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Background Current practice guidelines for optimal infusion rates during early intravenous hydration in patients with acute pancreatitis (AP) remain inconsistent. This systematic review and meta-analysis aimed to compare treatment outcomes between aggressive and non-aggressive intravenous hydration in severe and non-severe AP. Methods This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We systematically searched PubMed, Embase and Cochrane Library for randomized controlled trials (RCTs) on November 23, 2022, and hand-searched the reference lists of included RCTs, relevant review articles and clinical guidelines. We included RCTs that compared clinical outcomes from aggressive and non-aggressive intravenous hydration in AP. Meta-analysis was performed using a random-effects model for participants with severe AP and non-severe AP. Our primary outcome was all-cause mortality, and several secondary outcomes included fluid-related complications, clinical improvement and APACHE II scores within 48 h. Results We included a total of 9 RCTs with 953 participants. The meta-analysis indicated that, compared to non-aggressive intravenous hydration, aggressive intravenous hydration significantly increased mortality risk in severe AP (pooled RR: 2.45, 95% CI: 1.37, 4.40), while the result in non-severe AP was inconclusive (pooled RR: 2.26, 95% CI: 0.54, 9.44). However, aggressive intravenous hydration significantly increased fluid-related complication risk in both severe (pooled RR: 2.22, 95% CI 1.36, 3.63) and non-severe AP (pooled RR: 3.25, 95% CI: 1.53, 6.93). The meta-analysis indicated worse APACHE II scores (pooled mean difference: 3.31, 95% CI: 1.79, 4.84) in severe AP, and no increased likelihood of clinical improvement (pooled RR:1.20, 95% CI: 0.63, 2.29) in non-severe AP. Sensitivity analyses including only RCTs with goal-directed fluid therapy after initial fluid resuscitation therapy yielded consistent results. Conclusions Aggressive intravenous hydration increased the mortality risk in severe AP, and fluid-related complication risk in both severe and non-severe AP. More conservative intravenous fluid resuscitation protocols for AP are suggested. Graphical Abstract

ObjectiveThe aim of this meta-analysis was to determine the role of an aggressive intravenous hydration protocol of Lactated Ringer’s solution in patients with mild acute pancreatitis (MAP).MethodsA systematic search was conducted in PubMed, EMBASE, Cochrane Library, and China National Knowledge Infrastructure (CNKI) to identify randomized controlled trials (RCTs) published before August 19, 2022. The clinical outcomes were evaluated using the standard mean difference (SMD), mean difference (MD), risk ratio (RR), and 95% confidence interval (CI). The primary outcome was clinical improvement, while the secondary outcomes were the development of systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS), relief of epigastric abdominal pain, and length of hospital stay (LoH). Statistical analysis was performed with RevMan 5.4. Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) Working Group system was used to determine the quality of evidences.ResultsThere were five RCTs with 370 MAP patients included, and the overall methodological quality was moderate. Aggressive hydration protocol was comparable to standard hydration protocol in terms of clinical improvement (RR = 1.33, 95%CI = 0.95–1.87, P = 0.10; very low evidence). Fewer events of SIRS (RR = 0.48, 95%CI = 0.31–0.72, P < 0.001; low evidence) and MODS (RR = 0.34, 95%CI = 0.13–0.91, P = 0.03; moderate evidence) were reported in patients receiving aggressive hydration protocol. Meanwhile, aggressive hydration protocol also significantly relieved epigastric abdominal pain (SMD = −0.53, 95%CI = −0.81 to −0.25, P < 0.001; low evidence) and shorten the LoH (MD = −2.36, 95%CI = −3.17 to −1.55, P < 0.001; low evidence) compared with standard hydration protocol.ConclusionFor patients with MAP, aggressive hydration protocol may be more effective than standard hydration protocol at lowering SIRS and MODS rates, relieving epigastric abdominal pain, and shortening the LoH. Due to the small number of studies that are eligible and poor methodological quality of eligible studies, further studies are required to validate our findings.