Aggressive Versus Moderate Fluid Replacement for Acute Pancreatitis: An Updated Systematic Review and Meta-Analysis

Introduction: Fluid replacement is the primary modality of treatment for acute pancreatitis. Since the results regarding aggressive versus moderate fluid replenishment for acute pancreatitis are inconsistent, we sought to compare patient outcomes between the 2 fluid resuscitation groups to determine the superior resuscitation protocol in our meta-analysis. Methods: We searched MEDLINE (PubMed), Embase, International Clinical Trials Registry Platform (ICTRP), Cochrane Central Register of Controlled Trials, and Google Scholar for all available randomized controlled trials (RCTs) assessing the outcomes for patients treated using different protocols of fluids resuscitation with the aggressive fluid replacement defined by most trials as 20 ml/kg bolus followed by 3 ml/kg/hr compared to moderate fluid replacement which was defined differently by all trials ranging from 10 ml/kg followed by 1.5 ml/kg/hr. to 5-10 ml/kg/hr. Dichotomous outcomes were reported as relative risk (RR) along with 95% confidence intervals (CI) while continuous outcomes were reported as mean difference (MD) along with 95% CI. Results: Our meta-analysis included 6 RCTs involving a total of 632 patients. Our results showed that aggressive fluid resuscitation is associated with higher mortality as compared to moderate fluid replacement (RR=2.40, CI= 1.38-4.19). On subgroup analysis based on age, there was no significant difference between the subgroups (P= 0.45). On excluding 2 of our studies that were at high risk of bias, our sensitivity analysis yielded no significant difference in mortality between the 2 groups. For all of our secondary outcomes which included the development of organ failure, severe pancreatitis, pancreatic necrosis, clinical improvement, development of SIRS, persistent SIRS, and length of hospital stay, the results indicate that there was not a significant difference between the 2 groups (Figure 1). Conclusion: Aggressive fluid resuscitation is associated with higher mortality as compared to moderate fluid replacement. However, RCTs with larger sample sizes and better designs to minimize bias are needed to further elucidate patient outcomes, especially in the younger demographic.Figure 1.: Comparison of mortality between patients receiving aggressive fluid or moderate fluid replacement for acute pancreatitis; IV, inverse variance.