1
|
Lee JE, Jung H. Selection of intraoperative fluid for kidney transplantation. Anesth Pain Med (Seoul) 2025; 20:14-22. [PMID: 39923768 PMCID: PMC11834872 DOI: 10.17085/apm.24180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2024] [Revised: 01/12/2025] [Accepted: 01/13/2025] [Indexed: 02/11/2025] Open
Abstract
The kidney, the most frequently transplanted organ, represents the optimal treatment for end-stage renal disease. Transplanted kidneys are highly vulnerable to perioperative injuries such as hypotension and hypovolemia, which can be influenced by perioperative fluid management. Postoperatively, delayed graft function increases the risk of graft failure. Although adequate volume administration can reduce delayed graft function, the type of intraoperative fluid most likely to benefit and support graft function remains unclear. Traditionally, crystalloids have been the primary choice for fluid management during kidney transplantation. Among these, 0.9% sodium chloride is the most commonly used, as its potassium-free composition minimizes the risk of hyperkalemia in patients with end-stage renal disease. Albumin is not routinely used, whereas synthetic colloids are discouraged owing to their nephrotoxicity. To date, 0.9% sodium chloride has demonstrated fewer advantages compared with balanced crystalloids, particularly regarding acid-base homeostasis, electrolyte balance, and delayed graft function. This review aims to examine the existing evidence on the effect of crystalloids and colloids on postoperative graft function and to recommend an appropriate fluid regimen, including balanced crystalloids, for kidney transplantation.
Collapse
Affiliation(s)
- Jeong Eun Lee
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Korea
| | - Hoon Jung
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Korea
| |
Collapse
|
2
|
Wan SS, Wyburn K, Chadban SJ, Collins MG. Balanced Electrolyte Solutions Versus 0.9% Saline for Kidney Transplantation: An Updated Systematic Review and Meta-analysis. Transplant Direct 2025; 11:e1687. [PMID: 39687510 PMCID: PMC11649268 DOI: 10.1097/txd.0000000000001687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 06/03/2024] [Accepted: 06/06/2024] [Indexed: 12/18/2024] Open
Abstract
Background Perioperative intravenous fluids are administered to kidney transplant recipients to maintain hemodynamic stability and graft perfusion; however, the ideal fluid remains uncertain. Although 0.9% saline (saline) is commonly used, its high chloride content causes hyperchloremic metabolic acidosis and may increase the risks of delayed graft function (DGF) and hyperkalemia. Balanced electrolyte solutions (BES) have a more physiological chloride concentration and may reduce these risks. Previous meta-analyses found insufficient evidence to compare BES with saline for these outcomes; however, new studies have recently been published. In this updated review, we compared the effects of BES with saline on the risk of DGF and hyperkalemia in kidney transplantation. Methods MEDLINE, Embase, and CENTRAL were searched for randomized controlled trials comparing BES with saline in kidney transplantation. The primary outcomes were DGF and hyperkalemia. Eligible studies were assessed for risk of bias and data were pooled for analysis. The Grading of Recommendations Assessment, Development, and Evaluation framework was used to assess the quality of evidence. Results Ten studies involving 1532 participants were included. The quality of evidence was high for deceased donor transplantation and very low for living donor transplantation. The relative risk (RR) of DGF associated with BES compared with saline was 0.83 (95% confidence interval [CI], 0.71-0.96; P = 0.01) in deceased donor transplantation. There was no difference in DGF in living donor transplantation (RR 0.79; 95% CI, 0.26-2.41; P = 0.68). There was no difference in hyperkalemia between groups (RR 0.87; 95% CI, 0.59-1.27; P = 0.46). Conclusions Compared with saline, BES reduces the risk of DGF in deceased donor kidney transplantation without increasing hyperkalemia.
Collapse
Affiliation(s)
- Susan S. Wan
- Department of Renal Medicine, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Kidney Node, Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia
- Department of Renal Medicine, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Kate Wyburn
- Department of Renal Medicine, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Kidney Node, Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia
| | - Steven J. Chadban
- Department of Renal Medicine, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Kidney Node, Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia
| | - Michael G. Collins
- Central Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, SA, Australia
- Faculty of Medical and Health Sciences, The University of Adelaide, Adelaide, SA, Australia
| |
Collapse
|
3
|
Chang T, Shih MC, Wu YL, Wu TT, Yang JT, Wu CY. Comparative efficacy of balanced crystalloids versus 0.9% saline on delayed graft function and perioperative outcomes in kidney transplantation: a meta-analysis of randomised controlled trials. Br J Anaesth 2024; 133:1173-1182. [PMID: 39277457 PMCID: PMC11589481 DOI: 10.1016/j.bja.2024.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 08/11/2024] [Accepted: 08/16/2024] [Indexed: 09/17/2024] Open
Abstract
BACKGROUND Delayed graft function after kidney transplantation is linked to poor graft survival and increased chronic allograft injury. Recent guidelines suggest using balanced crystalloids over 0.9% saline owing to better metabolic profiles, but their impact on DGF remains unclear. METHODS We searched PubMed, Embase, and Cochrane Central Registry of Clinical Trials from inception until February 29, 2024, and included RCTs that randomised adult participants to receive either intravenous balanced fluids or 0.9% saline intraoperatively. We pooled data using a random-effects model and present risk ratios (RRs) or mean differences, with 95% confidence intervals (CIs). We assessed individual study risk of bias using the modified Cochrane tool and certainty of evidence using GRADE. Outcomes analysed were delayed graft function incidence, vasopressor requirements, length of hospital stay, and postoperative metabolic profiles. RESULTS Of 106 publications identified, we included 11 RCTs (n=1717). Pooled analysis showed that the use of balanced fluids was associated with a lower incidence of delayed graft function compared with 0.9% saline (RR 0.82, 95% CI: 0.69 to 0.98, P=0.01, moderate certainty). Balanced crystalloids were associated with higher postoperative serum pH, higher serum bicarbonate, and lower serum chloride concentration, but effects on vasopressor requirements, length of hospital stay, and serum creatinine were uncertain. CONCLUSIONS Balanced crystalloid intravenous fluid therapy reduced delayed graft function incidence and maintained more favourable serum chemistry profiles compared with 0.9% saline in patients undergoing kidney transplantation. However, crystalloid type did not significantly influence vasopressor requirements and length of hospital stay.
Collapse
Affiliation(s)
- Tzu Chang
- Department of Anaesthesiology, Taipei City Hospital, Taipei, Taiwan; Department of Anaesthesiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming-Chieh Shih
- School of Medicine, College of Life Sciences and Medicine, National Tsing Hua University, Hsinchu, Taiwan
| | - Yi-Luen Wu
- Department of Anaesthesiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Tsung-Ta Wu
- Department of Anaesthesiology, National Taiwan University Hospital, Hsinchu Branch, Hsinchu, Taiwan
| | - Jen-Ting Yang
- Department of Anaesthesiology & Pain Medicine, University of Washington, Seattle, WA, USA
| | - Chun-Yu Wu
- Department of Anaesthesiology, National Taiwan University Hospital, Taipei, Taiwan; Department of Anaesthesiology, National Taiwan University Hospital, Hsinchu Branch, Hsinchu, Taiwan; National Taiwan University College of Medicine, Taipei, Taiwan.
| |
Collapse
|
4
|
Mayerhöfer T, Lehner GF, Joannidis M. [Volume therapy: which preparation for which situation?]. Med Klin Intensivmed Notfmed 2024; 119:640-649. [PMID: 39382683 PMCID: PMC11538216 DOI: 10.1007/s00063-024-01194-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2024] [Accepted: 09/09/2024] [Indexed: 10/10/2024]
Abstract
The most commonly used fluids for volume therapy are crystalloids and colloids. Crystalloids comprise 0.9% sodium chloride and balanced crystalloids (BC). Colloids can be divided into artificial colloids and human albumin (a natural colloid). Large studies show advantages for BC over 0.9% NaCl with respect to renal endpoints, probably due to the unphysiologically high chloride content of 0.9% NaCl. However, other studies, such as the BaSICS and PLUS trials, showed no significant differences in mortality in a heterogeneous population. Despite this, meta-analyses suggest advantages for BC. Therefore, BC should be preferred, especially in patients at increased risk of acute kidney injury, with acidemia and/or hyperchloremia. Except for specific indications (e.g., in patients with cirrhosis, sepsis resuscitation after initial volume therapy with BC), albumin should not be used. There is clear evidence of harm from hydroxyethyl starch in intensive care patients.
Collapse
Affiliation(s)
- Timo Mayerhöfer
- Gemeinsame Einrichtung für Intensiv- und Notfallmedizin, Department für Innere Medizin, Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich
| | - Georg F Lehner
- Gemeinsame Einrichtung für Intensiv- und Notfallmedizin, Department für Innere Medizin, Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich
| | - Michael Joannidis
- Gemeinsame Einrichtung für Intensiv- und Notfallmedizin, Department für Innere Medizin, Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich.
| |
Collapse
|
5
|
Nam JS, Kim WJ, Seo WW, Lee SW, Joung KW, Chin JH, Choi DK, Choi IC. Effects of Balanced Versus Saline-based Solutions on Acute Kidney Injury in Off-pump Coronary Artery Bypass Surgery: A Randomized Controlled Trial. J Cardiothorac Vasc Anesth 2024; 38:1923-1931. [PMID: 38960803 DOI: 10.1053/j.jvca.2024.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 04/05/2024] [Accepted: 06/03/2024] [Indexed: 07/05/2024]
Abstract
OBJECTIVES To determine whether balanced solutions can reduce the incidence of acute kidney injury after off-pump coronary artery bypass surgery compared with saline. DESIGN Randomized controlled trial. SETTING Single tertiary care center. PARTICIPANTS Patients who underwent off-pump coronary artery bypass surgery between June 2014 and July 2020. INTERVENTIONS Balanced solution-based chloride-restrictive intravenous fluid strategy. MEASUREMENTS AND MAIN RESULTS The primary outcome was acute kidney injury within 7 postoperative days, as defined by the 2012 Kidney Disease: Improving Global Outcomes Clinical Practice Guideline. The incidence of acute kidney injury was 4.4% (8/180) in the balanced group and 7.3% (13/178) in the saline group. The difference was not statistically significant (risk difference, -2.86%; 95% confidence interval [CI], -7.72% to 2.01%; risk ratio, 0.61, 95% CI, 0.26 to 1.43; p = 0.35). Compared with the balanced group, the saline group had higher levels of intraoperative serum chloride and lower base excess, which resulted in a lower pH. CONCLUSIONS In patients undergoing off-pump bypass surgery with a normal estimated glomerular filtration rate, the intraoperative balanced solution-based chloride-restrictive intravenous fluid administration strategy did not decrease the rate of postoperative acute kidney injury compared with the saline-based chloride-liberal intravenous fluid administration strategy.
Collapse
Affiliation(s)
- Jae-Sik Nam
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Wook-Jong Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
| | - Wan-Woo Seo
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang-Wook Lee
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyung-Woon Joung
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ji-Hyun Chin
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dae-Kee Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - In-Cheol Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| |
Collapse
|
6
|
Carvalho Pereira L, Carvalho Pereira I, Dias Delfino Cabral T, Viana P, Mendonça Ribeiro A, Amaral S. Balanced Crystalloids Versus Normal Saline in Kidney Transplant Patients: An Updated Systematic Review, Meta-analysis, and Trial Sequential Analysis. Anesth Analg 2024; 139:58-67. [PMID: 38578867 DOI: 10.1213/ane.0000000000006932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2024]
Abstract
BACKGROUND The use of balanced crystalloids over normal saline for perioperative fluid management during kidney transplantation and its benefits on acid-base and electrolyte balance along with its influence on postoperative clinical outcomes remains a topic of controversy. Therefore, we conducted this review to assess the impact of balanced solutions compared to normal saline on outcomes for kidney transplant patients. METHODS We searched MEDLINE, EMBASE, and Cochrane databases for randomized controlled trials (RCTs) comparing balanced lower-chloride solutions to normal saline in renal transplant patients. Our main outcome of interest was delayed graft function (DGF). Additionally, we examined acid-base and electrolyte measurements, along with postoperative renal function. We computed relative risk (RR) using the Mantel-Haenszel test for binary outcomes, and mean difference (MD) for continuous data, and applied DerSimonian and Laird random-effects models to address heterogeneity. Furthermore, we performed a trial sequential analysis (TSA) for all outcomes. RESULTS Twelve RCTs comprising a total of 1668 patients were included; 832 (49.9%) were assigned to receive balanced solutions. Balanced crystalloids reduced the occurrence of DGF compared to normal saline, with RR of 0.82 (95% confidence interval [CI], 0.71-0.94), P = .005; I² = 0%. The occurrence was 25% (194 of 787) in the balanced crystalloids group and 34% (240 of 701) in the normal saline group. Moreover, our TSA supported the primary outcome result and suggests that the sample size was sufficient for our conclusion. End-of-surgery chloride (MD, -8.80 mEq·L -1 ; 95% CI, -13.98 to -3.63 mEq.L -1 ; P < .001), bicarbonate (MD, 2.12 mEq·L -1 ; 95% CI, 1.02-3.21 mEq·L -1 ; P < .001), pH (MD, 0.06; 95% CI, 0.04-0.07; P < .001), and base excess (BE) (MD, 2.41 mEq·L -1 ; 95% CI, 0.88-3.95 mEq·L -1 ; P = .002) significantly favored the balanced crystalloids groups and the end of surgery potassium (MD, -0.17 mEq·L -1 ; 95% CI, -0.36 to 0.02 mEq·L -1 ; P = .07) did not differ between groups. However, creatinine did not differ in the first (MD, -0.06 mg·dL -1 ; 95% CI, -0.38 to 0.26 mg·dL -1 ; P = .71) and seventh (MD, -0.06 mg·dL -1 ; 95% CI, -0.18 to 0.06 mg·dL -1 ; P = .30) postoperative days nor urine output in the first (MD, -1.12 L; 95% CI, -3.67 to 1.43 L; P = .39) and seventh (MD, -0.01 L; 95% CI, -0.45 to 0.42 L; P = .95) postoperative days. CONCLUSIONS Balanced lower-chloride solutions significantly reduce the occurrence of DGF and provide an improved acid-base and electrolyte control in patients undergoing kidney transplantation.
