The Impact Of The Initial Resuscitation On The Prognosis Of Patients With Moderate Severe And Severe Acute Pancreatitis

Mild acute pancreatitis is a self-limited disease,the symptom is mild.Moderate severe or severe acute pancreatitis has severe symptoms,and the early complications are common and the mortality is high.Fluid resuscitation is a key stage in the early treatment of moderate severe or severe acute pancreatitis.In the early onset,overcoming intravascular fluid loss and preventing or reducing the fluid retention in the retroperitoneal space,abdominal cavity and the interstitial space,is of great significance to stop the progress from moderate to severe acute pancreatitis,reduce the mechanical ventilation rate and reduce the mortality,and improve prognosis.If the fluid infusion is not in time or insufficient,it will prolong the circulation failure time and lead to the increase of pancreatitic necrosis and the incidence of multiple organ dysfunction syndrome.Excess fluid infusion or inappropriate crystalloid-colloid ratio will increase fluid retention in the third gap,promote the occurrence of acute pulmonary edema and intra-abdominal hypertention.The effective rehydration target is not only to correct low blood volume,but also to stabilize capillary permeability,regulate inflammatory response,and maintain intestinal mucosal barrier function.However at present,it is still in controversy about the optimal fluid type,rehydration amount and rehydration rate in the early stage of moderate or severe acute pancreatitis.This study aims to investigate the impact of the initial resuscitation with different ratio of crystalloid-colloid on the prognosis of patients with moderate severe acute pancreatitis(MSAP),and investigate the impact of the initial resuscitation with different rate of fluid infusion on the prognosis of patients with severe acute pancreatitis(SAP).PartⅠThe Impact of the Initial Resuscitation with Different Ratio of Crystalloid-Colloid on the Prognosis of Patients with Moderate Severe Acute PancreatitisObjective To investigate the impact of the initial resuscitation with different ratio of crystalloid-colloid on the prognosis of patients with moderate severe acute pancreatitis(MSAP).Methods A retrospective analysis was made by reviewing the clinical data of 72 patients with first diagnosis of MSAP from January 2015 to July 2017.According to crystalloid-colloid ratio 4.5 or 7.5,which was the total volume of crystalloid fluid versus colloid fluid within first 7d,patients were divided into low crystalloid-colloid ratio group(crystalloid-colloid ratio <4.5,n=23),middle crystalloid-colloid ratio group(crystalloidcolloid ratio 4.5 ~ 7.5,n=25),high crystalloid-colloid ratio group(crystalloid-colloid ratio >7.5,n=24).Analyse the influence of the fluid resuscitation with different crystalloidcolloid ratio on the incidence of Severe Acute Pancreatitis(SAP)、Multiple Organs Dysfunction Sydrome(MODS)、mechanical ventilation,pancreatic necrosis and infection rate,50-day mortality,the duration of Systemic Inflammatory Response Syndrome(SIRS)and the time reaching full amount of enteral nutrition.Results(1)Within the first 7d,the total volume of crystalloid fluid(ml)in high ratio group was significantly higher than that in middle、low ratio group(14485±3917 vs.11544±2639、10771±2628,both P <0.05),and the total volume of colloid fluid(ml)was significantly lower than that in middle、low ratio group(996±528 vs.1968±574、3680±1310,both P <0.05);In addition,there was no statistic difference in the total volume of fluid infusion(15480±3910 vs.13512±3117、14451±3073,both P >0.05)and the speed of resuscitation V1(the ratio of total fluid volume within first 24 h versus the total fluid volume within 72h)and V2(the ratio of total fluid volume within first 72 h versus the total fluid volume within 7d)(0.384±0.088 vs.0.376±0.061、0.358±0.074,both P >0.05;0.515±0.054 vs.0.497±0.057、0.495±0.042,both P >0.05).(2)The incidence of SAP、MODS in high ratio group was significantly higher than that in middle ratio group(50.0% vs.16.0%,54.1% vs.20.0%,both P<0.0167),and the mechanical ventilation rate 、 pancreatic necrosis and infection rate 、 50-day mortality in high ratio group was higher than that in middle、low ratio group,but the difference was not significant(12.5 vs.4.0%、8.7%,both P>0.05;20.8% vs.8.0%、17.4%,both P>0.05;8.3% vs.0%、4.3%,both P>0.05).(3)About the duration of SIRS(d),high ratio group was significantly higher than that in middle ratio group(16.5±15.2 vs.8.2±6.4,P<0.05),and the time reaching full amount of enteral nutrition(d)in high ratio group was higher than that in middle ratio group(7.2±3.6 vs.4.8±2.5,P<0.05).Conclusion For the cases with MSAP,fluid resuscitation with appropriate crystalloid-colloid ratio can decrease the incidence of SAP、MODS,shorten the duration of SIRS,and promote the recovery of intestinal mucosal barrier function.Part Ⅱ The impact of the initial resuscitation with different rate of resuscitation on the prognosis of patients with severe acute pancreatitisObjective To investigate the impact of the initial resuscitation with different rate of fluid infusion on the prognosis of patients with severe acute pancreatitis(SAP).Methods A retrospective analysis was made by reviewing the clinical data of 40 patients with diagnosis of SAP from January 2016 to November 2017.According to the rate of fluid infusion 0.35 or 0.44(the ratio of total fluid volume within first 24 h versus the total fluid volume within 72h).Patients were divided into low rate of fluid infusion group(rate of fluid infusion <0.35,n=12),middle rate of fluid infusion group(rate of fluid infusion 0.35~0.44,n=14),high rate of fluid infusion group(rate of fluid infusion >0.44,n=14).Analyse the influence of initial fluid resuscitation with different rate of fluid infusion on the incidence of Multiple Organs Dysfunction Sydrome(MODS),mechanical ventilation rate,pancreatic necrosis and infection rate,40-day mortality,level of C-Reactive Protein(CRP)and the duration of Systemic Inflammatory Response Syndrome(SIRS).Results(1)Within the first 24 h,the total fluid volume in high rate group(4261±1084)ml > middle rate group(3364±914)ml > low rate group(2388±481)ml,all P <0.05.There was no statistic difference in the three groups about the total volume of fluid infusion within the first 72 h.The rate of fluid infusion in high rate group(0.48±0.04)> middle rate group(0.39±0.03)> low rate group(0.29±0.05),all P <0.05.And there was no significant difference in the three groups about the ratio of crystalloid-colloid within the first 72 h.(2)The incidence of MODS in middle rate group was significantly lower than that in high rate group(35.7% vs.85.7%,P < 0.0167).And the mechanical ventilation rate in middle rate group was lower than that in high rate group(14.2% vs.57.1%,P>0.0167).Pancreatic necrosis and infection rate and 40-day mortality in middle rate group was lower than that in high、low rate group(21.4% vs.42.8%、41.7%,both P>0.05;7.1% vs.28.5%、25.0%,both P > 0.05),but the difference was not significant.(3)There was no significant difference on the level of CRP within the first 24 h,after the 72 h of fluid resuscitation,the level of CRP in the middle rate group was significantly lower than that in high 、low rate group(171.7±74.1 vs.261.7±87.5、236.5±73.2,both P < 0.05).And about the duration of SIRS(d)in middle rate group was lower than that in high、low rate group(13.2±6.2 vs.27.8±24.4 、 18.2±11.3,both P > 0.05),but the difference was not significant.Conclusion For the cases with SAP,initial fluid resuscitation with appropriate rate of fluid infusion can decrease the incidence of MODS,control the cascade inflammatory response.It needs to be confirmed by clinical studies with large samples about whether it is beneficial to reduce the pancreatic necrosis and infection rate and mortality.