In this study, we gathered data pertaining to early fluid resuscitation in AP patients from relevant guidelines, consensuses, systematic assessments, and evidence summaries. We complemented these sources with semi-structured interviews to gain insights and recommendations regarding the quality of nursing care for fluid resuscitation in AP patients. These interviews were conducted with medical doctors and nurses in related fields. This approach was employed to address the gaps in the literature review and ensure that the initial draft of the proposed indicator system was comprehensive, systematic, and practical. Two rounds of expert correspondence were conducted using the Delphi method. We selected 15 experts who demonstrated expertise and authority based on their years of experience, educational backgrounds, and professional titles. The Delphi method, a well-established correspondence technique, was employed to assess the reliability of the study. This assessment considered experts’ motivation, authority, and level of agreement. The results of the correspondence test revealed that the experts displayed high motivation and authority. Their opinions regarding the research content exhibited minimal fluctuations. Additionally, Kendall’s harmony coefficient indicated a high level of consensus among the experts, making the research outcomes reliable. Furthermore, consensus-based percentages were used to reinforce the reliability of the study results.
4.3.1 Assessment as the first step will guide the nurse to initiate timely and precise resuscitation
The program applies to emergency, ward, and intensive care units. In the initial round of communication, experts recommended changing “time of diagnosis” to “time of onset.” They believed that “time of onset” would better assist medical staff in assessing the patient’s condition and progress initially. It also guides efforts to enhance disease literacy and awareness in the population before or after hospitalization, minimizing the time gap between illness onset and medical treatment. This approach also helps direct the development of initiatives to enhance disease literacy and awareness in the prehospital or posthospital population, further reducing the time gap between illness onset and when patients seek medical treatment. “Medical history” includes the history of the presenting illness and past medical history, aiding medical staff in identifying potential causes of AP and contraindications to rehydration. Rehydration protocols often consider body weight [29]. Even bedridden patients should have recent weight information obtained from patients or family members, as recommended by experts, to enhance practicality. Assessing prior treatments involves determining whether patients received relevant treatment before evaluation, influencing our protocol to avoid over- or under-rehydration. Furthermore, nurses must assess AP severity in patients. As early-stage AP severity assessment, especially within 24 h, remains unsatisfactorily resolved, expert opinion suggested omitting the phrase “use the revised Atlanta Classification.” According to the Expert Consensus on Prevention and Intervention of Severe Acute Pancreatitis in Emergency Care, it is advisable to include a “suspected severe acute pancreatitis (SSAP)” diagnosis in the current classification criteria to offer timely support and treatment [30]. The APACHE II score, Marshall’s score, Ranson’s score, and SOFA score can assist in early or retrospective AP severity assessments. Although the APACHE II score, Marshall score, Ranson score, SOFA score, etc., can determine AP severity early or retrospectively, they are not widely used in clinical practice due to complexity and inconvenience. However, the BISAP score is considered a practical method for predicting SAP due to its simplicity and accessibility [31]. Of course, these tools should not replace clinical judgment.
4.3.2 Reducing the time lag between attendance and resuscitation initiation is fully controllable for the nurse and seems simple, but it is great
In fact, the first few hours after the onset of the disease are considered crucial for preventing SIRS, progression of MODS and/or worsening of pancreatic necrosis [32]. Moreover, AP is dynamic and can progress to a serious illness, which can be influenced by timely intervention [33]. Early fluid resuscitation is key for achieving the most effective goal-directed fluid resuscitation in AP patients. There were two time intervals between the onset of disease, the time to medical care, and the time to resuscitation initiation. The first time difference is not easy to control, but we can minimize the second time difference between onset and fluid resuscitation, and nurses can minimize the damage to the pancreas and systemic microcirculation induced by the inflammatory cascade response by performing fluid disposal immediately [34–35]. Given its significance, we followed the experts’ advice to divide the primary indicator “admission assessment and management” into two separate indicators: “initial in-hospital assessment” and “initial in-hospital management.” The implementation of “immediate intravenous infusion” can be enhanced through measures like medical and nursing agreement prescriptions, as well as comprehensive packages of medications and medical devices.