Collapse
Affiliation(s)
- Lucas Carvalho Pereira
- From the Department of Medicine, Escola Bahiana de Medicina e Saúde Pública, Salvador, Bahia, Brazil
| | - Igor Carvalho Pereira
- From the Department of Medicine, Escola Bahiana de Medicina e Saúde Pública, Salvador, Bahia, Brazil
| | | | - Patricia Viana
- Department of Medicine, University of Extreme South of Santa Catarina, Criciuma, Santa Catarina, Brazil
| | - Arthur Mendonça Ribeiro
- Departament of Anesthesiology, Universidade Federal of Rio Grande do Sul, Rio Grande do Sul, Brazil
| | - Sara Amaral
- Department of Anesthesiology, Universidade Nova de Lisboa, Lisboa, Portugal
| |
Collapse
|
7
|
Imran M, Khlidj Y, Naeem A, Tanveer A, Fakih N, Kamran A, Abuelazm M. Perioperative balanced crystalloids versus normal saline during kidney transplantation: a systematic review and meta-analysis of randomized controlled trials. Int Urol Nephrol 2024; 56:2195-2213. [PMID: 38349600 DOI: 10.1007/s11255-023-03936-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 12/27/2023] [Indexed: 06/21/2024]
Abstract
BACKGROUND In kidney transplant (KT) surgery, the perioperative administration of intravenous (IV) fluids plays a crucial role, with potential effects on graft function. Our meta-analysis aims to assess the post-KT outcomes of perioperative balanced crystalloids (BC) versus normal saline (NS). METHODS We conducted a comprehensive search across five databases to identify relevant randomized controlled trials (RCTs). The search results were imported into Covidence for article eligibility screening, and all relevant outcome data were synthesized using risk ratios (RR) or mean differences (MD) with 95% confidence intervals (CIs) in meta-analysis models within RevMan 5.4. PROSPERO ID CRD42023448457. RESULTS Pooled data from 15 RCTs with 2,008 participants showed that the rate of delayed graft function (DGF) was significantly lower with BC (RR: 0.78, 95% CI [0.68, 0.91], P = 0.0009). Also, BC was associated with significantly higher post-op blood pH (MD: 0.05, 95% CI [0.03, 0.07], P < 0.01), lower serum chloride (MD: - 7.31, 95% CI [- 10.58, - 3.77], P < 0.01), and sodium (MD: - 1.94, 95% CI [- 3.32, - 0.55], P = 0.006) as compared to NS. However, serum potassium, serum creatinine, and urine output at POD 1 to 7 did not differ between the two groups. CONCLUSION BC significantly reduced the incidence of DGF, resulting in more stable post-operative acid-base parameters, and lower chloride levels compared to NS. Hence, substituting NS with BC offers a strategy to protect grafts from acidotic and hyperchloremic insults, optimizing KT outcomes.
Collapse
Affiliation(s)
- Muhammad Imran
- University College of Medicine and Dentistry, The University of Lahore, Lahore, Pakistan
| | - Yehya Khlidj
- Faculty of Medicine, University of Algiers, Algiers 16000, Algeria
| | | | - Aiman Tanveer
- University College of Medicine and Dentistry, The University of Lahore, Lahore, Pakistan
| | - Nour Fakih
- Department of Natural Sciences, Lebanese American University, Beirut, Lebanon.
| | - Ateeba Kamran
- Karachi Medical and Dental College, Karachi, Pakistan
| | | |
Collapse
|
8
|
Raes M, Kellum JA, Colman R, Wallaert S, Crivits M, Viaene F, Hemeryck M, Benoit D, Poelaert J, Hoste E. Effect of a single small volume fluid bolus with balanced or un-balanced fluids on chloride and acid-base status: a prospective randomized pilot study (the FLURES-trial). J Nephrol 2024; 37:1299-1308. [PMID: 38546940 DOI: 10.1007/s40620-024-01912-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 01/24/2024] [Indexed: 09/18/2024]
Abstract
OBJECTIVE To compare the short-term effects on acid base, electrolyte status and urine output of a single fluid bolus of saline to that of the balanced solution Plasmalyte® in critically ill patients. METHODS Prospective, randomized, controlled trial. Adult patients (≥ 18 years) admitted to the ICU receiving a fluid bolus were randomized to receive 1 L of saline (NaCl 0.9%, Baxter) or a balanced fluid [Plasmalyte® (Baxter)]. Blood samples and urine output were collected just before (T0), just after (T1), 2 h after (T2) (only for urinary output) and three hours after termination of the fluid bolus (T4). The effect of fluid boluses on serum chloride, apparent strong ion difference, base excess, urinary output and blood pressure or vasopressor need were analyzed. MAIN RESULTS Patients who received a 1 L saline fluid bolus had a significant increase in serum chloride (1.60; 95% CI 1.10 to 2.10; P < 0.001) and short-term decrease in apparent strong ion difference (- 1.85; 95% CI - 2.71 to - 0.99; P < 0.001) and base excess (- 0.90; 95% CI - 1.31 to - 0.50; P < 0.001). We observed a 17% increase in patients developing hyperchloremia in the saline group (0.17; 95% CI 0.05 to 0.29; P = 0.005). No significant difference in urinary output, blood pressure or vasopressor need was observed in either group. CONCLUSION Even a single, small bolus of saline, administered to critically ill patients, causes a significant increase in chloride concentration and a decrease in apparent strong ion difference and base excess, and an increase in the number of patients developing hyperchloremia. No difference in effect on urinary output, blood pressure or vasopressor need was observed between the two groups. EUDRACT NUMBER 2014-001005-41; date of registration: 28/10/2014. LOCAL EC APPROVAL EC project number 2014/038.
Collapse
Affiliation(s)
- M Raes
- Department of Intensive Care Medicine, Department of Internal Medicine and Pediatrics, Ghent University Hospital, Ghent University, Ghent, Belgium.
- Department of Anesthesiology, Brussels University Hospital, Brussels, Belgium.
- Department of Intensive Care, Brussels University Hospital, Brussels, Belgium.
| | - J A Kellum
- Division of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - R Colman
- Biostatistics Unit, University of Ghent, Ghent, Belgium
| | - S Wallaert
- Biostatistics Unit, University of Ghent, Ghent, Belgium
| | - M Crivits
- Department of Intensive Care Medicine, Department of Internal Medicine and Pediatrics, Ghent University Hospital, Ghent University, Ghent, Belgium
- Department of Anesthesiology, AZ Alma, Eeklo, Belgium
| | - F Viaene
- Department of Intensive Care Medicine, Department of Internal Medicine and Pediatrics, Ghent University Hospital, Ghent University, Ghent, Belgium
- Department of Anesthesiology, AZ Sint-Lucas, Ghent, Belgium
| | - M Hemeryck
- Department of Intensive Care Medicine, Department of Internal Medicine and Pediatrics, Ghent University Hospital, Ghent University, Ghent, Belgium
- Department of Anesthesiology, AZ Sint-Elisabeth, Zottegem, Belgium
| | - D Benoit
- Department of Intensive Care Medicine, Department of Internal Medicine and Pediatrics, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - J Poelaert
- Department of Intensive Care, Brussels University Hospital, Brussels, Belgium
| | - E Hoste
- Department of Intensive Care Medicine, Department of Internal Medicine and Pediatrics, Ghent University Hospital, Ghent University, Ghent, Belgium
- Research Foundation-Flanders, Brussels, Belgium
| |
Collapse
|
9
|
Medeiros H, Lima PH, Junior VS, Souza DA, Pinheiro AM, Martins RR, A H Costa KM, Junior JHD, Medeiros PJ, Da Silva WA. A Comparison Between Saline and Balanced Solutions in Kidney Transplants: A Randomized Clinical Trial. Cureus 2023; 15:e49813. [PMID: 38164322 PMCID: PMC10758014 DOI: 10.7759/cureus.49813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/01/2023] [Indexed: 01/03/2024] Open
Abstract
Objective This study aimed to investigate the impact of different types of intravenous fluids - normal saline (NS), lactated Ringer's solution (LR), and PlasmaLyte (PL) - on the acid-base balance and electrolyte concentration following kidney transplant, a common procedure for patients with end-stage renal disease (ESRD). Methodology A randomized controlled trial design was employed, wherein the primary parameters analyzed were postoperative pH and serum potassium levels. Postoperative concentrations of serum bicarbonate, sodium, chloride, and creatinine, as well as graft functionality, were assessed as secondary outcomes. These measurements were performed at the start and end of surgery, as well as 24 and 72 hours postoperatively. Results A total of 53 patients were included in the study and randomized into three cohorts: NS, LR, and PL, each of which showed comparability in terms of demographic and transplantation specifics. Notably, patients in the NS group exhibited a more significant decrease in pH (NS group: 7.285 ±0.098, LR group: 7.324 ±0.075, PL group: 7.7338 ±0.059) and bicarbonate levels (17.0 ±4.2, 20.9 ±2.8, 20.0 ±4.5) post 24 hours after the operation and displayed a similar pattern immediately after the surgery. However, there were no discernible differences in potassium (p=0.460), sodium (p=0.681), and chloride (p=0.321) levels across the groups. Furthermore, the study did not observe any significant differences in postoperative graft functionality. Conclusion The use of NS as the intraoperative fluid of choice led to lower pH and bicarbonate levels following kidney transplant, as compared to LR and PL. However, these results did not correlate with improvements in graft functionality.
Collapse
Affiliation(s)
- Heitor Medeiros
- Department of Anesthesiology, Hospital Universitário Onofre Lopes, Natal, BRA
| | - Paulo H Lima
- Department of Anesthesiology, Hospital Universitário Onofre Lopes, Natal, BRA
| | - Vital S Junior
- Department of Anesthesiology, Hospital Universitário Onofre Lopes, Natal, BRA
| | - Diego A Souza
- Department of Anesthesiology, Hospital Universitário Onofre Lopes, Natal, BRA
| | - Aline M Pinheiro
- Department of Anesthesiology, Hospital Universitário Onofre Lopes, Natal, BRA
| | - Rand R Martins
- Graduate Program of Pharmaceutical Assistance, Universidade Federal do Rio Grande do Norte, Natal, BRA
| | - Kellen M A H Costa
- Department of Nephrology, Universidade Federal do Rio Grande do Norte, Natal, BRA
| | | | - Paulo J Medeiros
- Department of Urology, Hospital Universitário Onofre Lopes, Natal, BRA
| | - Wallace A Da Silva
- Department of Anesthesiology, Hospital Universitário Onofre Lopes, Natal, BRA
| |
Collapse
|
10
|
Panchal V, Sivasubramanian BP, Samala Venkata V. Crystalloid Solutions in Hospital: A Review of Existing Literature. Cureus 2023; 15:e39411. [PMID: 37362468 PMCID: PMC10287545 DOI: 10.7759/cureus.39411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2023] [Indexed: 06/28/2023] Open
Abstract
Intravenous fluids (IVF) like normal saline (NS) and Ringer's lactate (RL) are often crucial in the management of hospitalized patients. Mishandling these fluids can lead to complications in about 20% of patients receiving them. In this review, we present the current evidence through the identification of observational studies and randomized trials that observed the optimal use of IVF. We found that NS may cause hyperchloremic metabolic acidosis in surgical patients, but there is no clear difference in mortality and long-term outcomes between NS and balanced crystalloids. Critically ill patients, particularly those in sepsis, benefit from balanced crystalloids, as high chloride content fluids like NS increase the risk of complications and mortality. In pancreatitis, NS has been shown to increase the risk of ICU admission when compared to RL; however, there is no significant difference in long-term outcomes and mortality between the fluids. RL is preferred for burns due to its isotonicity and lack of protein, preventing edema formation in an already dehydrated state. Plasma-lyte may resolve diabetic ketoacidosis faster, while prolonged NS use can lead to metabolic acidosis, acute kidney injury, and cerebral edema. In conclusion, NS, RL, and plasma-lyte are the most commonly used isotonic IVF in the hospital population. Incorrect choice of fluids in a different clinical scenario can lead to worse outcomes.
Collapse
Affiliation(s)
- Viraj Panchal
- Medicine, Smt. Nathiba Hargovandas Lakhmichand (NHL) Municipal Medical College, Ahmedabad, IND
| | - Barath Prashanth Sivasubramanian
- Infectious Diseases, University of Texas Health Science Center at San Antonio, San Antonio, USA
- Internal Medicine, ESIC Medical College & PGIMSR, Chennai, IND
| | | |
Collapse
|
11
|
Cao A, Bellfi LT, Schoen J, Greiffenstein P, Marr AB, Stuke L, Hunt JP, Pino R, Smith A. Perioperative Fluid Management in Surgical Patients: A Review. Am Surg 2022:31348221121565. [PMID: 35977846 DOI: 10.1177/00031348221121565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Intravenous (IV) fluids are one of the most widely prescribed medications. Despite their frequent usage, IV fluids are often not used appropriately. High-quality evidence to guide the surgeon in the perioperative period is sparse. A plethora of choices for IV fluids exists with limited evidence to help guide the surgeon in specific patient populations and situations. To address this, the authors have set out to provide a critical review of commonly used IV fluids to treat surgical patients. Gaps in the existing literature for the surgical population will also be discussed as potential target areas for future research.
