Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Mar 14, 2020; 26(10): 1098-1106
Published online Mar 14, 2020. doi: 10.3748/wjg.v26.i10.1098
Is aggressive intravenous fluid resuscitation beneficial in acute pancreatitis? A meta-analysis of randomized control trials and cohort studies
Mohamed M Gad, C. Roberto Simons-Linares
Mohamed M Gad, Internal Medicine Department, Medicine Institute, Cleveland Clinic, Cleveland, OH 44195, United States
C. Roberto Simons-Linares, Gastroenterology and Hepatology Department, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH 44195, United States
Author contributions: Simons-Linares CR has formulated the concept/study idea, study design, review literature, manuscript drafting, writing; Gad MM has review the literature, contributed to metaanalysis design, statistical support, and manuscript drafting.
Conflict-of-interest statement: The authors deny any conflict of interest.
PRISMA 2009 Checklist statement: This is study followed PRISMA guidelines.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: C. Roberto Simons-Linares, MD, MSc, Assistant Professor, Gastroenterology and Hepatology Department, Digestive Disease Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, United States.
Received: October 4, 2019
Peer-review started: October 4, 2019
First decision: November 4, 2019
Revised: January 12, 2020
Accepted: February 21, 2020
Article in press: February 21, 2020
Published online: March 14, 2020
Research background

The background, present status, and significance of the study should be described in detail. Intravenous fluid (IVF) resuscitation is the cornerstone for Acute pancreatitis (AP) management and Early Aggressive IVF therapy has been traditionally recommended. Recent evidence has raised concern for detrimental effect of aggressive IVF therapy, hence we analyzed the evidence of randomized controlled trials (RCTs) and cohort studies comparing aggressive IVF vs non-aggressive IVF therapy.

Research motivation

There is growing controversial evidence on AP IVF resuscitation and the IVF strategy remains a controversial topic. The purpose of our study was to conduct a rigorous systematic review and meta-analysis of IVF therapy for AP reported in randomized trials and cohort studies.

Research objectives

To investigate if aggressive IVF therapy in AP patients is beneficial to decrease mortality and improve outcomes.

Research methods

We perform a metaanalysis of RCTs and cohort studies. Three electronic databases (Pubmed, Cochrane, and Embase) were searched from inception till 25 December 2018 for studies comparing aggressive IVF to non-aggressive IVF therapy in patients with AP.

Research results

A total of 11 studies were included; giving a total of 2686 patients. Our study found that early aggressive IVF therapy did not improve mortality and it could potentially increase the risk for AKI, pulmonary edema leading to respiratory failure and mechanical ventilation requirement. This controversial topic remains to be studied and more studies are needed to investigate which subset of AP patients could benefit from aggressive IVF therapy.

Research conclusions

Early Aggressive IV fluid therapy did not improve mortality. RCTs are needed to first address the baseline accurate fluid status of the patient with a non-invasive hemodynamic assessment. There is very limited data comparing aggressive IVF to non-aggressive IVF therapy, and the published studies are very heterogenous; which difficults the proper assessment to draw conclusions. It seems that aggressive IVF therapy in AP patients is not for everyone and the look to identify the subset of AP patients who may benefit from is still ongoing. We first need to address a baseline and accurate fluid status of AP patient and we could use non-invasive hemodynamic assessment technology such as the one that has been extensively used in the critical care, trauma, burns and cardiology settings. Additionally, the fluid responsiveness of patients also needs to be studied, as all patients may not be responsive to aggressive IVF resuscitation, and hence additional therapies may be needed and remained to be elucidated.

Research perspectives

As there is very limited and heterogenous evidence to support aggressive IVF over goal-directed IVF therapy, further studies are needed to assess the baseline fluid status of the patient before, during, and after IVF resuscitation. Non-invasive identification of the fluid responder patients would be beneficial to help optimize the management of AP patients and avoid pancreatic necrosis, multiorgan failure and mortality.