Aggressive intravenous hydration with lactated Ringer’s solution for prevention of post-ERCP pancreatitis: a prospective randomized multicenter clinical trial

Abstract

Background and study aims The present study aimed to determine the type of intravenous hydration that is best suited to reducing the incidence of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. Patients and methods In a prospective randomized multicenter trial, average-to-high risk patients who underwent first-time ERCP were randomly assigned to three groups (1:1:1) who received: aggressive intravenous hydration (3 mL/kg/h during ERCP, a 20-mL/kg bolus and 3 mL/kg/h for 8 hours after ERCP) with either lactated Ringer’s solution (LRS) or normal saline solution (NSS), or standard intravenous hydration with LRS (1.5 mL/kg/h during and for 8 hours after ERCP). The primary end point was post-ERCP pancreatitis (PEP). Results 395 patients were enrolled, and 385 completed the protocols. The three groups showed no significant differences in demographic characteristics. There was a significant difference in the intention-to-treat (ITT) PEP rate between the aggressive LRS group (3.0 %, 95 % confidence interval [CI] 0.1 % – 5.9 %; 4 /132), the aggressive NSS group (6.7 %, 95 %CI 2.5 % – 10.9 %; 9 /134) and the standard LRS group (11.6 %, 95 %CI 6.1 % – 17.2 %; 15 /129; P = 0.03). In the two-group comparisons, the ITT PEP rate was significantly lower for the aggressive LRS group than for the standard LRS group (relative risk [RR] 0.26, 95 %CI 0.08 – 0.76; P = 0.008). There was no significant difference in the ITT PEP rate between the aggressive NSS group and the standard LRS group (RR 0.57, 95 %CI 0.26 – 1.27; P = 0.17). Conclusion Aggressive hydration with LRS is the best approach to intravenous hydration for the prevention of PEP in average-to-high risk patients.

Recent advances in understanding and managing acute pancreatitis

“…In 2014, two hypothesis-generating retrospective studies reported that greater peri-procedural intravenous fluid volume was an independent protective factor against moderate to severe PEP 95 and was associated with shorter hospital LOS 96 . Very recent meta-analyses and RCTs support using LR prior to ERCP to prevent PEP 97 – 100 and to reduce moderate to severe PEP 97 , 98 . Interestingly, a recent RCT shows that the combination of rectal indomethacin and LR compared with combination placebo and normal saline reduced the risk of PEP in high-risk patients 101 .…”

Post-endoscopic retrograde cholangiopancreatography pancreatitis prevention using topical epinephrine: systematic review and meta-analysis

“…2). Other factors that impact risk of PEP, including intravenous hydration, procedural expertise, and procedural technique modification are not consistently reported in studies and might confound our study results [15,31].…”

Optimal Timing of Single-Stage Retrograde Endoscopic Common Bile Duct Stone Removal in Mild and Moderate Acute Cholangitis: A Prospective Trial

“…At the same time, 100 mg of indomethacin was administered anally to all patients who did not have a history of allergy (17). Aggressive intravenous hydration (including 3 mL/kg/h during ERCP, a 20-mL/kg bolus, and 3 mL/kg/h for eight hours after ERCP) with lactated Ringer's solution was administered to all patients without contraindications (18). CBD stones were extracted using a balloon and/or basket catheter.…”