Collapse
Affiliation(s)
- Alex Cao
- 12258Louisiana State University Health Sciences Center, School of Medicine, New Orleans, LA, USA
| | | | - Jonathan Schoen
- 12258Louisiana State University Health Sciences Center, School of Medicine, New Orleans, LA, USA
| | - Patrick Greiffenstein
- 12258Louisiana State University Health Sciences Center, School of Medicine, New Orleans, LA, USA
| | - Alan B Marr
- 12258Louisiana State University Health Sciences Center, School of Medicine, New Orleans, LA, USA
| | - Lance Stuke
- 12258Louisiana State University Health Sciences Center, School of Medicine, New Orleans, LA, USA
| | - John P Hunt
- 12258Louisiana State University Health Sciences Center, School of Medicine, New Orleans, LA, USA
| | - Richard Pino
- 12258Louisiana State University Health Sciences Center, School of Medicine, New Orleans, LA, USA
| | - Alison Smith
- 12258Louisiana State University Health Sciences Center, School of Medicine, New Orleans, LA, USA
| |
Collapse
|
12
|
Beran A, Altorok N, Srour O, Malhas SE, Khokher W, Mhanna M, Ayesh H, Aladamat N, Abuhelwa Z, Srour K, Mahmood A, Altorok N, Taleb M, Assaly R. Balanced Crystalloids versus Normal Saline in Adults with Sepsis: A Comprehensive Systematic Review and Meta-Analysis. J Clin Med 2022; 11:1971. [PMID: 35407578 PMCID: PMC8999853 DOI: 10.3390/jcm11071971] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 03/26/2022] [Accepted: 03/28/2022] [Indexed: 02/08/2023] Open
Abstract
The crystalloid fluid of choice in sepsis remains debatable. We aimed to perform a comprehensive meta-analysis to compare the effect of balanced crystalloids (BC) vs. normal saline (NS) in adults with sepsis. A systematic search of PubMed, EMBASE, and Web of Sciences databases through 22 January 2022, was performed for studies that compared BC vs. NS in adults with sepsis. Our outcomes included mortality and acute kidney injury (AKI), need for renal replacement therapy (RRT), and ICU length of stay (LOS). Pooled risk ratio (RR) and mean difference (MD) with the corresponding 95% confidence intervals (CIs) were obtained using a random-effect model. Fifteen studies involving 20,329 patients were included. Overall, BC showed a significant reduction in the overall mortality (RR 0.88, 95% CI 0.81-0.96), 28/30-day mortality (RR 0.87, 95% CI 0.79-0.95), and AKI (RR 0.85, 95% CI 0.77-0.93) but similar 90-day mortality (RR 0.96, 95% CI 0.90-1.03), need for RRT (RR 0.91, 95% CI 0.76-1.08), and ICU LOS (MD -0.25 days, 95% CI -3.44, 2.95), were observed between the two groups. However, subgroup analysis of randomized controlled trials (RCTs) showed no statistically significant differences in overall mortality (RR 0.92, 95% CI 0.82-1.02), AKI (RR 0.71, 95% CI 0.47-1.06), and need for RRT (RR 0.71, 95% CI 0.36-1.41). Our meta-analysis demonstrates that overall BC was associated with reduced mortality and AKI in sepsis compared to NS among patients with sepsis. However, subgroup analysis of RCTs showed no significant differences in both overall mortality and AKI between the groups. There was no significant difference in the need for RRT or ICU LOS between BC and NS. Pending further data, our study supports using BC over NS for fluid resuscitation in adults with sepsis. Further large-scale RCTs are necessary to validate our findings.
Collapse
Affiliation(s)
- Azizullah Beran
- Department of Internal Medicine, University of Toledo, Toledo, OH 43606, USA; (N.A.); (O.S.); (S.-E.M.); (W.K.); (M.M.); (H.A.); (Z.A.); (A.M.); (N.A.); (R.A.)
| | - Nehaya Altorok
- Department of Internal Medicine, University of Toledo, Toledo, OH 43606, USA; (N.A.); (O.S.); (S.-E.M.); (W.K.); (M.M.); (H.A.); (Z.A.); (A.M.); (N.A.); (R.A.)
| | - Omar Srour
- Department of Internal Medicine, University of Toledo, Toledo, OH 43606, USA; (N.A.); (O.S.); (S.-E.M.); (W.K.); (M.M.); (H.A.); (Z.A.); (A.M.); (N.A.); (R.A.)
| | - Saif-Eddin Malhas
- Department of Internal Medicine, University of Toledo, Toledo, OH 43606, USA; (N.A.); (O.S.); (S.-E.M.); (W.K.); (M.M.); (H.A.); (Z.A.); (A.M.); (N.A.); (R.A.)
| | - Waleed Khokher
- Department of Internal Medicine, University of Toledo, Toledo, OH 43606, USA; (N.A.); (O.S.); (S.-E.M.); (W.K.); (M.M.); (H.A.); (Z.A.); (A.M.); (N.A.); (R.A.)
| | - Mohammed Mhanna
- Department of Internal Medicine, University of Toledo, Toledo, OH 43606, USA; (N.A.); (O.S.); (S.-E.M.); (W.K.); (M.M.); (H.A.); (Z.A.); (A.M.); (N.A.); (R.A.)
| | - Hazem Ayesh
- Department of Internal Medicine, University of Toledo, Toledo, OH 43606, USA; (N.A.); (O.S.); (S.-E.M.); (W.K.); (M.M.); (H.A.); (Z.A.); (A.M.); (N.A.); (R.A.)
| | - Nameer Aladamat
- Department of Neurology, University of Toledo, Toledo, OH 43606, USA;
| | - Ziad Abuhelwa
- Department of Internal Medicine, University of Toledo, Toledo, OH 43606, USA; (N.A.); (O.S.); (S.-E.M.); (W.K.); (M.M.); (H.A.); (Z.A.); (A.M.); (N.A.); (R.A.)
| | - Khaled Srour
- Department of Critical Care Medicine, Henry Ford Health System, Detroit, MI 48202, USA;
| | - Asif Mahmood
- Department of Internal Medicine, University of Toledo, Toledo, OH 43606, USA; (N.A.); (O.S.); (S.-E.M.); (W.K.); (M.M.); (H.A.); (Z.A.); (A.M.); (N.A.); (R.A.)
| | - Nezam Altorok
- Department of Internal Medicine, University of Toledo, Toledo, OH 43606, USA; (N.A.); (O.S.); (S.-E.M.); (W.K.); (M.M.); (H.A.); (Z.A.); (A.M.); (N.A.); (R.A.)
- Department of Rheumatology, University of Toledo, Toledo, OH 43606, USA
| | - Mohammad Taleb
- Department of Pulmonary and Critical Care Medicine, University of Toledo, Toledo, OH 43606, USA;
| | - Ragheb Assaly
- Department of Internal Medicine, University of Toledo, Toledo, OH 43606, USA; (N.A.); (O.S.); (S.-E.M.); (W.K.); (M.M.); (H.A.); (Z.A.); (A.M.); (N.A.); (R.A.)
- Department of Pulmonary and Critical Care Medicine, University of Toledo, Toledo, OH 43606, USA;
| |
Collapse
|
13
|
Jung S, Kim J, Lee J, Choi SY, Joo HJ, Koo BN. Effects of the Type of Intraoperative Fluid in Living Donor Kidney Transplantation: A Single-Center Retrospective Cohort Study. Yonsei Med J 2022; 63:380-388. [PMID: 35352890 PMCID: PMC8965431 DOI: 10.3349/ymj.2022.63.4.380] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 11/23/2021] [Accepted: 12/11/2021] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Perioperative fluid management in kidney transplant recipients is crucial to supporting the fluid, acid-base, and electrolyte balance required for graft perfusion. However, the choice of intraoperative crystalloids in kidney transplantation remains controversial. We conducted a single-center retrospective cohort study to evaluate the impact of intraoperative fluids on acid-base and electrolyte balance and graft outcomes. MATERIALS AND METHODS We included 282 living donor kidney transplant recipients from January 2010 to December 2017. Patients were classified into two groups based on the type of intraoperative crystalloids used (157 patients in the half saline group and 125 patients in the balanced crystalloid solutions group, Plasma-lyte). RESULTS Compared with the half saline group, the Plasma-lyte group showed less metabolic acidosis and hyponatremia during surgery. Hyperkalemia incidence was not significantly different between the two groups. Changes in postoperative graft function assessed by blood urea nitrogen and creatinine were significantly different between the two groups. Patients in the Plasma-lyte group exhibited consistently higher glomerular filtration rates than those in the half saline group at 1 month and 1 year after transplantation after adjusting for demographic differences. CONCLUSION Intraoperative Plasma-lyte can lead to more favorable results in terms of acid-base balance during kidney transplantation. Patients who received Plasma-lyte showed superior postoperative graft function at 1 month and 1 year after transplantation. Further studies are needed to evaluate the superiority of intraoperative Plasma-lyte over other types of crystalloids in relation to graft outcomes.
Collapse
Affiliation(s)
- Seungho Jung
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jeongmin Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Juhan Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Su Youn Choi
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Hye Ji Joo
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Bon-Nyeo Koo
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea.
| |
Collapse
|
14
|
Fayed A, ALKouny A, ALHarbi M, ALTheaby A, Aboalsamh G. Crystalloid fluids and delayed graft function in kidney transplant: A cohort study. Saudi J Anaesth 2022; 16:38-44. [PMID: 35261587 PMCID: PMC8846252 DOI: 10.4103/sja.sja_334_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 06/07/2021] [Accepted: 06/08/2021] [Indexed: 11/21/2022] Open
Abstract
Background: Normal saline is commonly used in the perioperative kidney transplant period; its high chloride content can cause hyperchloremic metabolic acidosis giving a possible advantage to balanced electrolyte solutions due to their lower chloride content. The evidence regarding the best practices in fluid management during kidney transplantation and its effect on the incidence of delayed graft function (DGF) is still limited. Materials and Methods: One hundred thirty-eight patients were included and followed up for seven days after surgery. Administered crystalloid type and volume were compared among patients with and without DGF, along with additional patient and surgical variables. To investigate whether intraoperative fluid type/amount influence DGF, patients were categorized into three groups: those who received mainly (>50%) lactated Ringer's solution, normal saline, or plasmaLyte. A logistic regression analysis was used to define variables independently correlated with DGF, and odds ratios (OR) with a 95% confidence interval (CI) were reported. Results: The incidence of DGF was 8.7%. Cold ischemia time independently increased the odds of DGF (OR = 1.006 (95% CI: 1.002–1.011) while fluid type (saline versus PlasmaLyte OR = 5.28, 95% CI: 0.76–36.88) or amount (OR = 1.00, 95% CI: 1.00–1.01) did not significantly modify the odds of DGF. Central venous pressure, systolic blood pressure, and mean arterial pressure were higher in the non-DGF group, but this was not statistically significant (P > 0.05). Significant intraoperative acidosis developed in patients who received normal saline compared to those in PlasmaLyte and lactated Ringer's groups; however, acid–base balance and electrolytes did not vary significantly between the DGF and non-DGF groups. Conclusion: DGF was primarily influenced by surgical factors such as cold ischemia time, whereas intraoperative fluid type or amount did not affect DGF incidence.
Collapse
|
15
|
Bezinover D, Mukhtar A, Wagener G, Wray C, Blasi A, Kronish K, Zerillo J, Tomescu D, Pustavoitau A, Gitman M, Singh A, Saner FH. Hemodynamic Instability During Liver Transplantation in Patients With End-stage Liver Disease: A Consensus Document from ILTS, LICAGE, and SATA. Transplantation 2021; 105:2184-2200. [PMID: 33534523 DOI: 10.1097/tp.0000000000003642] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Hemodynamic instability (HDI) during liver transplantation (LT) can be difficult to manage and increases postoperative morbidity and mortality. In addition to surgical causes of HDI, patient- and graft-related factors are also important. Nitric oxide-mediated vasodilatation is a common denominator associated with end-stage liver disease related to HDI. Despite intense investigation, optimal management strategies remain elusive. In this consensus article, experts from the International Liver Transplantation Society, the Liver Intensive Care Group of Europe, and the Society for the Advancement of Transplant Anesthesia performed a rigorous review of the most current literature regarding the epidemiology, causes, and management of HDI during LT. Special attention has been paid to unique LT-associated conditions including the causes and management of vasoplegic syndrome, cardiomyopathies, LT-related arrhythmias, right and left ventricular dysfunction, and the specifics of medical and fluid management in end-stage liver disease as well as problems specifically related to portal circulation. When possible, management recommendations are made.
Collapse
Affiliation(s)
- Dmitri Bezinover
- Department of Anesthesiology and Perioperative Medicine, Pennsylvania State University, Penn State Health, Milton S. Hershey Medical Center, Hershey, PA. Represents ILTS and LICAGE
| | - Ahmed Mukhtar
- Department of Anesthesia and Surgical Intensive Care, Cairo University, Almanyal, Cairo, Egypt. Represents LICAGE
| | - Gebhard Wagener
- Department of Anesthesiology, Columbia University Medical Center, New York, NY. Represents SATA and ILTS
| | - Christopher Wray
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles, Ronald Reagan Medical Center, Los Angeles, CA. Represents SATA
| | - Annabel Blasi
- Department of Anesthesia, IDIBAPS (Institut d´investigació biomèdica Agustí Pi i Sunyé) Hospital Clinic, Villaroel, Barcelona, Spain. Represents LICAGE and ILTS
| | - Kate Kronish
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA. Represents SATA
| | - Jeron Zerillo
- Department of Anesthesiology, Perioperative and Pain Medicine, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY. Represents SATA and ILTS
| | - Dana Tomescu
- Department of Anesthesiology and Intensive Care, Carol Davila University of Medicine and Pharmacy, Fundeni Clinical Institute, Bucharest, Romania. Represents LICAGE
| | - Aliaksei Pustavoitau
- Department of Anesthesia and Critical Care Medicine, Johns Hopkins Hospital, Johns Hopkins School of Medicine, Baltimore, MD. Represents ILTS
| | - Marina Gitman
- Department of Anesthesiology, University of Illinois Hospital, Chicago, IL. Represents SATA and ILTS
| | - Anil Singh
- Department of Liver Transplant and GI Critical Care, Sir HN Reliance Foundation Hospital, Cirgaon, Mumbai, India. Represents ILTS
| | - Fuat H Saner
- Department of General, Visceral and Transplant Surgery, Essen University Medical Center, Essen, Germany. Represents LICAGE
| |
Collapse
|
16
|
Salinero A, Mitzova-Vladinov G. Battle of the Crystalloids in the Operating Room: A Literature Review. J Perianesth Nurs 2021; 36:629-637. [PMID: 34479770 DOI: 10.1016/j.jopan.2021.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 03/22/2021] [Accepted: 03/24/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE The purpose of this article is to synthesize the evidence regarding the commonalities and differences between the three most common crystalloid solutions used in the operating room (normal saline [NS], lactated Ringer's [LR], and Plasmalyte [PL]) in order to determine best practice. DESIGN This study is an integrative review of literature. METHODS A review of the literature was conducted using the PubMed, CINAHL Plus, and Cochrane Library databases. The inclusion criteria included adult patients undergoing surgery who received either NS, LR, and/or PL (or similar solutions) for fluid maintenance therapy. FINDINGS A total of 15 articles from 2008 to 2020 conducted in a surgical setting were selected for the review; eleven randomized controlled studies, three observational studies, and one cohort-controlled trial. CONCLUSIONS The findings suggest balanced crystalloid solutions are superior to NS in the operating room in terms of maintaining a stable acid-base balance. PL is preferable to LR because it most closely resembles plasma concentration. Future research is needed to determine the cost-effectiveness of the solutions.
