first 48 hours.
Clinical Recommendation Fluid requirements should be reassessed frequently within 6 hours of admission and over the next 24-48 hours.
The goal of aggressive hydration should be to decrease the blood urea nitrogen.
Performance Target 96.5%
Indicator Type (Structure/Process/
Outcome)
Process Indicator Level (Hospital/Patient) Patient
Target Population Patients diagnosed with acute pancreatitis Rationale (i.e. How does the indicator
lead to desired health outcome)?
Maintaining perfusion of the microcirculation of the pancreas is of critical importance and reassessment at frequent intervals ensures adequate hydration.
Supporting Literature
Source Methodology and GRADE
1. Tenner S, Baillie J, DeWitt J et al. American College of
Gastroenterology Guideline: Management of Acute Pancreatitis. Am J Gastroenterol. 2013 Sep; 108(9):1400-15; 1416.
3- Expert opinion only
Weak recommendation, likely to change as data becomes available 2. Tenner S. Initial management of acute pancreatitis: critical issues
during the first 72 hours. Am J Gastroenterol 2004; 99: 2489 – 94.
3- Expert opinion only
Weak recommendation, likely to change as data becomes available 3. Fisher JM & Gardner T. The "Golden Hours" of Management of Acute
Pancreatitis. Am J Gastroenterol 2012:107:1146-1150
3- Expert opinion only
Weak recommendation, likely to change as data becomes available 4. Warndorf MG, Kurtzman JT, Bartel MJ et al. Early fluid resuscitation
reduces morbidity among patients with acute pancreatitis. Clin Gastroenterol Hepatol 2011 ; 9 : 705 – 9
1C- Observational studies
Intermediate-strength recommendation, may change when stronger evidence is available
5. Gardner TB, Vege SS, Pearson RK et al. Fluid resuscitation in acute pancreatitis. Clin Gastroenterol Hepatol 2008; 6: 1070 – 6.
1C- Observational studies
Intermediate-strength recommendation, may change when stronger evidence is available
6. Gardner TB, Vege SS, Chari ST et al. Faster rate of initial fluid resuscitation in severe acute pancreatitis diminishes in-hospital mortality. Pancreatology 2009; 9: 770 – 6.
1C- Observational studies
Intermediate-strength recommendation, may change when stronger evidence is available
| I n i t i a l M a n a g e m e n t ( B a s e l i n e - 7 2 h o u r s ) 7. Wu BU, Hwang JQ, Gardner TH et al. Lactated Ringer’s solution
reduces systemic inflammation compared with saline in patients with acute pancreatitis. Clin Gastroenterol Hepatol 2011; 9: 710 – 7.
1A/1B- Randomized trials without/with important limitations Strong recommendation; likely to apply to most clinical settings 8. Wu BU and Conwell DL. Acute Pancreatitis Part I: Approach to Early
Management. Clin Gastro Gastroenterol. 2010 May; 8:410-416.
3- Expert opinion only
Weak recommendation, likely to change as data becomes available 9. Wall I, Badalov N, Baradarian R et al. Decreased morbidity and
mortality in patients with acute pancreatitis related to aggressive intravenous hydration. Pancreas 2011; 40: 547 – 50.
1C- Observational studies
Intermediate-strength recommendation, may change when stronger evidence is available
10. Buxbaum JL, Quezada M, Da B, et al. Early Aggressive Hydration Hastens Clinical Improvement in Mild Acute Pancreatitis. Am J Gastroenterol 2017; 112:797-803.
1A/1B- Randomized trials without/with important limitations Strong recommendation; likely to apply to most clinical settings 11. Singh VK, Gardner TB, Papachristou GI, et al. An international
multicenter study of early intravenous fluid administration and outcome in acute pancreatitis. United European Gastroenterology Journal 2017;
5 (4): 491-498.
1C- Observational studies
Intermediate-strength recommendation, may change when stronger evidence is available
12. Brown A, Orav J, Banks PA. Hemoconcentration is an early marker for organ failure and necrotizing pancreatitis. Pancreas 2000; 20: 367 – 72.
