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Specific crystalloid solutions versus normal saline for acute pancreatitis (AP) – meta- analysis with trial sequential analysis

Background & aim: Intravenous fluid resuscitation is a cornerstone of treatment for pts with acute pancreatitis (AP) directed to prevent hypovolaemia and organ hypoperfusion. Specific crystalloid solutions with additional potential anti-inflammatory and buffer agents such as lactate or acetate, and lower chloride levels have been researched in different critically-ill pts compared to the use of normale saline, showing potential superiority. We aimed to evalute the effects of these specific crystalloids in AP pts and assess the level of available evidence. Methods: We performed electronic searches of Medline, Web of Science, Scopus, and The Cochrane Library for randomized controlled trials assessing the use of specific crystalloid solutions for treatment of AP. Mortality and organ failure (OF) were assessed as primary outcomes. Secondary outcomes included SIRS, pancreatic necrosis (PN), infected pancreatic necrosis (IPN), local complications (LC), and length of hospital stay. TSA was performed for the primary outcomes, and secondary outcomes showing a significant result in meta-analysis, with alpha of 5%, and power of 80%. Results for dichotomous outcomes were expressed as risk ratios (RRs) with 95% confidence intervals (CIs), and continuous results were expressed as mean differences (MDs) with 95% CIs. Results: Three RCTs with a total of 127 patients were included in the analysis. All trials compared the use of RL (n=) compared to NS (n=). The mortality and OF rates were similar in both groups with RRs 0.36 (95% CI 0.04 to 3.30 ; I2=0%) and 0.39 (95% CI 0.09 to 1.76 ; I2=0%), respectively. Development of PN was reduced with RL (RR 0.28 ; 95% CI 0.09 to 0.91 ; I2=0%). SIRS rates at 24h were lower among pts receiving RL (RR 0.38 ; 95% CI 0.15 to 0.98 ; I2=36%) and the length of hospital stay was shorter (MD -0.80 ; 95% CI -1.23 to -0.37 ; I2=78%). TSA was not performed for mortality due to too little information available. To detect a RR reduction (RRR) for OF of 30% and a rate of 20% among controls, a total of 1231 pts are required. A 30% RRR with 30% PN rate among controls would require a 1151 pts, while a 30% RRR with 40% SIRS rate among controls would require 2227 pts. A required information size of 218 pts was calculated based on a minimal relevant effect of reducing hospital stay for 1 day (SD=1.52). To detect All TSA analyses were performed for the total of 127 randomized pts. Conclusion: Evidence favoring use of Ringer's lactate over normal saline for treatment of AP is very low. We couldn't identify RCTs evaluating other specific and balanced crystalloid solutions. Further research is needed.

Acute pancreatitis ; crystalloid solution ; fluid replacement ; meta-analysis

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