SGEM#382: Don’t Go Chasing Waterfalls to Treat Pancreatitis

Date: November 10th, 2022 Reference: de-Madaria E et al. Aggressive or Moderate Fluid Resuscitation in Acute Pancreatitis (WATERFALL). NEJM 2022. Guest Skeptic: Dr. Salim R. Rezaie completed his medical school training at Texas A&M Health Science Center and continued his medical education with a combined Emergency Medicine/Internal Medicine residency at East Carolina University. Currently, Salim works as a community emergency physician at Greater San Antonio Emergency Physicians (GSEP), where he is the director of clinical education. Salim is also the creator and founder of REBEL EM and REBEL Cast, a free, critical appraisal blog and podcast that try to cut down knowledge translation gaps of research to bedside clinical practice. Case: A 38-year-old male presents to the emergency department (ED) with acute mid epigastric abdominal pain with nausea and vomiting.  As part of the patient’s workup, he has an elevated lipase, and a CT abdomen and pelvis ultimately shows the patient to have acute pancreatitis. You remember a new trial was just published on whether to use aggressive versus nonaggressive goal-directed fluid resuscitation in the early phase of acute pancreatitis and wonder which would be better for this patient. Background: It’s interesting to see how fluid resuscitation has been debated over the years. This includes fluid type and rate for things like renal colic (SGEM#32), pediatric diabetic ketoacidosis  (SGEM#255), hyponatremia (SGEM#326), trauma (SGEM#369), and critically ill adults (SGEM#347 and SGEM#368). Standard management of acute pancreatitis has focused mainly on hydration, analgesia, and investigation for an underlying cause.  Recent evidence has challenged the routine use of aggressive large volume fluid resuscitation with the potential to increase the severity of pancreatitis as well as fluid overload.  High-quality evidence demonstrating harms of aggressive fluid resuscitation in acute pancreatitis have been lacking. Clinical Question: Does the use of a moderate fluid resuscitation strategy in acute pancreatitis decrease the rate of progression to moderate/severe pancreatitis in comparison to aggressive fluid resuscitation? Reference: de-Madaria E et al. Aggressive or Moderate Fluid Resuscitation in Acute Pancreatitis (WATERFALL). NEJM 2022. Population: Adult patients (≥18 years of age) diagnosed with acute pancreatitis based on the Revised Atlanta Classification (Requires 2 of 3: Typical abdominal pain, serum amylase or lipase level higher than three times the upper limit of normal, or signs of acute pancreatitis on imaging) that presented within 24 hours of pain onset Exclusions: Patients who met the criteria for moderately severe or severe disease at baseline (shock, respiratory failure, and renal failure) or who had baseline heart failure (NYHA II, III, or IV), uncontrolled arterial hypertension, electrolyte disturbances (hypernatremia, hyponatremia, hyperkalemia, hypercalcemia), an estimated life expectancy of <1 year, chronic pancreatitis, chronic renal failure, or decompensated cirrhosis Intervention: Moderate fluid resuscitation (bolus of 10 cc/kg lactated Ringer’s [LR] over two hours in patients with hypovolemia or no bolus in those with normovolemia followed by 1.5 cc/kg/hour of LR) Comparison: Aggressive fluid resuscitation (bolus of 20 cc/kg LR over two hours regardless of fluid status followed by 3.0 cc/kg/hour of LR) Outcome: Primary Outcome: Progression to moderately severe or severe acute pancreatitis (according to the Revised Atlanta Classification). Secondary Outcomes: Organ failure, local complications, persistent organ failure, respiratory Failure, hospital length of stay (LOS), ICU admission, and ICU LOS 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,