1C- Observational studies
Intermediate-strength recommendation, may change when stronger evidence is available
13. Wu BU, Johannes RS, Sun X et al. Early changes in blood urea
nitrogen predict mortality in acute pancreatitis. Gastroenterology 2009;
137: 129 – 35.
1C- Observational studies
Intermediate-strength recommendation, may change when stronger evidence is available
14. Haydock MD, Mittal A, Wilms HR, Phillips A, Petrov MS, Windsor JA. Fluid therapy in acute pancreatitis: anybody's guess. Ann Surg.
2013 Feb;257(2):182-8. doi: 10.1097/SLA.0b013e31827773ff. Review.
1C+ Overwhelming evidence from observational studies
Strong recommendation; can apply to most practice settings in most situations
15. Gardner TB, Olenec CA, Chertoff JD, Mackenzie TA, Robertson DJ.
Hemoconcentration and pancreatic necrosis: further defining the relationship. Pancreas. 2006 Aug; 33(2):169-73. PubMed PMID:
16868483.
1C- Observational studies
Intermediate-strength recommendation, may change when stronger evidence is available
16. Lankisch PG, Mahlke R, Blum T, Bruns A, Bruns D, Maisonneuve P, Lowenfels AB. Hemoconcentration: an early marker of severe and/or necrotizing pancreatitis? A critical appraisal. Am J Gastroenterol. 2001 Jul; 96(7):2081-5. PubMed PMID: 11467635.
1C- Observational studies
Intermediate-strength recommendation, may change when stronger evidence is available
17. van Dijk SM, Hallensleben NDL, van Santvoort HC, Fockens P, van Goor H, Bruno MJ, Besselink MG; Dutch Pancreatitis Study Group..
Acute pancreatitis: recent advances through randomised trials. Gut.
3- Expert opinion only
Weak recommendation, likely to change as data becomes available
| I n i t i a l M a n a g e m e n t ( B a s e l i n e - 7 2 h o u r s ) 2017 Nov;66(11):2024-2032. doi: 10.1136/gutjnl-2016-313595. Epub
2017 Aug 24. Review. PubMed PMID: 28838972
18. Yadav D, Agarwal N, Pitchumoni CS. A critical evaluation of laboratory tests in acute pancreatitis. Am J Gastroenterol. 2002 Jun;97(6):1309-18. Review. PubMed PMID: 12094843.
3- Expert opinion only
Weak recommendation, likely to change as data becomes available 19. Koutroumpakis E, Wu BU, Bakker OJ, Dudekula A, Singh VK,
Besselink MG, Yadav D, Mounzer R, van Santvoort HC, Whitcomb DC, Gooszen HG, Banks PA, Papachristou GI. Admission Hematocrit and Rise in Blood Urea Nitrogen at 24 h Outperform other Laboratory Markers in Predicting Persistent Organ Failure and Pancreatic Necrosis in Acute Pancreatitis: A Post Hoc Analysis of Three Large Prospective Databases. Am J Gastroenterol. 2015 Dec;110(12):1707-16. doi:
10.1038/ajg.2015.370. Epub 2015 Nov 10. Erratum in: Am J Gastroenterol. 2016 Aug;111(8):1216. Mounzer, Rawad [added].
PubMed PMID: 26553208.
1C- Observational studies
Intermediate-strength recommendation, may change when stronger evidence is available
20. Aggarwal A, Manrai M, Kochhar R. Fluid resuscitation in acute pancreatitis. World J Gastroenterol. 2014 Dec 28;20(48):18092-103.
doi: 10.3748/wjg.v20.i48.18092. Review. PubMed PMID: 25561779;
PubMed Central PMCID: PMC4277949.
3- Expert opinion only
Weak recommendation, likely to change as data becomes available
21. Arvanitakis M, Dumonceau JM , Albert J, et al. Endoscopic management of acute necrotizing pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) evidence-based multidisciplinary guidelines. Endoscopy. 2018 Apr; 50: 524–546. doi:
https://doi.org/10.1055/a-0588-5365
3- Expert opinion only
Weak recommendation, likely to change as data becomes available
| R o l e o f E R C P i n A c u t e P a n c r e a t i t i s