Hepatic Failure/GI/Endocrine Emergencies

Early aggressive volume resuscitation (i.e., within the first 24 hours) has been shown to be more

effective than later aggressive volume resuscitation. Studies that have continuously used aggressive

hydration strategies beyond the first 24 hours of presentation of AP have not shown benefit.

Although early aggressive volume resuscitation is recommended by the guidelines, this

approach is defined in several different ways, including either 5–10 mL/kg/hr or 250–

500 mL/hr for the first 12– 24 hours. In addition, the 2018 American Gastroenterological

Association (AGA) guidelines suggest using either noninvasive (e.g., heart rate, mean arterial

pressure, urine output) or invasive measures (e.g., stroke volume variation) to determine fluid

responsiveness.

ii.

A 2022 randomized controlled trial compared aggressive fluid resuscitation (defined as 20

mL/kg bolus followed by 3 mL/kg/hr) with moderate fluid resuscitation (defined as 1.5 mL/

kg/hr for all patients, with hypovolemic patients receiving an initial 10 mL/kg bolus). Of note,

all study patients were diagnosed with acute pancreatitis, and the outcome was progression

to moderately severe or severe pancreatitis. The study was stopped early, however, because

of increased harm in patients who received aggressive resuscitation, primarily fluid overload

(20.5% vs. 6.3%; p=0.004) without any differences in efficacy outcomes. This finding suggests

that less aggressive fluid strategies may be warranted, particularly for patients who present with

less severe pancreatitis. However, in patients who present with severe AP, more rapid initial

aggressive volume resuscitation may still be warrented. The most recent 2024 ACG guidelines

for treatment of AP recommend fluid resuscitation, in line with the fluid management strategy,

in line with the “moderate fluid resuscitation” arm of this study.

Selection of intravenous fluid for initial volume resuscitation in AP may be important, favoring

pH-balanced fluids. Low pH activates trypsinogen, implying that low-pH fluids exacerbate

inflammatory response in AP. In a randomized controlled trial comparing initial resuscitation

(within the first 24 hours) with lactated Ringer solution to 0.9% sodium chloride for patients with

AP, there was a significant reduction in SIRS after 24 hours in patients resuscitated with lactated

Ringer compared with 0.9% sodium chloride (84% reduction vs. 0%, respectively, p=0.035). The

study also showed a significant reduction in C-reactive protein concentrations with administration

of lactated Ringer solution compared with 0.9% sodium chloride. However, two recent randomized

controlled trials comparing resuscitation with lactated Ringer solution and 0.9% sodium chloride

showed similar early (within first 24 hours) reductions in SIRS with lactated Ringer solution, but

no differences in SIRS prevalence after 24 hours or clinical outcomes, including mortality. Thus,

because no study has shown meaningful clinical differences in fluid selection, the 2018 AGA

guidelines make no recommendation on intravenous fluid of choice. However, the more recent

2024 ACG guidelines suggest lactated Ringer solution as the resuscitation of choice in AP.

cardiovascular or renal failure, aggressive hydration may not be beneficial if there is no response

within the first 6–12 hours.

Insulin for hypertriglyceridemia-induced AP

High-dose insulin infusion is the treatment mainstay for severe AP secondary to

hypertriglyceridemia.

ii.

Insulin is initiated at 0.1 units/kg/hour, with dose adjusted on the basis of serum triglyceride

concentrations, which are typically checked every 12 hours. If serum triglycerides do not

decrease by at least 25%–50% in 24 hours, the insulin infusion is increased by 0.05 units/kg/

hour until the goal serum triglyceride is achieved (ideally less than 500 mg/dL).

iii.

To prevent hypoglycemia with high-dose insulin, blood glucose (BG) should be monitored

hourly, and a dextrose infusion should be initiated and adjusted to maintain the BG at around

150 mg/dL.