Lactated Ringer's Solution Reduces Severity, Mortality, Systemic and Local Complications in Acute Pancreatitis: A Systematic Review and Meta-Analysis

The 12-Year Experience of the Hungarian Pancreatic Study Group

The Hungarian Pancreatic Study Group (HPSG) was established with the aim of advancing pancreatology. Our summary outlines the methodologies, key results, and future directions of the HPSG. Methodological elements included, the formation of strategic national and international collaborations, the establishment of patient registries and biobanks, and a strong focus on education and guideline development. Key results encompassed, pioneering research on pancreatic ductal function and the role of cystic fibrosis transmembrane conductance regulator (CFTR) in inflammation, significant advancements in understanding acute and chronic pancreatitis, and the execution of numerous clinical trials to explore new therapeutic approaches. Despite challenges, such as securing funding and translating research into clinical practice, the HPSG's commitment to patient care and scientific innovation has been unwavering. The group aims to deepen research into pancreatic cancer and chronic pancreatitis, conduct more randomized controlled trials (RCTs), and expand its efforts internationally by involving global staff and patients. The authors hope that this summary inspires others to undertake similar initiatives and contribute to the global advancement of medical research and patient care in pancreatology.

Normal saline versus Ringer's solution and critical-illness mortality in acute pancreatitis: a nationwide inpatient database study

BACKGROUND

Fluid resuscitation is fundamental in acute pancreatitis (AP) treatment. However, the optimal choice between normal saline (NS) and Ringer's solution (RS), and its impact on mortality in critically ill patients, remains controversial. This retrospective cohort study, utilizing a national Japanese inpatient database, investigates this question.

METHODS

Using the Japanese Diagnosis Procedure Combination database between July 2010 and March 2021, we identified adult patients hospitalized in intensive care units (ICU) or high-dependency care units (HDU) for AP who survived at least three days and received sufficient fluid resuscitation (≥ [10 ml/kg/hr*1 h + 1 ml/kg/hr*71 h] ml) within three days of admission including emergency room infusions. Patients were classified into groups based on the predominant fluid type received: the NS group (> 80% normal saline) and the RS group (> 80% Ringer's solution). Propensity score matching was employed to reduce potential confounding factors and facilitate a balanced comparison of in-hospital mortality between the two groups.

RESULTS

Our analysis included 8710 patients with AP. Of these, 657 (7.5%) received predominantly NS, and 8053 (92.5%) received predominantly RS. Propensity score matching yielded 578 well-balanced pairs for comparison. The NS group demonstrated significantly higher in-hospital mortality than the RS group (12.8% [474/578] vs. 8.5% [49/578]; risk difference, 4.3%; 95% confidence interval, 0.3% to 8.3%).

CONCLUSIONS

In patients admitted to ICU or HDU with AP receiving adequate fluid resuscitation, RS can be a preferred infusion treatment compared to NS.

Tactics of infusion therapy in patients with acute destructive pancreatitis: a narrative review

INTRODUCTION: Infusion therapy is the main method of correcting pathological changes that occur during the phase of “aseptic” inflammation in acute pancreatitis. OBJECTIVE: Summarize current data on infusion therapy regimens in patients with acute destructive pancreatitis, the advisability of using various infusion solutions and options for monitoring the effectiveness of therapy. MATERIALS AND METHODS: The study was carried out in accordance with international reporting requirements for reviews (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). The search was carried out in the following Internet search engines Pubmed and Cochrane Controlled Clinical Trials Register. To select articles, a literature reference search method was also used. The search strategy did not include restrictions on language, article type, or date. RESULTS: The analysis of literature data revealed two approaches to infusion therapy. The initial interest in “aggressive (4 liters per day or more)” infusion therapy regimens in the first 24 hours of the disease has now been replaced by a trend towards less “aggressive” regimens due to the publication of works on the high incidence of various complications (progression of organ dysfunction, local complications). When considering the qualitative composition of infusion therapy, preference should certainly be given to crystalloids. Basic monitoring of infusion therapy should include non-invasive methods: heart rate, blood pressure, diuresis rate. CONCLUSIONS: The analysis demonstrated different approaches to the tactics of infusion therapy in this category of patients. further research into the effectiveness and safety of infusion therapy, taking into account the varying severity of acute pancreatitis, the possibility of the influence of the qualitative composition of the infusion on the course of this disease and the formation of recommendations for initial and maintenance infusion therapy based on the principles of personalized medicine.

