This article is a collaboration between ֱ and:
PHILADELPHIA -- The use of Ringer's lactate rather than normal saline for intravenous hydration in patients with acute pancreatitis showed promise in a meta-analysis, although the effects on mortality did not reach statistical significance, a researcher reported here.
In five studies comparing the two hydration approaches, there was a trend toward lower mortality among patients given Ringer's lactate, with an odds ratio of 0.61 (95% CI 0.28-1.29, P=0.20), according to Umair Iqbal, MD, of Bassett Medical Center in Cooperstown, New York.
However, patients receiving Ringer's lactate had a significantly lower risk of developing systemic inflammatory response syndrome (SIRS) 24 hours after admission (OR 0.38, 95% CI 0.15-0.98, P=0.05), he reported at the American College of Gastroenterology (ACG) annual meeting.
"As we all know, fluid hydration is the most crucial step in the management of acute pancreatitis, and the current ACG guidelines recommend crystalloids for the initial management. However, the guidelines are not clear which crystalloids to use," he said.
Previous studies have suggested that in acute pancreatitis patients, more balanced solutions like Ringer's lactate might be beneficial. For instance, found that Ringer's lactate was associated with an anti-inflammatory effect, while normal saline was associated with proinflammatory effects and hyperchloremic acidosis.
To compare outcomes with the two approaches, Iqbal's group conducted a literature research through December 2017. Initially they identified 4,000 articles, with five meeting their criteria for inclusion in the meta-analysis. The largest sample size was 198 patients and the smallest included 40. Two were retrospective cohort studies and three were randomized controlled trials; all were assessed as having fair to good quality and low heterogeneity (I2=46%).
The total number of patients for the mortality analysis was 428, with 259 in the saline group and 169 in the Ringer's lactate group. There were 26 deaths in the normal saline group and nine in the Ringer's lactate group, which was not significantly different.
Only three studies included SIRS as an outcome, with 127 patients. There was no difference at baseline in rates of SIRS, but by 24 hours, the syndrome had developed in 17 patients receiving normal saline compared with seven given Ringer's lactate.
The anti-inflammatory effects of Ringer's lactate may result from its slightly higher pH.
"Studies show that acidosis enhances inflammation and necrosis in acute pancreatitis. Lactate in Ringer's lactate is metabolized in the liver, which results in lower metabolic acidosis and hence protective effects," Iqbal explained.
In addition, Ringer's lactate may directly decrease the inflammatory response. In vitro, Ringer's lactate prevents activation of NF-KB, the transcription factor involved in this inflammatory process.
"Larger randomized controlled trials are necessary to further strengthen the association of Ringer's lactate with favorable outcomes in patients with acute pancreatitis, but our findings may help clinicians in making decisions regarding choice of fluid for management of these patients," he concluded.
A study limitation was that the cause of death was not given in all studies and the time between exposure to fluids and death was not consistently reported.
Disclosures
Iqbal and co-authors disclosed no relevant relationships with industry.
Primary Source
American College of Gastroenterology
Iqbal U, et al “Ringer’s lactate vs normal saline in acute pancreatitis: A systematic review and meta-analysis” ACG 2018;Abstract 19.