EM Match Advice: The EM Rotation, ERAS, and Am I Competitive?

EM Match iconToday launches a series of Google Hangout videos, which was created and expertly facilitated by Dr. Michael Gisondi (@MikeGisondi) from Northwestern. In this series, he recruited an amazing panel of program directors from around the country, who have kindly volunteered their time to share their insights and expertise. In these videos, you get a sense of each panelist’s personalities while they outdo each other with behind-the-scenes advice and stories, which would normally be shared only at the institutional level. Our videocasts are a unique must-see for medical students, interested in and applying into Emergency Medicine (EM). Keep a look out for more videos in the future!

The EM Rotation

Dr. Gisondi facilitates a great discussion featuring esteemed residency program directors Dr. Lainie Yarris (Oregon Health Sciences University), Dr. Maria Moreira (Denver Health), and Dr. Jan Schoenberger (LAC-USC), with the occasional outburst/question by Dr. Michelle Lin (UCSF-SFGH).

Timestamps

  • 00:00  Dr. Mike Gisondi introduces the series and talks about 3 key publications to review for the EM medical student and how to succeed in the EM rotation
  • 05:11  Dr. Lainie Yarris discusses “what defines an honors level performance?”
  • 08:23  Dr. Maria Moreira discusses the differences between an away and a home rotation?
  • 11:24  Dr. Maria Moreira discusses the art of getting a Standardized Letter of Evaluation (SLOE) from their EM rotation
  • 13:43  Dr. Jan Schoenberger discusses how to be a stellar stand-out in a rotation with only a pass-fail system in the EM rotation.
  • 14:45  Dr. Michelle Lin poses the question to the PD’s about — “I didn’t get an honors, now what?”
  • 16:28  Dr. Schoenberger addresses advising/counseling approaches
  • 17:35  Dr. Lin asks about the “departmental SLOE” letter
  • 18:10  Dr. Schoenberger talks about her departmental SLOE
  • 18:45  Dr. Yarris talks about her departmental SLOE and the value of intangible, behavioral characteristics in applicants
  • 19:45  Dr. Moreira talks about her department’s SLOE approach and reminds us that programs want diversity in the program
  • 22:48  Dr. Yarris – pearls and pitfalls
  • 24:05  Dr. Moreira - pearls and pitfalls
  • 26:36  Dr. Schoenberger – pearls and pitfalls
  • 29:18  Dr. Gisondi wraps things up by asking the 3 program directors to share something awesome back their program and something that we might not know about their program.

References

  1. Mahadevan S, Garmel GM. The outstanding medical student in emergency medicine. Acad Emerg Med. 2001 Apr;8(4):402-3. PMID: 11282680.
  2. AAEM Rules of the Road for Medical Students (2003), a free PDF.
  3. Davenport C, Honigman B, Druck J. The 3-minute emergency medicine medical student presentation: a variation on a theme. Acad Emerg Med. 2008 Jul;15(7):683-7. PMID: 18691216.

 

Electronic Residency Application Service (ERAS)

Dr. Gisondi (Northwestern) facilitates a great discussion featuring star residency program directors Dr. Gene Hern (Highland-Alameda), Dr. Laura Hopson (Univ of Michigan), and Dr. Josh Broder (Duke), with an occasional question by Dr. Michelle Lin (UCSF-SFGH).

