Hospital management of diabetic ketoacidosis: are clinical guidelines implemented effectively?

A study was undertaken in order to examine the quality of management of diabetic ketoacidosis (DKA) in a teaching hospital and to assess whether the introduction of clinical guidelines contributed to a satisfactory outcome. Data on presentation and management of 71 cases of DKA admitted in one calendar year (1994) were collected and analysed. Comparing the data to standards set in guidelines, inadequacies of clinical management were identified including delay in initiation of intravenous fluid replacement (greater than 30 min) and intravenous insulin (greater than 60 min) in 70 % and 69 % of cases, respectively; under-replacement with intravenous fluid in the first 24 h (less than 6.5 l) in 70 % of cases, and insufficient intravenous potassium replacement (less than 70 mmol) in the first 24 h in 70 % of cases. Suboptimal management of DKA may have contributed towards death in one of the three fatalities, and to morbidity in other patients. In 22.5 % of cases (group 1) in whom the guidelines were alleged to have been followed, intravenous fluid, potassium, and insulin had been administered earlier and in larger quantities compared to the remaining cases (group 2). However, in most cases in group 1 the standards set by the guidelines were unfulfilled and the incidence of hypokalaemia, hypoglycaemia, and duration of in-patient stay did not differ from group 2. The treatment of DKA by non-specialist general medical staff in a large teaching hospital was frequently inadequate and was associated with significant mortality and morbidity. The introduction of guidelines had moderately influenced the process of managing DKA but not the outcome, probably because of the low rate of their implementation by junior doctors. © 1997 by John Wiley & Sons, Ltd.     

Profile of diabetic ketoacidosis at the National Diabetes and Endocrine Center in Tripoli,Libya, 2015

BackgroundDiabetic ketoacidosis (DKA) is a major acute metabolic complication of type I diabetes mellitus but may occur in type II diabetes during severe stressful conditions.AimThe aim of this study was to describe the clinical profile of DKA patients admitted to the National Diabetes and Endocrine Center in Tripoli, Libya, during 2015.Patients and methodsThe profiles of 490 patients admitted with DKA were retrospectively studied. All the data was collected from the patient files.ResultsMost of the patients (91.6%) were admitted to the intensive care unit. The mean age was 35.9 years. DKA was more common among young males with type I diabetes. The average duration of diabetes disease of the patient when admitted with DKA was 16.8 ± 8.2 years. The frequencies of patients admitted with mild, moderate or severe diabetic ketoacidosis were 49.8%, 32.7% and 17.8%, respectively. The most frequent causes of admission were insulin omission (21.8%), infection (20.2%), and wrong dose (11%). The cause of DKA was not known for 29.8% of the patients. DKA was more common among young males, and the rate increased with longer duration of the condition. Most of the patients (93.1%) were discharged in good health, and mortality was 0.6%.ConclusionMales and patients with a long duration of diabetes disease are more prone to develop DKA. The common causes of DKA were unknown in our study; however, admission of individuals with less serious illness, insulin omission, and infection may contribute to the development of DKA.     

Clinical profile and outcomes in COVID-19 patients with diabetic ketoacidosis: A systematic review of literature

