In this episode of Inpatient Update, Dr. Mason Turner is joined by hospitalist Dr. Daniel Hardgrove to rethink two common fluid decisions:
- Acute pancreatitis — should aggressive IV fluids still be the default?
- LR vs normal saline — does balanced crystalloid actually improve outcomes?
Practical take-homes, real-world discussion, and what to change on rounds tomorrow.
Articles & PubMed Links
Aggressive or Moderate Fluid Resuscitation in Acute Pancreatitis
New England Journal of Medicine, 2022
WATERFALL Trial
Compared:
- Aggressive fluids: 20 mL/kg bolus + 3 mL/kg/hr
- Moderate fluids: bolus only if hypovolemic + 1.5 mL/kg/hr
Key Findings
- No improvement in moderately severe/severe pancreatitis
- More fluid overload with aggressive fluids
- Trial stopped early for harm
- Shorter length of stay with moderate fluids
Takeaway
For acute pancreatitis, stop reflexively flooding patients.
Give fluids if hypovolemic.
Start moderate.
Reassess early.
Stop when no longer needed.
Pubmed: https://pubmed.ncbi.nlm.nih.gov/36103415/
A Crossover Trial of Hospital-Wide Lactated Ringer’s Solution vs Normal Saline
New England Journal of Medicine, 2025
FLUID Trial
Hospital-wide crossover trial comparing:
- Lactated Ringer’s
- Normal saline
Key Findings
No significant difference in:
- Death or readmission at 90 days
- Mortality
- Dialysis
- Length of stay
- ED visits
Takeaway
LR is reasonable.
Normal saline is reasonable.
For most hospitalized patients, the choice probably matters less than we thought.
Pubmed: https://pubmed.ncbi.nlm.nih.gov/40503714/
Practice-Changing Takeaways
- Pancreatitis: moderate, reassessed fluids beat automatic aggressive hydration.
- Crystalloid choice: LR is not clearly superior to saline for broad hospital use.
- Fluids are treatment, not autopilot.
Bottom Line
If you change nothing else this week:
- Don’t automatically flood pancreatitis patients.
- Put a stop time or reassessment point on maintenance fluids.
- Use LR or saline thoughtfully based on the patient.
Treat the patient. Not the reflex.
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