Timestamps

  • 00:00  Dr. Gisondi introduces the series and talks about 3 key publications to review about what are important in the ERAS application
  • 09:37  Dr. Hern talks about his perspectives about the ERAS and what matters to him and his program at Highland
  • 15:00  Dr. Hern discusses what parts of the ERAS the student should focus more time on.
  • 16:25  Dr. Hern reviews what doesn’t matter as much on the ERAS.
  • 17:41  Dr. Hopson drops pearls about what to do and where to focus your time on the ERAS application.
  • 21:38  Dr. Hopson shares her perspectives about looking for the well-rounded, multitasking applicant.
  • 22:15  Dr. Hopson talks about red-flags in filling out the ERAS application.
  • 26:00  Dr. Broder shares his thoughts about how a non-superstar applicant can shine on his/her application.
  • 28:37  Dr. Gisondi and Dr. Hern talk about how some red flags in the application can be addressed.
  • 31:20  Dr. Hopson recommends teaming up with your mentor/advisor in addressing any red flags in the SLOE.
  • 32:10  Dr. Broder shares his comments how he approaches thinks about any red-flag candidates.
  • 33:07  Dr. Lin shares her thoughts about the personal statement and concerns about honesty on the application.
  • 34:58  Dr. Hern talks about his 2005 BMJ Med Educ study about errors/omissions on the ERAS applications (BMJ Med Educ 2005).
  • 36:16  Dr. Hopson talks about poor integrity, in the form of inconsistent information within the application packet, being a huge red flag in applications.
  • 37:33  Dr. Broder and Dr. Gisondi banter about application misrepresentation.
  • 39:04  Dr. Hene talks about final thoughts – pearls and pitfalls
  • 41:38  Dr. Hopson talks about final thoughts – pearls and pitfalls. In a nutshell: Be yourself.
  • 42:11  Dr. Broder talks about final thoughts – pearls and pitfalls.
  • 43:13  Dr. Lin talks about final thoughts – pearls and pitfalls.
  • 44:16  The panel talks about the “drop dead” deadline for the ERAS application.
  • 45:10  Dr. Lin challenges the panel by asking about the few programs who may offer interviews before the Dean’s letter comes out.
  • 47:46  Dr. Hern shares why one should apply to Highland.
  • 49:28  Dr. Hopson shares why one should apply to University of Michigan.
  • 50:22  Dr. Broder shares why one should apply to Duke.

References

  1. Hayden SR, Hayden M, Gamst A. What characteristics of applicants to emergency medicine residency programs predict future success as an emergency medicine resident? Acad Emerg Med. 2005 Mar;12(3):206-10. PMID: 15741582.
  2. Breyer MJ, Sadosty A, Biros M. Factors Affecting Candidate Placement on an Emergency Medicine Residency Program’s Rank Order List. West J Emerg Med. 2012 Dec;13(6):458-62. PMID: 23359215. Free PDF.
  3. Green M, Jones P, Thomas JX Jr. Selection criteria for residency: results of a national program directors survey. Acad Med. 2009 Mar;84(3):362-7. PMID: 19240447.
  4. Katz ED, Shockley L, Kass L, Howes D, Tupesis JP, Weaver C, Sayan OR, Hogan V, Begue J, Vrocher D, Frazer J, Evans T, Hern G, Riviello R, Rivera A, Kinoshita K, Ferguson E. Identifying inaccuracies on emergency medicine residency applications. BMC Med Educ. 2005 Aug 16;5:30. PMID: 16105178. Free article link.

 

Mirror Mirror on the Wall: Am I Competitive?

Dr. Gisondi (Northwestern) kicks off a great conversation and debate about the knowing how competitive you are, as an applicant. This panel features star residency program directors Dr. Andrew Perron (Maine Medical Center), Dr. Madonna Fernandez (Harbor-UCLA), and Dr. Kevin Biese (UNC Chapel Hill), with comments by Dr. Michelle Lin (UCSF-SFGH).

