Update on the strategy for intravenous fluid treatment in acute pancreatitis

Fluid therapy/resuscitation is mandatory in acute pancreatitis due to the pathophysiology of fluid loss as a consequence of the inflammatory process.For many years,without clear evidence,early and aggressive fluid resuscitation with crystalloid solutions(normal saline solution or Ringer lactate solution)was recommended.Recently,many randomized control trials and meta-analyses on fluid therapy have revealed that high fluid rate infusion is associated with increased mortality and severe adverse events compared to those resulting from moderate fluid rates,and this has triggered a paradigm shift in fluid management strategies.Meanwhile,there is evidence to show that Ringer lactate solution is superior to normal saline solutions in this context.The purpose of this review is to provide an update on the strategies for intravenous fluid treatment in acute pancreatitis,including the type,optimal amount,rate of infusion,and monitoring guides.Recommendations from recent guidelines are critically evaluated for this review in order to reach the authors'recommendations based on the available evidence.

Fluid resuscitation in acute pancreatitis

Acute pancreatitis remains a clinical challenge, despite an exponential increase in our knowledge of its complex pathophysiological changes. Early fluid therapy is the cornerstone of treatment and is universally recommended; however, there is a lack of consensus regarding the type, rate, amount and end points of fluid replacement. Further confusion is added with the newer studies reporting better results with controlled fluid therapy. This review focuses on the pathophysiology of fluid depletion in acute pancreatitis, as well as the rationale for fluid replacement, the type, optimal amount, rate of infusion and monitoring of such patients. The basic goal of fluid epletion should be to prevent or minimize the systemic response to inflammatory markers. For this review, various studies and reviews were critically evaluated, along with authors’ recommendations, for predicted severe or severe pancreatitis based on the available evidence.

Plasma-Lyte 148: A clinical review

AIM To outline the physiochemical properties and specific clinical uses of Plasma-Lyte 148 as choice of solution for fluid intervention in critical illness, surgery and perioperative medicine.METHODS We performed an electronic literature search from Medline and Pub Med(via Ovid), anesthesia and pharmacology textbooks, and online sources including studies that compared Plasma-Lyte 148 to other crystalloid solutions. The following keywords were used: "surgery", "anaesthesia", "anesthesia", "anesthesiology", "anaesthesiology", "fluids", "fluid therapy", "crystalloid", "saline", "plasma-Lyte", "plasmalyte", "hartmann's", "ringers" "acetate", "gluconate", "malate", "lactate". All relevant articles were accessed in full. We summarized the data and reported the data in tables and text. RESULTS We retrieved 104 articles relevant to the choice of Plasma-Lyte 148 for fluid intervention in critical illness, surgery and perioperative medicine. We analyzed the data and reported the results in tables and text.CONCLUSION Plasma-Lyte 148 is an isotonic, buffered intravenous crystalloid solution with a physiochemical composition that closely reflects human plasma. Emerging data supports the use of buffered crystalloid solutions in preference to saline in improving physicochemical outcomes. Further large randomized controlled trials assessing the comparative effectiveness of PlasmaLyte 148 and other crystalloid solutions in measuring clinically important outcomes such as morbidity and mortality are needed.

Perioperative fluid management in major hepatic resection: an integrative review

BACKGROUND: Fluid intervention and vasoactive pharmacological support during hepatic resection depend on the preference of the attending clinician, institutional resources, and practice culture. Evidence-based recommendations to guide perioperative fluid management are currently limited. Therefore, we provide a contemporary clinical integrative overview of the fundamental principles underpinning fluid intervention and hemodynamic optimization for adult patients undergoing major hepatic resection. DATA SOURCES: A literature review was performed of MEDLINE, EMBASE and the Cochrane Central Registry of Controlled Trials using the terms 'surgery', 'anesthesia', 'starch', 'hydroxyethyl starch derivatives', 'albumin', 'gelatin', 'liver resection', 'hepatic resection', 'fluids', 'fluid therapy', 'crystalloid', 'colloid', 'saline', 'plasma-Lyte', 'plasmalyte', 'hartmann's', 'acetate', and 'lactate'. Search results for MEDLINE and EMBASE were additionally limited to studies on human populations that included adult age groups and publications in English. RESULTS: A total of 113 articles were included after appropriate inclusion criteria screening. Perioperative fluid management as it relates to various anesthetic and surgical techniques is discussed.CONCLUSIONS: Clinicians should have a fundamental understanding of the surgical phases of the resection, hemodynamic goals, and anesthesia challenges in attempts to individualize therapy to the patient's underlying pathophysiological condition. Therefore, an ideal approach for perioperative fluid therapy is always individualized. Planning and designing large-scale clinical trials are imperative to define the optimal type and amount of fluid for patients undergoing major hepatic resection. Further clinical trials evaluating different intraoperative goal-directed strategies are also eagerly awaited.

