RCT

WATERFALL

Aggressive versus Moderate Fluid Resuscitation in Acute Pancreatitis

NEJM, 2022 · Multicenter open-label randomized controlled trial (n=249)

Clinical question

Is aggressive fluid resuscitation superior to moderate fluid resuscitation in acute pancreatitis?

Population: Adults presenting with acute pancreatitis within 24 hours of pain onset
Intervention: Aggressive resuscitation (20 mL/kg bolus + 3 mL/kg/h Lactated Ringer's)
Comparator: Moderate resuscitation (10 mL/kg bolus if hypovolemic + 1.5 mL/kg/h Lactated Ringer's)
Primary outcome: Development of moderately severe or severe acute pancreatitis
Result: Trial stopped early for safety: aggressive resuscitation caused a 3-fold higher incidence of fluid overload (20.5% vs 6.3%, P=0.004) without reducing severe pancreatitis (22.1% vs 17.3%, P=0.32).

What the trial found

Aggressive large-volume fluid loading causes volume overload and harm without improving clinical resolution.

Current guideline position

Standard of care in modern pancreatic critical care.

Clinical interpretation

Reversed decades of dogmatic aggressive hydration in acute pancreatitis toward moderate goal-directed therapy.

Clinical Context & Relevant Topics (1)

Disease Reference

Severe Acute Pancreatitis

Revised Atlanta severity staging, goal-directed fluid resuscitation informed by WATERFALL, oral/enteral nutrition as tolerated, antibiotic avoidance in sterile necrosis, and the PANTER step-up approach.

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