As a clinical pharmacist, you must be kept up to date. New evidence will lead to questions about treating acute pancreatitis..
Fluids. The standard has been to give aggressive fluids in the first 24 hours. But this is based on limited evidence linking early hydration to lower mortality. Now stronger data show that aggressive fluids don’t improve outcomes and lead to fluid overload, compared to moderate hydration. These data are in patients with mild pancreatitis, those without complications (necrosis, organ failure, etc), which is most common. Expect this to change practice. Continue to give fluids early. But generally start with a moderate approach, such as 1.5 mL/kg/hr. Add a 10 mL/kg bolus for patients with hypovolemia. Lean toward lactated Ringer’s (LR). The debate continues about whether LR reduces kidney injury compared to normal saline (0.9% NaCl). Studies differ and outcomes are mixed. But limited data in acute pancreatitis suggest LR is associated with reduced length of stay compared to normal saline. Follow vitals and other parameters to adjust fluids. Also consider titrating based on BUN and hematocrit, since high values in pancreatitis are linked to increased mortality. Usually stop fluids when patients tolerate oral intake.
Antibiotics. New data suggest that using a procalcitonin algorithm decreases antibiotic use for acute pancreatitis. But these data are mainly in mild cases. And we know not to use empiric antibiotics in these patients, since the cause is usually noninfectious (alcohol, gallstones, etc). Don’t add procalcitonin to your pancreatitis protocols. Instead, save antibiotics for when imaging shows pancreatic necrosis WITH gas, or if patients clinically deteriorate. Don’t start them for necrosis withOUT gas, this doesn’t prevent infection. When antibiotics are indicated, reach for broad-spectrum agents that can penetrate the area like a carbapenem alone, cefepime plus metronidazole, etc. Read our note, "Treating ACUTE pancreatitis".
REFERENCES
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de-Madaria E, Buxbaum JL, Maisonneuve P, García García de Paredes A, Zapater P, Guilabert L, Vaillo-Rocamora A, Rodríguez-Gandía MÁ, Donate-Ortega J, Lozada-Hernández EE, Collazo Moreno AJR, Lira-Aguilar A, Llovet LP, Mehta R, Tandel R, Navarro P, Sánchez-Pardo AM, Sánchez-Marin C, Cobreros M, Fernández-Cabrera I, Casals-Seoane F, Casas Deza D, Lauret-Braña E, Martí-Marqués E, Camacho-Montaño LM, Ubieto V, Ganuza M, Bolado F; ERICA Consortium. Aggressive or Moderate Fluid Resuscitation in Acute Pancreatitis. N Engl J Med. 2022 Sep 15;387(11):989-1000. Available at: https://www.nejm.org/doi/10.1056/NEJMoa2202884
Siriwardena AK, Jegatheeswaran S, Mason JM; PROCAP investigators. A procalcitonin-based algorithm to guide antibiotic use in patients with acute pancreatitis (PROCAP): a single-centre, patient-blinded, randomised controlled trial. Lancet Gastroenterol Hepatol. 2022 Oct;7(10):913-921. Available at: https://www.thelancet.com/journals/langas/article/PIIS2468-1253(22)00212-6/fulltext
Baron TH, DiMaio CJ, Wang AY, Morgan KA. American Gastroenterological Association Clinical Practice Update: Management of Pancreatic Necrosis. Gastroenterology. 2020 Jan;158(1):67-75.e1. Available at: https://pubmed.ncbi.nlm.nih.gov/31479658/
Crockett SD, Wani S, Gardner TB, Falck-Ytter Y, Barkun AN; American Gastroenterological Association Institute Clinical Guidelines Committee. American Gastroenterological Association Institute Guideline on Initial Management of Acute Pancreatitis. Gastroenterology. 2018 Mar;154(4):1096-1101. Available at: https://www.gastrojournal.org/article/S0016-5085(18)30076-3/fulltext?referrer=https%3A%2F%2Fpubmed.ncbi.nlm.nih.gov%2F