Timestamps

  • 00:00  Dr. Gisondi launches this panel discussion on determining your competitiveness in the application process. He
  • 03:19  Dr. Gisondi delves right into a great PDF that summarizes some recent statistics about How Competitive is the EM Match that he and Jill Craig compiled. FYI, “SOAP” in the document means Supplemental Offer and Acceptance Program. For a more full listing see the NRMP website [1].
  • 07:26  Dr. Lin discusses what her take-away points after looking at the trends.
  • 09:08  Dr. Biese follows up with his take-away points from these trends.
  • 09:31  Dr. Gisondi weighs in on these trends as well. “There’s a home for (almost) every EM applicant.”
  • 11:00  Dr. Gisondi discusses relevant papers [2-4].
  • 15:58  Dr. Lin fields the first question about — how many programs should I apply to?
  • 18:00  Dr. Perron makes a grand entrance and stresses the importance of a knowledgeable advisor.
  • 19:03   Dr. Perron shares stories about application numbers.
  • 21:32   The panel debates about how many programs to interview at. What is the interview-canceling etiquette? What about couples matching? Tax-break tips?
  • 26:40  Dr. Biese talks about how applications are screened once their submitted into ERAS.
  • 30:09  Dr. Gisondi shares on his perspectives on the numbers game (i.e. USMLE scores).
  • 32:40  The panel rapid-fires about how to address stumbling blocks in one’s application (e.g. below average scores or poor shelf exam scores).
  • 37:34  Dr. Biese shares a story about why a “creative” personal statement that stands out maybe isn’t a good idea.
  • 40:04  Dr. Fernandez shares how to find a great advisor about matching into EM, especially if there’s no home EM residency department to help advise. Think about SAEM/CDEM’s e-Advisor system (application system).
  • 43:40  Dr. Fernandez and Dr. Biese describe what makes a quality advisor.
  • 47:30  Dr. Gisondi and Dr. Fernandez share who/what might be questionable resources for advice and why.
  • 51:18  Dr. Lin summarizes it all to the bottom line – Get a good advisor.
  • 52:43  Dr. Biese clarifies that there are two games afoot – get an interview vs get ranked highly on rank day.
  • 54:27  The panel each leaves a short take-away pearl/pitfall.
  • 57:30  The panel shares something that one might not know about their residency program.

References

  1. NRMP Match Results and Data 2014 (PDF)
  2. Crane JT, Ferraro CM. Selection criteria for emergency medicine residency applicants. Acad Emerg Med. 2000 Jan;7(1):54-60. PubMed PMID: 10894243.
  3. Girzadas DV Jr, Harwood RC, Delis SN, Stevison K, Keng G, Cipparrone N, Carlson A, Tsonis GD. Emergency medicine standardized letter of recommendation: predictors of guaranteed match. Acad Emerg Med. 2001 Jun;8(6):648-53. PMID: 11388941.
  4. Lotfipour S, Luu R, Hayden SR, Vaca F, Hoonpongsimanont W, Langdorf M. Becoming an emergency medicine resident: a practical guide for medical students. J Emerg Med. 2008 Oct;35(3):339-44. PMID: 18547776.

 

Author information

Michelle Lin, MD

ALiEM Editor-in-Chief

Editorial Board Member, Annals of Emergency Medicine

UCSF Academy Endowed Chair for EM Education

UCSF Associate Professor of Emergency Medicine

San Francisco General Hospital

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Code of Ethics: Nurses value quality nursing care for all people.

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The Code of Ethics for Nurses in Australia is an incredibly empowering document.
It is a call to uphold your questioning. A call to protect the value of quality nursing care. It is a call for accountability. A call for action.

The code has been developed and supported by the Australian Nursing and Midwifery Board of Australia, Australian College of Nursing, and the  Australian Nursing & Midwifery Federation. It is intended to “provide nurses with a reference point from which to reflect on the conduct of themselves and others” as well as acting as a guide in our ethical decision making and practice.

Many of you are probably aware of the code and some may have read through it. But in my opinion it is really worth taking some time to read through these value statements carefully,  reflecting on how this code relates to the clinical environment we work in.
How does this code speak to us with respect to our own experiences of quality care delivery within the hospital system?
What issues does it raise for us?
How does it guide our response?

