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01.04.2013 | Experimental

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

verfasst von: 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

Erschienen in: Intensive Care Medicine | Ausgabe 4/2013

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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.

Nur mit Berechtigung zugänglich

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 86:465–470PubMedCrossRef

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):995–1000PubMedCrossRef

Yadav D, Lowenfels AB (2006) Trends in the epidemiology of the first attack of acute pancreatitis: a systematic review. Pancreas 33:323–330PubMedCrossRef

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 33:336–344PubMedCrossRef

Baron TH, Morgan DE (1999) Acute necrotizing pancreatitis. N Engl J Med 340:1412–1417PubMedCrossRef

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 32:2524–2536PubMedCrossRef

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 6:232–239PubMedCrossRef

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 9:652–661PubMedCrossRef

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 33:96–103CrossRef

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 345:1368–1377PubMedCrossRef

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 36:296–327PubMedCrossRef

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 39:259–265PubMedCrossRef

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 134:172–178PubMedCrossRef

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 35:64–68PubMedCrossRef

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 98:591–597PubMedCrossRef

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:R100PubMedCrossRef

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 28:392–398PubMedCrossRef

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 20:473–479PubMedCrossRef

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 12:212–218PubMedCrossRef

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 245:674–683PubMedCrossRef

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 13:200–206PubMedCrossRef

23.

Beger HG, Rau BM (2007) Severe acute pancreatitis: clinical course and management. World J Gastroenterol 13:5043–5051PubMed

24.

Heinrich S, Schafer M, Rousson V, Clavien PA (2006) Evidence-based treatment of acute pancreatitis: a look at established paradigms. Ann Surg 243:154–168PubMedCrossRef

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 36:2348–2354PubMedCrossRef

26.

Knol JA, Inman MG, Strodel WE, Eckhauser FE (1987) Pancreatic response to crystalloid resuscitation in experimental pancreatitis. J Surg Res 43:387–392PubMedCrossRef

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 95:1648–1657PubMed

28.

Banks PA, Freeman ML (2006) Practice guidelines in acute pancreatitis. Am J Gastroenterol 101:2379–2400PubMedCrossRef

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 25:195–210PubMed

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 9:770–776PubMedCrossRef

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 108:735–748PubMedCrossRef

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:R118PubMedCrossRef

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 97:820–826PubMedCrossRef

36.

Bellamy MC (2006) Wet, dry or something else? Br J Anaesth 97:755–757PubMedCrossRef

37.

Fernandez-Mondejar E, Guerrero-Lopez F, Colmenero M (2007) How important is the measurement of extravascular lung water? Curr Opin Crit Care 13:79–83PubMedCrossRef

38.

Sakka SG, Klein M, Reinhart K, Meier-Hellmann A (2002) Prognostic value of extravascular lung water in critically ill patients. Chest 122:2080–2086PubMedCrossRef

39.

Kirov MY, Kuzkov VV, Fernandez-Mondejar E, Bjertnaes LJ (2006) Measuring extravascular lung water: animals and humans are not the same. Crit Care 10:415PubMedCrossRef

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 34:1437–1443PubMedCrossRef

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 29:476–480PubMed

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 38:592–597PubMedCrossRef

43.

Teboul JL, Monnet X (2008) Prediction of volume responsiveness in critically ill patients with spontaneous breathing activity. Curr Opin Crit Care 14:334–339PubMedCrossRef

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 38:819–825PubMedCrossRef

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 35:85–90PubMedCrossRef

46.

Monnet X, Teboul JL (2008) Passive leg raising. Intensive Care Med 34:659–663PubMedCrossRef

Titel: The impact of early goal-directed fluid management on survival in an experimental model of severe acute pancreatitis
verfasst von: 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
Publikationsdatum: 01.04.2013
Verlag: Springer-Verlag
Erschienen in: Intensive Care Medicine / Ausgabe 4/2013
Print ISSN: 0342-4642
Elektronische ISSN: 1432-1238
DOI: https://doi.org/10.1007/s00134-012-2775-x

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

Abstract

Purpose

Methods

Results

Conclusions

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Springer Medizin

Abstract

Purpose

Methods

Results

Conclusions

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