Update on the strategy for intravenous fluid treatment in acute pancreatitis

Table 1 Modified Marshall scoring system for organ dysfunction

	Scorea
Organ system	0	1	2	3	4
Respiration (PaO2/FiO2)b	> 400	301-400	201-300	101-200	< 101
Kidney (serum creatinine), µmol/L	< 134	134-169	170-310	311-439	> 439
Kidney (serum creatinine), mg/dL	< 1.4	1.4-1.8	1.9-3.6	3.7-4.9	> 4.9
Cardiovascular (systolic blood pressure), mmHg	> 90	< 90, fluid responsive	< 90, not fluid responsive	< 90, pH < 7.3	< 90, pH < 7.2

^aScore ≥ 2 for any system defines the presence of organ failure.

^bFor nonventilated patients, FiO₂ can be estimated by the rate of supplemental oxygen (Room air, 21%; 2 L/min, 25%; 4 L/min, 30%; 6-8 L/min, 40%; 9-10 L/min, 50%).

FiO₂: Fraction of inspired oxygen; PaO₂: Partial pressure of arterial oxygen.

Table 2 Summary of randomized controlled trials comparing different intravenous fluid resuscitation strategies in acute pancreatitis

Ref.	Design	N	Participants	Randomization	Aggressive resuscitation	Volume	Nonaggressive resuscitation	Volume	Effect of early aggressive resuscitation
Mao et al[44], 2009	Superiority	76	Severe AP	72 h	Rapid volume expansion (10-15 ml/kg/h)	4 ± 2 L Crystalloid; 1.3 ± 0.8 L; Colloid in 24 h	Controlled volume expansion (5-10 ml/kg/h)	2.4 ± 1.9 L Crystalloid; 0.9 ± 0.6 L; Colloid in 24 h	Harmful, more sepsis, mortality, mechanical ventilation, and ACS
Mao et al[46], 2010	Superiority	115	Severe AP	24 h	Rapid hemodilution with goal Hct < 35% at 48 h	-	Slow hemodilution with goal Hct > 35% at 48 h	-	Harmful, more sepsis, and mortality
Wu et al[31], 2011	Factorial	40	Any severity	6 h	Goal-directed with 20 ml/kg bolus + 3 or 1.5 ml/kg/h of LR or NS	4.3 L in 24h	LR or NS fluid therapy adjusted by treating physician	4.6 L in 24h	Similar, SIRS, and CRP at 24 h
Buxbaum et al[22], 2017	Superiority	60	Predicted mild AP	4 h	20 ml/kg bolus + 3 ml/kg/h of LR	5.6 L in 24 h; 7.6 L in 36 h	10 ml/kg bolus then 1.5 ml/kg/h of LR	3.9 L in 24 h; 5.6 L in 36 h	Beneficial, less composite outcome, SIRS, and hemoconcentration
Cuéllar-Monterrubio JE et al[45], 2020	Two-tailed	88	Any severity AP, more than 24 hr disease onset	4 h	20 mL/kg bolus + 3 mL/kg/hr first 24 hours and then 30 mL/kg for the next 24 hours	8.54 ± 1.83 L in 48 h	20 ml/kg bolus (if hypovolemia, 3/45) - 1.5 ml/kg/h of HS first 24 hours and then 30 mL/kg for the next 24 hours	5.13 ± 1.28 L in 48 h	No benefit, no differences found in SIRS, pancreatic necrosis, Respiratory complication, AKI, and LOS
De-Madaria E et al[47], 2022	Two-tailed	249	Mild AP, less than 24 h disease onset	8 h	20 ml/kg bolus + 3 ml/kg/h of LR	7.8 (6.5-9.8) L in 48h	10 mL/kg bolus (if hypovolumia) - 1.5 ml/kg/h of LR	5.5 (4.0-6.8) L in 48 h	Harmful, more fluid overload

AP: Acute pancreatitis; ACS: Abdominal compartment syndrome; LR: Lactated Ringer’s; NS: Normal saline; SIRS: Systemic inflammatory response syndrome; CRP: C-reactive protein; HS: Hartmann’s solution; AKI: Acute kidney injury; LOS: Length of stay.

Table 3 Authors’ recommendations for fluid resuscitation strategy in acute pancreatitis

Parameter	Recommendation
Who	All patients with any severity
Timing	Early fluid resuscitation is better
Type of fluid	Ringer lactate solutions better than normal saline solutions
	Avoid synthetic colloids (HES or Dextran), Limited data in human albumin
Amount of fluid
Mild pancreatitis	3 L in 24 h and 4-6 L in 48 h
Moderate or severe pancreatitis	3-4 L in 24 h and 6-8 L in 48 h based on clinical/lab parameters
Rate of infusion
Mild pancreatitis	1.5 mL/kg/h with bolus dose 10 mL/kg/h in 1-2 h in patients with hypovolemia, BUN > 25, Hematocrit ≥ 44%, AKI, Age < 40 yr, and Alcoholic etiology
Moderate or severe pancreatitis	1.5-3 mL/kg/h with bolus dose 10-20 mL/kg/h in 1-2 hours or higher in hypotension
Monitoring goals	MAP ≥ 65 mmHg, Urine output ≥ 0.5 mL/kg/h
	Hematocrit < 44% and/or BUN < 25 mg/dL at 12 and 24 h (for guided fluid rate adjustment)
	Invasive monitoring and dynamic parameters needed in ICU patients or cardio/renal dysfunction patients
Duration	24-48 h, Infusion can stop after 24 h if oral feeding can be tolerated in mild pancreatitis

HES: Hydroxyethyl starch; BUN: Blood urea nitrogen; AKI: Acute kidney injury; MAP: Mean arterial pressure.