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WATERFALL RCT – Are We Flooding Pancreatitis Patients With Fluid?

October 28, 2022

Written by Vivian Lei

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Conservative fluid administration in patients with acute pancreatitis can achieve similar clinical outcomes compared with aggressive resuscitation, with less risk of volume overload.

Why does this matter?
Historically, pancreatitis has been treated with early and aggressive fluid resuscitation. However, conflicting data exist on the ideal volume of IV fluids to administer. The WATERFALL study was designed to investigate different fluid management strategies and potential harms.

Still flooding patients with fluids? That’s so antediluvian…
This was a multicenter RCT in which 249 patients with acute pancreatitis were randomized to aggressive (20 ml/kg bolus followed by 3 ml/kg/h) or moderate fluid resuscitation (10 ml/kg bolus if hypovolemic followed by 1.5 mg/kg/h) and assessed at regular intervals throughout hospitalization for development of worsening pancreatitis and volume overload.

Patients receiving aggressive resuscitation had a median of 7.8 L of lactated Ringer’s in 48 hours, while those receiving moderate resuscitation had 5.5 L. The trial was halted early for safety reasons, because aggressive resuscitation was significantly associated with a higher incidence of volume overload compared to moderate resuscitation (20.5% compared to 6.3%). There were no significant differences in clinical outcomes, including development of moderately severe or severe pancreatitis (22.1% in aggressive vs. 17.3% in moderate group), local complications like necrotizing pancreatitis, ICU admission, persistent organ failure, respiratory failure, need for nutritional support, or death. Most clinical outcomes trended worse for those in the aggressive resuscitation group, although the study was limited by an underpowered sample size given the early trial termination.

Aggressive or Moderate Fluid Resuscitation in Acute Pancreatitis. N Engl J Med. 2022 Sep 15;387(11):989-1000. doi: 10.1056/NEJMoa2202884.

What are your thoughts?