Thanksgiving is approaching... and you know what that means. Pancreatitis is coming...
Pancreatitis is problematic. Pancreatitis can range from mild cases (that can be managed on an outpatient basis) to life-threatening, necrotizing cases where patients rapidly deteriorate and become septic. Sometimes pancreatitis can be a challenge to diagnose, a challenge to explain to owners, and even a greater challenge to treat. Treatment typically consists of:
- Fluid therapy
- Anti-emetics (e.g., maropitant, ondansestron)
- Clinicopathologic monitoring (e.g., PT/PTT, electrolytes, etc.)
- Feeding tube placement and nutritional support (once nausea and vomiting are controlled)
- Antibiotics (for severe necrotizing pancreatitis and those patients at risk for sepsis, etc.)
When considering treatment options for pancreatitis, the VETgirl team is often asked, what are your thoughts on the use of fresh frozen plasma (FFP)?
Before we discuss our thoughts, let's review the common reasons to even consider plasma:
1) Pancreatitis patients may have a low albumin level (hypoalbuminemia). The administration of plasma, which contains albumin, would therefore help to increase their albumin levels.
2) Plasma contains anti-proteases (e.g. alpha-macroglobulins, anti-trypsins). Administraton of these antiproteases would therefore counteract the proteases that are released as a result of pancreatic inflammation.
While there are veterinary team members who will report that empirically their patients improved with the use of plasma therapy for the treatment of pancreatitis, there is little to no literature to support its use. Prospective studies in the human field have failed to document any decrease in morbidity or mortality with the use of plasma therapy. Moreover, there are several veterinary studies which also show no decrease in morbidity or mortality and unfortunately an increase in morbidity with the use of plasma therapy for pancreatitis patients.
VETgirl's take? If your patient is coagulopathic (e.g., prolonged PT/PTT), then the use of FFP is warranted. However, keep in mind that plasma transfusions are not benign, and while rare, complications such as transfusion related circulatory overload (TACO) and transfusion-related acute lung injury (TRALI) can be seen.
As for the use of FFP to increase albumin in these hypoalbuinemic patients: the VETgirl team believes the use of plasma therapy for administration of albumin is an often ineffective therapy. Remembering you need to give approximately 20-40ml/kg of plasma to raise the albumin level by 0.5-1 g/dL (as compared with the dose of 6-20 ml/kg of plasma to treat a coagulopathy). The use of FFP is a very expensive therapy when used to increase albumin levels, when colloids can be used alternatively [Of course, this opens up the whole can of worms of whether or not colloids cause acute kidney injury (AKI) or not. Check out our podcasts on that here.] In pancreatitis cases with multi-organ dysfunction syndrome (MODS) and AKI or azotemia, we wouldn't recommend the use of colloids, however, until further evidence assessing the safely of colloids in veterinary patients can be reviewed.
So, should we be reaching for FFP in every pancreatitis case? Likely, not. In severe cases (e.g., necrotizing pancreatitis) that are coagulopathic or have clinical signs of SIRS, sepsis, or MODS, yes. Otherwise for colloidal support, the VETgirl team recommends albumin therapy or synthetic colloid therapy, saving the plasma therapy for another patient in need.
1. Chen C-C, Wang S-S, Lee F-Y. Action of antiproteases on the inflammatory response in acute pancreatitis. JOP: Journal of the Pancreas. 2007;8(4 Suppl):488–494.
2. Leese T, Holliday M, Watkins M, et al. A multicentre controlled clinical trial of high-volume fresh frozen plasma therapy in prognostically severe acute pancreatitis. Annals of the Royal College of Surgeons of England. 1991;73(4):207.
3. Leese T, Holliday M, Heath D, Hall A, Bell P. Multicentre clinical trial of low volume fresh frozen plasma therapy in acute pancreatitis. British Journal of Surgery. 1987;74(10):907–911.
4. Wyncoll D. The management of severe acute necrotising pancreatitis: an evidence-based review of the literature. Intensive Care Medicine. 1999;25(2):146–156.