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For medical professionals only, refer to
the timing of rehydration, the speed of rehydration.
.
.
.
Case data
.
Consider that the patient may have hyperlipidemic pancreatitis
due to taking toremifene.
After the patient was admitted to the hospital, toremifene was discontinued, and the treatment plan was blood lipid disparation, continuous renal replacement therapy, and successively gave sodium lactate Ringer injection and glucose sodium chloride injection for liquid resuscitation, intravenous injection of somatostatin injection to inhibit pancreatic enzyme secretion, intravenous infusion of usinastatin injection to inhibit pancreatic enzyme activity, butorphanol injection intravenous pumping analgesia, levofloxacin anti-infection, etc
.
Case study
of fluid resuscitation
Timing
of fluid resuscitation Fluid resuscitation options
of fluid resuscitation and speed of fluid resuscitation
of fluid resuscitation Goal of fluid resuscitation
Focus
the timing of rehydration, the speed of rehydration.
.
.
.
Acute pancreatitis (AP) is a disease characterized by acute inflammation of the pancreas and histological destruction of acinar cells, and is one of the common digestive emergencies, often developed locally and involving systemic organs and systems, resulting in severe acute pancreatitis
.
In the past 20 years, the incidence of AP in China has increased from 0.
19% to 0.
71%, and the course of the disease is self-limited, but about 20% of patients will develop moderate or severe pancreatitis, and the case fatality rate can reach 13%~35% [1].
Let's start with a case [2].
Case data
The patient, a 40-year-old female, was admitted to hospital
on 20 December 2021 with "persistent mid-epigastric pain with vomiting for 14 hours".
The patient's vegetarian diet is mainly light, denying the history of drug and food allergies, denying the history of hypertension, heart disease, diabetes and other chronic medical history, denying the history of infectious diseases, and denying the history of
trauma, poisoning and blood transfusion.
He underwent radical mastectomy for right ductal carcinoma and took toremifene
after surgery.
History and findings:
On April 27, 2020, the TG of the patient was 3.
24 mmol· L-1； On April 29, 2020, he underwent radical breast-conserving resection at our hospital, and underwent several postoperative adjuvant radiotherapy
after discharge.
Patients have been taking toremifene 60 mg, Po, QD
regularly since July 3, 2020.
On August 3, 2020, the TG of the patient's outpatient examination was 3.
94 mmol· L-1
。
On February 15, 2021, the patient developed paroxysmal epigastric cramps with radiating pain in the lower back without eating greasy food, and was hospitalized in our hospital and diagnosed with hyperlipidemic pancreatitis (TG 96.
44 mmol· L-1), after admission, he was instructed to stop taking toremifene, and after 13 days of treatment, he was discharged from the hospital
.
The patient resumed taking toremifene from March 1, 2021 and added fenofibrate 200 mg, po, qd, and on March 17, 2021, the patient's repeat TG was 3.
41 mmol· L-1
。 On December 5, 2021, the patient stopped taking fenofibrate on his own, and half a month later, he developed persistent epigastric pain with nausea and vomiting, vomit was gastric contents, no hematemesis, melena, fearless cold, fever, chest tightness, shortness of breath and other discomforts, and was admitted to the hospital for treatment
.
Admission examination: body temperature 36.
9°C, breathing 15 times·min-1, pulse 93 times·min-1, blood pressure 110/88 mmHg; Abdominal softness, abdominal tenderness, no rebound tenderness, no exception
.
Blood routine for auxiliary examination: white blood cell count 15.
9×109· L-1[Reference value: (3.
5~9.
5),
Neutrophils 0.
888 (0.
4~0.
75); blood biochemical test: amylase 256 IU· L-1（35～135 IU· L-1), lipase 197.
00 IU· L-1（5.
60～51.
3 IU· L-1), potassium 3.
12 mmol· L-1（3.
5～5.
3 mmol· L-1), sodium 125 mmol· L-1（137～147 mmol· L-1），TG 113.
13 mmol· L-1（< 1.
7 mmol· L-1), total cholesterol (TC) 20.
90 mmol· L-1（3.
0～5.
7 mmol· L-1), high-density lipoprotein cholesterol (HDL-C) 0.
