Is aggressive intravenous fluid resuscitation beneficial in acute pancreatitis? A meta-analysis of randomized control trials and cohort studies

BACKGROUND There is conflincting evidence on the intravenous fluid(IVF)strategy for acute pancreatitis(AP).We perform a metaanalysis of the available evidence.AIM To investigate if aggressive IVF therapy in AP patients is beneficial to decrease mortality and improve outcomes.METHODS Metaanalysis of available randomized controlled trials and cohort studies comparing aggressive IVF vs non-aggressive IVF resuscitation.RESULTS There was no significant difference in mortality between the aggressive(n=1229)and non-aggressive IVF(n=1397)patients.Patients receiving aggressive IVF therapy had higher risk for acute kidney injury and acute respiratory distress syndrome.There also was no significant difference in the overall incidence of systemic inflammatory response syndrome,persistent organ failure,pancreatic necrosis when comparing both study groups.CONCLUSION Early aggressive IVF therapy did not improve mortality.Moreover,aggressive IVF therapy could potentially increase the risk for acute kidney injury and pulmonary edema leading to respiratory failure and mechanical ventilation.Studies are needed to investigate which subset of AP patients could benefit from aggressive IVF therapy.

Aggressive versus controlled fluid resuscitation in acute pancreatitis: A systematic review and meta-analysis of randomized controlled trials

Background:Early fluid resuscitation is one of the fundamental treatments for acute pancreatitis(AP),but there is no consensus on the optimal fluid rate.This systematic review and meta-analysis aimed to compare the efficacy and safety of aggressive vs.controlled fluid resuscitation(CFR)in AP.Methods:The Cochrane Central Register of Controlled Trials(CENTRAL),MEDLINE,Embase,and Web of Science databases were searched up to September 30,2022,for randomized controlled trials(RCTs)comparing aggressive with controlled rates of early fluid resuscitation in AP patients without organ failure on admission.The following keywords were used in the search strategy:"pancreatitis,""fluid therapy,""fluid resuscitation,"and"randomized controlled trial."There was no language restriction.The Grading of Recommendations Assessment,Development and Evaluation(GRADE)framework was used to assess the certainty of evidence.Trial sequential analysis(TSA)was used to control the risk of random errors and assess the conclusions.Results:A total of five RCTs,involving 481 participants,were included in this study.For primary outcomes,there was no significant difference in the development of severe AP(relative risk[RR]:1.87,95%confidence interval[CI]0.95-3.68;P=0.07;n=437;moderate quality of evidence)or hypovolemia(RR:0.98,95%CI:0.32-2.97;P=0.97;n=437;moderate quality of evidence)between the aggressive and CFR groups.A significantly higher risk of fluid overload(RR:3.25,95%CI:1.53-6.93;P<0.01;n=249;low quality of evidence)was observed in the aggressive fluid resuscitation(AFR)group than the controlled group.Additionally,the risk of intensive care unit admission(P=0.02)and the length of hospital stay(P<0.01)as partial secondary outcomes were higher in the AFR group.TSA suggested that more studies were required to draw precise conclusions.Conclusion:For AP patients without organ failure on admission,CFR may be superior to AFR with respect to both efficacy and safety outcomes.Registration:PROSPERO;https://www.crd.york.ac.uk/PROSPERO/;CRD 42022363945.

Update on the strategy for intravenous fluid treatment in acute pancreatitis

Fluid therapy/resuscitation is mandatory in acute pancreatitis due to the pathophysiology of fluid loss as a consequence of the inflammatory process.For many years,without clear evidence,early and aggressive fluid resuscitation with crystalloid solutions(normal saline solution or Ringer lactate solution)was recommended.Recently,many randomized control trials and meta-analyses on fluid therapy have revealed that high fluid rate infusion is associated with increased mortality and severe adverse events compared to those resulting from moderate fluid rates,and this has triggered a paradigm shift in fluid management strategies.Meanwhile,there is evidence to show that Ringer lactate solution is superior to normal saline solutions in this context.The purpose of this review is to provide an update on the strategies for intravenous fluid treatment in acute pancreatitis,including the type,optimal amount,rate of infusion,and monitoring guides.Recommendations from recent guidelines are critically evaluated for this review in order to reach the authors'recommendations based on the available evidence.