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The impact of early goal-directed fluid management on survival in an experimental model of severe acute pancreatitis

Constantin J. C. Trepte| Kai A. Bachmann| Jan H. Stork| Till J. Friedheim| Andrea Hinsch| Matthias S. Goepfert| Olliver Mann| Jakob R. Izbicki| Alwin E. Goetz| Daniel A. Reuter
Experimental
Volume 39, Issue 4 / April , 2013

Pages 717 - 726

Abstract

Purpose

Severe acute pancreatitis (SAP) remains a life-threatening disease with classic etiology of systemic inflammatory response and mortality between 30 and 50 %. The aim of the present study is to compare two different treatment strategies of goal-directed hemodynamic management and evaluate their impact on survival, microcirculation, tissue oxygenation, and histopathologic damage in acute pancreatitis in a prospective animal study.

Methods

Thirty-four domestic pigs were randomly assigned to two different treatment groups. After induction of acute pancreatitis, in group 1 volume administration was guided by central venous pressure (CVP >12 mmHg) and mean arterial pressure (MAP). In group 2, hemodynamic management was guided primarily by left-ventricular stroke volume variation (SVV <10 %), MAP, and cardiac output (CO). Treatment according to randomization was performed for 6 h, and tissue oxygen tension in the pancreas and pancreatic microcirculation were evaluated. Thereafter, animals were observed for 7 days and then sacrificed. Standardized tissue specimens were taken post mortem, and histopathologic scoring was performed.

Results

Survival after 7 days was 29.4 % in group 2 versus 11.8 % in group 1 (p < 0.05). Pancreatic oxygen tension (138.0 ± 89.5 mmHg versus 71.1 ± 35.3 mmHg; p < 0.05) and pancreatic microcirculation (1,209.9 ± 630 AU versus 732 ± 315 AU; p < 0.05) were significantly higher in group 2. Significantly less histopathologic damage within the pancreas could be analyzed post mortem in group 2.

Conclusions

Goal-directed hemodynamic management guided by stroke volume variation led to improved survival, tissue oxygenation, and microcirculatory perfusion, as well as less histopathologic damage in an animal model of severe acute pancreatitis.

