SPEAKER_01 0:19

Hello and welcome to Inpatient Update. I'm your host, Mason Turner, and this is your podcast for practice changing evidence for the working hospitalist. Today on the show, I'm joined by Dr. Daniel Hardgrove, as we bring out the evidence questioning two fluid decisions we often take for granted as settled doctrine. Should acute pancreatitis get aggressive hydration? And is LR actually better than normal saline? Let's get into it. Well, Dr. Hardgrove, thank you so much for being here and joining me today.

SPEAKER_00 0:51

Yeah, Dr. Turner, good to see you, man. It's been a while. Well, for the audience, Dr.

SPEAKER_01 0:56

Daniel Hardgrove is a clinical practicing hospitalist. He's an assistant professor of medicine at the University of Alabama, Birmingham, and a great friend, a residency buddy, and again, just so delighted to have you with me. Yeah, happy to be here. Well, Dr. Hardgrove, so if you get you get a call from the ED, you've got, let's say, a 43-year-old lady, epigastric pain, elevated live pays, greater than three times your upper limit of normal. We're seeing inflammation on the uh the CT scan, classic pancreatitis. What's your what orders are you putting in? What are your go-to orders?

SPEAKER_00 1:39

Fluids, fluids, fluids, admission orders, I guess should be in there somewhere. Uh an NPO order. That's it. Yeah, I backed it. Did I mention fluids? Yeah, that's it.

SPEAKER_01 1:50

Uh pain meds and fluids. And it feels like kind of it's just like, oh, that's what we can do as far as management. So yeah, the the classic thing has always been we slam these people with fluids. And and again, as we're kind of alluding to, like, we don't really have anything else we can do for them, and they're in such pain, and we've all seen it go wrong. And we're like, all right, what we can do is get fluids because it makes physiologic sense. But there was actually a study which was published in the New England Journal of Medicine in 2022, and it asked that question in early acute pancreatitis, should we be slamming people with fluids like we have, like the thing we know to do, or should we be tempering the amount of fluids we give to people and being less aggressive? And the bottom line was that people kind of did worse with the heavy fluids. So it was a randomized trial, randomized control trial, enrolled 250 patients, and they all had acute pancreatitis, and it randomized them to either aggressive fluids or moderate fluids. And so the aggressive fluids they defined as hitting them up front with a 20 cc per kg bolus and then continuing them at three cc's per kg of fluid. And the moderate was you only blue as bolus them with fluids if they seem like they're actually volume down, and then you hit them with 10 cc's per kg of fluid still. So you're still giving them fluid, just less, and you're targeting it somewhat to what's your exam? What do you think is clinically indicated? And what they looked at as a primary outcome was progression to moderately severe and severe pancreatitis by the Atlanta criteria. And so what they found was that for the aggressive fluid group, 20 over a little over 22% had severe pancreatitis bad outcomes. And in the moderate group, it was 17. This was not statistically significant, but certainly a signal that the moderate fluid did better. But then when they looked at fluid overload as a secondary outcome for harm, much more significant, 20%, over 20% in the uh heavy fluid group, and really looking at all the numbers they looked at uh progression to the ICU. We talked about the volume overload, it was all worse in the aggressive fluid group, and so much so that the numbers on this are so low because they stopped the trial because they weren't seeing a benefit in these patients and were seeing a harm. So the big takeaway was from this the headline is aggressive fluids, carte blanche, we're seeing no better outcomes. In fact, worse outcomes and surely volume overload, less aggressive fluids, and we're seeing better outcomes. So, Dr. Hargrove, what's your what's your take? Are you convinced? Is this changing the orders you place and the way you approach these patients in the future?