 

“Nurses who value quality nursing care recognise that they are accountable for the decisions they make regarding a person’s care; accept their moral and legal responsibilities for ensuring they have the knowledge, skills and experience necessary to provide safe and competent nursing care; and practise within the boundaries of their professional role. Nurses who value quality nursing care ensure the professional roles they undertake are in accordance with the agreed practice standards of the profession. Nurses are also entitled to conscientiously refuse to participate in care and treatment they believe on religious or moral grounds to be unacceptable (‘conscientious objection’).

Nurses recognise that people are entitled to quality nursing care, and will strive to secure for them the best available nursing care. In pursuit of this aim, nurses are entitled to participate in decisions regarding a person’s nursing care and are obliged to question nursing care they regard as potentially unethical or illegal. Nurses actively participate in minimising risks for individuals.

Nurses take steps to ensure that not only they, but also their colleagues, provide quality nursing care. In keeping with approved reporting processes, this may involve reporting, to an appropriate authority, cases of unsafe, incompetent, unethical or illegal practice. Nurses also support colleagues whom they reasonably consider are complying with this expectation.

Nurses, individually and collectively, participate in creating and maintaining ethical, equitable, culturally and socially responsive, clinically appropriate and economically sustainable nursing and health care services for all people living in Australia. Nurses value their role in providing health counselling and education in the broader community. Nurses, individually and collectively, encourage professional and public participation in shaping social policies and institutions; advocate for policies and legislation that promote social justice, improved social conditions and a fair sharing of community resources; and acknowledge the role and expertise of community groups in providing care and support for people. This includes protecting cultural practices beneficial to all people, and acting to mitigate harmful cultural practices.”

[Note: sections in bold highlighted by me]

 


Reference: Code of Ethics for Nurses in Australia (pdf).
Developed under the auspices of Australian Nursing and Midwifery Board of Australia, Australian College of Nursing, and the  Australian Nursing & Midwifery Federation.

Original featured image via: COD newsroom.


Medizin wird weiblich – was kann man lernen?

Die Strukturen in deutschen Krankenhäusern orientieren sich noch sehr stark an militärische Strukturen. Schließlich bildete die preussische Militärakademie, die Pépinière, die Grundlage für die Facon von Krankenhäusern, welche heute zumindest in der Arbeitsweise in deutschen Krankenhäusern noch existent ist. Doch vieles ändert sich und Veränderungen beginnen im Kopf! In Krankenhäusern ändert sich vieles, unter anderem das Geschlecht der im ärztlichen Dienst tätigen Mitarbeiter. Und hier sind wir schon beim Thema der Zeit: Das Gender-Thema:

In der Süddeutschen Zeitung wird thematisiert, weshalb zunächst 17 Frauen in der Vorstandsetage von DAX Unternehmen aktiv waren, von denen zwischenzeitlich 8 Frauen zurückgetreten sind. Individuelles Versagen oder Problem des Systems? Vermutlich eher ein Problem des Systems wie im Krankenhaus: Die “Hierarchie von Männern” passt nicht zu der Arbeitsweise von Frauen. Diese wird als sachorientiert und analytisch im SZ Artikel beschrieben.

Und da kommen wir gleich zum Thema des “Hochstapler Syndroms” und der Art und Weise, auf welche Anzeigen sich Frauen eher melden oder eben schon gar nicht den Hut in den Kreis werfen. Spannende Artikel, vielleicht einiges übertragbar. Anderes vielleicht aber auch nicht. Ein interessantes Thema, auch die Notfallmedizin betreffend.

Veränderungen beginnen im Kopf!

ECG of the Week – 18th August 2014 – Interpretation

This ECG is from a 25 yr old male presenting with 3 days of sharp central chest pain.

Check out the comments on our original post here.