Keywords

References

  1. Appelros S, Borgstrom A (1999) Incidence, aetiology and mortality rate of acute pancreatitis over 10 years in a defined urban population in Sweden. Br J Surg 86:465–470
    • View reference on PubMed
    • View reference on publisher's website
  2. Phillip V, Huber W, Hagemes F, Lorenz S, Matheis U, Preinfalk S, Schuster T, Lippl F, Saugel B, Schmid RM (2011) Incidence of acute pancreatitis does not increase during Oktoberfest, but is higher than previously described in Germany. Clin Gastroenterol Hepatol 9(11):995–1000
    • View reference on PubMed
    • View reference on publisher's website
  3. Yadav D, Lowenfels AB (2006) Trends in the epidemiology of the first attack of acute pancreatitis: a systematic review. Pancreas 33:323–330
    • View reference on PubMed
    • View reference on publisher's website
  4. Frey CF, Zhou H, Harvey DJ, White RH (2006) The incidence and case-fatality rates of acute biliary, alcoholic, and idiopathic pancreatitis in California, 1994–2001. Pancreas 33:336–344
    • View reference on PubMed
    • View reference on publisher's website
  5. Baron TH, Morgan DE (1999) Acute necrotizing pancreatitis. N Engl J Med 340:1412–1417
    • View reference on PubMed
    • View reference on publisher's website
  6. Nathens AB, Curtis JR, Beale RJ, Cook DJ, Moreno RP, Romand JA, Skerrett SJ, Stapleton RD, Ware LB, Waldmann CS (2004) Management of the critically ill patient with severe acute pancreatitis. Crit Care Med 32:2524–2536
    • View reference on PubMed
    • View reference on publisher's website
  7. Freitag M, Standl TG, Kleinhans H, Gottschalk A, Mann O, Rempf C, Bachmann K, Gocht A, Petri S, Izbicki JR, Strate T (2006) Improvement of impaired microcirculation and tissue oxygenation by hemodilution with hydroxyethyl starch plus cell-free hemoglobin in acute porcine pancreatitis. Pancreatology 6:232–239
    • View reference on PubMed
    • View reference on publisher's website
  8. Mann O, Kaifi J, Bloechle C, Schneider CG, Yekebas E, Kluth D, Izbicki JR, Strate T (2009) Therapeutic small-volume resuscitation preserves pancreatic microcirculation in acute experimental pancreatitis of graded severity in rats. Pancreatology 9:652–661
    • View reference on PubMed
    • View reference on publisher's website
  9. Göpfert MS, Reuter DA, Akyol D, Lamm P, Kilger E, Goetz AE (2007) Goal-directed fluid management reduces vasopressor and catecholamine use in cardiac surgery patients. Intensive Care Med 33:96–103
  10. Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, Peterson E, Tomlanovich M (2001) Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 345:1368–1377
    • View reference on PubMed
    • View reference on publisher's website
  11. Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, Reinhart K, Angus DC, Brun-Buisson C, Beale R, Calandra T, Dhainaut JF, Gerlach H, Harvey M, Marini JJ, Marshall J, Ranieri M, Ramsay G, Sevransky J, Thompson BT, Townsend S, Vender JS, Zimmerman JL, Vincent JL (2008) Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 36:296–327
    • View reference on PubMed
    • View reference on publisher's website
  12. Boyd JH, Forbes J, Nakada TA, Walley KR, Russell JA (2011) Fluid resuscitation in septic shock: a positive fluid balance and elevated central venous pressure are associated with increased mortality. Crit Care Med 39:259–265
    • View reference on PubMed
    • View reference on publisher's website
  13. Marik PE, Baram M, Vahid B (2008) Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest 134:172–178
    • View reference on PubMed
    • View reference on publisher's website
  14. Osman D, Ridel C, Ray P, Monnet X, Anguel N, Richard C, Teboul JL (2007) Cardiac filling pressures are not appropriate to predict hemodynamic response to volume challenge. Crit Care Med 35:64–68
    • View reference on PubMed
    • View reference on publisher's website
  15. Kubitz JC, Annecke T, Forkl S, Kemming GI, Kronas N, Goetz AE, Reuter DA (2007) Validation of pulse contour derived stroke volume variation during modifications of cardiac afterload. Br J Anaesth 98:591–597
    • View reference on PubMed
    • View reference on publisher's website
  16. Lopes MR, Oliveira MA, Pereira VO, Lemos IP, Auler JO Jr, Michard F (2007) Goal-directed fluid management based on pulse pressure variation monitoring during high-risk surgery: a pilot randomized controlled trial. Crit Care 11:R100
    • View reference on PubMed
    • View reference on publisher's website
  17. Reuter DA, Felbinger TW, Schmidt C, Kilger E, Goedje O, Lamm P, Goetz AE (2002) Stroke volume variations for assessment of cardiac responsiveness to volume loading in mechanically ventilated patients after cardiac surgery. Intensive Care Med 28:392–398
  18. Liu DL, Svanberg K, Wang I, Andersson-Engels S, Svanberg S (1997) Laser Doppler perfusion imaging: new technique for determination of perfusion and reperfusion of splanchnic organs and tumor tissue. Lasers Surg Med 20:473–479
    • View reference on PubMed
    • View reference on publisher's website
  19. Bloechle C, Emmermann A, Strate T, Scheurlen UJ, Schneider C, Achilles E, Wolf M, Mack D, Zornig C, Broelsch CE (1998) Laparoscopic versus open repair of gastric perforation and abdominal lavage of associated peritonitis in pigs. Surg Endosc 12:212–218
    • View reference on PubMed
    • View reference on publisher's website
  20. Bassi C, Larvin M, Villatoro E (2003) Antibiotic therapy for prophylaxis against infection of pancreatic necrosis in acute pancreatitis. Cochrane Database Syst Rev 2006(4):CD002941
  21. Dellinger EP, Tellado JM, Soto NE, Ashley SW, Barie PS, Dugernier T, Imrie CW, Johnson CD, Knaebel HP, Laterre PF, Maravi-Poma E, Kissler JJ, Sanchez-Garcia M, Utzolino S (2007) Early antibiotic treatment for severe acute necrotizing pancreatitis: a randomized, double-blind, placebo-controlled study. Ann Surg 245:674–683
    • View reference on PubMed
    • View reference on publisher's website
