The FLIP Study
Fluid resuscitation In Pancreatitis
Acute pancreatitis is a common condition to encounter on a general surgical on call take, and whilst the majority of cases are classed as only mild/moderate severity whereby symptoms settle with simple conservative measures, in up to 20% of cases the condition is classed as severe and potentially life threatening.
There is a wealth of evidence to suggest that the initial management decisions within the first 48-72 hours heavily influence the disease course, length of stay and overall morbidity and mortality. However despite this knowledge there is very little guidance from national organisations, and poor quality evidence within the research literature, regarding optimal intravenous fluid administration, which is ultimately the cornerstone of management in these patients to replace third space losses, prevent hypovolaemia and ultimately avoid organ hypoperfusion and associated failure.
Typically “goal directed therapy” is the buzz phrase with regards to optimal fluid administration, whereby IV fluids are titrated against various clinical and biochemical targets reflecting perfusion, such as HR, BP, UO, urea and hct. Historically this mantra has been the cornerstone of sepsis management, with good evidence it reduces mortality, and given the similarities in physiological upset caused by the SIRS response in AP, it would be assumed the principles of sepsis management very much apply in a similar way; however no research studies have been able to replicate the same beneficial outcomes as seen in sepsis.
Published guidelines and research literature lack quality evidence with regards to optimal fluid administration in patients with pancreatitis in the early disease period (i.e. first 48-72 hrs) which no doubt is the most essential time for optimal resuscitation. With that in mind, the FLIP study will consist of two phases:
Establish current clinical practice within the North East regarding the rate of IV fluid administration, and the effect this has on patient outcomes, concentrating on subsequent disease severity (mild/moderate/severe/necrotizing), overall morbidity and mortality, and length of stay – in addition the predictive value of the various scoring systems will be examined
Following phase 1 of the study, and using information garnered from this, an RCT will be designed with varying regimens of fluid administration rates/protocols to determine the optimal rate for improved patient outcome