99 mmol· L-1（1.
03～1.
55 mmol· L-1), low-density lipoprotein cholesterol (LDL-C) 1.
27 mmol· L-1（1.
89～4.
21 mmol· L-1）
。
(Swipe to see more)
.
Consider that the patient may have hyperlipidemic pancreatitis
due to taking toremifene.
After the patient was admitted to the hospital, toremifene was discontinued, and the treatment plan was blood lipid disparation, continuous renal replacement therapy, and successively gave sodium lactate Ringer injection and glucose sodium chloride injection for liquid resuscitation, intravenous injection of somatostatin injection to inhibit pancreatic enzyme secretion, intravenous infusion of usinastatin injection to inhibit pancreatic enzyme activity, butorphanol injection intravenous pumping analgesia, levofloxacin anti-infection, etc
.
After symptomatic supportive treatment, the vital signs were stable, there was no abdominal pain, diarrhea, nausea and vomiting, chills and fever, and no obvious abnormalities
were found in blood routine, biochemical and imaging examinations.
On January 3, 2022, the patient improved and was discharged from the hospital, instructed to continue taking fenofibrate, and suspend taking toremififene, a low-fat diet, and avoid overeating
.
The TG of the retest on January 18, 2022 was 1.
8 mmol· L-1, informing patients to monitor blood lipids regularly and not be suitable for follow-up
.
Case study
This case was toremifene-induced hypertriglyceridemic acute pancreatitis, and comprehensive treatment such as sodium lactate Ringer injection and glucose sodium chloride injection for liquid resuscitation had a significant
effect.
Compared with signs of hypovolemia due to trauma or bleeding, hypovolemia in AP is caused
by a specific inflammatory response.
Proper fluid resuscitation is the cornerstone of AP therapy by correcting fluid loss, maintaining adequate intravascular volume, improving microcirculatory perfusion and tissue oxygenation, restoring microcirculatory perfusion of the pancreas and intestine, and helping to reverse bacterial translocation and secondary pancreatic infection due to ischemia in the intestine and pancreas, and the importance of fluid resuscitation is emphasized in all AP guidelines [3-5].
。
What are the four points you need to pay attention to regarding fluid resuscitation in AP? Read on
.
of fluid resuscitation
AP patients started fluid replacement within 4 h after admission and continued for 12~24 h, and the patient's vital signs, urine output, urea nitrogen and hematocrit
were evaluated at intervals of 8~12 h.
Fluid therapy is indicated for patients with severe volume depletion within 72 hours of onset and meeting 3 or more of the following indicators:
Heart rate≥ 120 beats per minute;
mean arterial pressure ≥ 85 mmHg or ≤60 mmHg;
Serum lactate concentration ≥ 2 mmol/L, urine output ≤ 0.
5 mL/(kg·h), erythrohematocrit ≥ 44%[6].
Timing
of fluid resuscitation Fluid resuscitation options
According to the guidelines for the diagnosis and treatment of AP in China, crystalloid solutions such as sodium lactate, Ringer solution, and normal saline can be used for fluid resuscitation
of AP.
In the choice of liquid resuscitation crystalloid, the use of sodium lactate Ringer's solution or normal saline is not recommended
.
Note: Patients with AP with hepatic and renal insufficiency are not recommended to infuse sodium lactate Ringer's solution
.
Due to the increased risk of organ failure, artificial colloidal solutions
such as hydroxyethyl starch are not recommended.
Perfusion of albumin and plasma products may be considered in patients with AP in one of the following: in patients with severe dehydration or shock; The mean arterial pressure fluctuates around 65 mmHg when the crystalloid is infusion at the prescribed rate and volume; There was no significant improvement in blood flow after intravenous pressor booster drugs; with severe capillary leak syndrome [1,7].
of fluid resuscitation and speed of fluid resuscitation
The pace of fluid resuscitation follows the principle of "individualization, precision, and limitation," and fluid volume
must be adjusted according to the age, body weight, and pre-existing renal and/or cardiac conditions of the patient with AP.
For patients with AP with shock or dehydration, the initial 30~45 minutes after admission are infusion with 20 mL/kg of fluid, and the subsequent 24 hours are infusion with 5~10 mL/(kg·h), crystalloid/colloidal solution = 3:1, and appropriate fluids
are given to patients without dehydration.
