Fluid type and volume reduce risk of post-ERCP pancreatitis and length of hospital stay in high-risk patients: a secondary analysis of the INDIEH trial

Abstract

Background and study aims Impact of intravenous fluid administration on prophylaxis against post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) has not been rigorously evaluated among patients at high-risk for PEP. Patients and methods Effect of volume and type of fluid administered on PEP incidence was studied through a secondary analysis of high-risk patients who underwent endoscopic retrograde cholangopancreatography (ERCP) as a part of a randomized controlled trial in which all patients received rectal indomethacin. Periprocedural fluid was defined as fluid infused during and after ERCP. Results A total 960 patients were randomized during the trial, of whom 476 (49.6 %) received periprocedural fluids (mean volume = 1245 mL [± 629]). There was a trend towards a lower incidence of PEP in patients who received periprocedural fluid vs. those who did not (5.2 % vs. 8.0 %, P = 0.079). Among those receiving fluids, those who did not develop PEP received a higher mean volume of fluid vs. who developed PEP (1012 ± 725 mL vs. 752 ± 783 mL, P = 0.036). Among 174 patients (37 %) who received LR, patients who did not develop PEP received a higher mean volume of LR vs. those who developed PEP (570 ± 559 mL vs. 329 ± 356 mL, P = 0.006). Length of hospital stay decreased as the volume of periprocedural volume administration increased (r = 0.16, P < 0.001). Conclusion Higher fluid volume and lactated Ringerʼs use during the periprocedural period was associated with a decreased risk of PEP and length of hospital stay beyond rectal indomethacin in high risk patients.

Frequent guidewire passage into the pancreatic duct is an independent risk factor for postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) among high‐risk individuals: A post‐hoc analysis of a randomized controlled trial data

“…There is increasing evidence of the role of periprocedural hydration for PEP prophylaxis and our study results are consistent with this 24 . In another analysis of secondary end‐points of our RCT, we showed that the use of LR and higher volumes of fluid significantly decrease the risk of PEP 25 . There was an increased PEP risk among patients with malignant biliary stricture(s) in our cohort (OR 3.51, 95% 1.52–8.10, P = 0.003).…”

“…24 In another analysis of secondary end-points of our RCT, we showed that the use of LR and higher volumes of fluid significantly decrease the risk of PEP. 25 There was an increased PEP risk among patients with malignant biliary stricture(s) in our cohort (OR 3.51, 95%…”

Controversies in ERCP: Indications and preparation

“…Secondary analysis of the INDIEH trial[ 105 ] found that higher fluid volume and the use of lactated Ringer's solution were associated with a decreased risk of PEP and length of hospital stay when used in conjunction with rectal indomethacin in high-risk patients. [ 125 ] In two recent network meta-analyses, the combination of rectal Indomethacin and aggressive hydration was found the most effective strategy to prevent PEP. [ 126 127 ] The results of RCTs such as the Fluyt trial[ 128 ] investigating the combination of aggressive hydration plus rectal NSAIDs in average-risk to high-risk patients are awaited with interest.…”

Efficacy of aggressive hydration with normal saline versus lactated Ringer’s solution for the prevention of post-ERCP pancreatitis in high-risk patients: a randomized controlled trial

“…Talukdar et. al found that a higher mean volume of IV fluid (IVF) (752 ± 783 mL vs 1012 ± 725, P = 0.036) and use of LR (OR, 0.56; 95 % confidence intervals (CI) 0.31-0.99) was associated with a lower risk of PEP in a secondary analysis of an international multicenter PEP prevention trial in high-risk patients [13].…”