Collapse
Affiliation(s)
- Alejandra Salinero
- University of Miami School of Nursing and Health Studies, Coral Gables, FL.
| | | |
Collapse
|
17
|
Wagener G, Bezinover D, Wang C, Kroepfl E, Diaz G, Giordano C, West J, Kindscher JD, Moguilevitch M, Nicolau-Raducu R, Planinsic RM, Rosenfeld DM, Lindberg S, Schumann R, Pivalizza EG. Fluid Management During Kidney Transplantation: A Consensus Statement of the Committee on Transplant Anesthesia of the American Society of Anesthesiologists. Transplantation 2021; 105:1677-1684. [PMID: 33323765 DOI: 10.1097/tp.0000000000003581] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Intraoperative fluid management may affect the outcome after kidney transplantation. However, the amount and type of fluid administered, and monitoring techniques vary greatly between institutions and there are limited prospective randomized trials and meta-analyses to guide fluid management in kidney transplant recipients. METHODS Members of the American Society of Anesthesiologists (ASA) committee on transplantation reviewed the current literature on the amount and type of fluids (albumin, starches, 0.9% saline, and balanced crystalloid solutions) administered and the different monitors used to assess fluid status, resulting in this consensus statement with recommendations based on the best available evidence. RESULTS Review of the current literature suggests that starch solutions are associated with increased risk of renal injury in randomized trials and should be avoided in kidney donors and recipients. There is no evidence supporting the routine use of albumin solutions in kidney transplants. Balanced crystalloid solutions such as Lactated Ringer are associated with less acidosis and may lead to less hyperkalemia than 0.9% saline solutions. Central venous pressure is only weakly supported as a tool to assess fluid status. CONCLUSIONS These recommendations may be useful to anesthesiologists making fluid management decisions during kidney transplantation and facilitate future research on this topic.
Collapse
Affiliation(s)
| | | | - Cynthia Wang
- Greater Los Angeles VA Healthcare System, Los Angeles, CA
| | | | | | | | - James West
- Methodist-LeBonheur Healthcare Memphis, TN
| | | | | | | | | | | | | | | | | |
Collapse
|
18
|
Kolodzie K, Cakmakkaya OS, Boparai ES, Tavakol M, Feiner JR, Kim MO, Newman TB, Niemann CU. Perioperative Normal Saline Administration and Delayed Graft Function in Patients Undergoing Kidney Transplantation: A Retrospective Cohort Study. Anesthesiology 2021; 135:621-632. [PMID: 34265037 DOI: 10.1097/aln.0000000000003887] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Perioperative normal saline administration remains common practice during kidney transplantation. The authors hypothesized that the proportion of balanced crystalloids versus normal saline administered during the perioperative period would be associated with the likelihood of delayed graft function. METHODS The authors linked outcome data from a national transplant registry with institutional anesthesia records from 2005 to 2015. The cohort included adult living and deceased donor transplants, and recipients with or without need for dialysis before transplant. The primary exposure was the percent normal saline of the total amount of crystalloids administered perioperatively, categorized into a low (less than or equal to 30%), intermediate (greater than 30% but less than 80%), and high normal saline group (greater than or equal to 80%). The primary outcome was the incidence of delayed graft function, defined as the need for dialysis within 1 week of transplant. The authors adjusted for the following potential confounders and covariates: transplant year, total crystalloid volume, surgical duration, vasopressor infusions, and erythrocyte transfusions; recipient sex, age, body mass index, race, number of human leukocyte antigen mismatches, and dialysis vintage; and donor type, age, and sex. RESULTS The authors analyzed 2,515 records. The incidence of delayed graft function in the low, intermediate, and high normal saline group was 15.8% (61/385), 17.5% (113/646), and 21% (311/1,484), respectively. The adjusted odds ratio (95% CI) for delayed graft function was 1.24 (0.85 to 1.81) for the intermediate and 1.55 (1.09 to 2.19) for the high normal saline group compared with the low normal saline group. For deceased donor transplants, delayed graft function in the low, intermediate, and high normal saline group was 24% (54/225 [reference]), 28.6% (99/346; adjusted odds ratio, 1.28 [0.85 to 1.93]), and 30.8% (277/901; adjusted odds ratio, 1.52 [1.05 to 2.21]); and for living donor transplants, 4.4% (7/160 [reference]), 4.7% (14/300; adjusted odds ratio, 1.15 [0.42 to 3.10]), and 5.8% (34/583; adjusted odds ratio, 1.66 [0.65 to 4.25]), respectively. CONCLUSIONS High percent normal saline administration is associated with delayed graft function in kidney transplant recipients. EDITOR’S PERSPECTIVE
Collapse
|
19
|
Jahangir A, Sahra S, Niazi MRK, Siddiqui FS, Anwar MY, Jahangir A, El-Charabaty EJ. Comparison of normal saline solution with low-chloride solutions in renal transplants: a meta-analysis. Kidney Res Clin Pract 2021; 40:484-495. [PMID: 34233443 PMCID: PMC8476298 DOI: 10.23876/j.krcp.21.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 04/25/2021] [Indexed: 11/23/2022] Open
Abstract
Background Normal saline solution (NSS) has been the fluid of choice for renal transplant patients, but it can lead to hyperchloremic acidosis and hyperkalemia. This study was performed to compare the safety profile of low-chloride solutions with that of NSS in renal transplant patients. Methods We conducted a systemic review search on PubMed, Embase, and the Central Cochrane Registry. Randomized clinical trials (RCTs) and matched cohort studies involving NSS as the control arm and low-chloride solutions as an intervention arm were chosen. The standardized mean difference for continuous variables, the odds ratio (OR) for discrete variables, and a 95% confidence interval (CI) for effect sizes were used. A p-value of <0.05 was considered statistically significant. Analysis was performed using a random-effects model irrespective of heterogeneity, which was evaluated using I2 statistics. Results Nine RCTs and one cohort study with a total of 726 patients were included. After transplantation, serum potassium was significantly lower in the low-chloride group (standardized mean difference compared to NSS group, –0.38 mEq/L; 95% CI, –0.66 to –0.11; p = 0.007). Similarly, postoperative chloride was lower in the low-chloride group (–2.41 mEq/L [–3.34 to –1.48], p < 0.001). No statistically significance was observed in delayed graft function (OR, 0.98 [0.56–1.69], p = 0.93), day 3 creatinine (–0.14 mg/dL [–0.46 to 0.18], p = 0.38), or day 7 urine output (–0.08 L [–0.29 to 0.12], p = 0.43). Conclusion Use of NSS during renal transplant leads to increased incidence of hyperchloremic acidosis with subsequent hyperkalemia, but clinical significance in the form of delayed graft function or postoperative creatinine remains comparable to that of low-chloride solutions.
Collapse
Affiliation(s)
- Abdullah Jahangir
- Department of Internal Medicine, Staten Island University Hospital, Northwell Health, Staten Island, NY, United States
| | - Syeda Sahra
- Department of Internal Medicine, Staten Island University Hospital, Northwell Health, Staten Island, NY, United States
| | - Muhammad Rafay Khan Niazi
- Department of Internal Medicine, Staten Island University Hospital, Northwell Health, Staten Island, NY, United States
| | - Fasih Sami Siddiqui
- Department of Internal Medicine, Staten Island University Hospital, Northwell Health, Staten Island, NY, United States
| | - Muhammad Yasir Anwar
- Department of Internal Medicine, King Edward Medical University, Lahore, Pakistan
| | - Ahmad Jahangir
- Department of Internal Medicine, King Edward Medical University, Lahore, Pakistan
| | - Elie J El-Charabaty
- Department of Internal Medicine, Staten Island University Hospital, Northwell Health, Staten Island, NY, United States
| |
Collapse
|
20
|
von der Forst M, Weigand MA, Siegler BH. [How balanced should a crystalloid solution be?]. Anaesthesist 2021; 70:522-525. [PMID: 34019105 DOI: 10.1007/s00101-021-00955-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Maik von der Forst
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Deutschland
| | - Markus A Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Deutschland
| | - Benedikt H Siegler
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Deutschland.
| |
Collapse
|
21
|
Østergaard AM, Jørgensen AN, Bøvling S, Ekeløf NP, Mose FH, Bech JN. Effect of 0.9% NaCl compared to plasma-lyte on biomarkers of kidney injury, sodium excretion and tubular transport proteins in patients undergoing primary uncemented hip replacement - a randomized trial. BMC Nephrol 2021; 22:111. [PMID: 33771116 PMCID: PMC7995716 DOI: 10.1186/s12882-021-02310-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 03/15/2021] [Indexed: 11/28/2022] Open
Abstract
Background Isotonic saline (IS) is widely used to secure perioperative cardiovascular stability. However, the high amount of chloride in IS can induce hyperchloremic acidosis. Therefore, IS is suspected to increase the risk of acute kidney injury (AKI). Biomarkers may have potential as indicators. Methods In a double-blinded, placebo-controlled study, 38 patients undergoing primary uncemented hip replacement were randomized to IS or PlasmaLyte (PL). Infusion was given during surgery as 15 ml/kg the first hour and 5 ml/kg the following two hours. Urinary samples were collected upon admission and the day after surgery. As surgery was initiated, urine was collected over the course of 4 h. Hereafter, another urine collection proceeded until the morning. Urine was analyzed for markers of AKI neutrophil gelatinase-associated lipocalin (NGAL) and kidney injury molecule-1 (KIM-1). Arterious and venous blood samples for measurements of pH and plasma electrolytes including chloride (p-Cl) were collected as surgery was initiated, at the end of surgery and the following morning. Results IS induced an increase in p-Cl (111 ± 2 mmol/L after IS and 108 ± 3 after PL, p = 0.004) and a decrease in pH (7.39 ± 0.02 after IS and 7.43 ± 0.03 after PL, p = 0.001). Urinary NGAL excretion increased in both groups (ΔNGAL: 5.5 [4.1; 11.7] μg/mmol creatinine p = 0.004 after IS vs. 5.5 [2.1;9.4] μg/mmol creatinine after PL, p < 0.001). No difference was found between the groups (p = 0.839). Similarly, urinary KIM-1 excretion increased in both groups (ΔKIM-1: IS 115.8 [74.1; 156.2] ng/mmol creatinine, p < 0.001 vs. PL 152.4 [120.1; 307.9] ng/mmol creatinine, p < 0.001). No difference between the groups (p = 0.064). FENa increased (1.08 ± 0.52% after IS and 1.66 ± 1.15% after PL, p = 0.032). ENaC excretion was different within groups (p = 0.019). Conclusion A significantly higher plasma chloride and a lower pH was present in the group receiving isotonic saline. However, u-NGAL and u-KIM-1 increased significantly in both groups after surgery despite absence of changes in creatinine. These results indicate that surgery induced subclinical kidney injury. Also, the IS group had a delayed sodium excretion as compared to the PL group which may indicate that IS affects renal sodium excretion differently from PL. Trial registration ClinicalTrials.gov Identifier: NCT02528448, 19/08/2015
Collapse
Affiliation(s)
- A M Østergaard
- University Clinic in Nephrology and Hypertension and University of Aarhus, Gødstrup Hospital, Laegaardvej 12, 7500, Holstebro, Denmark.
| | - A N Jørgensen
- University Clinic in Nephrology and Hypertension and University of Aarhus, Gødstrup Hospital, Laegaardvej 12, 7500, Holstebro, Denmark
| | - S Bøvling
- Department of Orthopaedic Surgery, Gødstrup Hospital, Holstebro, Denmark
| | - N P Ekeløf
- Department of Anaesthesiology, Gødstrup Hospital, Holstebro, Denmark
| | - F H Mose
- University Clinic in Nephrology and Hypertension and University of Aarhus, Gødstrup Hospital, Laegaardvej 12, 7500, Holstebro, Denmark
| | - J N Bech
- University Clinic in Nephrology and Hypertension and University of Aarhus, Gødstrup Hospital, Laegaardvej 12, 7500, Holstebro, Denmark
| |
Collapse
|
22
|
Low- versus High-Chloride Content Intravenous Solutions for Perioperative Patients: A Systematic Review and Meta-Analysis. BIOMED RESEARCH INTERNATIONAL 2021; 2021:3571397. [PMID: 33490269 PMCID: PMC7801087 DOI: 10.1155/2021/3571397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 12/16/2020] [Accepted: 12/24/2020] [Indexed: 11/23/2022]
Abstract
Background Studies have shown complications of normal saline infusion because of its high-chloride content. Therefore, in the present study, we aimed to explore whether the use of low- versus high-chloride solutions benefited the unselected and specifically perioperative patients and was associated with different outcomes. Methods Studies on the use of low- versus high-chloride content intravenous solutions for perioperative patients, published up to July 15, 2019, were systematically reviewed, and primary and secondary outcomes were quantitatively summarized. Results A total of 14 eligible randomized controlled trials with 943 perioperative patients were included. Five studies reported all-cause mortality, and eight studies provided detailed data on renal replacement therapy (RRT). The pooled result suggested no statistically significant difference in the effect of low- versus high-chloride solutions on all-cause mortality (risk ratio (RR) = 1.39; 95%confidence interval (CI) = 0.23–8.26) and RRT (RR = 1.05; 95%CI = 0.63–1.76). The pooled results on acute kidney injury (AKI) and the use of allogenic blood transfusion (P > 0.05) were similar. Conclusion Among specific perioperative patients, the use of low- versus high-chloride content intravenous solutions did not reduce the all-cause mortality, risk of severe AKI, or rate of RRT use. Further large randomized clinical trials are needed to confirm or refute this finding.
Collapse
|
23
|
Intravenous Fluid of Choice in Major Abdominal Surgery: A Systematic Review. Crit Care Res Pract 2020; 2020:2170828. [PMID: 32832150 PMCID: PMC7421038 DOI: 10.1155/2020/2170828] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 05/29/2020] [Accepted: 06/30/2020] [Indexed: 12/29/2022] Open
Abstract
Background Intravenous fluid therapy plays a role in maintaining the hemodynamic status for tissue perfusion and electrolyte hemostasis during surgery. Recent trials in critically ill patients reported serious side effects of some types of fluids. Since the most suitable type of fluid is debatable, a consensus in perioperative patients has not been reached. Method We performed a systematic review of randomized control trials (RCTs) that compared two or more types of fluids in major abdominal surgery. The outcomes were related to bleeding, hemodynamic status, length of hospital stay, and complications, such as kidney injury, electrolyte abnormality, major cardiac adverse event, nausea, vomiting, and mortality. A literature search was performed using Medline and EMBASE up to December 2019. The data were pooled to investigate the effect of fluid on macrocirculation and intravascular volume effect. Results Forty-three RCTs were included. Eighteen fluids were compared: nine were crystalloids and nine were colloids. The results were categorized into macrocirculation and intravascular volume effect, microcirculation, anti-inflammatory parameters, vascular permeability, renal function (colloids), renal function and electrolytes (crystalloids), coagulation and bleeding, return of bowel function, and postoperative nausea vomiting (PONV). We found that no specific type of fluid led to mortality and every type of colloid was equivalent in volume expansion and did not cause kidney injury. However, hydroxyethyl starch and dextran may lead to increased bleeding. Normal saline can cause kidney injury which can lead to renal replacement therapy, and dextrose fluid can decrease PONV. Conclusion In our opinion, it is safe to give a balanced crystalloid as the maintenance fluid and give a colloid, such as HES130/0.4, 4% gelatin, or human albumin, as a volume expander.