Controversies in fluid therapy: Type, dose and toxicity

Fluid therapy is perhaps the most common intervention received by acutely ill hospitalized patients; however, a number of critical questions on the efficacy and safety of the type and dose remain. In this review, recent insights derived from randomized trials in terms of fluid type, dose and toxicity are discussed. We contend that the prescription of fluid therapy is context-specific and that any fluid can be harmful if administered inappropriately. When contrasting ‘‘crystalloid vs colloid'', differences in efficacy are modest but differences in safety are significant. Differences in chloride load and strong ion difference across solutions appear to be clinically important. Phases of fluid therapy in acutely ill patients are recognized, including acute resuscitation, maintaining homeostasis, and recovery phases. Quantitative toxicity(fluid overload) is associated with adverse outcomes and can be mitigated when fluid therapy basedon functional hemodynamic parameters that predict volume responsiveness and minimization of non-essential fluid. Qualitative toxicity(fluid type), in particular for iatrogenic acute kidney injury and metabolic acidosis, remain a concern for synthetic colloids and isotonic saline, respectively. Physiologically balanced crystalloids may be the ‘‘default'' fluid for acutely ill patients and the role for colloids, in particular hydroxyethyl starch, is increasingly unclear. We contend the prescription of fluid therapy is analogous to the prescription of any drug used in critically ill patients.

Postpartum posterior reversible encephalopathy syndrome secondary to preeclampsia and cerebrospinal fluid leakage:A case report and literature review

BACKGROUND Postpartum posterior reversible encephalopathy syndrome(PRES) is not uncommon.Its mechanisms and risk factors are not clear.CASE SUMMARY A 28-year-old woman underwent cesarean section but had inadvertent dural puncture during epidural anesthesia.To manage the symptoms of intracranial hypotension,crystalloid fluid was infused.However,the patient developed postpartum preeclampsia and PRES.The patient was treated with diazepam and dehydration therapy.The signs of cerebral lesions on magnetic resonance imaging disappeared on postpartum day 7.CONCLUSION Postpartum preeclampsia and PRES can develop concomitantly.Treating postdural puncture headaches with infusion of crystalloid fluid may precipitate the development of PRES.

The Effect of Clinically Used Crystalloid Solution on the Clearance Rate of Lactic Acid in Septic Shock Patients

Objective: To explore the effect of clinically available crystalloids on lactate clearance in patients with septic shock Methods: Sixty-eight patients with septic shock who were treated in our hospital from January 2017 to January 2019 were enrolled in the study. The selected patients were randomly divided into three groups: sodium lactate Ringer's solution group (LR group), saline group (NS group) and compound sodium chloride injection group (RS group), each group received the corresponding crystal liquid for fluid resuscitation, compare three groups Heart rate (HR), mean arterial pressure (MAP), cardiac output, procalcitonin (PCT), and C-reactive protein (CRP) before and after treatment, compared with the treatment of 24 hours of lactate clearance and APACHE II scores, and the overall hospitalization time and mortality rate of the three groups of patients were statistically compared;Results: (1) The difference of HR, MAP and cardiac output between the three groups before treatment was not statistically significant (P>0.05), treatment for 24h The HR of the post-Lactate Ringer's solution group was lower than that of the control group, and the MAP and cardiac output were higher than the control group (P<0.05). (2) The difference of PCT, CRP and BNP levels between the three groups before and after treatment was not statistically significant. (P>0.05);(3) Compared with the results, there was no statistically significant difference in the clearance rate of lactate clearance between the three groups (P>0.05). Three groups before and after treatment APACHE II score was not statistically significant difference comparison (P> 0.05). (4) Three groups The overall hospitalization time and mortality rate of the patients were not statistically significant (P>0.05). Conclusion: Lactate Ringer's solution can better maintain the circulation capacity and blood pressure, which can alleviate the clinical symptoms of patients with septic shock, but no obvious effect on lactic acid clearance. The effect of resuscitation with clinically available crystalloid sodium lactate Ringer's solution, saline and compound sodium chloride injection was not statistically significant in patients with septic shock.

MORPHOMETRIC EVALUATION ON MYOCARDIAL PROTECTION OF COLD CRYSTALLOID VERSUS WARM BLOOD CARDIOPLEGIA

Twenty patients undergoing open-heart valve replacement were divided randomly into two groups in this study; intermittent perfusion of cold crystalloid (St. Thomas Hospital solution) with hypothermic cardiopulmonary bypass (CPB) (hypothermic group) and continuous administration of warm blood cardioplegia with normothermic CPB (normothermic group) respectively. Tissue samples were taken from the right atrium before weaning from CPB and from the right appendage 30 minutes after removal of the cross-clamp. The results of pathological study in these two groups were as follows: the structural alterations were most severe during the ischemic period in the hypothermic group. Damages of the myocardial