Periprocedural Intravenous Fluid Administration for the Prevention of Post–Endoscopic Retrograde Cholangiopancreatography Pancreatitis

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To the Editor:
We read with great interest the article by Grunwald et al1 on hemodynamic variation and intravenous (IV) fluid administration during endoscopic retrograde cholangiopancreatography (ERCP) and the association with post–ERCP pancreatitis (PEP). The aim of their study was to determine whether intraprocedural hypotension and the amount of IV fluids with lactated Ringer’s solution administered during ERCP were associated with development of PEP. They used a case-control study design, in a 1:3 ratio of cases to controls with matching only taking temporality of procedures (within 1 mo of each other) into account. Unfortunately, this resulted in case and control groups that markedly differed in their baseline risk for development of PEP. The case group had significantly more patients undergoing ERCP for pancreas/pancreatic duct evaluation or found to have ampullary stenosis or an ampullary mass at the time of procedure, all of which increase the risk for development of PEP. Conversely, the control group had significantly more patients who underwent ERCP for the indication of stent evaluation, removal, or exchange, which is likely associated with a lower rate of PEP.
Furthermore, they measured dehydration using a blood urea nitrogen to creatinine ratio of over 20:1 as a surrogate marker; however, this does not determine whether their patients were euvolemic at baseline, if, as expected, they were kept nil per os for 8 to 16 hours before their procedure. Random chance alone may have put more hypovolemic patients in the case group. This may explain why the case group received on average 24% more IV fluids than the control group, along with a wider range of total IV fluid volume administered (case group: mean, 547 mL; range, 0–2000 mL vs control group: mean, 440 mL; range, 0–1400 mL).
We would appreciate more information on which patients developed PEP and what amount of volume they had individually received. In addition, they found an association between increasing amount of IV fluids administered and risk of PEP, which has not been previously observed. Conversely, 2 randomized controlled studies have shown that large periprocedural IV fluid infusions resulted in a decrease in the development of PEP.2,3 Rather than shy away from periprocedural volume expansion with lactated Ringer’s solution as suggested by Grunwald et al1 perhaps we should, in selected patients, embrace this safe, inexpensive, and readily available prophylactic modality for the prevention of PEP.

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