Collapse
|
24
|
Haines RW, Kirwan CJ, Prowle JR. Managing Chloride and Bicarbonate in the Prevention and Treatment of Acute Kidney Injury. Semin Nephrol 2020; 39:473-483. [PMID: 31514911 DOI: 10.1016/j.semnephrol.2019.06.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Intravenous crystalloid therapy is one of the most ubiquitous aspects of hospital and critical care medicine. In recent years, there has been increasing focus on the electrolyte composition, and particularly chloride content, of crystalloid solutions. This has led to increasing clinical adoption of balanced solutions, containing substrates for bicarbonate generation and consequently a lower chloride content, in place of 0.9% saline. In this article we review the physiochemical rationale for avoidance of 0.9% saline and the effects of hyperchloremic acidosis on renal physiology. Finally, we review the current evidence and rationale for use of balanced solutions greater than 0.9% saline in acutely ill patients in a variety of clinical settings, as well as considering the role for sodium bicarbonate in preventing or correcting metabolic acidosis. In conclusion, there is a strong physiological rationale for avoidance of iatrogenic hyperchloremic acidosis from 0.9% saline administration in acutely unwell patients and an association with adverse renal outcomes in several studies. However, evidence from large definitive multicenter randomized trials is not yet available to establish the dose-relationship between 0.9% saline administration and potential harm and inform us if some 0.9% saline use is acceptable or if any exposure confers harm.
Collapse
Affiliation(s)
- Ryan W Haines
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom; William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Christopher J Kirwan
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom; William Harvey Research Institute, Queen Mary University of London, London, United Kingdom; Department of Renal Medicine and Transplantation, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - John R Prowle
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom; William Harvey Research Institute, Queen Mary University of London, London, United Kingdom; Department of Renal Medicine and Transplantation, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom.
| |
Collapse
|
25
|
Tejchman K, Sierocka A, Kotowski M, Zair L, Pilichowska E, Ostrowski M, Sieńko J. Acid-Base Balance Disorders During Kidney Preservation in Cold Ischemia. Transplant Proc 2020; 52:2036-2042. [PMID: 32334797 DOI: 10.1016/j.transproceed.2020.01.099] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Revised: 01/06/2020] [Accepted: 01/26/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Acid-base balance disorders are a crucial element of ischemia-reperfusion injury during organ transplantation. Hypoxia during organ procurement and storage cause cellular homeostasis imbalance with impact on further graft function. Acidosis in preserved kidney caused by lactate accumulation may have an important role as a common denominator of various pathways leading to cellular damage. METHODS Our trial sought to answer questions regarding a range of pH alterations in the kidney before the transplantation, their potential cause, and how this may affect further outcome of the kidney transplantation procedure. Perfusion fluid for pH analysis was obtained from perfusion pump (PP) or through kidney flushing at the end of preservation depending on the storage method. RESULTS A total of 66 sample results were collated with the data from the transplant registry, hospitalization, and outpatient department. Statistical analysis was conducted linking pH results with factors related to donor, recipient, preservation, and outcome according to designed schematics. Mean perfusate pH was significantly lower in simple hypothermia (SH) vs the PP storage group (6.77 vs 7.11; P < .001). All samples of perfusate pH in the SH group were below physiological values (<7.35), and in 10% of samples in the SH group, pH >7.00. CONCLUSIONS We concluded that kidney storage in cold ischemia is associated with organ acidosis independent of preservation method and that SH is correlated with significantly bigger acidosis than storage in PP, which is an important procedure removing an excessive amount of hydrogen ions from kidney microcirculation, decreasing cell damage.
Collapse
Affiliation(s)
- Karol Tejchman
- Department of General and Transplantation Surgery, Pomeranian Medical University, Szczecin, Poland.
| | - Anita Sierocka
- Department of General Mini-invasive and Gastroenterological Surgery, Pomeranian Medical University, Szczecin, Poland
| | - Maciej Kotowski
- Department of General and Transplantation Surgery, Pomeranian Medical University, Szczecin, Poland
| | - Labib Zair
- Department of General and Transplantation Surgery, Pomeranian Medical University, Szczecin, Poland
| | - Ewa Pilichowska
- Department of General and Transplantation Surgery, Pomeranian Medical University, Szczecin, Poland
| | - Marek Ostrowski
- Department of General and Transplantation Surgery, Pomeranian Medical University, Szczecin, Poland
| | - Jerzy Sieńko
- Department of General and Transplantation Surgery, Pomeranian Medical University, Szczecin, Poland
| |
Collapse
|
26
|
Nesseler N, Rached A, Ross JT, Launey Y, Vigneau C, Bensalah K, Beloeil H, Mallédant Y, Garlantezec R, Seguin P. Association between perioperative normal saline and delayed graft function in deceased-donor kidney transplantation: a retrospective observational study. Can J Anaesth 2020; 67:421-429. [PMID: 31989473 DOI: 10.1007/s12630-020-01577-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 10/07/2019] [Accepted: 10/13/2019] [Indexed: 01/24/2023] Open
Abstract
PURPOSE Isotonic 0.9% sodium chloride (normal saline; NS) solution use is common, but its high chloride content has been shown to contribute to acid-base disturbances and acute kidney injury (AKI). As kidney transplant recipients are at high risk of postoperative AKI and renal replacement therapy, we aimed to evaluate the impact of perioperative NS administration on graft function after kidney transplantation. METHODS All adult patients undergoing deceased-donor kidney transplantation between January 2010 and December 2014 at the Rennes University Hospital were included. Logistic regression models were constructed to evaluate the association of hyperchloremia and hyperchloremic acidosis on delayed graft function (DGF), defined as the need for renal replacement therapy within the first week after transplantation. RESULTS Three hundred and fifty-nine patients were included, 20% developed DGF. The mean (standard deviation) volume of NS infused in the operating room and in the standard postoperative intensive care unit stay was 4,832 (2,242) mL. In the first 24 postoperative hours, 11% of patients developed hyperchloremia and 11% developed hyperchloremic acidosis. These outcomes were not associated with significantly higher total volumes of NS administration or with DGF. In contrast, multivariable analysis showed that cold ischemia time, donor terminal creatinine, and perioperative NS volume were all independent predictors of DGF. CONCLUSION Perioperative NS infusion volume was associated with DGF in deceased-donor kidney transplant recipients. Conversely, postoperative hyperchloremia and hyperchloremic acidosis were not associated with an increased risk of DGF, suggesting other mechanisms than a chloride effect.
Collapse
Affiliation(s)
- Nicolas Nesseler
- Department of Anesthesia and Critical Care, Pontchaillou, University Hospital of Rennes, Rennes, France.
- Univ Rennes, CHU de Rennes, Inra, Inserm, Institut NUMECAN, Rennes, France.
- Univ Rennes, CHU Rennes (Centre d'Investigation Clinique de Rennes), Rennes, France.
| | - Alexandre Rached
- Department of Anesthesia and Critical Care, Pontchaillou, University Hospital of Rennes, Rennes, France
| | - James T Ross
- Department of Surgery, University of California, San Francisco, CA, USA
| | - Yoann Launey
- Department of Anesthesia and Critical Care, Pontchaillou, University Hospital of Rennes, Rennes, France
- Univ Rennes, CHU de Rennes, Inra, Inserm, Institut NUMECAN, Rennes, France
| | - Cécile Vigneau
- Department of Nephrology, Pontchaillou, University Hospital of Rennes, Rennes, France
| | - Karim Bensalah
- Department of Urology, Pontchaillou, University Hospital of Rennes, Rennes, France
| | - Hélène Beloeil
- Department of Anesthesia and Critical Care, Pontchaillou, University Hospital of Rennes, Rennes, France
- Univ Rennes, CHU de Rennes, Inra, Inserm, Institut NUMECAN, Rennes, France
- Univ Rennes, CHU Rennes (Centre d'Investigation Clinique de Rennes), Rennes, France
| | - Yannick Mallédant
- Department of Anesthesia and Critical Care, Pontchaillou, University Hospital of Rennes, Rennes, France
- Univ Rennes, CHU de Rennes, Inra, Inserm, Institut NUMECAN, Rennes, France
| | - Ronan Garlantezec
- Univ Rennes, CHU de Rennes, Irset (Institut de recherche en santé, environnement et travail), Rennes, France
- Department of Public Health and Epidemiology, Pontchaillou, University Hospital of Rennes, Rennes, France
| | - Philippe Seguin
- Department of Anesthesia and Critical Care, Pontchaillou, University Hospital of Rennes, Rennes, France
- Univ Rennes, CHU de Rennes, Inra, Inserm, Institut NUMECAN, Rennes, France
- Univ Rennes, CHU Rennes (Centre d'Investigation Clinique de Rennes), Rennes, France
| |
Collapse
|
27
|
Prevention of Ischemia-Reperfusion Injury in Human Kidney Transplantation: A Meta-Analysis of Randomized Controlled Trials. Nephrourol Mon 2020. [DOI: 10.5812/numonthly.101590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
|
28
|
Abstract
Intravenous fluid therapy is the most common intervention received by acutely ill patients. Historically, saline (0.9% sodium chloride) has been the most frequently administered intravenous fluid, especially in North America. Balanced crystalloid solutions (e.g., lactated Ringer's, Plasma-Lyte) are an increasingly used alternative to saline. Balanced crystalloids have a sodium, potassium, and chloride content closer to that of extracellular fluid and, when given intravenously, have fewer adverse effects on acid-base balance. Preclinical research has demonstrated that saline may cause hyperchloremic metabolic acidosis, inflammation, hypotension, acute kidney injury, and death. Studies of patients and healthy human volunteers suggest that even relatively small volumes of saline may exert physiological effects. Randomized trials in the operating room have demonstrated that using balanced crystalloids rather than saline prevents the development of hyperchloremic metabolic acidosis and may reduce the need for vasopressors. Observational studies among critically ill adults have associated receipt of balanced crystalloids with lower rates of complications, including acute kidney injury and death. Most recently, large randomized trials among critically ill adults have examined whether balanced crystalloids result in less death or severe renal dysfunction than saline. Although some of these trials are still ongoing, a growing body of evidence raises fundamental concerns regarding saline as the primary intravenous crystalloid for critically ill adults and highlights fundamental unanswered questions for future research about fluid therapy in critical illness.
Collapse
Affiliation(s)
- Matthew W Semler
- 1 Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; and
| | - John A Kellum
- 2 The Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| |
Collapse
|
29
|
Arslantas R, Dogu Z, Cevik BE. Normal Saline Versus Balanced Crystalloid Solutions for Kidney Transplantation. Transplant Proc 2019; 51:2262-2264. [DOI: 10.1016/j.transproceed.2019.03.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Revised: 02/17/2019] [Accepted: 03/12/2019] [Indexed: 10/26/2022]
|
30
|
Kawano-Dourado L, Zampieri FG, Azevedo LCP, Corrêa TD, Figueiró M, Semler MW, Kellum JA, Cavalcanti AB. Low- Versus High-Chloride Content Intravenous Solutions for Critically Ill and Perioperative Adult Patients: A Systematic Review and Meta-analysis. Anesth Analg 2018; 126:513-521. [PMID: 29189271 DOI: 10.1213/ane.0000000000002641] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND To assess whether use of low-chloride solutions in unselected critically ill or perioperative adult patients for maintenance or resuscitation reduces mortality and renal replacement therapy (RRT) use when compared to high-chloride fluids. METHODS Systematic review and meta-analysis with random-effects inverse variance model. PubMed, Cochrane library, EMBASE, LILACS, and Web of Science were searched from inception to October 2016. Published and unpublished randomized controlled trials in any language that enrolled critically ill and/or perioperative adult patients and compared a low- to a highchloride solution for volume maintenance or resuscitation. The primary outcomes were mortality and RRT use. We conducted trial sequential analyses and assessed risk of bias of individual trials and the overall quality of evidence. Fifteen trials with 4067 patients, most at low risk of bias, were identified. Of those, only 11 and 10 trials had data on mortality and RRT use, respectively. A total of 3710 patients were included in the mortality analysis and 3724 in the RRT analysis. RESULTS No statistically significant impact on mortality (odds ratio, 0.90; 95% confidence interval, 0.69-1.17; P = .44; I = 0%) or RRT use (odds ratio, 1.12; 95% confidence interval, 0.80-1.58; P = .52; I = 0%) was found. Overall quality of evidence was low for both primary outcomes. Trial sequential analyses highlighted that the sample size needed was much larger than that available for properly powered outcome assessment. CONCLUSIONS The current evidence on low- versus high-chloride solutions for unselected critically ill or perioperative adult patients demonstrates no benefit, but suffers from considerable imprecision. We noted a limited exposure volume for study fluids and a relatively low risk of the populations in each study. Together with the relatively small pooled sample size, these data leave us underpowered to detect potentially important differences. Results from well-conducted, adequately powered randomized controlled trials examining sufficiently large fluid exposure are necessary.