  22. Besselink MG, van Santvoort HC, Witteman BJ, Gooszen HG (2007) Management of severe acute pancreatitis: it is all about timing. Curr Opin Crit Care 13:200–206
    • View reference on PubMed
    • View reference on publisher's website
  23. Beger HG, Rau BM (2007) Severe acute pancreatitis: clinical course and management. World J Gastroenterol 13:5043–5051
    • View reference on PubMed
  24. Heinrich S, Schafer M, Rousson V, Clavien PA (2006) Evidence-based treatment of acute pancreatitis: a look at established paradigms. Ann Surg 243:154–168
    • View reference on PubMed
    • View reference on publisher's website
  25. Huber W, Umgelter A, Reindl W, Franzen M, Schmidt C, von Delius S, Geisler F, Eckel F, Fritsch R, Siveke J, Henschel B, Schmid RM (2008) Volume assessment in patients with necrotizing pancreatitis: a comparison of intrathoracic blood volume index, central venous pressure, and hematocrit, and their correlation to cardiac index and extravascular lung water index. Crit Care Med 36:2348–2354
    • View reference on PubMed
    • View reference on publisher's website
  26. Knol JA, Inman MG, Strodel WE, Eckhauser FE (1987) Pancreatic response to crystalloid resuscitation in experimental pancreatitis. J Surg Res 43:387–392
    • View reference on PubMed
    • View reference on publisher's website
  27. Niederau C, Crass RA, Silver G, Ferrell LD, Grendell JH (1988) Therapeutic regimens in acute experimental hemorrhagic pancreatitis. Effects of hydration, oxygenation, peritoneal lavage, and a potent protease inhibitor. Gastroenterology 95:1648–1657
    • View reference on PubMed
  28. Banks PA, Freeman ML (2006) Practice guidelines in acute pancreatitis. Am J Gastroenterol 101:2379–2400
    • View reference on PubMed
    • View reference on publisher's website
  29. Dervenis C, Johnson CD, Bassi C, Bradley E, Imrie CW, McMahon MJ, Modlin I (1999) Diagnosis, objective assessment of severity, and management of acute pancreatitis. Santorini consensus conference. Int J Pancreatol 25:195–210
    • View reference on PubMed
  30. Gardner TB, Vege SS, Chari ST, Petersen BT, Topazian MD, Clain JE, Pearson RK, Levy MJ, Sarr MG (2009) Faster rate of initial fluid resuscitation in severe acute pancreatitis diminishes in-hospital mortality. Pancreatology 9:770–776
    • View reference on PubMed
    • View reference on publisher's website
  31. Mao EQ, Tang YQ, Fei J, Qin S, Wu J, Li L, Min D, Zhang SD (2009) Fluid therapy for severe acute pancreatitis in acute response stage. Chin Med J (Engl) 122:169–173
  32. Mao EQ, Fei J, Peng YB, Huang J, Tang YQ, Zhang SD (2010) Rapid hemodilution is associated with increased sepsis and mortality among patients with severe acute pancreatitis. Chin Med J (Engl) 123:1639–1644
  33. Gelman S (2008) Venous function and central venous pressure: a physiologic story. Anesthesiology 108:735–748
    • View reference on PubMed
    • View reference on publisher's website
  34. Benes J, Chytra I, Altmann P, Hluchy M, Kasal E, Svitak R, Pradl R, Stepan M (2010) Intraoperative fluid optimization using stroke volume variation in high risk surgical patients: results of prospective randomized study. Crit Care 14:R118
    • View reference on PubMed
    • View reference on publisher's website
  35. Gan TJ, Soppitt A, Maroof M, el-Moalem H, Robertson KM, Moretti E, Dwane P, Glass PS (2002) Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery. Anesthesiology 97:820–826
    • View reference on PubMed
    • View reference on publisher's website
  36. Bellamy MC (2006) Wet, dry or something else? Br J Anaesth 97:755–757
    • View reference on PubMed
    • View reference on publisher's website
  37. Fernandez-Mondejar E, Guerrero-Lopez F, Colmenero M (2007) How important is the measurement of extravascular lung water? Curr Opin Crit Care 13:79–83
    • View reference on PubMed
    • View reference on publisher's website
  38. Sakka SG, Klein M, Reinhart K, Meier-Hellmann A (2002) Prognostic value of extravascular lung water in critically ill patients. Chest 122:2080–2086
    • View reference on PubMed
    • View reference on publisher's website
  39. Kirov MY, Kuzkov VV, Fernandez-Mondejar E, Bjertnaes LJ (2006) Measuring extravascular lung water: animals and humans are not the same. Crit Care 10:415
    • View reference on PubMed
    • View reference on publisher's website
  40. Rossi P, Wanecek M, Rudehill A, Konrad D, Weitzberg E, Oldner A (2006) Comparison of a single indicator and gravimetric technique for estimation of extravascular lung water in endotoxemic pigs. Crit Care Med 34:1437–1443
    • View reference on PubMed
    • View reference on publisher's website
  41. Reuter DA, Bayerlein J, Goepfert MS, Weis FC, Kilger E, Lamm P, Goetz AE (2003) Influence of tidal volume on left ventricular stroke volume variation measured by pulse contour analysis in mechanically ventilated patients. Intensive Care Med 29:476–480
    • View reference on PubMed
  42. Mesquida J, Espinal C, Gruartmoner G, Masip J, Sabatier C, Baigorri F, Pinsky MR, Artigas A (2012) Prognostic implications of tissue oxygen saturation in human septic shock. Intensive Care Med 38:592–597
  43. Teboul JL, Monnet X (2008) Prediction of volume responsiveness in critically ill patients with spontaneous breathing activity. Curr Opin Crit Care 14:334–339
    • View reference on PubMed
    • View reference on publisher's website
  44. Preau S, Saulnier F, Dewavrin F, Durocher A, Chagnon JL (2010) Passive leg raising is predictive of fluid responsiveness in spontaneously breathing patients with severe sepsis or acute pancreatitis. Crit Care Med 38:819–825
    • View reference on PubMed
    • View reference on publisher's website
  45. Jabot J, Teboul JL, Richard C, Monnet X (2009) Passive leg raising for predicting fluid responsiveness: importance of the postural change. Intensive Care Med 35:85–90
  46. Monnet X, Teboul JL (2008) Passive leg raising. Intensive Care Med 34:659–663

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