Click to enlarge
Rate:
  • 110 bpm
Rhythm:
  • Regular
  • Sinus rhythm
Axis:
  • Normal
Intervals:
  • PR - Normal (160ms)
  • QRS - Normal (80ms)
  • QT - 300ms (QTc Bazette 410 ms)
Segments:
  • Widespread ST elevation leads I, II, III, aVF, V2-6
    • Concave morphology
  • ST Depression lead aVR
Additional:
  • PR depression leads I, II, III, aVF, V4-6
  • PR elevation lead aVR
  • Down-sloping T-P segment best seen in lead II
Interpretation:
  • Pericarditis 
  • Note sinus tachycardia - ? effusion

What happened ?

The patient was admitted under the cardiology team. Blood tests showed a negative troponin but raised inflammatory markers and D-dimer. A subsequent CTPA showed a pericardial effusion and the patient underwent pericardiocentesis for a large effusion, total drainage of ~900mls of fluid ! 
The ultimate diagnosis was of viral pericarditis complicated by pericardial effusion.

References / Further Reading

Life in the Fast Lane

Textbook
  • Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.

The myth of large-volume resuscitation in acute pancreatitis

Coauthored with Paul Farkas, consultant in Gastroenterology.

Introduction

Severe pancreatitis causes fluid extravasation from the vasculature, sometimes causing shock.   Traditionally this has been managed by administration of large volumes of crystalloid.   For example, the 2013 American College of Gastroenterology Guideline recommended providing 250-500 ml/hour of crystalloid for the first 12-24 hours of hospitalization.   They recommended targeting fluid resuscitation to achieve dilution of laboratory values, stating that "the goal to decrease hematocrit and blood urea nitrogen and maintain a normal creatinine during the first day of hospitalization cannot be overemphasized."   There has been the notion that providing large volumes of fluid early in the course might lessen the ultimate severity of the pancreatitis.   


Currently there is increasing awareness about the potential harm of excess fluid administration.   Although it was traditionally thought that fluid is good for the kidneys, volume overload may impair renal function due to reduced venous outflow causing poor perfusion and renal edema (Prowle 2013).   Especially pertinent in pancreatitis, volume overload increases the risk of intra-abdominal compartment syndrome and pulmonary edema.

Although some are extremely enthusiastic about fluid administration, ultimately fluid is neither goodnor evil but rather it is a double-edged sword.   The challenge is to develop a rational, evidence-based resuscitation strategy utilizing the ideal amount of fluid to achieve adequate tissue perfusion without causing harm.  

Theory: The paradox of volume management in acute pancreatitis

Fluid therapy for acute pancreatitis is extremely frustrating.   Pancreatitis increases capillary permeability.   Therefore, patients are often intravascularly depleted and thus volume-responsive.   Administering volume usually causes hemodynamic improvements, that are unfortunately short-lived because the fluid rapidly leaks out of the vasculature.   Therefore, fluid administration may cause a temporary improvement in hemodynamics at the cost of worsening volume overload.

A central question is how aggressively to restore intravascular volume during the initial phase of resuscitation.   Attempting to fully restore intravascular volume may cause a greater elevation of intravascular pressures, encouraging fluid to extravasate out of the vasculature.   Therefore, it is possible that the best approach is a more gradual fluid resuscitation with the goal of maintaining a low yet adequateintravascular volume.   It is possible that mild intravascular hypovolemia may be a compensatory mechanism in severe pancreatitis, and rendering the patient intravascularly euvolemic could actually be dangerous.

Evidence: Prospective Randomized Controlled Trials (RCTs)

The only RCTs available were performed in China at a single medical center.   These studies have many limitations, including the use of Chinese herbal medications, hydroxyethyl starch, somatostatin, and varying ratios of crystalloid:colloid.   Nonetheless these RCTs are the best human data available.