Background and aimTo conduct a systematic literature review and analyze the demographic/biochemical parameters and clinical outcomes of COVID-19 patients with diabetic ketoacidosis (DKA) and combined DKA/HHS (hyperglycemic hyperosmolar syndrome).MethodsPubMed, Scopus, Embase, and Google Scholar databases were systematically searched till August 3, 2020 to identify studies reporting COVID-19 patients with DKA and combined DKA/HHS. A total of 19 articles reporting 110 patients met the eligibility criteria.ResultsOf the 110 patients, 91 (83%) patients had isolated DKA while 19 (17%) had DKA/HHS. The majority of the patients were male (63%) and belonged to black ethnicity (36%). The median age at presentation ranged from 45.5 to 59.0 years. Most of the patients (77%) had pre-existing type 2 diabetes mellitus. Only 10% of the patients had newly diagnosed diabetes mellitus. The median blood glucose at presentation ranged from 486.0 to 568.5 mg/dl, being higher in patients with DKA/HHS compared to isolated DKA. The volume of fluid replaced in the first 24 h was higher in patients with DKA/HHS in contrast to patients with DKA alone. The in-hospital mortality rate was 45%, with higher mortality in the DKA/HHS group than in the isolated DKA group (67% vs. 29%). pH was lower in patients who had died compared to those who were discharged.ConclusionDKA in COVID-19 patients portends a poor prognosis with a mortality rate approaching 50%. Differentiating isolated DKA from combined DKA/HHS is essential as the latter represents nearly one-fifth of the DKA cases and tends to have higher mortality than DKA alone.     

Treatment of diabetic ketoacidosis in adults in Denmark: a national survey

The aims of this study were to investigate management routines of diabetic ketoacidosis (DKA) in adult patients in departments of internal medicine in Denmark and to relate current routines of treatment to available evidence. A questionnaire requesting information on management routines of DKA was sent to all departments of internal medicine in Denmark responsible of managing DKA. Fifty-nine departments (88%) returned the questionnaire and/or a copy of their management protocol. At 19 departments (32%), all patients with DKA were managed in an intensive care unit (ICU). Twenty-four different insulin regimens and 21 fluid protocols were identified. Routines of insulin therapy varied in terms of doses and routes of administration. Fifty-eight departments (97%) used isotonic saline for hydration. Potassium supplements were administered as a separate infusion of either isotonic potassium-sodium-chloride (83%) or isotonic potassium-chloride (10%). Recommended volumes to be administered during the first 8h of treatment varied significantly (median 4800ml, range 3750-7700ml). Use of bicarbonate was endorsed by 80%. This study shows significant variations in management routines of DKA in Denmark. In many cases, the treatment routines employed are not supported by evidence from clinical trials. We recommend implementation of national and/or European guidelines for management of DKA in adult patients.     

Long-term risk of stroke in type 2 diabetes patients with diabetic ketoacidosis: A population-based,propensity score-matched,longitudinal follow-up study

AimTo investigate the long-term risk of stroke in type 2 diabetes (T2D) patients with previous episodes of diabetic ketoacidosis (DKA).MethodsThis retrospective nationwide population-based cohort study was conducted using Taiwan's National Health Insurance database. Claims data from 2000 to 2002 were extracted for 3572 T2D patients with DKA and 7144 controls matched for age, gender, diabetes complications severity index, frequency of clinical visits and baseline comorbidities. Patients with type 1 diabetes (T1D), identified by glucagon C-peptide stimulation or glutamic acid decarboxylase (GAD) antibody blood tests and possession of a catastrophic illness certificate were excluded. All patients were tracked until a new stroke diagnosis, death or the end of 2011.ResultsOf the 3572 selected patients, 270 with DKA and 404 of the 7144 controls were diagnosed with a new stroke, giving an incidence rate ratio (IRR) of 1.56 (95% CI: 1.34–1.82; P < 0.0001). DKA patients had a higher risk of ischaemic stroke than those without DKA (IRR: 1.62, 95% CI: 1.34–1.96; P < 0.0001), and DKA patients with hypertension and hyperlipidaemia were at even greater risk of stroke. Also, DKA patients were at particular risk for stroke during the first half-year following DKA diagnosis. After adjusting for patient characteristics and comorbidities, these patients were 1.55 times more likely to have a stroke than those without DKA (95% CI: 1.332–1.813, P < 0.0001).ConclusionT2D patients with previous DKA have a higher risk of stroke, especially ischaemic strokes.     