SPEAKER_00 5:10

It does, it does in some ways. I'll say um when I was looking through this. First off, our our model is we I don't do a lot of initial admissions myself, but I frequently get these people 12, 24 hours after they've been admitted. So the initial bolus has already been done, and usually they're on some kind of maintenance fluids if they've been taken care of well. So so I'm usually at that point. The the the part that I found interesting or that that would be most applicable to me is when you're looking to stop or slow down the fluids. Um and and I saw where in this one, right, in the aggressive, in the aggressive group, they waited until 48 hours before potentially reducing or stopping the maintenance fluids versus the 20 hours in the moderate group. And uh I think that that is just another I don't know, part of this trial that points to reassessing the fluid status earlier and potentially pulling it off sooner to prevent some of these bad outcomes. So, you know, that's when I see these patients, I'm at that point where, hey, we're maybe trying to start some PO intake. Maybe I need to be more aggressive about pulling off the fluids, or certainly not bolusing more, maybe reducing the rate, you know, coming down from a 200 to to a 100 cc's an hour. So I no, I the this was a great study that kind of kind of helped reinforce some of some of what I was already thinking about doing. But it's good to see the numbers that are that they are impressive.

SPEAKER_01 6:34

Yeah. No, agreed. So for the aggressive, if you're dealing with a you know, the prototypical 70 kg patient for the aggressive fluids, that's 1.4 liters as the bolus up front. So, you know, if anyone's doing that, it's at least a liter and a half, right? And then the continuous rate is 210. So 200, 250 bolus a liter plus pushing two liters up front is practically what one would be doing if they were actually doing this on just a typical patient, but somewhere in that ballpark. The moderate would be a 700cc bolus up front if they need it. Again, they only did that if they needed it based on their clinical exam, and then 115 cc's an hour up front. And so, like that, I mean, kind of to your point, I mean, that's that makes a lot of sense and feels about right to me. It's certainly not historically as aggressive as through a lot of my training I've been doing fluids, but it it would feel okay. I wouldn't feel like, oh, I'm not giving them anything. If they look a little dry, I think I think makes a lot of sense because these people, I mean, if for no other reason, these people aren't taking much PO because they're miserable.

SPEAKER_00 7:52

Yeah.

SPEAKER_01 7:52

Um, and theirs were debatably making them in PO. And that's another thing that in the guidelines, more and more there's been some push to early feeding if they feel like they can tolerate it.

SPEAKER_00 8:04

Yeah, absolutely. I was gonna say that too. Actually, usually by the time I'm seeing them, if they're not, I try, let them have clears as soon as they're ready for it, clears and start advancing. Um because that just that advances everything in the hospital course of this. I think what was one of the other numbers in here, the length of stay. Um I think I might have seen it a day less length of stay when you're more moderate, all about getting these people better faster.

SPEAKER_01 8:27

I think it was five versus six or six versus seven days. Yeah, is an improved length of stay, a full day less. And yeah, and I agree. The early PO helps with that too. That wasn't exactly what this trial was on, but certainly is another part of the more recent guidelines for for the management of pancreatitis are it's a lot of just like if you feel up for it, eat. If you don't, don't. But I think a lot of the reason we we want to go hard and fast with the fluids is kind of like we were saying at the top, like we don't have anything else to do with these people. And when it goes bad, it can just go so bad. What do you think? What's the the worst complication you've seen from pancreatitis or a patient that like kind of sticks out to you of like something that was really terrible?

SPEAKER_00 9:14

Oh, well, uh I mean, certainly you you get shock, hype, you know, high shock, and whether it's uh thinking specific to our institution, right? We have the chronic pancreatitis where they have a cyst that decides to to necrotize and they end up in the ICU with septic shock. I that's that's probably the worst generic patient I can think of right now that we've seen.

SPEAKER_01 9:35

Oh yeah.

SPEAKER_00 9:36

It's yeah, and by that point, obviously, it's uh well, you're you're getting the full shock septic shock treatment and probably in the ICU.

