Early Goal-directed Volume Resuscitation in Severe Acute Pancreatitis
Early Goal-directed Volume Resuscitation in Severe Acute Pancreatitis
Acute pancreatitis (AP) is a common disorder with rising incidence varying between 35 and 80
 per 100,000 in Europe and the USA. About 15% of patients develop necrotizing pancreatitis
 (NP) with a mortality of up to 42% and frequently prolonged hospitalisation in the survivors.
 Despite a fulminant pathophysiology comparable to that of sepsis, the management of NP is
 still re-active, symptomatic and mainly based on paradigms with low grade evidence. In sepsis
 beneficial effects of early goal-directed fluid resuscitation resulting in reduced mortality
 have been clearly shown. With regard to these data and several studies of NP demonstrating
 the deleterious effects of fluid loss and haemoconcentration within the first 24h after
 admission, early goal-directed fluid resuscitation has the potential of improving outcome
 also in NP. Therefore, it is the aim of this RCT to demonstrate beneficial effects of early
 goal-directed resuscitation using an algorithm based on modern haemodynamic parameters such
 as Intra-thoracic Blood Volume Index (ITBI), Extravascular Lung Water Index (ELWI) and Stroke
 Volume Variation (SVV) which can be easily and safely obtained due to recent progress in
 haemodynamic monitoring. The algorithm is aimed at maintaining adequate resuscitation (ITBI,
 SVV) as well as preventing pulmonary over-hydration (ELWI).The use of a similar algorithm in
 cardiac surgery patients resulted in a significant reduction in catecholamine use, lactate
 levels, duration of ventilation and ICU stay.
Resuscitation using crystalloids and/or colloids with the following goals:

 ITBI: 850 -1000 ml/sqm, if ELWI <=12*ml/kg 750 - 850 ml/sqm, if ELWI >12*ml/kg and/or
 PaO2:FiO2 <200

 *ELWI <=12ml/kg, if MAP>65mmHg without catecholamines <=14ml/kg, if catecholamines required
 for MAP>65mmHg SVV <10% (only in controlled ventilation and sinus rhythm) MAP >65mmHg (MAP:
 Mean Arterial Pressure) IAPP >60mmHg (IAPP: Intra-abdominal Perfusion Pressure)
Inclusion Criteria:

 1. Diagnosis of pancreatitis:

 -  Typical pain

 -  Increase in serum lipase or amylase

 2. Onset of abdominal pain within <=48h before admission

 3. APACHE II >= 8

 4. Evidence of >= 1 predictor of severe pancreatitis:

 -  Haematocrit >44% (male) or >40% (female), respectively

 -  Blood glucose > 125 mg/dl;

 -  CRP >= 10 mg/dl;

 -  Age > 55 years;

 -  Leukocytes >= 16 G/L

 -  GOT > 250 U/L;

 -  LDH > 350 U/L

 -  Calcium < 2,0 mmol/L

 -  CK > upper normal range

 -  Balthazar-score(CT classification) Grade C-E

 -  Any organ failure

 Exclusion Criteria:

 1. Pregnancy

 2. NYHA >II

 3. Pre-existing disease with life expectancy < 3 months