Comparison of normal saline versus Lactated Ringer's solution for fluid resuscitation in patients with mild acute pancreatitis, A randomized controlled trial

Choosakul, Sararak; Harinwan, Kamin; Chirapongsathorn, Sakkarin; Opuchar, Krit; Sanpajit, Theeranun; Piyanirun, Wanich; Puttapitakpong, Chaipichit

doi:10.1016/j.pan.2018.04.016

Cited by 64 publications

(72 citation statements)

References 22 publications

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“…NEFA levels, however, subsequently increased over baseline (shown as # in Figure 5C), which is consistent with progression of fat necrosis over the 3 day course of pancreatitis, and the weak electrostatic interaction between calcium and NEFA, only a small part of which are covalently bound [28]. Similar to human studies [8,9], there was a significant increase in serum CRP noted on day 1, which was prevented by calcium ( Figure 5D). Both renal injury ( Figure 5E) and shock ( Figure 5F) were significantly prevented till day 2 by calcium treatment.…”

Section: Therapeutic Extracellular Calcium Supplementation Prevents Hsupporting

confidence: 75%

“…This is similar to the improvements in SIRS, CRP, and pancreatic necrosis noted with Ringer's lactate in two meta-analysis (ours and by Iqbal et al [10]). Thus, the benefits noted with Ringer's lactate [7][8][9][10] in patients with severe pancreatitis are likely due to the calcium it contains, which binds NEFA like LA with an ionic interaction and also covalently; the relative contributions of which remain unknown.…”

Section: Discussionmentioning

confidence: 99%

“…Ringer's lactate (RL) is buffered and contains calcium and lactate. Clinical studies show RL infusion during pancreatitis allows early improvement in systemic inflammatory response syndrome (SIRS) and C-reactive protein (CRP) when compared with saline infusion [7][8][9], but not survival [10]. RL's benefits have been mechanistically attributed to lactate inhibiting macrophage activation [7] or negatively regulating toll-like receptor 4(TLR4) in a G protein-coupled receptor 81(GPR81)-dependent manner [11].…”

Section: Introductionmentioning

confidence: 99%

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Ringer’s Lactate Prevents Early Organ Failure by Providing Extracellular Calcium

Khatua

Yaron

El-Kurdi

et al. 2020

JCM

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Objective: Ringer’s lactate may improve early systemic inflammation during critical illnesses like severe acute pancreatitis, which are associated with hypocalcemia. Ringer’s lactate is buffered and contains lactate and calcium. We, thus analyzed extracellular calcium or lactate’s effects on the mechanisms, intermediary markers, and organ failure in models mimicking human disease with nonesterified fatty acid (NEFA) elevation. Methods: Meta-analyses and experimental studies were performed. Experimentally, extracellular calcium and lactate were compared in their interaction with linoleic acid (LA; a NEFA increased in human severe pancreatitis), and its subsequent effects on mitochondrial depolarization and cytosolic calcium signaling resulting in cell injury. In vivo, the effect of LA was studied on organ failure, along with the effect of calcium or lactate (pH 7.4) on severe acute pancreatitis-associated organ failure. A meta-analysis of human randomized control trials comparing Ringer’s lactate to normal saline was done, focusing on necrosis and organ failure. Results: Calcium reacted ionically with LA and reduced lipotoxic necrosis. In vivo, LA induced organ failure and hypocalcemia. During severe pancreatitis, calcium supplementation in saline pH 7.4, unlike lactate, prevented hypocalcemia, increased NEFA saponification, reduced circulating NEFA and C-reactive protein, reduced pancreatic necrosis adjacent to fat necrosis, and normalized shock (carotid pulse distension) and blood urea nitrogen elevation on day 1. This, however, did not prevent the later increase in serum NEFA which caused delayed organ failure. Meta-analysis showed Ringer’s lactate reduced necrosis, but not organ failure, compared with normal saline. Conclusion: Hypocalcemia occurs due to excess NEFA binding calcium during a critical illness. Ringer’s lactate’s early benefits in systemic inflammation are by the calcium it provides reacting ionically with NEFA. This, however, does not prevent later organ failure from sustained NEFA generation. Future studies comparing calcium supplemented saline resuscitation to Ringer’s lactate may provide insights to this pathophysiology.

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Section: Therapeutic Extracellular Calcium Supplementation Prevents Hsupporting

confidence: 75%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Ringer’s Lactate Prevents Early Organ Failure by Providing Extracellular Calcium

Khatua

Yaron

El-Kurdi

et al. 2020

JCM

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“…1. In total, nine studies [6,[8][9][10][16][17][18][19][20] met the inclusion criteria. The main characteristics of the included studies are summarized in Table 1.…”

Section: Search Results and Study Characteristicsmentioning

confidence: 99%

“…These studies were published between 2011 and 2018. Six studies [6,[8][9][10]17,20] focused on patients in ICU, two studies [18,19] focused on patients with acute pancreatitis and one study [16] included trauma patients.…”