SPEAKER_01 9:44

Yeah. And then, gosh, I mean, there's just so many terrible pancreatitis as we see. And yeah, the the physiology being so hyperinflammatory in the sepsis type physiology, it makes sense that we're driving them hard with fluids. It also makes sense just on paper, you know, the the pancreas is all inflamed, it's endematous, it's losing fluid, and therefore we need to give them fluid, and it's the thing we can do that can help and prevent that. Or, like, you know, I mean, there's just so many terrible things we've seen, like the necrotizing pancreatitis. I tell patients all the time, like, I wouldn't wish pancreatitis on my worst enemy. Like your digestive juices just wreaking havoc, the same things that you're using to digest a steak when you eat it are just wreaking havoc in your own body and on its own organ. I mean, it it's horrendous. And you know, whether it's it does terrible things in the belly, even gets up into the lungs sometimes. I distinctly remember working in the VAICU as a resident and having a patient with a pleural fusion related to the pancreatitis, and it just wouldn't heal, and just like to the chest tubes and just constant. And I mean, these people are so many of them, and we see them a lot at our our tertiary referral centers because they're getting necrosectomies or they're getting stents in their biliary tree or whatever. And like these people get bad recurrent pancreatitis, and their lives are never the same. It's terrible. And so when we have a terrible, terrible potential outcome, we feel like we have to do something. And so I think this like aggressive fluids came from like this makes some sense, and so let's do something to do something. But I think, you know, we're seeing in a lot of ways that you treat the patient in front of you and do what really makes sense for them based on their volume status and don't just be following, blindly following a protocol that's not necessarily going to treat your patient.

SPEAKER_00 11:39

Right. Exactly. And fluid overload, obviously, we we that's one of our biggest patient populations is heart failure. Those people get pancreatitis too. And I have seen it more than a time or two that uh we treat someone for pancreatitis and we put them into to fluid overload, right? So that's absolutely I love I I don't have the line right in front of me from this, but or maybe it was one of your lines where yeah, treat the treat the patient in front of you if they are volume down or if they're hypovolemic, absolutely. Give them the fluid they need. But if they're eupholemic, then maybe we can get by with just the maintenance fluids.

SPEAKER_01 12:12

And probably the best service we can do to these patients is really trying to help them prevent it from happening again. So doing that workup for a cause. And if it's the lipids, treat the lipids. If it's a med, stop the med. If it's their gallstones, most commonly, then you know, remove their gallbladder. Or, I mean, probably the biggest one would be if we can do it, get the patient to stop drinking. Obviously, for the recurrent pancreatitis, I mean, that's just a massive drive room. And so instead of just, you know, following a protocol for fluids, if instead you're focusing on counseling your patient and doing things you can support them for treatment of their alcohol use disorder, if that's the patient, then that's probably the best service you can possibly give these patients. Um do you have any other any other thoughts or insights or value on the the waterfall trial on pancreatitis?

SPEAKER_00 13:04

Yeah, the only thing I said, I mean, just to bring home the point I think we've already said is is obviously you're seeing your patients every day treat based on the patient you're seeing. And and my recommendation in particular for learners is always set a limit on it. Don't just start fluids with a with no end date. You know, it's give them uh a rate for a liter, or I I usually will do a day. I'm gonna give you fluids for a day, and I'm gonna decide tomorrow whether to re-up it or not. That can help us reduce the chance of overloading these people, which we see in this trial can cause a lot of issues.

SPEAKER_01 13:39

How often do you order a bolus of fluids?

SPEAKER_00 13:44

I think I ordered it. I ordered a couple today, uh hours ago. Yeah.

SPEAKER_01 13:50

Yeah. When's the last time? Um just within minutes.

SPEAKER_00 13:55

Um what about ordering one right now?

SPEAKER_01 14:00

Uh yeah, thank thank goodness for haiku. Um uh what about continuous influ fusions of fluids?

SPEAKER_00 14:08

Uh that is also very common. Also had to do some of that today, the daily. It's all the time, every day. Don't even think about it.

SPEAKER_01 14:16

So in this all the time, don't even think about it. Daily order. Do you do you have an opinion on do you have a what's your preferred crystalloid?