Collapse
Affiliation(s)
- Leticia Kawano-Dourado
- From the Research Institute, Hospital do Coração (HCor), São Paulo, Brazil.,Pulmonary Division, Heart Institute (InCor), University of Sao Paulo Medical School, São Paulo, Brazil
| | - Fernando G Zampieri
- From the Research Institute, Hospital do Coração (HCor), São Paulo, Brazil.,Intensive Care Unit, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Luciano C P Azevedo
- Intensive Care Unit, Hospital Sirio Libanes, São Paulo, Brazil.,Emergency Medicine Discipline, University of São Paulo Medical School, São Paulo, Brazil
| | - Thiago D Corrêa
- Intensive Care Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Mabel Figueiró
- From the Research Institute, Hospital do Coração (HCor), São Paulo, Brazil
| | - Matthew W Semler
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - John A Kellum
- The Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | |
Collapse
|
31
|
Odor PM, Bampoe S, Dushianthan A, Bennett-Guerrero E, Cro S, Gan TJ, Grocott MPW, James MFM, Mythen MG, O'Malley CMN, Roche AM, Rowan K, Burdett E. Perioperative administration of buffered versus non-buffered crystalloid intravenous fluid to improve outcomes following adult surgical procedures: a Cochrane systematic review. Perioper Med (Lond) 2018; 7:27. [PMID: 30559961 PMCID: PMC6291967 DOI: 10.1186/s13741-018-0108-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 10/14/2018] [Indexed: 12/12/2022] Open
Abstract
Background Buffered intravenous fluid preparations contain substrates to maintain acid-base status. The objective of this systematic review was to compare the effects of buffered and non-buffered fluids administered during the perioperative period on clinical and biochemical outcomes. Methods We searched MEDLINE, EMBASE, CINAHL and the Cochrane Library until May 2017 and included all randomised controlled trials that evaluated buffered versus non-buffered fluids, whether crystalloid or colloid, administered to surgical patients. We assessed the selected studies for risk of bias and graded the level of evidence in accordance with Cochrane recommendations. Results We identified 19 publications of 18 randomised controlled trials, totalling 1096 participants. Mean difference (MD) in postoperative pH was 0.05 units lower immediately following surgery in the non-buffered group (12 studies of 720 participants; 95% confidence interval (CI) 0.04 to 0.07; I2 = 61%). This difference did not persist on postoperative day 1. Serum chloride concentration was higher in the non-buffered group at the end of surgery (10 trials of 530 participants; MD 6.77 mmol/L, 95% CI 3.38 to 10.17). This effect persisted until postoperative day 1 (5 trials of 258 participants; MD 8.48 mmol/L, 95% CI 1.08 to 15.88). Quality of this evidence was moderate. We identified variable protocols for fluid administration and total volumes of fluid administered to patients intraoperatively. Outcome data was variably reported at disparate time points and with heterogeneous patient groups. Consequently, the effect size and overall confidence interval was reduced, despite the relatively low inherent risk of bias. There was insufficient evidence on the effect of fluid composition on mortality and organ dysfunction. Confidence intervals of this outcome were wide and the quality of evidence was low (3 trials of 276 participants for mortality; odds ratio (OR) 1.85, 95% CI 0.37 to 9.33; I2 = 0%). Conclusions Small effect sizes for biochemical outcomes and lack of correlated clinical follow-up data mean that robust conclusions on major morbidity and mortality associated with buffered versus non-buffered perioperative fluid choices are still lacking. Buffered fluid may have biochemical benefits, including a significant reduction in postoperative hyperchloraemia and metabolic acidosis. Electronic supplementary material The online version of this article (10.1186/s13741-018-0108-5) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Peter M Odor
- 1Department of Anaesthesia and Critical Care, University College London, Gower St, London, WC1E 6BT UK
| | - Sohail Bampoe
- 2Centre for Anaesthesia and Perioperative Medicine, University College London, London, UK
| | - Ahilanandan Dushianthan
- 3General Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | - Suzie Cro
- 5Medical Research Council Clinical Trials Unit, London, UK
| | - Tong J Gan
- 4Department of Anesthesiology, Stony Brook Medicine, Stony Brook, NY USA
| | - Michael P W Grocott
- 6Critical Care Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Michael F M James
- 7Department of Anaesthesia, University of Cape Town, Cape Town, South Africa
| | - Michael G Mythen
- 1Department of Anaesthesia and Critical Care, University College London, Gower St, London, WC1E 6BT UK
| | | | - Anthony M Roche
- 9Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA USA
| | - Kathy Rowan
- 10Intensive Care National Audit & Research Centre, London, UK
| | - Edward Burdett
- 11Department of Anaesthesia, UCL Centre for Anaesthesia, London, UK
| |
Collapse
|
32
|
Rein JL, Coca SG. "I don't get no respect": the role of chloride in acute kidney injury. Am J Physiol Renal Physiol 2018; 316:F587-F605. [PMID: 30539650 DOI: 10.1152/ajprenal.00130.2018] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Acute kidney injury (AKI) is a major public health problem that complicates 10-40% of hospital admissions. Importantly, AKI is independently associated with increased risk of progression to chronic kidney disease, end-stage renal disease, cardiovascular events, and increased risk of in-hospital and long-term mortality. The chloride content of intravenous fluid has garnered much attention over the last decade, as well as its association with excess use and adverse outcomes, including AKI. Numerous studies show that changes in serum chloride concentration, independent of serum sodium and bicarbonate, are associated with increased risk of AKI, morbidity, and mortality. This comprehensive review details the complex renal physiology regarding the role of chloride in regulating renal blood flow, glomerular filtration rate, tubuloglomerular feedback, and tubular injury, as well as the findings of clinical research related to the chloride content of intravenous fluids, changes in serum chloride concentration, and AKI. Chloride is underappreciated in both physiology and pathophysiology. Although the exact mechanism is debated, avoidance of excessive chloride administration is a reasonable treatment option for all patients and especially in those at risk for AKI. Therefore, high-risk patients and those with "incipient" AKI should receive balanced solutions rather than normal saline to minimize the risk of AKI.
Collapse
Affiliation(s)
- Joshua L Rein
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai , New York, New York
| | - Steven G Coca
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai , New York, New York
| |
Collapse
|
33
|
The effects of Plasma-Lyte 148 solution on blood coagulation: an in-vitro, volunteer study using rotational thromboelastometry. Blood Coagul Fibrinolysis 2018; 29:446-450. [PMID: 29846277 PMCID: PMC6085130 DOI: 10.1097/mbc.0000000000000741] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The current study aimed to measure the effects of Plasma-Lyte 148 solution on the blood coagulation profile according to the hemodilution level using rotational thromboelastometry (ROTEM) tests. Venous blood was collected from 12 healthy volunteers and divided into four specimen bottles, which were diluted at different levels with Plasma-Lyte 148 (0, 20, 40, and 60%). Following this, ROTEM tests were performed on the study samples. We found that as the hemodilution level increased, the ROTEM values showed a hypocoagulable pattern. The change rate of the maximum clot firmness (MCF) of INTEM was greater in the 40 (P = 0.015) and 60% (P < 0.001) dilutions than it was in the 20% dilution. Greater lengthening of the clot formation time of EXTEM was observed in the 60% dilution than it was in the 20% dilution (P < 0.001). The alpha-angle of EXTEM showed a greater decrease in the 60% dilution than it did in the 20% dilution (P < 0.001). A larger change rate of the MCF of EXTEM was observed in the 40 (P = 0.003) and 60% (P < 0.001) dilutions than it was in the 20% dilution. A greater decrease in the MCF of FIBTEM was identified in the 40 (P = 0.009) and 60% (P < 0.001) dilutions than in the 20% dilution. All coagulation pathways exhibited hypocoagulable patterns as the hemodilution level increased. However, most of the mean values of ROTEM parameters were within the normal reference range, except for those of the 60% dilution.
Collapse
|
34
|
Duffy RA, Foroozesh MB, Loflin RD, Ie SR, Icard BL, Tegge AN, Nogueira JR, Kuehl DR, Smith DC, Loschner AL. Normal saline versus Normosol™-R in sepsis resuscitation: A retrospective cohort study. J Intensive Care Soc 2018; 20:223-230. [PMID: 31447915 DOI: 10.1177/1751143718786113] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Objective To determine the effect of Normosol™-R as compared to normal saline on the outcomes of acute kidney injury and the need for renal replacement therapy in the resuscitation phase of sepsis. Design Our study is a retrospective before-and-after cohort study. Setting The study occurred at a 700-bed tertiary academic level 1-trauma center. Patients A total of 1218 patients were enrolled through emergency department admissions. The normal saline (before) cohort was defined as the dates between 1 March and 30 September 2014 and the Normosol™-R (after) cohort was assessed from 1 March to 30 September 2015. Interventions None. Measurements and main results Intravenous fluid volumes received during the first 24 h, 72 h, and total hospital stays were compared. Sodium, chloride, potassium, and bicarbonate levels at 72 h were also compared. The medical coded diagnosis of acute kidney failure, need for renal replacement therapy, hospital LOS, ICU admission, ICU LOS, in-hospital mortality, and need for mechanical ventilation were all compared. There was no significant difference in intravenous fluid volumes between groups. Regression modelling controlling for baseline characteristics and 24-h fluid intake volume found no differences between groups for the primary outcomes of acute kidney injury (P = 0.99) and renal replacement therapy (P = 0.88). Patients in the Normosol™-R cohort were found to have a lower rate of hyperchloremia at 72 h post-admission (28% vs. 13%, P < 0.0001). There was a trend toward a decrease in the hospital and ICU LOS in the Normosol™-R cohort; however, the data were not statistically significant. Conclusions This study was unable to detect any difference in outcomes between sepsis patients who received intravenous fluid resuscitation with either a balanced crystalloid (Normosol™-R) or normal saline, except for a decreased rate of hyperchloremia.
Collapse
Affiliation(s)
- Ryan A Duffy
- Department of Pulmonary, Critical Care and Sleep Medicine, Virginia Tech Carilion School of Medicine, Carilion Clinic, Roanoke, VA, USA
| | - Mathab B Foroozesh
- Department of Pulmonary, Critical Care and Sleep Medicine, Virginia Tech Carilion School of Medicine, Carilion Clinic, Roanoke, VA, USA
| | - Robert D Loflin
- Department of Emergency Medicine, Virginia Tech Carilion School of Medicine, Carilion Clinic, Roanoke, VA, USA
| | - Susanti R Ie
- Department of Pulmonary, Critical Care and Sleep Medicine, Virginia Tech Carilion School of Medicine, Carilion Clinic, Roanoke, VA, USA
| | - Bradley L Icard
- Department of Pulmonary, Critical Care and Sleep Medicine, Virginia Tech Carilion School of Medicine, Carilion Clinic, Roanoke, VA, USA
| | - Allison N Tegge
- Department of Statistics, Virginia Tech Carilion School of Medicine and Research Institute, Roanoke, VA, USA
| | - Jonathan R Nogueira
- Department of Emergency Medicine, Virginia Tech Carilion School of Medicine, Carilion Clinic, Roanoke, VA, USA
| | - Damon R Kuehl
- Department of Emergency Medicine, Virginia Tech Carilion School of Medicine, Carilion Clinic, Roanoke, VA, USA
| | - Dan C Smith
- Department of Pulmonary, Critical Care and Sleep Medicine, Virginia Tech Carilion School of Medicine, Carilion Clinic, Roanoke, VA, USA
| | - Anthony L Loschner
- Department of Pulmonary, Critical Care and Sleep Medicine, Virginia Tech Carilion School of Medicine, Carilion Clinic, Roanoke, VA, USA
| |
Collapse
|
35
|
Kisu I, Umene K, Adachi M, Emoto K, Nogami Y, Banno K, Itagaki I, Kawamoto I, Nakagawa T, Narita H, Yoshida A, Tsuchiya H, Ogasawara K, Aoki D. Allowable warm ischemic time and morphological and biochemical changes in uterine ischemia/reperfusion injury in cynomolgus macaque: a basic study for uterus transplantation. Hum Reprod 2018; 32:2026-2035. [PMID: 28938750 DOI: 10.1093/humrep/dex250] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 07/11/2017] [Indexed: 12/16/2022] Open
Abstract
STUDY QUESTION How long is the allowable warm ischemic time of the uterus and what morphological and biochemical changes are caused by uterine ischemia/reperfusion injury in cynomolgus macaques? SUMMARY ANSWER Warm ischemia in the uterus of cynomolgus macaques is tolerated for up to 4 h and reperfusion after uterine ischemia caused no further morphological and biochemical changes. WHAT IS KNOWN ALREADY Uterus transplantation is a potential option for women with uterine factor infertility. The allowable warm ischemic time and ischemia/reperfusion injury of the uterus in humans and non-human primates is unknown. STUDY DESIGN, SIZE, DURATION This experimental study included 18 female cynomolgus macaques with periodic menstruation. PARTICIPANTS/MATERIALS, SETTING, METHODS Animals were divided into six groups of three monkeys each: a control group and groups with uterine ischemia for 0.5, 1, 2, 4 and 8 h. Biopsies of uterine tissues were performed before blood flow blockage, after each blockage time, and after reperfusion for 3 h. Blood sampling was performed after each blockage time, and after reperfusion for 5, 15 and 30 min for measurement of biochemical data. Resumption of menstruation was monitored after the surgical procedure. Morphological, physiological and biochemical changes after ischemia and reperfusion were evaluated. MAIN RESULTS AND THE ROLE OF CHANCE Mild muscle degeneration and zonal degeneration were observed in all animals subjected to warm ischemia for 4 or 8 h, but there were no marked differences in the appearance of specimens immediately after ischemia and after reperfusion for 3 h in animals subjected to 4 or 8 h of warm ischemia. There were no significant changes in any biochemical parameters at any time point in each group. Periodical menstruation resumed in all animals with warm ischemia up to 4 h, but did not recover in animals with warm ischemia for 8 h with atrophic uteri. LIMITATIONS, REASON FOR CAUTION Warm ischemia in actual transplantation was not exactly mimicked in this study because uteri were not perfused, cooled, transplanted or reanastomosed with vessels. Results in non-human primates cannot always be extrapolated to humans. WIDER IMPLICATIONS OF THE FINDINGS The findings suggest that the tolerable warm ischemia time in the uterus is expected to be longer than that in other vital organs. STUDY FUNDING/COMPETING INTEREST(S) This study was supported by the Japan Society for the Promotion of Science (JSPS) KAKENHI Grant Number 26713050. None of the authors has a conflict of interest to declare.
