Evolution of early fluid therapy in acute pancreatitis: Balancing perfusion needs with fluid toxicity

Table 1 Recent guidelines and pivotal turning points shaping early fluid resuscitation in acute pancreatitis

Ref.	Year	Study type/scope	Main message	Comment
Párniczky et al[3]	2025	International guideline	Moderate monitored hydration	Guideline
Tenner et al[4]	2024	ACG guideline	Early fluid therapy remains central	Guideline
de-Madaria et al[11]	2022	Multicenter RCT	Overload without clear benefit	Pivotal

ACG: American College of Gastroenterology; RCT: Randomized controlled trial.

Table 2 Representative contemporary studies informing fluid selection, reassessment, and precision-oriented practice in acute pancreatitis

Ref.	Year	Study design/population	Main findings	Comment
Li et al[15]	2020	Severe hemoconcentrated AP	More noninvasive ventilation	Pulmonary risk
Lee et al[23]	2021	Randomized trial; LR vs NS	LR favored	Key trial
Chen et al[27]	2022	Updated meta-analysis; LR vs NS	LR superior to NS	Supports LR
Froghi et al[50]	2022	Feasibility RCT of ward-based GDFT	Ward-based reassessment feasible	Practical
Ehsan et al[17]	2024	Updated meta-analysis	No reproducible net benefit	Restrictive
Hong et al[29]	2024	Updated meta-analysis; LR vs NS	Recent evidence favored LR	Consistent
Evans et al[51]	2024	Meta-analysis and trial sequential analysis	Routine aggressive therapy unsupported	Sequential
Kong et al[41]	2025	Machine learning-guided fluid study	ML-guided strategy improved outcomes	Frontier

AP: Acute pancreatitis; GDFT: Goal-directed fluid therapy; LR: Lactated Ringer’s solution; ML: Machine learning; NS: Normal saline; RCT: Randomized controlled trial.

Table 3 Representative studies comparing Lactated Ringer’s solution with normal saline in acute pancreatitis

Ref.	Year	Study type/population	Main findings	Comment
Lee et al[23]	2021	Randomized trial; mild AP	LR favored	Key trial
Zhou et al[56]	2021	Meta-analysis of RCTs	Pooled signal favored LR	Synthesis
Kow et al[25]	2022	Systematic review and meta-analysis	LR remained favorable	Consistent
Vedantam et al[28]	2022	Updated meta-analysis	Benefit varied by endpoint	Mixed
Hong et al[29]	2024	Updated meta-analysis	Recent pooled data favored LR	Supports LR
Guilabert et al[33]	2024	Multicenter RCT protocol	Prospective testing ongoing	Ongoing

AP: Acute pancreatitis; LR: Lactated Ringer’s solution; RCT: Randomized controlled trial.

Table 4 High-risk clinical phenotypes and practical implications for fluid strategy in acute pancreatitis

Phenotype	Why risk is higher	Practical implication	Ref.
Severe AP with evolving organ failure	Inflammation may uncouple fluid load from effective perfusion	Reassess frequently	[34,36,53]
Hypertriglyceridemia-associated AP	Distinct metabolic drivers may alter fluid tolerance	Avoid a generic algorithm	[37-39]
Obesity and reduced thoracic reserve	Positive balance may trigger respiratory compromise	Use smaller test boluses
Cardiorenal or unstable high-risk presentations	Fluid tolerance may be low and organ-support needs may evolve rapidly	Escalate support earlier	[54,55,57,58]

AP: Acute pancreatitis.