SPEAKER_00 14:29

My preferred crystalloid has been lactated ringers, LR. And if you asked me to give a reason, I would say it sounds better. Sounds more professional, and and and probably what we all learn is it's the it's the more physiologic, it's the the closer to what we get. And so I've been using LR probably since residency, and like I said, haven't really thought much else about it until you gave until we found some articles to read here.

SPEAKER_01 14:55

Yeah. I mean, I I similarly, it was the practice pattern in residency when we both trained that trained that LR is more physiologic, it's better. I've been an LR guy and haven't looked back since. So I was similarly quite intrigued by the fluid trial that came out and looked at just this LR versus normal saline. Is one right and the other wrong? Throw down and really figure this out. And this was actually a really interesting trial and a really interesting trial design. So this was the fluid trial, hospital-wide lactated ringers versus normal saline. Um, it was also a New England journal from 2025. And it specifically answered that question we're talking about, but it framed it in a really interesting way. So, what do you think? If so, you prefer LR. This isn't another question for you, Dr. Hardgrove. Do you think patient outcomes would be better if the whole hospital was forced to do what Dr. Hardgrove does, would patient outcomes be better?

SPEAKER_00 15:58

Before reading, before reading this, what we're about to go over, I might have guessed yes.

SPEAKER_01 16:03

And and Yeah, I think I would have too.

SPEAKER_00 16:05

Yeah. Just uh again, you said you tell me physiologic, if we're all getting physiologic fluids. Yeah, that sounds better. Plus, you know, the the first comp potential complication of normal saline uh that doesn't happen with LR that I would think of is the uh acidemia, the hyperchloremic uh acidosis. I'm like, if we can just cut that out as a potential, you know, hydrogenic uh problem, then maybe we improve outcomes.

SPEAKER_01 16:31

Yeah, no, agreed. I would have thought LR is better and it's better enough, more physiologic enough, that if you're doing it with a massive number of orders, if we changed it hospital-wide, even if it's only marginally better, I would have thought that was a big enough sample size to make a difference. And so they tried to look at just that. And so what they did was they assigned hospital-wide, there's either available LR or normal saline. You only get one. There was like a washout period and a wash-in period and all of that. And then they go 12 weeks, they take a break, they switch, and then they do the other, the other fluid. And so, about as rigorous of a trial as I think you could do on just in general, as a fluid you pick, which is better. And the headline takeaway was meh. Um, not not a significant difference to our chagrin. And so, just kind of speaking to this, again, it was randomized. There were 43,000 some patients. It was in seven different hospitals. And again, there's not a ton of exclusion and exclusion. It was just basically they did it as a hospital-wise policy. You're either LR or normal saline. And the first thing they looked at, the primary outcome was death and readmission. Obviously, like the thing we care about. Um, and this was within 90 days, and what they found was 20.3 percent in the LR group, 21.4 percent in the saline group, non-significant, non-significant confidence interval, relative risk of 0.97. Again, it crossed one. We weren't seeing a difference. They looked at death 6.9 versus 7.6 percent, readmissions 15.1 versus 15.4%. They did a bunch of others, and it's all similarly essentially exactly the same. So surprised?

SPEAKER_00 18:32

Not so much, I'll I'll be honest. It it it it I we can kind of get down into it where I think they're they're where we might see potential differences, and I think the study even acknowledges it is you get into the subgroups of it, but big picture, you know, across across all the different etiologies we might need fluids for, the giving giving fluids is probably more important than anything else, than the specific type of fluid that you give them. So, no, I mean I I like the study. I I thought it was interesting that you know you can actually restrict uh the type of fluid that surgeons would use on something is is a wild concept.

SPEAKER_01 19:11

Yeah, right. And now again, to your point, this is looking at massively the aggregate. And what I think we really need to think about is treating the patient in front of you similarly and saying for what pathologies is maybe one of these better than the other? Do you have a thought or a time where maybe one of these is would still be better than the other if we do a subgroup?

