital pharmacy, as well as many other resources to help in your practice. To sign up go to pharmacyjoe.com/academy.
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