Lessons From Clinical Trials on Early Aggressive Intravenous Hydration in Acute Pancreatitis: A Meta-analysis: Presidential Poster

Abstract

Purpose: Despite limited clinical research in humans, guidelines have uniformly stated that early aggressive intravenous hydration (EAIH) is an important part of the management in patients with acute pancreatitis (AP). Recent clinical studies evaluating the efficacy of EAIH have demonstrated conflicting results. The purpose of our study was to systematically review, analyze and combine the different studies in a meta-analysis in order to determine the efficacy of EAIH in the management in patients with AP. Methods: A systematic search of the literature was performed to identify clinical trials evaluating the role of EAIH in patients with AP. In order to be included in the analysis, the published study needed to include patients with AP enrolled in a consecutive, prospective or retrospective fashion; provide information regarding gender, etiology, amount of fluid for each group, outcome such as organ failure, necrosis, and/or mortality, and the amount of fluid provided over the initial 24-72 hours. When combining the various studies, the weighted mean of power (sample size) was used to determine the relative value of significance. Sensitivity analysis evaluated study design, inclusion criteria, timing, type of fluids and severity of patients included. Results: Nine published studies fulfilled the criteria to be included in the analysis, which included 1,179 patients: 668 patients in the EAIH group, 511 patients in the control group. The volume of fluid provided over time differed considerably. However, when combining the studies, the EAIH group received 4,325 ± 2,322 cc during the first 24 hours and the control group received 2,643 ± 2,822 cc during the first 24 hours. There were no significant differences in the age, gender, and etiology distribution among the studies (p>0.05). There was no significant difference in the development of organ failure, pancreatic necrosis, morbidity or mortality (p>0.05). However, in a subgroup analysis (sensitivity analysis), there was a decrease in morbidity and mortality when the hydration was provided more aggressively during the first 6-12 hours (p=0.02). In addition, when excluding studies that only included patients with severe disease, there was a significant reduction in morbidity in patients undergoing EAIH during the first 24 hours (p=0.03). Conclusion: EAIH appears to be most beneficial in preventing morbidity and mortality when applied to patients with AP early in the course of the disease, within the first 6-24 hours. There does not appear to be a benefit to aggressive hydration in patients with AP beyond the first 24 hours. The benefit of EAIH appears to be in patients with mild disease, preventing the development of organ failure and/or pancreatic necrosis.