Aggressive Hydration With Lactated Ringer's Solution Reduces Pancreatitis After Endoscopic Retrograde Cholangiopancreatography

Abstract

Background & Aims Pancreatitis is the most common serious complication of endoscopic retrograde cholangiopancreatography (ERCP). We performed a pilot study to determine whether aggressive peri-procedural hydration with lactated Ringer’s solution reduces the incidence of pancreatitis following ERCP. Methods Patients who underwent first-time ERCP were randomly assigned to groups (2:1) that received aggressive hydration with lactated Ringer’s solution (3 cc/kg/hr during the procedure, a 20 cc/kg bolus after the procedure, and 3cc/kg/hr for 8 hours following the procedure, n=39) or standard hydration with the same solution (1.5 cc/kg/hr during and for 8 hrs after procedure, n=23). Serum levels of amylase, visual analog pain scores (scale of 0–10), and volume overload were assessed at baseline and 2, 8, and 24 hrs after ERCP. The primary endpoint, post-ERCP pancreatitis was defined as hyperamylasemia (level of amylase > 3 times the upper limit of normal) and increased epigastric pain (≥3 points on visual analog scale) persisting for ≥24 hrs after the procedure. Secondary endpoints included hyper-amylasemia, increased pain, and volume overload. Results None of the patients who received aggressive hydration developed post-ERCP pancreatitis, compared with 17% of patients who received standard hydration (P=.016). Hyperamylasemia developed in 23% of patients who received aggressive hydration vs 39% of those who received standard hydration (P=.116, non-significant); increased epigastric pain developed in 8% of patients who received aggressive hydration vs 22% of those who received standard hydration (P=.146, non-significant). No patients had evidence of volume overload. Conclusions Based on a pilot study, aggressive intravenous hydration with lactated Ringer’s solution appears to reduce the development of post-ERCP pancreatitis and is not associated with volume overload. ClinicalTrials.gov number, NCT 01758549

EPC/HPSG evidence-based guidelines for the management of pediatric pancreatitis

“…In adults the administration of plasma expanders is not recommended based on current evidence 60,69 . Aggressive intravenous hydration with lactated Ringer's solution appears to reduce the development of post-ERCP pancreatitis and is not associated with volume overload 72 . Other studies show no added benefit from lactated Ringer's solution compared to normal saline in terms of mortality and the duration of hospital stay 73 .…”

“…No specific pain management guidelines are available in pediatric AP. The World Health Organization recommendations for pain management in children should be considered [72]. In the presence of mild pain, paracetamol and ibuprofen are the medicines of choice.…”

Adverse events

“…A pilot study on 62 average-risk patients showed that aggressive hydration was associated with a lower rate of post-ERCP pancreatitis (0% vs. 17%, p = 0.016) [29]. This interesting observation needs confirmation before it can be recommended in routine practice.…”

“…One important caveat is that additional skills are required to pass small guidewires deep into the pancreatic duct, so that the safety and value of the method are unproven in less experienced hands. Because of this and since more recent studies, as discussed earlier, have shown higher efficacy and cost-effectiveness as well as lower adverse events associated with rectal indomethacin as compared to pancreatic prophylactic stent placement or the combination of both methods, the use of prophylactic pancreatic stent placement may decrease [29,31].…”

Az endoszkópos retrográd cholangiopancreatographiát követő heveny hasnyálmirigy-gyulladás megelőzése

“…Az ajánlást retrospektív [21] elemzés és egy kis esetszámú prospektív tanulmány [22] erősítette meg.…”