Clinical characteristics of diabetic ketoacidosis in users and non-users of SGLT2 inhibitors

AimThis study investigated the clinical characteristics of diabetic ketoacidosis (DKA) and compared the DKA characteristics between patients treated with and without SGLT2 inhibitors.MethodsData were collected from patients aged ≥ 18 years admitted for DKA at nine centres in Korea between September 2014 and April 2017. The electronic medical records of these subjects were retrospectively reviewed. Based on their history of medications taken before admission, subjects were classified as either users or non-users of SGLT2 inhibitors and their clinical characteristics of DKA were compared.ResultsDuring the study, the main subtype of DKA episodes (n = 523) was identified as type 2 diabetes (51%). Average hospitalization duration was 11 days, and average intensive care unit (ICU) time was 2.5 days. The in-hospital mortality rate was 3%, but no users of SGLT2 inhibitors died during DKA treatment. In patients taking SGLT2 inhibitors (n = 15), DKA manifested at 124 days, on average, after starting the inhibitors (range: 7–380 days). Also, SGLT2 inhibitors users had significantly lower plasma glucose levels (413 mg/dL) compared with non-users (554 mg/dL), and longer ICU stays (4 vs. 2 days; P = 0.019).ConclusionIn this report of recent data on the clinical features of DKA in Korea, patients using SGLT2 inhibitors needed longer treatment in ICUs compared with non-users and had lower levels of blood glucose, whereas DKA associated with SGLT2 inhibitors was rare.     

Practical management of diabetic ketoacidosis and hyperosmolar coma

In diabetic ketoacidosis (DKA) and particularly in hyperosmolar coma, rapid normalisation of the measured extracellular fluid abnormalities cannot be equated with optimal management. In both disorders there are complex imbalances between extra- and intracellular compartments that are best corrected in a series of rational steps, based on an understanding of pathophysiology. Fluid administration in DKA can generally be divided into three successive phases: (i) a short period of rapid isotonic saline infusion, (ii) slower infusion of isotonic saline with potassium chloride, and (iii) glucose-potassium infusion until oral food intake is well established. In severe cases, there is a definite place for judicious use of isotonic sodium bicarbonate in small amounts. While insulin infusion is desirable, intramuscular insulin remains a satisfactory alternative. Biochemical monitoring is mandatory and management must be reviewed and modified every three to four hours on the basis of the clinical and biochemical response. In the management of hyperosmolar coma, insulin and fluid therapy are more conservative, with the aim of achieving complete rehydration and normoglycaemia only after 36 to 72 hours. Pulmonary complications and the effects of tissue ischaemia, as well as thromboembolic events, remain important causes of death in both disorders. The frequent recurrences of DKA that occur in a group of psychiatrically-unstable young patients remain an unsolved problem.     

糖尿病酮症酸中毒合并急性心肌梗死14例临床分析

目的 探讨糖尿病酮症酸中毒(DKA)合并急性心肌梗死(AMI)的发病情况及临床特点.方法 回顾性分析我院1998～2006年共14例2型糖尿病酮症酸中毒合并AMI患者的临床资料.结果 1998～2006年共检出DKA合并AMI患者14例;发病时同时诊断DKA合并AMI者11例,占79%;先出现DKA后出现AMI者3例,占21%;DKA合并AMI发病时以气促、消化道症状和糖尿病典型"三多"症状多见,伴随胸痛者只有29%;心电图表现为非ST段抬高性心肌梗死(NSTEMI)者6例,占43%;所有患者发病时心功能均明显降低,Killip分级3～4级者占71%;治疗上均按DKA和AMI原则处理,但限制补液量,14例患者中经抢救治疗后8例死亡(57%),含3例合并慢性肾衰竭尿毒症患者.结论 DKA合并AMI患者AMI多与DKA同时发生亦可后发,且AMI表现多不典型,发病时心功能差,病死率高.     

