In Acute Pancreatitis, Ringer's Lactate Tops Saline

Megan Brooks

October 09, 2018

PHILADELPHIA — For intravenous hydration in patients with acute pancreatitis, Ringer's lactate might be a better choice than normal saline, a systematic review and meta-analysis suggests.

With lactated Ringer's solution, there was a trend toward lower mortality and fewer patients developed systemic inflammatory response syndrome than with normal saline.

Patients with acute pancreatitis have "profound hypovolemia and we have known for a long time that early fluid resuscitation is vital," said Nikhil Kumta, MD, from Mount Sinai Hospital and the Icahn School of Medicine at Mount Sinai in New York City, who was not involved in the study.

"A lot of data have shown that if you give pretty aggressive fluids in the first 24 hours, the patients will often have better outcomes than patients who are not resuscitated as aggressively upfront," he explained.

But "the fluid of choice has kind of always been sort of a question mark," he told Medscape Medical News.

Common Cause of Hospitalization

Acute pancreatitis is one of the most common causes of hospitalization in the United States. Adequate intravenous hydration with crystalloids is the first step in management and is associated with improved survival. Normal saline is most commonly used, but recent studies have suggested that Ringer's lactate can improve survival and decrease the development of systemic inflammatory response syndrome, a marker of poor outcome.

A systematic review and meta-analysis of five studies that compared saline with Ringer's lactate for the management of acute pancreatitis was conducted by Umair Iqbal, MD, from the Geisinger School of Medicine and Bassett Medical Center in Cooperstown, New York, and his colleagues.

The primary end point was the difference in mortality, and secondary end point was the development of systemic inflammatory response syndrome in 24 hours, Iqbal explained here at the American College of Gastroenterology (ACG) 2018 Annual Scientific Meeting.

The five studies — three randomized controlled trials and two retrospective cohort studies — had a total of 428 patients. Only three studies, with 127 patients, reported the secondary outcome of systemic inflammatory response syndrome at 24 hours.

The studies were judged to be of "fair to good" quality and there were no significant differences in baseline characteristics between the patients treated with Ringer's lactate and those treated with normal saline, Iqbal reported.

The results showed a trend toward lower mortality with Ringer's lactate than with normal saline, but the difference was not significant (pooled odds ratio [OR], 0.61; 95% confidence interval [CI], 0.28 - 1.29; P = .20).

However, patients who received Ringer's lactate were significantly less likely to develop systemic inflammatory response syndrome at 24 hours (pooled OR, 0.38; 955 CI, 0.15 - 0.98; P = .05).

The apparent anti-inflammatory effect of Ringer's lactate has two possible explanations, Iqbal and coauthors note in their abstract.

First, the pH is slightly higher in Ringer's lactate than in normal saline, and studies have shown that acidosis enhances inflammation and necrosis in acute pancreatitis. The lactate in Ringer's lactate is metabolized in the liver, which results in lower metabolic acidosis and, hence, protective effects, they explain.

Second, they suggest that Ringer's lactate directly decreases the inflammatory response in these patients. The presence of Ringer's lactate in vitro prevents activation of a key transcription factor involved in the inflammatory process.

In terms of limitations of the analysis, Iqbal noted that the definition of mortality was not clear in some of the studies. Specifically, the cause of death and the time between exposure to Ringer's lactate or normal saline and death was not reported consistently in the studies, he said.

In addition, the sample sizes for the three randomized controlled trials were modest. "Larger randomized controlled trials are needed to strengthen the association of Ringer's lactate with favorable outcomes in patients with acute pancreatitis," Iqbal said.

I think most of us in practice are shifting toward the use of lactated Ringer's.

"The ACG guidelines for the management of acute pancreatitis recommend using lactated Ringer's, which is thought to reduce systemic inflammation," Kumta told Medscape Medical News

Now, this study "shows that lactated Ringer's can reduce the overall inflammatory response and supports its use in early aggressive fluid hydration in a patient with acute pancreatitis," he said.

"I think most of us in practice are shifting toward the use of lactated Ringer's," he added.

The study had no specific funding. Igbal and Kumta have disclosed no relevant financial relationships.

American College of Gastroenterology (ACG) 2018 Annual Scientific Meeting: Oral abstract 19. Presented October 9, 2018.

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