Non-aggressive Lactated Ringer’s resuscitation improves outcomes and has a favorable safety profile in acute pancreatitis: a comprehensive systematic review and component network meta-analysis of Randomized Controlled Trials using GRADE and CINeMA approaches

Background Acute pancreatitis (AP) frequently requires early fluid resuscitation to restore intravascular volume, preserve pancreatic perfusion, and prevent organ failure. However, the optimal fluid type and resuscitation strategy remain controversial. Methods We performed a component network meta-analysis (CNMA) of randomized controlled trials comparing fluids (normal saline [NS], lactated Ringer [LR], other balanced multi-electrolyte solutions [BMES], and naso-jejunal hydration solution [NJ]) and resuscitation strategies (aggressive vs. non-aggressive) in patients with new-onset AP. Primary endpoints were progression to moderately severe or severe AP, systemic inflammatory response syndrome (SIRS), and adverse events. Secondary endpoints included mortality, local complications, organ failure, and length of stay (LOS). Incremental component effects were expressed as incremental odds ratios (iOR) or mean differences (iMD). Certainty of evidence was evaluated using CINeMA and GRADE. Results Twelve trials (1,216 patients) were included. LR significantly reduced progression to moderately severe/severe AP (iOR 0.51; 95% CI 0.33; 0.79) and pancreatitis-related local complications (iOR 0.53; 95% CI 0.33; 0.85). BMES and LR reduced LOS by approximately 4 and 1 day, respectively, compared with NS. Aggressive resuscitation increased adverse events (iOR 3.35; 95% CI 1.52; 7.37). Heterogeneity and inconsistency were generally low for primary endpoints. Conclusions Balanced crystalloids, particularly LR, are associated with improved clinical outcomes compared with NS in early AP management, reducing disease progression, local complications, and hospital stay. Aggressive fluid regimens increase adverse events without a clear benefit. These findings support the preferential use of LR within a moderate, goal-directed resuscitation strategy, although the certainty of evidence was generally low to moderate due to risk of bias and imprecision.