Buxbaum James L, Quezada Michael, Da Ben, Jani Niraj, Lane Christianne, Mwengela Didi, Kelly Thomas, Jhun Paul, Dhanireddy Kiran, Laine Loren
Division of Gastroenterology, University of Southern California, Keck School of Medicine, Los Angeles, California, USA.
Department of Preventive Medicine, University of Southern California, Keck School of Medicine, Los Angeles, California, USA.
Am J Gastroenterol. 2017 May;112(5):797-803. doi: 10.1038/ajg.2017.40. Epub 2017 Mar 7.
Early aggressive intravenous hydration is recommended for acute pancreatitis treatment although randomized trials have not documented benefit. We performed a randomized trial of aggressive vs. standard hydration in the initial management of mild acute pancreatitis.
Sixty patients with acute pancreatitis without systemic inflammatory response syndrome (SIRS) or organ failure were randomized within 4 h of diagnosis to aggressive (20 ml/kg bolus followed by 3 ml/kg/h) vs. standard (10 ml/kg bolus followed by 1.5 mg/kg/h) hydration with Lactated Ringer's solution. Patients were assessed at 12-h intervals. At each interval, in both groups, if hematocrit, blood urea nitrogen (BUN), or creatinine was increased, a bolus of 20 ml/kg followed by 3 ml/kg/h was given; if labs were decreased and epigastric pain was decreased (measured on 0-10 visual analog scale), hydration was then given at 1.5 ml/kg/h and clear liquid diet was started. The primary endpoint, clinical improvement within 36 h, was defined as the combination of decreased hematocrit, BUN, and creatinine; improved pain; and tolerance of oral diet.
The mean age of the patients was 45 years and only 14 (23%) had comorbidities. A higher proportion of patients treated with aggressive vs. standard hydration showed clinical improvement at 36 h: 70 vs. 42% (P=0.03). The rate of clinical improvement was greater with aggressive vs. standard hydration by Cox regression analysis: adjusted hazard ratio=2.32, 95% confidence interval 1.21-4.45. Persistent SIRS occurred less commonly with aggressive hydration (7.4 vs. 21.1%; adjusted odds ratio (OR)=0.12, 0.02-0.94) as did hemoconcentration (11.1 vs. 36.4%, adjusted OR=0.08, 0.01-0.49). No patients developed signs of volume overload.
Early aggressive intravenous hydration with Lactated Ringer's solution hastens clinical improvement in patients with mild acute pancreatitis.
尽管随机试验尚未证实其益处，但急性胰腺炎治疗仍推荐早期积极静脉补液。我们对轻度急性胰腺炎初始治疗中积极补液与标准补液进行了一项随机试验。
60例无全身炎症反应综合征（SIRS）或器官衰竭的急性胰腺炎患者在诊断后4小时内被随机分为积极补液组（20ml/kg推注，随后3ml/kg/h）和标准补液组（10ml/kg推注，随后1.5ml/kg/h），均使用乳酸林格氏液。每12小时对患者进行评估。在每个时间间隔，两组中若血细胞比容、血尿素氮（BUN）或肌酐升高，则给予20ml/kg推注，随后3ml/kg/h；若实验室指标下降且上腹部疼痛减轻（采用0至10视觉模拟量表测量），则以1.5ml/kg/h补液并开始给予清流食。主要终点为36小时内临床改善，定义为血细胞比容、BUN和肌酐下降；疼痛改善；以及能耐受口服饮食。
患者的平均年龄为45岁，只有14例（23%）有合并症。积极补液组与标准补液组相比，在36小时时有更高比例的患者显示临床改善：分别为70%和42%（P = 0.03）。通过Cox回归分析，积极补液组的临床改善率高于标准补液组：调整后的风险比 = 2.32，95%置信区间为1.21 - 4.45。积极补液时持续性SIRS的发生较少（7.4%对21.1%；调整后的优势比（OR）= 0.12，0.02 - 0.94），血液浓缩情况也是如此（11.1%对36.4%，调整后的OR = 0.08，0.01 - 0.49）。没有患者出现容量超负荷的体征。
早期使用乳酸林格氏液进行积极静脉补液可加速轻度急性胰腺炎患者的临床改善。
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