A multicentre double-blind superiority trial at three Korean academic hospitals randomised 813 adults with native papillae and moderate-to-high risk of post-ERCP pancreatitis to lactated Ringer's or an acetate-buffered balanced crystalloid. Rectal NSAIDs are unavailable in this setting, which makes fluid the primary preventive strategy rather than an adjunct.
The protocol is worth noting on its own: 10 mL/kg boluses before and after ERCP, then 3 mL/kg/h for four hours, extended to eight only if abdominal pain developed or worsened. That symptom-guided design addresses the practical objection to the standard eight-hour protocol, which is unworkable in an outpatient list.
Pancreatitis occurred in 12.4% with Ringer's and 11.5% with acetate, a relative risk of 0.93 with an interval from 0.64 to 1.35. Mild and moderate rates were similar; no severe pancreatitis and no fluid overload occurred in either arm.
The incidental finding may be the more useful one. Of the 68.3% of patients still asymptomatic at four hours who therefore received only the shortened protocol, pancreatitis occurred in 7.4% with no severe cases — which suggests two-thirds of patients can leave after four hours of hydration rather than eight.
- Ringer's remains first line; acetate offers no advantage
- Specific to settings without rectal NSAIDs, which are first line where available
- The symptom-guided 4-hour protocol let 68% stop at four hours
- Those shortened-protocol patients had 7.4% pancreatitis and no severe cases
- No fluid overload in either arm despite aggressive hydration
The statistics, in plain English
This was a superiority trial, so a relative risk of 0.93 with an interval from 0.64 to 1.35 means superiority was not shown — not that the two fluids are equivalent, which would require a non-inferiority design with a prespecified margin. The practical conclusion, that Ringer's remains first line, follows from it being the established option rather than from the acetate arm being worse.
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