Читать книгу Clinical Pancreatology for Practising Gastroenterologists and Surgeons - Группа авторов - Страница 109

Time is of the essence in managing AP. There is no pharmacological therapy for AP. Fluid resuscitation is the mainstay of therapy in AP, where patients often present in a volume‐depleted state due to vomiting, poor oral intake, and insensible losses. An acute surge in release of inflammatory mediators results in increased vascular permeability and third spacing of fluids [30]. Early administration of adequate fluid therapy to prevent hypovolemia and organ hypoperfusion is critical in the management of AP. Despite multiple guidelines and publications, a recent exhaustive technical review by the AGA observed that there is no clear evidence to recommend the volume, type, duration, or rate of fluid administration [28]. Current clinical guidelines recommend goal‐directed fluid therapy which focuses on administering intravenous fluids and monitoring heart rate, mean arterial pressure, central venous pressure, urine output, blood urea nitrogen concentration, and hematocrit [29]. Inadequate fluid resuscitation in the first 24 hours, as evidenced by hemoconcentration, has been associated with increased rate of pancreatic necrosis [31,32]. Aggressive intravenous fluid resuscitation during the initial few hours provides microcirculatory and macrocirculatory support to prevent development of pancreatic necrosis [33]. Although the evidence supporting goal‐directed aggressive fluid therapy in AP is relatively limited in demonstrating improvement in important outcomes such as mortality and organ failure, using such metrics has been shown to improve outcomes in sepsis, which has a similar picture to AP [34,35]. Also, using such goal‐directed fluid hydration avoids overly aggressive fluid therapy, which can lead to complications such as volume overload and abdominal compartment syndrome [36,37]. Recent data suggests moderate to aggressive fluid administration is most beneficial if administered in the first 24 hours [38] and has little impact after this point [37,39,40]. The optimal recommended infusion rate in the first 24 hours is 250–500 ml/hour, unless there are cardiovascular, renal, or other medial comorbid conditions [5].