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The foundation for therapy of patients with AP is fluid restoration, as the major effect of pancreatic inflammation is fluid sequestration. The goals of fluid therapy are to replenish the lost circulatory fluids to maintain organ system perfusion and oxygenation including the pancreas. Unfortunately, our recommendations are not based on conclusive scientific information [61]. Sinha et al. [62] reported variables that independently predicted increased fluid sequestration within the first 48 hours after hospital admission; these included younger age (<40 years), alcohol etiology, hemoconcentration, and SIRS. Increasing volumes of fluid sequestration were associated with longer hospitalizations, persistent SIRS, and persistent organ system failure [63]. Buxbaum et al. [64] reported a randomized trial of patients with nonsevere AP to aggressive (20 ml/kg bolus followed by 3 ml/kg per hour vs. standard therapy with 10 ml/kg bolus followed by 1.5 ml/kg per hour) hydration with Ringer’s lactate solution. They found that a significantly higher proportion of patients treated with aggressive compared with standard hydration showed clinical improvement. In addition to higher volumes of fluid, early fluid resuscitation reduces morbidity among patients with AP. Warndorf et al. [65] reported that early resuscitation, defined as the administration of one‐third or more of the total 72‐hour fluid volume within 24 hours of presentation, was associated with decreased SIRS as well as reduced organ failure, lower rate of admissions to the intensive care unit (ICU), and reduced length of hospitalization; the fluid of choice is Ringer’s lactate [65]. The clinical goals of fluid replacement therapy are to achieve hemodynamic stability. Clinically, we follow the parameters of heart rate, urine output, and blood pressure; in addition, we follow the laboratory markers BUN and hematocrit. Thus, the volumes infused are based on the patient’s vital signs, incorporating blood pressure, pulse and respiratory rates, age, cardiac and renal disease, laboratory values (BUN, creatinine and hematocrit), and the presence of SIRS. This so‐called goal‐directed therapy for fluid management is defined as titration of intravenous fluids to specific clinical and biochemical targets of perfusion [66].

Table 1.6 Fluid therapy for patients with moderately severe or severe acute pancreatitis.

Source: adapted from DiMagno MJ. Clinical update on fluid therapy and nutritional support in acute pancreatitis. Pancreatology 2015;15(6):583–588.

Bolus of Ringer’s lactate: administer 1 liter in the emergency roomInfusion of Ringer’s lactate at 5–10 ml/kg per hour until clinical hemodynamic stability and laboratory parameters are reachedChange intravenous fluid rate to 3 ml/kg per hour once parameters are reached

Fluid therapy is most effective if given early in the course of AP. This was shown by an international multicenter study which found that early moderate (>500–1000 ml) compared to nonaggressive (<500 ml) fluid volume administration in the emergency room was associated with lower rates of local complications; indeed, the groups who received aggressive therapy (>1000 ml) also had a significantly lower need for intervention [67]. We utilize a combination of initial bolus and high‐volume intravenous infusion and assess our goal‐directed therapy using the patient’s vital signs, hourly urine output, and measurement of BUN, creatinine and hematocrit every six to eight hours. When hemodynamic stability is achieved and laboratory values are normal (BUN <20 mg/dl and hematocrit <35%), we decrease rates of infusion (Table 1.6).