SPEAKER_00 19:36

Well, what I like, and I'll say actually backing up a little bit too, where I uh the before coming when I was in the the office here this week, I knew we were gonna be talking about this, and I polled my workrooms. Like, by the way, what do y'all do? And and I'll say one of the workrooms was was about 50-50, and on it 50-50, each person is just I feel like using LR, I feel like using normal saline this day. Went to another one and it was it was universal LR. So um it seems like it kind of a similar to us where people tend towards LR, but kind of have the same idea where it's it's both are okay. And and getting back to your question, where one where you might think about it, and and I I'll say I do this when you're ch when I'm giving fluids for what is suspected hypovolemic hyponatremia, I think to give sodium. When someone's sodium is low, I want to give them what I know is sodium, which I know LR should in theory work for that as well. But that that is just my practice at the very least. I couldn't cite any data on whether that's the right thing to do over LR.

SPEAKER_01 20:35

But yeah, I've had a uh nephrologist yell at me to do that because of the point more so their point was that ever so slightly hypotonic. And so thinking like you don't want to be giving them that teeny bit of free water.

SPEAKER_00 20:49

Is is getting yelled at by a nephrologist that just a universal experience for hospitalists?

SPEAKER_01 20:53

Oh yeah, totally, totally. And it was a nice yelling. Um, sorry, were you gonna say something else when I interrupted with my nephrologist experience?

SPEAKER_00 21:02

I'm sure there are subgroups here and and just looking, I would wonder about the better choice in specifically sepsis or DKA or these other things. I don't think we can say for certain that one is better or worse than the other in those specific things, but in general, it's nice to know that if you need fluids, generally you're gonna be okay. And and the the differences in clinical outcomes might be kind of in the details in the minutiae there, but not really game-changing in big picture. Yeah. Yeah. I even had the question, I mean, i if we're talking about thousands and thousands of patients and uses of these fluids, LR, at least on my brief search, does cost a touch more than normal saline. I mean, it's, you know, 25 cents more per liter, but multiply that out by that tens of thousands, and that's could be something.

SPEAKER_01 21:51

One other thing I was going to say about fluids was I did dig a little bit into this. There are some varying guidelines. There are a couple of different gastroenterology societies that currently have guidelines, and one of them currently does still recommend LR specifically, and then the other one says, yeah, it's a toss-up, it's a wash. There are some small uh randomized trials that do indicate that LR might be a little bit better specifically in your pancreatitis patients. So again, I think sort of my takeaway from really both things is like treat the patient in front of you, look at the factors that relate to that patient specifically, and do what makes sense. And so for this, um, when it comes to picking your crystalloid fluid, most of the time it's probably pretty much a wash and just giving whatever you feel confident with, have available is probably gonna be fine, but do be conscientious of the small differences in the fluids and give them when appropriate. And there could be some subgroups where it really makes a difference. And so my takeaways here. Okay First, for acute pancreatitis, stop treating aggressive fluids as the default. If the patient is hypovolemic, give fluid. But if they are not, start more moderate and reassess. Indiscriminately giving a big bolus and high rate maintenance fluids cause significantly more fluid overload without improving pancreatitis outcomes. Fluid should be a response to the patient's volume status, not the diagnosis. Second, when it comes to picking an IV fluid, dealer's choice, LR still makes physiologic sense and I'll still use it often. But for broad hospitalized patients, choosing LR over Saline does not seem to be the outcome-changing decision that we sometimes make it out to be. The better move is to pick the fluid that makes sense for the patient in front of you, not just fall back on your crystalloid reflex. So the practice change is simple. Stop treating fluids like autopilot. Give them for a reason. Choose a reasonable crystalloid, give a reasonable amount for your patient and reassess before the order keeps going just because it was started. Well, thanks so much, Dr. Hardgrove. I've really enjoyed having you. This was a lot of fun. It's been good to good to catch up and also good to just talk some medicine to our listeners. If this episode was helpful, send it to one person who takes care of hospitalized patients. And if you want the article links and key takeaways from each episode, join the email list at subscribe.com. Thank you for listening. This has been inpatient update.