4.3.3 As implementers and supervisors of early fluid resuscitation in AP patients, nurses help AP patients meet perfusion needs while avoiding fluid overload
What fluid is chosen to establish resuscitation access, crystalloid or colloid? Most guidelines recommend a balanced salt solution such as Ringer’s lactate, which has a more favorable anti-inflammatory effect than 0.9% NaCl for SIRS and C-reactive protein control within 24 h [36]. Therefore, Ringer’s lactate was directly adopted in the programme, which also facilitates the stock of self-contained drugs in the nursing units of each hospital. For hydroxyethyl, a common colloid in the clinic, large randomized controlled trials have shown adverse effects such as renal impairment; thus, the current evidence does not support the use of artificial colloids such as hydroxyethyl in SAP patients [37]. The use of colloids in critically ill patients is controversial and needs to be determined by a doctor according to the patient’s situation; therefore, according to expert opinion, these patients were excluded. The rate of fluid resuscitation should be goal-oriented according to the guidelines, but there are significant differences among the studies. The Chinese 2021 guidelines [1] specify an initial rate of 5–10 mL/kg/h for the first 24 h. However, there is no specific recommendation regarding the duration of this rate. Some sources suggest a duration of 24 h. It is important to note that administering too much fluid over 24 h has been linked to a worse prognosis [38]. An open-center randomized controlled trial of fluid resuscitation in patients with SAP was published in 2022 in the New England Journal of OLPO-RCTs. This trial investigated the safety and efficacy of weight-based active fluid resuscitation versus moderate fluid resuscitation in the treatment of AP. Active fluid resuscitation involved a push of 20 mL/kg for more than 2 h, followed by 3 mL/kg/h. Moderate fluid resuscitation consisted of a push of 10 mL/kg only when hypovolemia was present, followed by 1.5 mL/kg/h. The study revealed that active fluid resuscitation was associated with a higher risk of volume overload and did not lead to improved clinical outcomes [29]. Initially, the research team favored the moderate fluid resuscitation approach from this study. However, recognizing the potential risk of inadequate resuscitation when using fixed infusion rates, a more tailored approach became necessary. Volume expansion should be adjusted within the first few hours of admission based on a careful assessment of the patient’s volume status, especially in severe cases. Consequently, fluids should be initiated at a rate of 5–10 mL/kg/h. If resuscitation goals are achieved at any point during the first 24 h, the fluid rate should be reduced to 2–3 mL/kg/h [1, 39]. It is important to highlight that patients who do not exhibit a rapid clinical response within the initial 6–12 h of fluid therapy may not benefit from large volumes of fluid administration [40]. Five experts believe that reducing the fluid volume after 12 h may cause the total volume of fluid received by patients to increase, so it was discussed that patients who do not show a rapid clinical response after 6 h are advised to slow the drip rate and ask for a relevant consultation. There is also no definitive conclusion about the amount of fluid needed to replenish AP patients, but nurses should be aware that, in most cases, 2.5 4 L of fluid in the first 24 h will achieve the resuscitation goal, but there are people who may need up to 5 L or more per day in the initial phase [41].
In conclusion, acute pancreatitis represents a multifaceted and evolving disease process, highlighting the significance of personalized fluid therapy [42]. Excessive intravenous fluid administration can result in water and salt overload, potentially exacerbating the condition [43]. In the context of critically ill patients, vigilance and meticulous patient monitoring are imperative due to the potential risks associated with improper fluid management [44]. Close clinical and hemodynamic monitoring and a clear definition of resuscitation goals are fundamental. Nurses, as sentinels and end-performers of fluid resuscitation, need to assess patients frequently, with commonly accepted goals of reversing urine output, treating tachycardia, and hypotension, as well as improving laboratory markers and adjusting management based on clinical findings and trends. Certain laboratory values, such as hematocrit and blood urea nitrogen, have traditionally served as markers for hypovolemia and can offer valuable insights into assessing fluid status. Elevated values upon admission and their subsequent increase during the initial 24 to 48 h may indicate inadequate fluid resuscitation [45]. In cases of SAP, precise fluid therapy adjustments are essential. Similar to other situations requiring substantial fluid management typically encountered in the ICU, a combination of noninvasive clinical assessments, invasive hemodynamic parameters, and laboratory indicators should guide healthcare professionals and nurses during the early stages of SAP. This approach ensures that organ perfusion requirements are met through appropriate fluid administration while mitigating the adverse effects of fluid overload. Furthermore, it is crucial to note that in the specific context of SAP, complications like bowel wall edema and retroperitoneal edema can lead to the development of abdominal compartment syndrome, posing significant challenges [46]. Therefore, intra-abdominal pressure measurements are recommended for patients with abdominal issues to monitor the potential emergence of abdominal compartment syndrome [47].
4.3.4 As health educators for early fluid resuscitation in AP, nurses play an important role in promoting patient compliance in performing fluid therapy
Nurses play a crucial role in developing and implementing health education. Effective health education enables AP patients to gain a comprehensive understanding of the information and purpose behind fluid resuscitation, enhancing their treatment adherence, particularly during the initial active rehydration phase. Nurses should communicate to patients the importance of good compliance for effective early fluid resuscitation treatment. They should refrain from making arbitrary adjustments to the drip rate to prevent any decrease in compliance, which could reduce therapeutic effectiveness. Furthermore, nurses should actively encourage patients to participate in activities that promote patient safety.