When the mean arterial pressure persists < 60 mmHg, it is restored to more than 60 mmHg with vasopressor at the same time as rapid infusion within 30 minutes, and then the infusion rate is controlled within<b11> 5~10 mL/(kg·h).
The need for fluid resuscitation is assessed every 6 hours at the time of rehydration, and the rate of fluid replacement can be halved
if blood urea nitrogen is decreasing or decreasing.
In critically ill AP patients with cardiorenal insufficiency, fluid management requires maintaining adequate cardiac output to prevent renal hypoperfusion and avoid adverse effects caused by fluid overload to maintain a balanced state of fluid distribution in the body [1,6].
of fluid resuscitation Goal of fluid resuscitation
While expanding volume with fluid resuscitation, histiocyte edema caused by excessive fluid resuscitation and its impact on organ function
should be avoided.
The following indicators indicate successful resuscitation: urine output > 0.
5~1 mL/(kg·h), mean arterial pressure > 65 mmHg, central venous pressure 8~12 mmHg, central venous oxygen saturation ≥ 70%, heart rate < 120 beats/minute, blood urea nitrogen < 7.
14 mmol/L (if blood urea nitrogen > 7.
14 mmol/L, decreased by at least 1.
79 mmol/L within 24 hours), red blood cell specific product of 35%~44
。
Once fluid resuscitation is met, the rate and volume of fluid replacement should be controlled, and low-dose diuretics or renal replacement therapy should be used if necessary to excrete excess fluid infused during the fluid phase to avoid pulmonary edema and increased intraperitoneal pressure [1,5].
Focus
1.
Early fluid resuscitation is a very important treatment for AP
.
2.
For patients with AP with early shock or accompanied by dehydration, short-term rapid fluid resuscitation
is recommended.
Give appropriate fluids
to patients without dehydration.
Early intravenous fluids in the first 12~24 hours are the most beneficial
.
3.
Isotonic crystals (sodium lactate, Ringer solution, normal saline)
are preferred for fluid resuscitation.
4.
The speed of fluid resuscitation follows the principle
of "individualization, precision, and limitation".
5.
Fluid overload can have harmful effects, so the amount and speed of infusion should be dynamically adjusted
with reference to hematocrit, blood urea nitrogen, urine output and lactic acid level.
References:
[1] Emergency Branch of Chinese Medical Association, Beijing-Tianjin-Hebei Emergency First Aid Alliance, Emergency Branch of Beijing Medical Association, Emergency Physician Specialty Branch of Beijing Medical Doctor Association, Emergency First Aid Branch of China Medical and Health Culture Association.
Expert consensus on emergency diagnosis and treatment of acute pancreatitis[J].
Chinese Journal of Emergency Medicine,2021,30(2):161-172.
)
[2] LV Zhijie, SHEN Lirong.
Toremifene induced hypertriglyceridemia leads to acute pancreatitis: 1 case[J].
Chinese Journal of New Drugs and Clinic,2022,41(7):446-448.
)
[3] Wang Pengxu, Shang Dong.
Analysis of major guidelines at home and abroad for acute pancreatitis[J].
Journal of Hepatobiliary and Pancreatic Surgery,2017,29 (1):1-5.
)
[4] Expert consensus on the diagnosis and treatment of acute pancreatitis with hypertriglyceridemia expert group.
Expert consensus on the diagnosis and treatment of acute pancreatitis with hypertriglyceridemia[J].
Chinese Journal of General Practice,2021,24(30):3781-3793.
)
[5] Pancreatic Surgery Group, Surgical Branch of Chinese Medical Association.
Guidelines for the diagnosis and treatment of acute pancreatitis in China ( 2021)[J].
Chinese Journal of Digestive Surgery,2021,20(7):730-739.
)
[6] Mao E.
Intensive management of severe acute pancreatitis [J].
Ann Transl Med，2019，7(22)：687．
[7]Ｒhodes A，Evans LE，Alhazzani W，et al.
Surviving sepsisCampaign：international guidelines for management of sepsis and septic shock：2016[J].
Intensive Care Med， 2017，43(3)：304-377．
