Intensive vs. moderate fluid resuscitation in acute pancreatitis: A systematic review and meta-analysis

Intravenous fluid resuscitation is central to the early management of acute pancreatitis (AP), but the optimal intensity remains uncertain. This systematic review and meta-analysis compared intensive or aggressive vs. moderate fluid resuscitation in adults with AP.

This systematic review and meta-analysis followed PRISMA 2020 and was registered in PROSPERO (CRD42024626152). PubMed, Scopus, Web of Science, and Embase were searched from inception to February 15, 2024 for Randomized Controlled Trials (RCT) enrolling adults with acute pancreatitis and comparing intensive/aggressive vs. moderate fluid resuscitation. The primary outcome was in-hospital mortality; secondary outcomes were length of hospital stay, persistence of systemic inflammatory response syndrome (SIRS), fluid-overload complications, and early clinical improvement (≤36h). Risk of bias was assessed with RoB 2.0. Pooled relative risks (RR) and mean differences (MD) with 95% confidence intervals (CI) were calculated using fixed- or random-effects models according to heterogeneity (I²). Analyses were performed in RevMan 5.4.1.

Seven RCTs were included. IFR was associated with higher mortality than MFR (RR 2.60; 95% CI 1.48-4.57; I²=0%). IFR did not reduce LOS (MD 1.21 days; 95% CI 0.72-1.69; I²=65%) or SIRS persistence (RR 0.87; 95% CI 0.50-1.52; I²=26%). Fluid-overload complications were more frequent with IFR (RR 3.34; 95% CI 1.60-6.98; I²=0%). Early clinical improvement did not differ (RR 1.20; 95% CI 0.63-2.29; I²=72%). Risk of bias was generally low.

Across randomized evidence, intensive hydration offers no clinical benefit over moderate regimens and is associated with higher mortality and greater risk of fluid overload. Findings support moderate, goal-directed, individualized fluid therapy in acute pancreatitis and highlight the need for large multicenter RCTs to refine fluid targets and monitoring endpoints.