Hyperosmolar diabetic ketoacidosis-- review of literature and the shifting paradigm in evaluation and management

BackgroundHyperosmolar diabetic ketoacidosis (H-DKA), a distinct clinical entity, is the overlap of diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS).AimWe describe the clinical presentation, metabolic aberrations, and associated morbidity/mortality of these cases with H-DKA. We highlight the problem areas of medical care which require particular attention when caring for pediatric diabetes patients presenting with H-DKA.MethodsIn our study we reviewed the literature back to 1963 and retrieved twenty-four cases meeting the criteria of H-DKA: glucose >600 mg/dL, pH < 7.3, bicarbonate <15 mEq/L, and serum osmolality >320 mOsm/kg, while adding three cases from our institution.ResultsAverage age of presentation of H-DKA was 10.2 years ± 4.5 years in females and 13.3 years ± 4 years in males, HbA1c was 13%. Biochemical parameters were consistent with severe dehydration: serum osmolality = 394.8±55 mOsm/kg, BUN = 48±22 mg/dL, creatinine = 2.81±1.03 mg/dL. Acute kidney injury, present in 12 cases, was the most frequent end-organ complication.ConclusionMulti-organ involvement with AKI, rhabdomyolysis, pancreatitis, neurological and cardiac issues such as arrhythmias, are common in H-DKA. Aggressive fluid management, insulin therapy and supportive care can prevent acute and long term adverse outcomes in children and adolescents.     

The association between GLP-1 receptor agonist and diabetic ketoacidosis in the FDA adverse event reporting system

Background and aimsIn 2019, the Medicines and Healthcare products Regulatory Agency (MHRA) of the United Kingdom (UK) and food and drug administration (FDA) of the United States of America (US) suggested that the relationship between glucagon-like peptide-1 receptor agonists (GLP-1RA) and diabetic ketoacidosis (DKA) deserved attention. This study is aiming to assess the association between GLP-1RA and DKA/ketosis in the FDA Adverse Event Reporting System (FAERS) database.Methods and resultsUsing FAERS database, we firstly extract the number of DKA reports from the first quarter (Q1) of 2004 to the fourth quarter (Q4) of 2019 and calculate proportional reporting ratios (PRRs). We then mined each FAERS file from 2004 Q1 to 2020 Q4 and obtained detailed information on DKA reports. From the first quarter (Q1) of 2004 to the fourth quarter (Q4) of 2019, there are 1382 DKA cases (1491 ketosis cases) associated with GLP-1RA in the FAERS database. There was a slight disproportionate reporting of DKA associated with overall GLP-1RA (PRR 1.49, 95%CI 1.24–1.79, p < 0.001) after excluding the impact of SGLT2i, T1D and insulin. Any disproportionality disappeared after selecting the GLP-1RA combined with insulin for comparison.ConclusionsWhen GLP-1RA not combined with insulin, the disproportionality of DKA reports associated with GLP-1RA was observed. Our analysis mined the FAERS database to provide evidence and highlight the potential association between DKA adverse events and GLP-1RA therapy that clinicians tend to overlook.     

Treatment of diabetic ketoacidosis with subcutaneous insulin lispro: A review of the current evidence from clinical studies

AimLow-dose intravenous infusions of regular insulin, usually initiated in the emergency department and continued in the intensive care unit (ICU), are the standard care for patients with diabetic ketoacidosis (DKA) to ensure rapid resolution of hyperglycaemia and ketoacidosis. Several studies have evaluated whether subcutaneous injections of the rapid-acting analogue insulin lispro may be an alternative to intravenous insulin infusion for avoiding ICU admissions of uncomplicated DKA cases.MethodsThis review summarizes the current clinical evidence for the effectiveness and safety of subcutaneous insulin lispro injections in non-severe DKA patients. Relevant studies were identified by a systematic literature search through the PubMed database.ResultsTo date, four small randomized studies (156 patients overall; three studies in adults and one in paediatric patients with diabetes) have directly compared subcutaneous insulin lispro injections every 1–2 h vs continuous intravenous infusions of regular insulin. Patients with severe complications were excluded. In all studies, the mean time to resolution of DKA was similar in both treatment groups [range (three studies): lispro 10–14.8 h; regular insulin 11–13.2 h]. The mean time to resolution of hyperglycaemia, total insulin doses required, number of hospitalization days and number of hypoglycaemic episodes were similar in both treatment groups; no severe complications or DKA recurrences were reported, and one study showed a 39% cost reduction for the insulin lispro group.ConclusionIn patients with mild-to-moderate DKA, subcutaneous injections of insulin lispro every 1–2 h offer a feasible alternative to continuous intravenous infusions of regular insulin, and should now be evaluated in larger, more appropriately powered studies.     

