BJS, 2023, 1–3
https://doi.org/10.1093/bjs/znad155
Leading Article
Fluid treatment in acute pancreatitis: a careful
balancing act
Kristian Strand1,2,* and Jannicke H. Møller1
1
Department of Intensive Care, Stavanger University Hospital, Stavanger, Norway
2
Department of Clinical Medicine, University of Bergen, Bergen, Norway
*Correspondence to: Kristian Strand, Department of Intensive Care, Stavanger University Hospital, Gerd-Ragna Bloch Thorsens gate 8, 4011 Stavanger, Norway
(e-mail: kristian.strand@sus.no)
Preventing organ dysfunction due to hypoperfusion is the goal of 1.5 ml/kg/h respectively. Notably, patients presenting with
most therapies addressing circulatory failure. In shock states, shock and patients with moderately severe or severe acute
such as those caused by sepsis and acute pancreatitis, the pancreatitis were excluded. Initially planned to include 744
intravascular volume may be reduced. This may be the result of patients, the trial ended up including 249 patients after it was
several factors, such as dehydration from vomiting, reduced halted due to an interim analysis showing a significantly higher
fluid intake, and fever. The negative effect of the reduced incidence of fluid overload in the aggressive group (20.5
volume is compounded by interstitial fluid sequestration and compared with 6.9 per cent) without significant differences in
vasoplegia with venous pooling of blood leading to a reduced the incidence of the primary outcome of development of
preload of the heart. However effective in re-establishing moderately severe or severe acute pancreatitis. Although not
normal blood pressure and cardiac output, the administration of statistically significant, the incidences of important secondary
large volumes of intravenous fluids comes at a price. There is outcomes, such as pancreatic necrosis, organ failure, ICU
ample evidence from observational trials in the critically ill that admission, and death, were all numerically higher in the
overzealous volume administration may negatively affect aggressive group. The median amounts of fluid administered
outcomes leading to increased mortality, morbidity, and length were 7.8 l in the aggressive group and 5.5 l in the moderate group.
of stay1. In conditions of high systemic inflammation, the The WATERFALL study provides evidence that an aggressive
infusion of crystalloids has the potential to harm endothelial approach to fluid administration does not confer any benefits on
integrity leading to a vicious circle of increased intravascular patient-centred outcomes in mild acute pancreatitis. Whether
fluid loss and oedema, further compromising organ function in this can be extrapolated to patients with more severe disease is
critically ill patients. unknown, but the totality of evidence at this time does not
In acute pancreatitis, the presence of microcirculatory indicate that aggressive fluid administration is warranted.
dysfunction caused by local inflammation and the release Having this in mind, it is important that patients presenting
of inflammatory mediators leads to a systemic inflammatory with haemodynamic compromise due to hypovolaemia if
response that reduces pancreatic perfusion and aggravates injury. indicated by history, clinical examination, or a high haematocrit
This local and systemic inflammation may lead to intestinal are resuscitated with intravenous fluids, as simply leaving
paralysis and retroperitoneal oedema. This state may lead to organs underperfused is not an option that is in line with basic
intra-abdominal hypertension and eventually development of principles of resuscitation (Fig. 1). The question that remains
abdominal compartment syndrome as the most severe form. unanswered is how to optimize fluid administration in a way
Such severe conditions can further compromise a patient’s that reaps the benefits of increased perfusion while not
haemodynamic status, lead to further organ failure, and are exacerbating capillary leak and oedema.
associated with high mortality. Finding the sweet spot in fluid resuscitation is notoriously hard in
Fluid resuscitation has been the mainstay of initial therapy in the surgical ward, and even in a high-tech environment, such as the
acute pancreatitis. Even in the absence of obvious hypovolaemia ICU. Traditionally, administering fluids while a patient is on the
and shock, early fluid resuscitation has been propagated based ascending slope of the Frank–Starling curve has been the goal in
on evidence from experimental studies showing a reduction in patients in shock4. While administering fluid in non-fluid-tolerant
pancreatic injury and necrosis and thereby preventing the patients is certainly detrimental due to the increased stress on
progression to more severe forms2. However, there has been a vessel walls and the risk of reduced organ perfusion from high
lack of data from high-quality RCTs to guide use of fluid venous pressures, there is an understanding that even
administration. Enter the WATERFALL study published in 20223. fluid-responsive patients may experience serious side effects, as
This study was the first large RCT comparing different fluid these fluids accumulate over time outside the circulatory system.
administration strategies in acute pancreatitis. The WATERFALL In a patient with a protracted course of instability, a strategy of
study compared an initial crystalloid bolus of 20 ml/kg with a filling the patient to the point of loss of fluid responsiveness is
bolus of 10 ml/kg followed by an infusion of 3 ml/kg/h and likely to lead to gross oedema and the risk of organ dysfunction.
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