Fluid therapy in acute pancreatitis comparing balanced solutions and normal saline: A systematic review, meta-analysis and trial sequential analysis.

BACKGROUND

Isotonic crystalloids are recommended as the first choice for fluid therapy in acute pancreatitis (AP), with normal saline (NS) and lactate Ringer's (LR) used most often. Evidence based recommendations on the type of fluid are conflicting and generally come from small single-center randomized controlled trials (RCTs). We therefore conducted a systematic review and meta-analysis to compare the effect of balanced solutions (BS) versus NS on patient-centered clinical outcomes in AP.

METHODS

From four databases searched up to October 2024, we included only RCTs of adult patients with AP that compared the use of BS (including LR, acetate Ringer's, etc.) with NS. The primary outcome was the disease advances from AP to moderately severe and severe AP (MSAP/SAP). Trial sequential analyses (TSA) were conducted to control for type-I and type-II errors and Grading of Recommendations Assessment, Development, and Evaluation (GRADE) was used to assess the quality of evidence.

RESULTS

Six RCTs were identified and included, involving 260 patients treated with BS and 298 patients with NS. Patients who received the BS had less MSAP/SAP [odds ratio (OR) = 0.50, 95% confidence interval (CI): 0.29 to 0.85, P = 0.01, I = 0%; 5 studies, 299 patients], reduced the need of ICU admission (OR = 0.60, 95% CI: 0.39 to 0.93, P = 0.02, I = 0%; 5 studies, 507 patients) and shorter length of hospital stay [mean difference (MD) = -0.88, 95% CI:-1.48 to -0.28, P = 0.004, I = 0%; 6 studies, 558 patients; confirmed by TSA with high certainty] compared with those who received NS. The evidence for most of the clinical outcomes was rated as moderate to low due to the risk of bias, imprecision and inconsistency.

CONCLUSIONS

BS, compared with NS, was associated with improved clinical outcomes in patients with AP. However, given the moderate to low quality of evidence for most of the outcomes assessed, further trials are warranted.