Predictors of new-onset diabetic ketoacidosis in patients with moderate to severe COVID-19 receiving parenteral glucocorticoids: A prospective single-centre study among Indian type 2 diabetes patients

Background and aimCOVID-19 infection predisposes to diabetic ketoacidosis(DKA); whether glucocorticoids enhances this risk is unknown.We aimed to study the occurrence of DKA after initiating glucocorticoids in patients with type 2 diabetes mellitus(T2DM) and moderate-to-severe COVID-19, and identify predictors for it.MethodsPatients with T2DM and moderate or severe COVID-19 infection were prospectively observed for development of new-onset DKA for one week following initiation of parenteral dexamethasone. Clinical and biochemical parameters were compared between those who developed DKA (Group A) and those who didnot (Group B). Logistic regression was done to identify independent risk-factors predicting DKA; ROC-curve analysis to determine cut-offs for the parameters in predicting DKA.ResultsAmongst 302 patients screened, n = 196 were finally included, of whom 13.2% (n = 26,Group A) developed DKA. Patients in Group A were younger, had lower BMI, increased severity of COVID-19 infection, higher HbA1c%, CRP, IL-6, D-dimer and procalcitonin at admission (p_all < 0.02). Further, admission BMI (OR: 0.43, CI: 0.27–0.69), HbA1c % (OR: 1.68, CI: 1.16–2.43) and serum IL-6 (OR: 1.02, CI: 1.01–1.03) emerged as independent predictors for DKA. Out of these, IL-6 levels had the highest AUROC (0.93, CI: 0.89–0.98) with a cut-off of 50.95 pg/ml yielding a sensitivity of 88% and specificity of 85.2% in predicting DKA.ConclusionThere is significant incidence of new-onset DKA following parenteral glucocorticoids in T2DM patients with COVID-19, especially in those with BMI <25.56 kg/m², HbA1c% >8.35% and IL-6 levels >50.95 pg/ml at admission.     

The UK case–control study of cerebral oedema complicating diabetic ketoacidosis in children

Aims/hypothesis Cerebral oedema complicating diabetic ketoacidosis (DKA) remains the major cause of morbidity and mortality in children with type 1 diabetes, but its aetiology remains unknown. Our objective was to determine the impact of baseline biochemical factors and of treatment-related variables on risk of the development of cerebral oedema in children with DKA.Materials and methods This was a national UK case–control study. Through the British Paediatric Surveillance Unit we identified 43 cases of cerebral oedema. Through a parallel reporting system, we also identified 2,940 episodes of DKA and selected 169 control subjects on the basis of comparable age, sex, numbers of new or known cases of diabetes and date of admission. Baseline biochemical data and treatment-related variables were extracted from the clinical notes of cases and control subjects.Results Allowing for differences in age, sex and new or known diabetes, cases were more acidotic at diagnosis of DKA (odds ratio [OR] for events in the least acidotic compared with the most acidotic tertile=0.02 [95% CI: 0.002–0.15], p<0.001). In addition, cases had higher potassium and urea levels at baseline. Calculated osmolality and baseline glucose were not significantly different. After allowing for severity of acidosis, insulin administration in the first hour (OR 12.7 [1.41–114.5], p=0.02) and volume of fluid administered over the first 4 h (OR 6.55 [1.38–30.97], p=0.01) were associated with risk. Low baseline plasma sodium and an elevated p_aCO₂ also contributed to risk in the final regression model. Bicarbonate administration was not associated with increased risk of an event when corrected for acidosis.Conclusions/interpretation In this case–control study of DKA, baseline acidosis and abnormalities of sodium, potassium and urea concentrations were important predictors of risk of cerebral oedema. Additional risk factors identified were early administration of insulin and high volumes of fluid. These observations should be taken into account when designing treatment protocols.     

