897 Aggressive Hydration With Lactated Ringer for Prevention of Post-ERCP Pancreatitis: A Systematic Review and Meta-Analysis

Abstract

INTRODUCTION: Pancreatitis is the leading complication of endoscopic retrograde cholangiopancreatography (ERCP), resulting in considerable morbidity and, rarely, in death. Hydration is a mainstay of treatment for acute pancreatitis, independent of etiology. Aggressive hydration with lactated ringers (LR) has been suggested for prevention of post-ERCP pancreatitis (PEP). However, recent studies have reported contradictory results. The aim of this study was to perform a systematic review and meta-analysis to evaluate the impact of aggressive LR hydration in PEP incidence. METHODS: A comprehensive search of MEDLINE, EMBASE, Scopus, Cochrane Database was conducted from each database’s inception to search for comparative studies of aggressive LR vs standard therapy for prevention of PEP. Aggressive LR is defined as 3 ml/kg/hr during the procedure, a 20 ml/kg bolus after the procedure, and 3 ml/kg/hr for 8 hours following the procedure. The primary outcome of interest was PEP rates. Secondary outcomes were other adverse events. Outcomes were reported as pooled odds ratio (OR) with 95% confidence intervals (CI) with statistical significance (P < 0.05). RevMan 5.3 software was used for statistical analysis. RESULTS: Eight studies (7 randomized controlled trials and one prospective study) with a total of 3248 patients were included in the meta-analysis. There were 1623 patients in the aggressive LR group and 1625 patients in the standard therapy group. There was no difference between the groups regarding age and sex. Patients in the aggressive arm received 3 ml/kg/hr during the procedure, a 20 ml/kg bolus after the procedure, and 3 ml/kg/hr for 8 hours following the procedure compared to 1.5 ml/kg/hour during the procedure and for 8 hours after the procedure without a bolus in the standard hydration arm. The mean total fluid administered in the two groups was reported in 2 studies with a pooled mean of 3.25 L in the aggressive and 1.47 L in the standard group (P < 0.001). The PEP rate was significantly lower in the aggressive LR arm compared to standard therapy (OR 0.33, 95% CI 0.21-0.50, P < 0.0001). There was no heterogeneity between the studies (I2 = 0%). Peripheral edema as an adverse outcome of aggressive LR therapy was reported only in 2 (0.69%) patients in 2 studies and was managed conservatively. No significant adverse events were reported in any study. CONCLUSION: Aggressive hydration with LR is associated with a significant reduction in incidence of PEP, and therefore, should be practiced routinely.