Collapse
Affiliation(s)
- Iori Kisu
- Department of Obstetrics and Gynecology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Kiyoko Umene
- Department of Obstetrics and Gynecology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Masataka Adachi
- Department of Obstetrics and Gynecology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Katsura Emoto
- Department of Pathology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Yuya Nogami
- Department of Obstetrics and Gynecology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Kouji Banno
- Department of Obstetrics and Gynecology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Iori Itagaki
- Research Center for Animal Life Science, Shiga University of Medical Science, Setatsukinowa, Otsu, Shiga 520-2192, Japan.,The Corporation for Production and Research of Laboratory Primates, Sakura, Tsukuba, Ibaraki 305-0003, Japan
| | - Ikuo Kawamoto
- Research Center for Animal Life Science, Shiga University of Medical Science, Setatsukinowa, Otsu, Shiga 520-2192, Japan
| | - Takahiro Nakagawa
- Research Center for Animal Life Science, Shiga University of Medical Science, Setatsukinowa, Otsu, Shiga 520-2192, Japan
| | - Hayato Narita
- Research Center for Animal Life Science, Shiga University of Medical Science, Setatsukinowa, Otsu, Shiga 520-2192, Japan
| | - Atsushi Yoshida
- Research Center for Animal Life Science, Shiga University of Medical Science, Setatsukinowa, Otsu, Shiga 520-2192, Japan
| | - Hideaki Tsuchiya
- Research Center for Animal Life Science, Shiga University of Medical Science, Setatsukinowa, Otsu, Shiga 520-2192, Japan
| | - Kazumasa Ogasawara
- Research Center for Animal Life Science, Shiga University of Medical Science, Setatsukinowa, Otsu, Shiga 520-2192, Japan.,Division of Pathology and Disease Regulation, Department of Pathology, Shiga University of Medical Science, Setatsukinowa, Otsu, Shiga 520-2192, Japan
| | - Daisuke Aoki
- Department of Obstetrics and Gynecology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| |
Collapse
|
36
|
Kwak HJ, Lim OK, Baik JM, Jo YY. Acid/base alterations during major abdominal surgery: 6% hydroxyethyl starch infusion versus 5% albumin. Korean J Anesthesiol 2018; 71:459-466. [PMID: 29684990 PMCID: PMC6283709 DOI: 10.4097/kja.d.18.27195] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 10/11/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To compare the effects of intraoperative infusions of balanced electrolyte solution (BES)-based hydroxyethyl starch (HES) and saline-based albumin on metabolic acidosis and acid/base changes during major abdominal surgery conducted using Stewart's approach. METHODS Forty patients, aged 20-65 years, undergoing major abdominal surgery, were randomly assigned to the HES group (n = 20; received 500 ml of BES-based 6% HES 130/0.4) or the albumin group (n = 20; received 500 ml of normal saline-based 5% albumin). Acid-base parameters were measured and calculated using results obtained from arterial blood samples taken after anesthesia induction (T1), 2 hours after surgery commencement (T2), immediately after surgery (T3), and 1 hour after arriving at a postanesthetic care unit (T4). RESULTS Arterial pH in the HES group was significantly higher than that in the albumin group at T3 (7.40 ± 0.04 vs. 7.38 ± 0.04, P = 0.043), and pH values exhibited significant intergroup difference over time (P = 0.002). Arterial pH was significantly lower at T3 and T4 in the HES group and at T2, T3, and T4 in the albumin group than at T1. Apparent strong ion difference (SIDa) was significantly lower at T2, T3, and T4 than at T1 in both groups. Total plasma weak nonvolatile acid (ATOT) was significantly lower in the HES group than in the albumin group at T2, T3 and T4 and exhibited a significant intergroup difference over time (P < 0.001). CONCLUSIONS BES-based 6% HES infusion was associated with lower arterial pH values at the end of surgery than saline-based 5% albumin infusion, but neither colloid caused clinically significant metabolic acidosis (defined as an arterial pH < 7.35).
Collapse
Affiliation(s)
- Hyun Jeong Kwak
- Department of Anesthesiology and Pain Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Oh Kyung Lim
- Department of Rehabilitation Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Jae Myung Baik
- Department of Anesthesiology and Pain Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Youn Yi Jo
- Department of Anesthesiology and Pain Medicine, Gachon University Gil Medical Center, Incheon, Korea
| |
Collapse
|
37
|
Pfortmueller CA, Kabon B, Schefold JC, Fleischmann E. Crystalloid fluid choice in the critically ill : Current knowledge and critical appraisal. Wien Klin Wochenschr 2018; 130:273-282. [PMID: 29500723 DOI: 10.1007/s00508-018-1327-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Accepted: 02/11/2018] [Indexed: 12/24/2022]
Abstract
Intravenous infusion of crystalloid solutions is one of the most frequently administered medications worldwide. Available crystalloid infusion solutions have a variety of compositions and have a major impact on body systems; however, administration of crystalloid fluids currently follows a "one fluid for all" approach than a patient-centered fluid prescription. Normal saline is associated with hyperchloremic metabolic acidosis, increased rates of acute kidney injury, increased hemodynamic instability and potentially mortality. Regarding balanced infusates, evidence remains less clear since most studies compared normal saline to buffered infusion solutes.; however, buffered solutes are not homogeneous. The term "buffered solutes" only refers to the concept of acid-buffering in infusion fluids but this does not necessarily imply that the solutes have similar physiological impacts. The currently available data indicate that balanced infusates might have some advantages; however, evidence still is inconclusive. Taking the available evidence together, there is no single fluid that is superior for all patients and settings, because all currently available infusates have distinct differences, advantages and disadvantages; therefore, it seems inevitable to abandon the "one fluid for all" strategy towards a more differentiated and patient-centered approach to fluid therapy in the critically ill.
Collapse
Affiliation(s)
- Carmen A Pfortmueller
- Clinic for General Anesthesiology, Intensive Care and Pain Management, Medical University of Vienna, Vienna, Austria. .,Department of Intensive Care, Inselspital, Bern University Hospital, Bern, Switzerland.
| | - Barbara Kabon
- Clinic for General Anesthesiology, Intensive Care and Pain Management, Medical University of Vienna, Vienna, Austria
| | - Joerg C Schefold
- Department of Intensive Care, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Edith Fleischmann
- Clinic for General Anesthesiology, Intensive Care and Pain Management, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
38
|
Choice of fluid type: physiological concepts and perioperative indications. Br J Anaesth 2018; 120:384-396. [DOI: 10.1016/j.bja.2017.10.022] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 10/22/2017] [Accepted: 10/25/2017] [Indexed: 02/06/2023] Open
|
39
|
Huang L, Zhou X, Yu H. Balanced crystalloids vs 0.9% saline for adult patients undergoing non-renal surgery: A meta-analysis. Int J Surg 2018; 51:1-9. [PMID: 29339230 DOI: 10.1016/j.ijsu.2018.01.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 01/04/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND Fluid maintenance and resuscitation is an important strategy during major surgeries. There has been a debate on the choice of crystalloids over the past decades. 0.9% saline (normal saline) is more likely to cause hyperchloremic acidosis when compared to balanced crystalloids with low chloride content. Meta-analyses comparing these two kinds of crystalloids have been performed in renal transplantations. We aim to compare the safety of balanced crystalloids to normal saline among adult patients undergoing non-renal surgery. METHODS Relevant articles were searched through PubMed, Embase and the Cochrane Library. Nine randomized controlled trials (including 871 participants) comparing balanced crystalloids to normal saline on adult patients undergoing non-renal surgery were finally included. Possible effects were calculated using meta-analysis. RESULTS Patients in the normal saline group had significantly lower postoperative pH (MD: 0.05; 95% CI: 0.04-0.06; p < .001; I2 = 82%) and base excess (MD: 2.04; 95% CI: 1.44-2.65; p < .001; I2 = 87%). The postoperative serum chloride level was significantly higher in the normal saline group (MD: -4.79; 95% CI: -8.13∼-1.45; p = .005; I2 = 95%). CONCLUSION Comparing to normal saline, balanced crystalloids are more beneficial in keeping postoperative electrolytes and acid-base balance among adult patients undergoing non-renal surgery. Future researches should pay more attention to meaningful clinical outcomes concerning the safety of balanced crystalloids and normal saline.
Collapse
Affiliation(s)
- Lili Huang
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, Sichuan, 610041, PR China.
| | - Xiaoshuang Zhou
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, Sichuan, 610041, PR China.
| | - Hai Yu
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, Sichuan, 610041, PR China.
| |
Collapse
|
40
|
Gonzalez-Castro A, Ortiz-Lasa M, Peñasco Y, González C, Blanco C, Rodriguez-Borregan JC. Elección de fluidos en el periodo perioperatorio del trasplante renal. Nefrologia 2017; 37:572-578. [DOI: 10.1016/j.nefro.2017.03.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 12/13/2016] [Accepted: 03/16/2017] [Indexed: 12/25/2022] Open
|
41
|
Reddy SK, Bailey MJ, Beasley RW, Bellomo R, Mackle DM, Psirides AJ, Young PJ. Effect of 0.9% Saline or Plasma-Lyte 148 as Crystalloid Fluid Therapy in the Intensive Care Unit on Blood Product Use and Postoperative Bleeding After Cardiac Surgery. J Cardiothorac Vasc Anesth 2017; 31:1630-1638. [DOI: 10.1053/j.jvca.2017.04.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Indexed: 11/11/2022]
|
42
|
Weinberg L, Harris L, Bellomo R, Ierino F, Story D, Eastwood G, Collins M, Churilov L, Mount P. Effects of intraoperative and early postoperative normal saline or Plasma-Lyte 148® on hyperkalaemia in deceased donor renal transplantation: a double-blind randomized trial. Br J Anaesth 2017; 119:606-615. [DOI: 10.1093/bja/aex163] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2017] [Indexed: 11/12/2022] Open
|
43
|
Bampoe S, Odor PM, Dushianthan A, Bennett‐Guerrero E, Cro S, Gan TJ, Grocott MPW, James MFM, Mythen MG, O'Malley CMN, Roche AM, Rowan K, Burdett E. Perioperative administration of buffered versus non-buffered crystalloid intravenous fluid to improve outcomes following adult surgical procedures. Cochrane Database Syst Rev 2017; 9:CD004089. [PMID: 28933805 PMCID: PMC6483610 DOI: 10.1002/14651858.cd004089.pub3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Perioperative fluid strategies influence clinical outcomes following major surgery. Many intravenous fluid preparations are based on simple solutions, such as normal saline, that feature an electrolyte composition that differs from that of physiological plasma. Buffered fluids have a theoretical advantage of containing a substrate that acts to maintain the body's acid-base status - typically a bicarbonate or a bicarbonate precursor such as maleate, gluconate, lactate, or acetate. Buffered fluids also provide additional electrolytes, including potassium, magnesium, and calcium, more closely matching the electrolyte balance of plasma. The putative benefits of buffered fluids have been compared with those of non-buffered fluids in the context of clinical studies conducted during the perioperative period. This review was published in 2012, and was updated in 2017. OBJECTIVES To review effects of perioperative intravenous administration of buffered versus non-buffered fluids for plasma volume expansion or maintenance, or both, on clinical outcomes in adults undergoing all types of surgery. SEARCH METHODS We electronically searched the Clinicaltrials.gov major trials registry, the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 6) in the Cochrane Library, MEDLINE (1966 to June 2016), Embase (1980 to June 2016), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to June 2016). We handsearched conference abstracts and, when possible, contacted leaders in the field. We reran the search in May 2017. We added one potential new study of interest to the list of 'Studies awaiting classification' and will incorporate this trial into formal review findings when we prepare the review update. SELECTION CRITERIA Only randomized controlled trials that compared buffered versus non-buffered intravenous fluids for surgical patients were eligible for inclusion. We excluded other forms of comparison such as crystalloids versus colloids and colloids versus different colloids. DATA COLLECTION AND ANALYSIS Two review authors screened references for eligibility, extracted data, and assessed risks of bias. We resolved disagreements by discussion and consensus, in collaboration with a third review author. We contacted trial authors to request additional information when appropriate. We presented pooled estimates for dichotomous outcomes as odds ratios (ORs) and for continuous outcomes as mean differences (MDs), with 95% confidence intervals (CIs). We analysed data via Review Manager 5.3 using fixed-effect models, and when heterogeneity was high (I² > 40%), we used random-effects models. MAIN RESULTS This review includes, in total, 19 publications of 18 randomized controlled trials with a total of 1096 participants. We incorporated five of those 19 studies (330 participants) after the June 2016 update. Outcome measures in the included studies were thematically similar, covering perioperative electrolyte status, renal function, and acid-base status; however, we found significant clinical and statistical heterogeneity among the included studies. We identified variable protocols for fluid administration and total volumes of fluid administered to patients intraoperatively. Trial authors variably reported outcome data at disparate time points and with heterogeneous patient groups. Consequently, many outcome measures are reported in small group sizes, reducing overall confidence in effect size, despite relatively low inherent bias in the included studies. Several studies reported orphan outcome measures. We did not include in the results of this review one large, ongoing study of saline versus Ringer's solution.We found insufficient evidence on effects of fluid therapies on mortality and postoperative organ dysfunction (defined as renal insufficiency leading to renal replacement therapy); confidence intervals were wide and included both clinically relevant benefit and harm: mortality (Peto OR 1.85, 95% CI 0.37 to 9.33; I² = 0%; 3 trials, 6 deaths, 276 participants; low-quality evidence); renal insufficiency (OR 0.82, 95% CI 0.34 to 1.98; I² = 0%; 4 trials, 22 events, 276 participants; low-quality evidence).We noted several metabolic differences, including a difference in postoperative pH measured at end of surgery of 0.05 units - lower in the non-buffered fluid group (12 studies with a total of 720 participants; 95% CI 0.04 to 0.07; I² = 61%). However, this difference was not maintained on postoperative day one. We rated the quality of evidence for this outcome as moderate. We observed a higher postoperative serum chloride level immediately after operation, with use of non-buffered fluids reported in 10 studies with a total of 530 participants (MD 6.77 mmol/L, 95% CI 3.38 to 10.17), and this difference persisted until day one postoperatively (five studies with a total of 258 participants; MD 8.48 mmol/L, 95% CI 1.08 to 15.88). We rated the quality of evidence for this outcome as moderate. AUTHORS' CONCLUSIONS Current evidence is insufficient to show effects of perioperative administration of buffered versus non-buffered crystalloid fluids on mortality and organ system function in adult patients following surgery. Benefits of buffered fluid were measurable in biochemical terms, particularly a significant reduction in postoperative hyperchloraemia and metabolic acidosis. Small effect sizes for biochemical outcomes and lack of correlated clinical follow-up data mean that robust conclusions on major morbidity and mortality associated with buffered versus non-buffered perioperative fluid choices are still lacking. Larger studies are needed to assess these relevant clinical outcomes.