Clinical and biochemical profile,precipitants and prognostic factors of diabetic ketoacidosis: A retrospective study from a tertiary care center of north India

BackgroundWe aimed to retrospectively investigate the clinical and biochemical profile of Diabetic ketoacidosis (DKA) patients and various precipitating and prognostic factors.MethodsThis was a hospital-based retrospective observational study, conducted in a tertiary care hospital in north India, from March 2014 to March 2017.ResultsAmong 50 patients who satisfied the study criteria, 10 (20%) had DKA as their first presentation. Most common symptoms were nausea and vomiting (74%). Noncompliance was the major precipitating cause in 26 cases (52%) followed by infections in 18 cases (36%). The mean value of blood sugar at presentation was 406.8 ± 130.4 mg/dl with serum ketone 5.38 ± 1.56 mmol/l and mean pH 7.128 ± 0.157 with severe DKA in 14 (28%) patients. Mean duration of hospital stay was 8.2.±5.0 days, and low hemoglobin (p = 0.019) and high pulse rate (p = 0.025) were independent predictors of a longer stay.ConclusionWith intensive care, mortality did not occur; however, non-compliance remained the most common precipitating cause of DKA followed by infections.     

Diabetic ketoacidosis in type 1 and type 2 diabetes mellitus: clinical and biochemical differences

BACKGROUND: Diabetic ketoacidosis (DKA), once thought to typify type 1 diabetes mellitus, has been reported to affect individuals with type 2 diabetes mellitus. An analysis and overview of the different clinical and biochemical characteristics of DKA that might be predicted between patients with type 1 and type 2 diabetes is needed. METHODS: We reviewed 176 admissions of patients with moderate-to-severe DKA. Patients were classified as having type 1 or type 2 diabetes based on treatment history and/or autoantibody status. Groups were compared for differences in symptoms, precipitants, vital statistics, biochemical profiles at presentation, and response to therapy. RESULTS: Of 138 patients admitted for moderate-to-severe DKA, 30 had type 2 diabetes. A greater proportion of the type 2 diabetes group was Latino American or African American (P<.001). Thirty-five admissions (19.9%) were for newly diagnosed diabetes. A total of 85% of all admissions involved discontinuation of medication use, 69.2% in the type 2 group. Infections were present in 21.6% of the type 1 and 48.4% of the type 2 diabetes admissions. A total of 21% of patients with type 1 diabetes and 70% with type 2 diabetes had a body mass index greater than 27. Although the type 1 diabetes group was more acidotic (arterial pH, 7.21 +/- 0.12 vs 7.27 +/- 0.08; P<.001), type 2 diabetes patients required longer treatment periods (36.0 +/- 11.6 vs 28.9 +/- 8.9 hours, P =.01) to achieve ketone-free urine. Complications from therapy were uncommon. CONCLUSIONS: A significant proportion of DKA occurs in patients with type 2 diabetes. The time-tested therapy for DKA of intravenous insulin with concomitant glucose as the plasma level decreases, sufficient fluid and electrolyte replacement, and attention to associated problems remains the standard of care, irrespective of the type of diabetes.     