Section: Search Results and Study Characteristicsmentioning

confidence: 99%

Balanced crystalloids versus normal saline for fluid resuscitation in critically ill patients: A systematic review and meta-analysis with trial sequential analysis

Liu

Wang

et al. 2019

The American Journal of Emergency Medicine

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a b s t r a c tIntroduction: Fluid resuscitation is a fundamental component of the management of critically ill patients, but whether choice of crystalloid affects patient outcomes remains controversial. Therefore, we performed this meta-analysis to compare the efficacy and safety of balanced crystalloids with normal saline. Methods: We searched the MEDLINE, Cochrane Central and EMBASE up to October 2018 to identify randomized controlled trials (RCTs) that compared balanced crystalloids versus normal saline in critically ill patients. The primary outcome was mortality. The secondary results were the incidence of acute kidney injury (AKI) and risk of receiving renal replacement therapy (RRT). Two authors independently screened articles based on the inclusion and exclusion criteria. The meta-analysis was conducted using Revman 5.3, trial sequential analysis (TSA) 0.9 and STATA 12.0. Results: Nine RCTs were identified. The pooled analyses showed that there were no significant differences in mortality (relative risk (RR) = 0.93, 95% confidence interval (CI) = 0.86, 1.01, P = 0.08), incidence of AKI (RR 0.94, 95% CI 0.88, 1.00, P = 0.06) or RRT use rate (RR 0.94, 95% CI 0.69, 1.27, P = 0.67) between balanced crystalloids and normal saline groups. However, TSA did not provide conclusive evidence. Conclusions: Among critically ill patients receiving crystalloid fluid therapy, use of a balanced crystalloid compared with normal saline did not reduce the mortality, risk of severe AKI or RRT use rate. Further large randomized clinical trials are needed to confirm or refute this finding. Trial registration: A protocol of this meta-analysis has been registered on PROSPERO (registration number: CRD42018094857).

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Acute Pancreatitis

Mederos

Reber

Girgis

2021

JAMA

494

321

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cute pancreatitis is one of the most common gastrointestinal conditions that results in hospital admission in the United States. The incidence of acute pancreatitis is estimated at 110 to 140 per 100 000 population, with an estimated more than 300 000 US emergency department visits per year. 1,2 Admissions due to acute pancreatitis have increased from 9.48 cases per 1000 hospitalizations in 2002 to 12.19 in 2013, with a median hospital cost of nearly $7000 per hospitalization. 3,4 Acute pancreatitis is a complex disease with a variable course that is often difficult to predict early in its development (eBox in the Supplement). Approximately 80% of patients develop mild to moderately severe disease (absence of organ failure >48 hours). 5,6 However, one-fifth of patients develop severe disease, with a mortality rate of approximately 20%. 5,7 The purpose of this review is to summarize evidence regarding the recognition of disease severity, fluid and nutrition management, and risk-reduction methods for the prevention of recurrent disease. MethodsPubMed and the Cochrane databases were searched for Englishlanguage studies published from January 2009 through August 2020 for randomized clinical trials (RCTs), meta-analyses, systematic reviews, and observational studies. Manual searches were performed of the references of selected articles, reviews, metaanalyses, and practice guidelines. Select studies prior to 2009 were included for historical context. Emphasis was given to RCTs and metaanalyses. All publications and citations included were mutually agreed on by the authors and selected for clinical importance and relevance with consideration to the general medical readership of JAMA. Sixty-six articles were included, which contained 8 RCTs, 12 meta-analyses, and 5 clinical guidelines. Pathogenesis and EtiologyAcute pancreatitis is characterized by damage to the acinar cells, the functional units of the exocrine pancreas, precipitating inappropriate release and activation of trypsinogen to trypsin within the acini. This triggers the activation of other digestive enzymes, the kinin system, and the complement cascade resulting in autodigestion of the pancreatic parenchyma. 8,9 Pancreatic duct obstruction (eg, gallstone pancreatitis) is one of the more common causes of acinar damage, causing an increase in ductal pressure, interstitial edema, and accumulation of enzyme-rich fluid within the pancreatic tissue. 10 Alternatively, primary acinar injury may be caused by a variety of other factors, such as calcium, which regulates trypsin activation. Inappropriate release of IMPORTANCE In the United States, acute pancreatitis is one of the leading causes of hospital admission from gastrointestinal diseases, with approximately 300 000 emergency department visits each year. Outcomes from acute pancreatitis are influenced by risk stratification, fluid and nutritional management, and follow-up care and risk-reduction strategies, which are the subject of this review.OBSERVATIONS MEDLINE was searched via PubMed as was the Cochrane data...

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Comparison of normal saline versus Lactated Ringer's solution for fluid resuscitation in patients with mild acute pancreatitis, A randomized controlled trial

Cited by 64 publications

References 22 publications

Ringer’s Lactate Prevents Early Organ Failure by Providing Extracellular Calcium

Ringer’s Lactate Prevents Early Organ Failure by Providing Extracellular Calcium

Balanced crystalloids versus normal saline for fluid resuscitation in critically ill patients: A systematic review and meta-analysis with trial sequential analysis

Acute Pancreatitis

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