Collapse
Affiliation(s)
- Sohail Bampoe
- University College LondonCentre for Anaesthesia and Perioperative MedicineLondonUKNW1 2BU
| | - Peter M Odor
- University College LondonDepartment Anaesthesia and Critical Care235 Euston Rd, FitzroviaLondonUKNW1 2BU
| | - Ahilanandan Dushianthan
- University Hospital Southampton NHS Foundation TrustGeneral Intensive Care UnitTremona RoadSouthamptonHampshireUKSO16 6YD
| | - Elliott Bennett‐Guerrero
- Stony Brook MedicineDepartment of AnesthesiologyHealth Science Tower, Level 4 (Rm 060)Stony BrookNYUSA
| | - Suzie Cro
- Medical Research Council Clinical Trials Unit222 Euston RoadLondonUKNW1 2DA
| | - Tong J Gan
- Stony Brook MedicineDepartment of AnesthesiologyHealth Science Tower, Level 4 (Rm 060)Stony BrookNYUSA
| | - Michael PW Grocott
- Faculty of Medicine, University of SouthamptonCritical Care Group, Clinical and Experimental SciencesTremona RoadSouthamptonHampshireUKSO16 6YD
| | - Michael FM James
- University of Cape TownDepartment of AnaesthesiaAnzio RoadObservatory 7925Cape TownWestern CapeSouth Africa7925
| | - Michael G Mythen
- University College LondonDepartment Anaesthesia and Critical Care235 Euston Rd, FitzroviaLondonUKNW1 2BU
| | | | - Anthony M Roche
- University of WashingtonDepartment of Anesthesiology and Pain MedicineBox 359724SeattleWAUSA98104
| | - Kathy Rowan
- Intensive Care National Audit & Research CentreNapier House24 High HolbornLondonUKWC1V 6AZ
| | - Edward Burdett
- UCL Centre for AnaesthesiaDepartment of Anaesthesia3rd floor PodiumUniversity College Hospital, 235 Euston RoadLondonUKNW1 2BU
| | | |
Collapse
|
44
|
Serpa Neto A, Martin Loeches I, Klanderman RB, Freitas Silva R, Gama de Abreu M, Pelosi P, Schultz MJ. Balanced versus isotonic saline resuscitation-a systematic review and meta-analysis of randomized controlled trials in operation rooms and intensive care units. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:323. [PMID: 28861420 DOI: 10.21037/atm.2017.07.38] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Fluid resuscitation is the cornerstone in treatment of shock, and intravenous fluid administration is the most frequent intervention in operation rooms and intensive care units (ICUs). The composition of fluids used for fluid resuscitation gained interest over the past decade, with recent focus on whether balanced solutions should be preferred over isotonic saline. METHODS Systematic review and meta-analysis of randomized controlled trials (RCTs) comparing fluid resuscitation with a balanced solution versus isotonic saline in adult patients in operation room or ICUs. Primary outcome was in-hospital mortality, secondary outcomes included occurrence of acute kidney injury (AKI) and need for renal replacement therapy (RRT). RESULTS The search identified 11 RCTs involving 2,703 patients; 8 trials were conducted in operation room and 3 in ICU. In-hospital mortality, as well as the occurrence of AKI and need for RRT was not different between resuscitation with balanced solutions versus isotonic saline, neither in operation room nor in ICU patients. Serum chloride levels, but not arterial pH, were significantly lower in patients resuscitated with balanced solutions. CONCLUSIONS Currently evidence insufficiently supports the use of balanced over isotonic saline for fluid resuscitation to improve outcome of operation room and ICU patients.
Collapse
Affiliation(s)
- Ary Serpa Neto
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Ignacio Martin Loeches
- Department of Clinical Medicine, St James's Hospital, Multidisciplinary Intensive Care Research Organization (MICRO), Trinity Centre for Health Sciences, Dublin, Ireland
| | - Robert B Klanderman
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Marcelo Gama de Abreu
- Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, IRCCS San Martino IST, University of Genoa, Genoa, Italy
| | - Marcus J Schultz
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | | |
Collapse
|
45
|
Corrêa TD, Cavalcanti AB, Assunção MSCD. Balanced crystalloids for septic shock resuscitation. Rev Bras Ter Intensiva 2017; 28:463-471. [PMID: 28099643 PMCID: PMC5225922 DOI: 10.5935/0103-507x.20160079] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 08/08/2016] [Indexed: 01/14/2023] Open
Abstract
Timely fluid administration is crucial to maintain tissue perfusion in septic
shock patients. However, the question concerning which fluid should be used for
septic shock resuscitation remains a matter of debate. A growing body of
evidence suggests that the type, amount and timing of fluid administration
during the course of sepsis may affect patient outcomes. Crystalloids have been
recommended as the first-line fluids for septic shock resuscitation.
Nevertheless, given the inconclusive nature of the available literature, no
definitive recommendations about the most appropriate crystalloid solution can
be made. Resuscitation of septic and non-septic critically ill patients with
unbalanced crystalloids, mainly 0.9% saline, has been associated with a higher
incidence of acid-base balance and electrolyte disorders and might be associated
with a higher incidence of acute kidney injury. This can result in greater
demand for renal replacement therapy and increased mortality. Balanced
crystalloids have been proposed as an alternative to unbalanced solutions in
order to mitigate their detrimental effects. Nevertheless, the safety and
effectiveness of balanced crystalloids for septic shock resuscitation need to be
further addressed in a well-designed, multicenter, pragmatic, randomized
controlled trial.
Collapse
Affiliation(s)
- Thiago Domingos Corrêa
- Unidade de Terapia Intensiva, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
| | | | | |
Collapse
|
46
|
Weinberg L, Collins N, Van Mourik K, Tan C, Bellomo R. Plasma-Lyte 148: A clinical review. World J Crit Care Med 2016; 5:235-250. [PMID: 27896148 PMCID: PMC5109922 DOI: 10.5492/wjccm.v5.i4.235] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Revised: 07/06/2016] [Accepted: 10/09/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To outline the physiochemical properties and specific clinical uses of Plasma-Lyte 148 as choice of solution for fluid intervention in critical illness, surgery and perioperative medicine.
METHODS We performed an electronic literature search from Medline and PubMed (via Ovid), anesthesia and pharmacology textbooks, and online sources including studies that compared Plasma-Lyte 148 to other crystalloid solutions. The following keywords were used: “surgery”, “anaesthesia”, “anesthesia”, “anesthesiology”, “anaesthesiology”, “fluids”, “fluid therapy”, “crystalloid”, “saline”, “plasma-Lyte”, “plasmalyte”, “hartmann’s”, “ringers”“acetate”, “gluconate”, “malate”, “lactate”. All relevant articles were accessed in full. We summarized the data and reported the data in tables and text.
RESULTS We retrieved 104 articles relevant to the choice of Plasma-Lyte 148 for fluid intervention in critical illness, surgery and perioperative medicine. We analyzed the data and reported the results in tables and text.
CONCLUSION Plasma-Lyte 148 is an isotonic, buffered intravenous crystalloid solution with a physiochemical composition that closely reflects human plasma. Emerging data supports the use of buffered crystalloid solutions in preference to saline in improving physicochemical outcomes. Further large randomized controlled trials assessing the comparative effectiveness of Plasma-Lyte 148 and other crystalloid solutions in measuring clinically important outcomes such as morbidity and mortality are needed.
Collapse
|
47
|
Abstract
BACKGROUND The ideal intravenous fluid for kidney transplantation has not been defined, despite the common use of normal saline during the peri-operative period. The high chloride content of normal saline is associated with an increased risk of hyperchloraemic metabolic acidosis, which may in turn increase the risk of hyperkalaemia and delayed graft function. Balanced electrolyte solutions have a lower chloride content which may decrease this risk and avoid the need for dialysis due to hyperkalaemia in the immediate post-transplant period. Randomised controlled trials (RCTs) addressing this issue have used biochemical outcomes to compare fluids and have been underpowered to address patient-centred outcomes such as delayed graft function. OBJECTIVES To examine the effect of lower-chloride solutions versus normal saline on delayed graft function, hyperkalaemia and acid-base status in kidney transplant recipients. SEARCH METHODS We searched the Cochrane Kidney and Transplant's Specialised Register to 26 November 2015 through contact with the Information Specialist using search terms relevant to this review. SELECTION CRITERIA RCTs of kidney transplant recipients that compared peri-operative intravenous lower-chloride solutions to normal saline were included. DATA COLLECTION AND ANALYSIS Two independent investigators assessed studies for eligibility and risk of bias. Data from individual studies were extracted using standardised forms and pooled according to a published protocol. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference (MD) and 95% CI for continuous outcomes. MAIN RESULTS Six studies (477 participants) were included in the review. All participants were adult kidney transplant recipients and 70% of participants underwent live-donor kidney transplantation. The overall risk of bias was low for selection bias and unclear for remaining domains. There was no difference in the risk of delayed graft function (3 studies, 298 participants: RR 1.03, 95% CI 0.62 to 1.70) or hyperkalaemia (2 studies, 199 participants: RR 0.48, 95% CI 0.04 to 6.10) for participants who received balanced electrolyte solutions compared to normal saline. Intraoperative balanced electrolyte solutions compared to normal saline were associated with higher blood pH (3 studies, 193 participants: MD 0.07, 95% CI 0.05 to 0.09), higher serum bicarbonate (3 studies, 215 participants: MD 3.02 mEq/L, 95% CI 2.00 to 4.05) and lower serum chloride (3 studies, 215 participants: MD -9.93 mmol/L, 95% CI -19.96 to 0.11). There were four cases of graft loss in the normal saline group and one in the balanced electrolyte solution group, and four cases of acute rejection in the normal saline group compared to two cases in the balanced electrolyte solution group. AUTHORS' CONCLUSIONS Balanced electrolyte solutions are associated with less hyperchloraemic metabolic acidosis compared to normal saline, however it remains uncertain whether lower-chloride solutions lead to improved graft outcomes compared to normal saline.
Collapse
Affiliation(s)
- Susan Wan
- The University of SydneyCentral Clinical SchoolSydneyNSWAustralia2006
| | - Matthew A Roberts
- Monash UniversityEastern Health Clinical SchoolBox HillVICAustralia3128
| | - Peter Mount
- Austin HealthDepartment of Nephrology145 Studley RoadMelbourneVICAustralia3084
| | | |
Collapse
|
48
|
Pfortmueller CA, Fleischmann E. Acetate-buffered crystalloid fluids: Current knowledge, a systematic review. J Crit Care 2016; 35:96-104. [PMID: 27481742 DOI: 10.1016/j.jcrc.2016.05.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 04/24/2016] [Accepted: 05/04/2016] [Indexed: 02/08/2023]
Abstract
INTRODUCTION The concept of fluid resuscitation with balanced solutions containing acetate is relatively new. The knowledge about acetate mostly originates from nephrological research, as acetate was primarily used as a dialysis buffer where much higher doses of acetate are infused. The aim of this review is to give an overview of the advantages and disadvantages of an acetate-buffered crystalloid fluid when compared with other crystalloid infusates. METHODS We report trials with the primary object of comparing an acetate-buffered infusion solute to another crystalloid infusate. A systematic literature search of MEDLINE and the Cochrane Controlled Clinical trials register was conducted to identify suitable studies. RESULTS The search strategy used produced 1205 potential titles. After eliminating doubles, 312 titles and abstracts were screened, and 31 references were retrieved for full-text analysis. A total of 27 scientific studies were included in the study. CONCLUSION Acetate-buffered crystalloid solutes do have a favorable influence on microcirculation. To what extent the acetate-buffered crystalloids influence kidney function is controversially discussed and not yet clear. Metabolic alkalosis did not occur in a single study in humans after an acetate-buffered infusate; potassium levels stayed stable in all studies. Cardiac output and contractility seem to be positively influenced; nonetheless, data on maintenance of a target blood pressure remain inconclusive. Whether acetate-buffered crystalloid fluids lead to lower rates of acute kidney injury and increased survival when compared with normal saline is yet unclear and may depend on the amount of fluid administered.
Collapse
Affiliation(s)
- Carmen A Pfortmueller
- Clinic for General Anesthesiology, Intensive Care and Pain Management, Medical University of Vienna, Vienna, Austria.
| | - Edith Fleischmann
- Clinic for General Anesthesiology, Intensive Care and Pain Management, Medical University of Vienna, Vienna, Austria.
| |
Collapse
|
49
|
Impact of common crystalloid solutions on resuscitation markers following Class I hemorrhage: A randomized control trial. J Trauma Acute Care Surg 2016; 79:732-40. [PMID: 26496098 DOI: 10.1097/ta.0000000000000833] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Resuscitation after hemorrhage with crystalloid solutions can lead to marked acidosis and iatrogenically worsen the lethal triad. The effect of differing solutions on base deficit and lactate has been sparsely prospectively studied in humans. We sought to quantify the effect of normal saline (NS) and lactated Ringer's (LR) resuscitation in voluntary blood donors as a model for Class I hemorrhage. METHODS A prospective randomized control trial was conducted in conjunction with blood drives. Donors were randomized to receive no intravenous fluid (noIVF), 2-L NS, or 2-L LR after blood donation of 500 mL. Lactate and base deficit were measured before and after fluid administration using an iSTAT. The mean laboratory values were compared between groups first using a global test followed by pairwise testing between groups using the Wilcoxon rank-sum and Kruskal-Wallis tests. The Bonferroni correction was used and a statistical significance of p < 0.0167 was set. RESULTS A total of 157 patients completed the study. The mean (SD) age was 39.2 (12.7), and 65.0% were female. Patients in each group lost equivalent amounts of total blood volume, and a similar amount was replaced in the crystalloid group (p > 0.0167). Donors had comparable increases in lactate and base deficit after donation regardless of the group (p > 0.0167). After resuscitation with 2-L crystalloid, the lactate level increased higher in the LR group than in the noIVF or the NS group (1.36 mmol/L vs. 1.00 mmol/L vs. 1.54 mmol/L, p < 0.0001). In addition, the resuscitation base deficit increased in the NS group more than in the noIVF or LR group (-0.65 vs. -3.06 vs. -0.34, p < 0.0001). CONCLUSION This study is one of the first human studies to prospectively demonstrate quantifiable differences in base deficit and lactate by type of crystalloid resuscitation. LR resuscitation elevated lactate levels, and NS negatively affected the base deficit. These findings are critical to the interpretation of trauma patient resuscitation with crystalloid solutions. LEVEL OF EVIDENCE Therapeutic study, level II.
Collapse
|
50
|
Reddy S, Weinberg L, Young P. Crystalloid fluid therapy. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:59. [PMID: 26976277 PMCID: PMC4791913 DOI: 10.1186/s13054-016-1217-5] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency medicine 2016. Other selected articles can be found online at http://www.biomedcentral.com/collections/annualupdate2016. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901.
Collapse
Affiliation(s)
- Sumeet Reddy
- Medical Research Institute of New Zealand, 6021, Wellington, New Zealand.
| | - Laurence Weinberg
- Austin Hospital, Department of Anesthesia, Melbourne, VIC, Australia.,Departments of Surgery and Anesthesia, University of Melbourne, Perioperative Pain Medicine Unit, Melbourne, VIC, Australia
| | - Paul Young
- Medical Research Institute of New Zealand, 6021, Wellington, New Zealand.,Wellington Regional Hospital, Intensive Care Unit, Wellington, New Zealand
| |
Collapse
|