Ann Hepatobiliary Pancreat Surg.  2023 Nov;27(4):394-402. 10.14701/ahbps.23-044.

Is aggressive intravenous fluid prescription the answer to reduce mortality in severe pancreatitis? The FLIP study: Fluid resuscitation in pancreatitis

• McGovern J
• Tingle SJ
• Northern Surgical Trainees Research Association (NOSTRA)
• Robinson S
• Moir J

• KMID: 2548506
• DOI: http://doi.org/10.14701/ahbps.23-044

Abstract

Backgrounds/Aims
Acute pancreatitis is an emergency presentation, which can range from mild to life threatening. Intravenous fluids are the cornerstone of management. Although the WATERFALL trial described the optimal fluid rate in mild/moderate pancreatitis, this trial excluded patients with moderate-severe/severe pancreatitis. The aim of this study was to establish clinical practice regarding intravenous fluid administration in acute pancreatitis and assess its effect on mortality.
Methods
Prospective multi-centre audit of patients with acute pancreatitis was conducted. Data were collected regarding intravenous fluid administration within 72 hours of admission. The primary outcome was 30-day mortality. Multivariable logistic regression was used to identify predictors of 30-day mortality.
Results
Those with severe pancreatitis received more fluid; median 5.7 L versus 4 L in 72 hours (p = 0.003). Participants with severe pancreatitis who died within 30 days received a median of 2,750 mL in the first 24 hours, compared to 4,000 mL in those who survived. The following factors were significant predictors of 30-day mortality: age, Glasgow score, C-reactive protein, ischaemic heart disease, and pancreatitis aetiology. Overall, volume of intravenous fluid was not associated with mortality. However, the effect of intravenous fluid volume on mortality differed significantly depending on pancreatitis severity. In severe pancreatitis, increased volume of intravenous fluid was associated with significant reductions in mortality (odds ratio = 0.655; 0.459–0.936; p = 0.020).
Conclusions
In severe pancreatitis, more aggressive fluid prescription was associated with decreased mortality; however, this was not the case in milder disease. Further prospective trials guiding fluid resuscitation in severe pancreatitis are needed, as the impact of fluid on this population appears to differ from that in those with milder disease.

Keyword

Pancreatitis; General surgery; Infusions

Figure

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  Fig. 1 Volume of intravenous fluid delivered. (A) Histogram displaying total volume of IV fluid delivered in the first 72 hours. (B) Violin and box blots displaying volume of IV fluid delivered on the first, second, and third days of admission. (C, D) Violin and box plots showing volume of IV fluid delivered to patients with non-severe and severe pancreatitis in the first 72 and 24 hours, respectively. Comparisons represent p-values from Mann–Whitney U tests. IV, intravenous.

• 

  Fig. 2 Volume of intravenous fluid by 30-day mortality displayed with violin and box plots. (A) Entire cohort. (B) Participants with non-severe pancreatitis. (C, D) Participants with severe pancreatitis, showing total IV fluid delivered in 72 and 24 hours, respectively. (E, F) Participants with a history of IHD and heart failure, respectively. Comparisons represent p-values from Mann-Whitney U tests. For subgroups with < 50 participants, data for individual participants are presented as a dot plot. IV, intravenous; IHD, ischaemic heart disease.

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