Mao 2009 randomized 76 patients with severe acute pancreatitis to a rapid fluid expansion group (Group I, initial fluid infusion rate 10-15 ml/kg/hr) or a controlled fluid expansion group (Group II, initial fluid infusion rate 5-10 ml/kg/hr).   For patients in the controlled fluid expansion group, vasopressors were given early to maintain blood pressure while patients underwent gradual fluid expansion.   Both groups ended up receiving the same amount of total fluid over the first three days, but the rapid expansion group received more fluid initially and sequestered more fluid (5.4 liters net positive versus 4.2 liters; see table below).   Patients in the rapid fluid expansion group had statistically significant increases in mechanical ventilation (34% vs. 26%), abdominal compartment syndrome (26% vs. 13%), sepsis (23% vs 15%), and death (75% vs. 64%).  


Hemoconcentration correlates with poor outcomes, and it has been proposed that sufficient fluid to reverse hemoconcentration might, therefore, improve outcomes.   Mao 2010 randomized 115 patients with severe acute pancreatitis to a rapid hemodilution group (target hematocrit <35% within 48 hours) or slow hemodilution group (target hematocrit >35% within 48 hours).   Patients in the rapid hemodilution group received more fluid at admission and during the first hospital day (table below).   The rapid hemodilution group had significantly higher rates of sepsis (79% vs. 58%), higher APACHE II scores, lower creatinine clearance, and increased mortality (34% vs. 15%).   Therefore, a strategy involving early aggressive volume resuscitation was again shown to worsen outcomes.   


Evidence: Correlational Studies

Gardner 2009 and Gardner 2011are the most commonly cited studies to support early aggressive fluid resuscitation.   Both studies were retrospective with the same design.   The pattern of fluid administration during the first 72 hours of hospitalization was analyzed, and patients were divided into an "early resuscitation" group (patients who received >33% of the total fluid within the first 24 hours) or a "late resuscitation" group (patients who received <33% of the total fluid within the first 24 hours).    Outcomes were compared between the two groups, with the implication that the late resuscitation group had received insufficient fluid during the first 24 hours. 

These two studies came to conflicting conclusions.   Gardner 2009 revealed an improvement in mortality among patients with severe pancreatitis in the early resuscitation group.   In contrast, Gardner 2011 found no difference in organ dysfunction or mortality in patients with severe pancreatitis in the early resuscitation group (early resuscitation was associated with improvement in organ function and length of stay only in patients with mild pancreatitis).   This difference may reflect that patients in the late resuscitation group received more fluid in Gardner 2011compared to Gardner 2009:


Other correlational studies have demonstrated worse outcomes among patients receiving large-volume resuscitation.   de Madaria 2011 found that patients receiving >4.1 liters within 24 hours had higher rates of respiratory failure, renal failure, and intra-abdominal fluid collections.   Eckerwall 2006 found that patients receiving >4 liters of fluid in the first 24 hours had increased risk of respiratory complications.   It is impossible to determine if patients do worse due to fluid administration, if more fluid is administered because patients have more severe disease, or both.   Ultimately it must be emphasized that all of these correlational studies are hypothesis generating only and cannot prove causality.  

American College of Gastroenterology (ACG) 2013 guidelines are not evidence-based.

ACG guidelines recommend that 250-500 ml/hour of isotonic crystalloid be given to all patients without comorbidities for 12-24 hours, in addition to boluses as required to establish hemodynamic stability.   In practice this often causes patients to receive 6-12 liters of fluid over the first 24 hours of hospitalization.   This amount of volume resuscitation is not supported by any evidence.   All available RCT data suggests that larger volumes of crystalloid may cause harm.   Even in the Gardner studies, the "early resuscitation" groups didn't receive anywhere near this amount of fluid.  

ACG guidelines also recommend aggressive hydration targeted to decrease the blood urea nitrogen level (BUN).   Although hemoconcentration correlates with worsened outcomes, available evidence does not support targeted hemodilution.   Mao 2010 demonstrated that fluid resuscitation to target a hematocrit <35 within 48 hours increased mortality.   Wu 2011 compared a goal-directed fluid resuscitation strategy using BUN to standard therapy, but patients in both groups received similar amounts of fluid and measuring BUN was not beneficial.   Targeting volume resuscitation against BUN has no precedent in the resuscitation of other critical illnesses.   For a patient who is meeting hemodynamic targets (i.e., adequate blood pressure and urine output), continuing volume resuscitation based on a BUN value is probably dangerous.  