Evaluating the efficacy of different volume resuscitation strategies in acute pancreatitis patients: a systematic review and meta-analysis

INTRODUCTION

Acute pancreatitis poses a significant health risk due to the potential for pancreatic necrosis and multi-organ failure. Fluid resuscitation has demonstrated positive effects; however, consensus on the ideal intravenous fluid type and infusion rate for optimal patient outcomes remains elusive.

METHODS

A comprehensive literature search was conducted using PubMed, Embase, the Cochrane Library, Scopus, and Google Scholar for studies published between 2005 and January 2023. Reference lists of potential studies were manually searched to identify additional relevant articles. Randomized controlled trials and retrospective studies comparing high (≥ 20 ml/kg/h), moderate (≥ 10 to < 20 ml/kg/h), and low (5 to < 10 ml/kg/h) fluid therapy in acute pancreatitis were considered.

RESULTS

Twelve studies met our inclusion criteria. Results indicated improved clinical outcomes with low versus moderate fluid therapy (OR = 0.73; 95% CI [0.13, 4.03]; p = 0.71) but higher mortality rates with low compared to moderate (OR = 0.80; 95% CI [0.37, 1.70]; p = 0.55), moderate compared to high (OR = 0.58; 95% CI [0.41, 0.81], p = 0.001), and low compared to high fluids (OR = 0.42; 95% CI [0.16, 1.10]; P = 0.08). Systematic complications improved with moderate versus low fluid therapy (OR = 1.22; 95% CI [0.84, 1.78]; p = 0.29), but no difference was found between moderate and high fluid therapy (OR = 0.59; 95% CI [0.41, 0.86]; p = 0.006).

DISCUSSION

This meta-analysis revealed differences in the clinical outcomes of patients with AP receiving low, moderate, and high fluid resuscitation. Low fluid infusion demonstrated better clinical outcomes but higher mortality, systemic complications, and SIRS persistence than moderate or high fluid therapy. Early fluid administration yielded better results than rapid fluid resuscitation.

Comparison of Fluid Resuscitation with Lactate Ringer's Versus Normal Saline in Acute Pancreatitis: An Updated Meta-Analysis

BACKGROUND

Fluid resuscitation is one of the main therapies for acute pancreatitis (AP). There is still no consensus on the type of fluid resuscitation. This study investigated the differences between lactate Ringer's (LR) and normal saline (NS) in treating AP.

METHODS

Two authors systematically searched Web of Science, Embase (via OVID), Cochrane Library, and PubMed to find all published research before July, 2023. The odds of moderately severe/severe AP and intensive care unit (ICU) admission are set as primary endpoints.

RESULTS

This meta-analysis included 5 RCTs and 4 observational studies with 1424 AP patients in LR (n = 651) and NS (n = 773) groups. The results suggested that the odds of moderately severe/severe AP (OR 0.48; 95%Cl 0.34 to 0.67; P < 0.001) and ICU admission (OR 0.37; 95%Cl 0.16 to 0.87; P = 0.02) were lower in the LR group compared to NS group. In addition, the LR group had lower rates of local complications (OR 0.54; 95%Cl 0.32 to 0.92; P = 0.02), lower level of CRP, as well as a shorter hospital stay (WMD, - 1.09 days; 95%Cl - 1.72 to - 0.47 days; P < 0.001) than the NS group. Other outcomes, such as mortality, the rate of organ failure, SIRS, acute fluid collection, pancreatic necrosis, pseudocysts, and volume overload, did not differ significantly between two groups (P > 0.05).

CONCLUSIONS

LR is preferred over NS as it decreases the odds of moderately severe/severe AP, the rate of ICU admission, local complication, and length of hospital stay. However, large-scale RCT are lacking to support these evidence.

Acute pancreatitis in children: risk factors, management, and outcomes

PURPOSE OF REVIEW

Pediatric acute pancreatitis is an infrequent but potentially serious condition in children. Most have mild cases with spontaneous resolution, but up to one-third of patients can have moderate or severe disease or progress to recurrent or chronic pancreatitis.

RECENT FINDINGS

Significant advances have been made in the field of pediatric pancreatology with a recognition that pediatric acute pancreatitis can vary significantly from adult disease with different risk factors and outcomes. There is better understanding of appropriate management for pediatric pancreatitis as well as growing literature in complications of pancreatitis.

SUMMARY

The most common risk factors for pediatric acute pancreatitis include biliary disease, drug/toxin and idiopathic. Management involves adequate fluid resuscitation, early enteral nutrition and appropriate pain control. Systemic and local complications, including SIRS, necrosis and fluid collections, can occur in up to one-third of patients and care is largely supportive with a careful step-up approach to fluid collections and necrosis.