Effects of different resuscitation fluid on severe acute pancreatitis

Abstract

Aim: To compare effects of different resuscitation fluid on microcirculation, inflammation, intestinal barrier and clinical results in severe acute pancreatitis (SAP).

Methods: One hundred and twenty patients with SAP were enrolled at the Pancreatic Disease Institute between January 2007 and March 2010. The patients were randomly treated with normal saline (NS group), combination of normal saline and hydroxyethyl starch (HES) (SH group), combination of normal saline, hydroxyethyl starch and glutamine (SHG group) in resuscitation. The ratio of normal saline to HES in the SH and SHG groups was 3:1. The glutamine (20% glutamine dipeptide, 100 mL/d) was supplemented into the resuscitation liquid in the SHG group. Complications and outcomes including respiratory and abdominal infection, sepsis, abdominal hemorrhage, intra-abdominal hypertension, abdominal compartment syndrome (ACS), renal failure, acute respiratory distress syndrome (ARDS), multiple organ dysfunction syndrome (MODS), operation intervention, length of intensive care unit stay, length of hospital stay, and mortality at 60 d were compared. Moreover, blood oxygen saturation (SpO2), gastric intramucosal pH value (pHi), intra-abdominal pressure (IAP), inflammation cytokines, urine lactulose/mannitol (L/M) ratio, and serum endotoxin were investigated to evaluate the inflammatory reaction and gut barrier.

Results: Compared to the NS group, patients in the SH and SHG groups accessed the endpoint more quickly (3.9 ± 0.23 d and 4.1 ± 0.21 d vs 5.8 ± 0.25 d, P < 0.05) with less fluid volume (67.26 ± 28.53 mL/kg/d, 61.79 ± 27.61 mL/kg per day vs 85.23 ± 21.27 mL/kg per day, P < 0.05). Compared to the NS group, incidence of renal dysfunction, ARDS, MODS and ACS in the SH and SHG groups was obviously lower. Furthermore, incidence of respiratory and abdominal infection was significantly decreased in the SH and SHG groups, while no significant difference in sepsis was seen. Moreover, less operation time was needed in the SH and SHG group than the NS group, but the difference was not significant. The mortality did not differ significantly among these groups. Blood SpO2 and gastric mucosal pHi in the SH and SHG groups increased more quickly than in the NS group, while IAP was significantly decreased in the SH and SHG group. Moreover, the serum tumor necrosis factor-α, interleukin-8 and C-reactive protein levels in the SH and SHG groups were obviously lower than in the NS group at each time point. Furthermore, urine L/M ratio and serum endotoxin were significantly lower in the SH group and further decreased in the SHG group.

Conclusion: Results indicated that combination of normal saline, HES and glutamine are more efficient in resuscitation of SAP by relieving inflammation and sustaining the intestinal barrier.

Keywords: Capillary leakage syndrome; Inflammatory reaction; Intestinal barrier; Intra-abdominal hypertension; Microcirculation.

Figures

Figure 1

Effect of different resuscitation fluids on changes in intra-abdominal pressure in severe acute pancreatitis. Intra-abdominal pressure (IAP) was indirectly measured via a bladder catheter during 7 d and performed twice daily. All of the patients had intra-abdominal hypertension on d 1 (IAP > 10 mmHg). aP < 0.05 vs normal saline (NS group). SH group: Combination of normal saline and hydroxyethyl starch; SHG group: Combination of normal saline, hydroxyethyl starch and glutamine; ACS: Abdominal compartment syndrome; IAH: Intra-abdominal hypertension.

Figure 2

Effect of different resuscitation fluids on circulation oxygen supply and microcirculation perfusion. A: Effect of different fluids on circulation oxygen supply was evaluated with pulse oxygen saturation (SpO2) by automatic monitoring; B: Microcirculation perfusion was assessed with gastric intramucosal pH value (pHi) by Tonocap monitor. aP < 0.05 vs normal saline (NS group). SH group: Combination of normal saline and hydroxyethyl starch; SHG group: Combination of normal saline, hydroxyethyl starch and glutamine.

Figure 3

Effects of different resuscitation fluids on serum cytokine and C-reactive protein. Serum tumor necrosis factor (TNF)-α (A), interleukin (IL)-8 (B) and C-reactive protein (CRP) (C) concentration was evaluated by enzyme-linked immuno sorbent assay. aP < 0.05 vs normal saline (NS) group; cP < 0.05 vs combination of normal saline and hydroxyethyl starch (SH group). SHG group: Combination of normal saline, hydroxyethyl starch and glutamine.

Figure 4

Effect of different fluids on intestinal mucosa barrier function. A: Lactulose/mannitol (L/M) ratio of urine in normal saline (NS group), combination of normal saline and hydroxyethyl starch (SH group) and combination of normal saline, hydroxyethyl starch and glutamine (SHG group) was measured by Hi-Crush Partners LP; B: Serum endotoxin in different groups was detected by quantitative chromogenic limulus amebocyte lysate assay reagent. aP < 0.05 vs NS group; cP < 0.05 vs SH group.