How should patients with acute pancreatitis be resuscitated?  

Patients with severe acute pancreatitis should probably be resuscitated with a balanced approach employing moderate amounts of fluid as well as vasopressors if needed.   This situation has many similarities to resuscitation of septic shock, and may be guided by the same principles.  

The 2013 guidelines issued by the International Association of Pancreatology and American Pancreatic Association suggested that most patients require about 2.5-4 liters over the first 24 hours, which seems consistent with the above data (note that this correlates with an infusion rate of no higher than 125 ml/hr, assuming the patient receives 1,000ml fluid initially).   Clearly fluid administration should be titrated to clinical response, with efforts to use as little as possible.   Nonetheless, it is useful to have a rough idea of the amount of fluid which may be beneficial.   It must be noted that the quality of existing evidence is low and further studies are needed to reach any firm conclusion (Haydock 2013).   This amount of fluid is similar to volumes used in current studies of septic shock (Marik 2014).  

There is little known about the ideal targets for resuscitation in pancreatitis, but this is absolutely critical to delivering the appropriate intensity of resuscitation.   For example, tachycardia may be misleading because a low-grade tachycardia may persist despite adequate resuscitation.   Continuing resuscitation with a goal of normalizing the heart rate could, therefore, lead to excessive fluid administration.   One of the most important goals of resuscitation is avoidance of renal failure, so adequate urine output, if present, is a powerful signal that the patient is sufficiently resuscitated.   However, if the patient has already progressed to intrinsic renal failure due to acute tubular necrosis, then urine output may remain low regardless of resuscitative efforts and can be misleading.   Central venous pressure is unhelpful (Huber 2008, Marik 2013).

Given that aggressive bolusing may promote fluid extravasation, it may be sensible to try to provide fluid in the form of a continuous infusion (to counteract continuous fluid losses from ongoing extravasation)(Hilton 2012).   Since fluid administration has limited long-term efficacy, supplementation with norepinephrine may be needed to support blood pressure, noting that this also increases preload due to venoconstriction and may improve renal function (Bellomo 2008).

Wu 2011 performed a prospective RCT of patients with acute pancreatitis randomized to resuscitation with normal saline or lactated Ringers.   One day after randomization, patients treated with lactated Ringers had significantly lower rates of C-reactive protein and lower rates of systemic inflammatory response syndrome (SIRS).   Although this is only one study, there are many other reasons to prefer lactated Ringers to normal saline.   Until more evidence is available, lactated Ringers may be the preferred crystalloid for resuscitation of acute pancreatitis (more information about lactated Ringers in prior post about pH-guided resuscitation).  

Conclusions
  • Although limited, all prospective RCT evidence reveals harm from large-volume resuscitation in acute pancreatitis.   
  • Excessive volume resuscitation increases the risk of respiratory failure, renal failure, abdominal fluid collections, sepsis, abdominal compartment syndrome, and death.  
  • The American Gastrointestinal Association 2013 guidelines recommend large-volume resuscitation with 250-500cc/hr crystalloid targeted to decrease the BUN.   These recommendations reflect dogma rather than current evidence.  
  • We agree with recent evidence-based guidelines by the IAP/APA which state that most patients may be treated adequately with a resuscitation of about 2,500-4,000 ml in the first 24 hours (corresponding to roughly 125 ml/hour crystalloid infusion).  
  • Compared to normal saline, Lactated Ringers produces lower cytokine levels and lower rates of SIRS.   Lactated ringers may be the preferred crystalloid for resuscitation of acute pancreatitis. 


Image credits: http://dekalbschoolwatch.blogspot.com/2011/06/theres-hole-in-my-bucket-dear-liza.html