Diabetic ketoacidosis: A consensus statement of the Italian Association of Medical Diabetologists (AMD), Italian Society of Diabetology (SID), Italian Society of Endocrinology and Pediatric Diabetoloy (SIEDP)

Background and aimDiabetic ketoacidosis (DKA) is a serious medical emergency once considered typical of type 1 diabetes (T1DM), but now reported to occur in type 2 and GDM patients as well. DKA can cause severe complications and even prove fatal. The aim of our study was to review recent international and national guidelines on diagnosis, clinical presentation and treatment of diabetic ketoacidosis, to provide practical clinical recommendations.Methods and resultsElectronic databases (MEDLINE (via PUB Med), Scopus, Cochrane library were searched for relevant literature. Most international and national guidelines indicate the same accurate flow chart to diagnose, to evaluate from clinical and laboratory point of view, and treat diabetic ketoacidosis.ConclusionPrompt diagnosis, rapid execution of laboratory analysis and correct treatment are imperative to reduce the mortality related to diabetic ketoacidosis. These recommendations are designed to help healthcare professionals reduce the frequency and burden of DKA.     

Pain management,fluid therapy and thromboprophylaxis after pancreatoduodenectomy: a worldwide survey among surgeons

BackgroundThe aim of this survey was to assess practices regarding pain management, fluid therapy and thromboprophylaxis in patients undergoing pancreatoduodenectomy on a global basis.MethodsThis survey study among surgeons from eight (inter)national scientific societies was performed according to the CHERRIES guideline.ResultsOverall, 236 surgeons completed the survey. ERAS protocols are used by 61% of surgeons and respectively 82%, 93%, 57% believed there is a relationship between pain management, fluid therapy, and thromboprophylaxis and clinical outcomes. Epidural analgesia (50%) was most popular followed by intravenous morphine (24%). A restrictive fluid therapy was used by 58% of surgeons. Chemical thromboprophylaxis was used by 88% of surgeons. Variations were observed between continents, most interesting being the choice for analgesic technique (transversus abdominis plane block was popular in North America), restrictive fluid therapy (little use in Asia and Oceania) and duration of chemical thromboprophylaxis (large variation).ConclusionThe results of this international survey showed that only 61% of surgeons practice ERAS protocols. Although the majority of surgeons presume a relationship between pain management, fluid therapy and thromboprophylaxis and clinical outcomes, variations in practices were observed. Additional studies are needed to further optimize, standardize and implement ERAS protocols after pancreatic surgery.     

Comparison of aggressive versus standard intravenous hydration for clinical improvement among patients with mild acute pancreatitis: A randomized controlled trial

BackgroundControversy remains regarding fluid management strategy, optimal volume and rate of intravenous fluid in mild acute pancreatitis. We performed a randomized controlled trial to compare clinical improvement and inflammatory markers between aggressive and standard fluid management.MethodsA single center prospective randomized controlled trial was conducted in a tertiary care hospital. We randomized patients with a diagnosis of mild acute pancreatitis using revised Atlanta classification in two groups, the aggressive (20 ml/kg bolus followed by 3 ml/kg/hr) and standard (10 ml/kg bolus followed by 1.5 ml/kg/hr) intravenous hydration with Lactated Ringer's solution. Primary outcome was clinical improvement at 24 and 36 hours.ResultsThe mean age of patients was 46 years and 34 patients (77%) were male. The average volumes of fluid during the first 24 hours in aggressive and standard groups was 4886 ml (71 ml/kg) and 3985 ml (53 ml/kg), respectively; p-value 0.002. Aggressive intravenous hydration did not significantly improve clinical outcome compared with standard intravenous hydration (45.45% vs. 31.82%, respectively; p-value 0.353). However, subgroup analysis between patients with obese and non-obese status, revealed aggressive intravenous hydration significantly improved clinical outcome within the first 24 hours in obese group.ConclusionAggressive intravenous hydration with Lactated Ringer's solution did not improve clinical outcome in mild acute pancreatitis but showed statistically significant improvement only in patients with obese status. Future studies should include a larger sample size to confirm these findings.