Metabolic profile in right lobe living donor hepatectomy: Comparison of lactated Ringer's solution and normal saline versus acetate based balanced salt solution - a pilot study

Effects of Different Crystalloid Fluids on Renal Tissue in an Experimental Model of Hemorrhagic Shock

Objective

The type of fluid that should be used in uncontrollable hemorrhages remains an area of research. This study was designed to compare the effects of resuscitation with Ringer's lactate (RL) solution versus a normal saline (NS) solution on hemodynamics, renal tissue histopathology, coagulation, and apoptosis in a rat model of hemorrhagic shock.

Methods

The study employed groups designated as the control, hemorrhage, NS, and RL groups. Heart rate, mean arterial pressure, and respiratory rate were monitored. Annexin A5 values were assayed, rotational thromboelastometry analysis was performed, and excised kidney tissue samples were histopathologically analyzed.

Results

Blood pressure levels were found to be significantly higher in the control group than those measured in the other groups. While the clotting time (CT) and clot formation time (CFT) in the hemorrhage group were significantly longer than those in the control and RL groups, the CT and CFT measured in the control group were significantly shorter compared to the RL group. The mean Annexin A5 level was in the hemorrhage group, which was significantly higher compared to the other groups. In the renal histopathological evaluation, the scores of proximal tubular injury, distal renal tubular injury, and interstitial renal tubular injury were found to be significantly lower in the control group compared to the other groups.

Conclusion

This study demonstrated that NS or RL can be used safely to improve the hemodynamic symptoms resulting from hemorrhagic shock as a means to reduce apoptosis, and to decrease findings in favor of coagulopathy in bedside coagulation tests during the early stages of hemorrhagic shock until the time of starting a blood transfusion.

The effect of acetate Ringer's solution versus lactate Ringer's solution on acid base physiology in infants with biliary atresia

BACKGROUND

The choice of the perioperative crystalloid is a key component of the fluid management and must take into account the liver function and the appearing metabolic disorders to avoid increase the liver extra metabolism. The aim of this study is to analyze the effect of acetate Ringer's solution or lactate Ringer's solution in biliary atresia patients.

METHODS

We included 68 infant patients aged between 21 ~ 65 d, ASA physical status II or III, who underwent elective Kasai hepatoportoenterostomy, received either AR and LR for intravenous fluid resuscitation according to their group allocation. Lactate concentration, serum electrolytes and pH were noteded before skin incision (T₁), end of surgery (T₂) and postoperative 12 h. We also recorded the time of operation, stay of hospital, loss of blood and urinary, total volume of infusion of crystalloid.

RESULTS

Lactate level was significantly higher in Group LR than in Group AR patients at T₂ (0.76 ± 0.13 versus 0.57 ± 0.22, P = 0.03). Compared with T₃, sodium and chlorine were significantly higher in two groups at T₂ (145.2 ± 3.1 versus 143.4 ± 3.4 and 104.6 ± 3.7 versus 105.2 ± 2.1). No significant differences were noted in potassium, HCO₃^- and calcium. There was no statistically significant difference in pH. No glycopenia was recorded in two groups. No significant difference was noted in administration of vasoactive drug (0.7% versus 1%).

CONCLUSIONS

Resuscitation with AR and LR was associated with similar clinical improvement in infants with biliary atresia. Use of AR reduced the level of lactate comparison with LR.

Efficacy of Different Fluid Resuscitation Methods on Coagulation Function of Rats with Traumatic Hemorrhagic Shock

BACKGROUND

Fluid resuscitation is widely used for treating traumatic hemorrhagic shock. We focused on the efficacies of different fluid resuscitation methods on improving coagulation function of traumatic hemorrhagic shock (THS) rats.

MATERIALS AND METHODS

Sprague-Dawley rats (n = 100) were randomly divided into 5 groups, namely, Sham group, THS group, acetic acid Ringer's fluid (AR) group, hydroxyethyl starch solution (HES) group, and AR + HES group. A THS rat model was established by left femoral bleeding. The effects of different fluid resuscitation methods on conventional coagulation function parameters, Rotational thromboelastometry parameters, platelet-derived microparticles and endothelial cell-derived microparticles content of the THS rats were detected by ACL TOP system, rotation thromboelastometry, and flow cytometry, respectively.

RESULTS

Using AR and HES alone had no significant effect on the coagulation function of THS rats, but the two in combination reduced the increases of thrombin time, prothrombin time, activated part thrombin time, international normalized ratio, fibrin degradation products, D-dimer and the decreases of platelet count and fibrinogen concentration induced by THS. The CT and CFT were significantly reduced, whereas α and MCF were increased in the THS rats in AR + HES group. The combination of AR and HES reversed the effect of THS on elevating platelet-derived microparticles and endothelial cell-derived microparticle levels. In addition, the coagulation was relatively the optimal in the AR, HES, and AR + HES groups when the mice were resuscitated to a mean arterial pressure of 60 mmHg.

CONCLUSIONS

AR combined with HES has a significant protective effect on coagulation function of THS rats when the mean arterial pressure reaches 60 mmHg.

Effect of liberal versus restrictive fluid therapy on intraoperative lactate levels in robot- assisted colorectal surgery

Background and Aims

Minimally invasive and robotic surgeries need lesser fluid replacement but the role of restricted fluids in robotic surgeries other than prostatic surgeries has not been clearly defined. Our primary aim was to evaluate the effects of a restrictive fluid regimen versus a liberal policy on intra-operative lactate in robotic colorectal surgery. Secondary outcomes were need for vasopressors, extubation on table, post-operative renal functions and length of ICU (LOICU) stay.

Methods

American society of anaesthesiologists (ASA) physical status I-II patients scheduled for robot-assisted colorectal surgery were randomised into one of two groups, receiving either 2 mL/kg/h (Group R) or 4mL/kg/h, (group L). Fluid boluses of 250 ml were administered if mean arterial pressure (MAP) <65 mmHg or urine output <0.5 ml/kg/h. Norepinephrine was added for the blood pressure after 2 fluid boluses. Surgical field was assessed by modified Boezaart's scale and surgeon satisfaction by Likert scale.

Results

Demographics and baseline renal functions were comparable. Adjusted intra-operative lactate at 2 h, 4 h, and 6 h and need for noradrenaline and post-operative creatinine were similar. One patient in the group L was ventilated due to hypothermia. The field was better at the 4 h in group R and comparable at other time points. The LOICU stay was longer in Group L.

Conclusion

The use of restrictive fluid strategy of 2 mL/kg/h (group R) does not increase lactate levels or creatinine, improves surgical field at 4 h and shortens ICU stay in comparison to a liberal 4 mL/kg/h (group L) in robotic colorectal surgery.

Balanced Crystalloid Solutions

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.

Enhanced recovery after surgery in liver resection: current concepts and controversies

Enhanced recovery after surgery (ERAS) attenuates the stress response to surgery in the perioperative period and hastens recovery. Liver resection is a complex surgical procedure where the enhanced recovery program has been shown to be safe and effective in terms of postoperative outcomes. ERAS programs have been shown to be associated with lower morbidity, shortened postoperative stay, and reduced cost with no difference in mortality and readmission rates. However, there are challenges that are unique to hepatic resection such as safety after epidural catheterization and postoperative coagulopathy, intraoperative fluids and postoperative organ dysfunction, need for low central venous pressure to reduce blood loss, and non-lactate containing intravenous fluids. This narrative review briefly discusses these concerns and controversies and suggests revisiting some of the strong recommendations made by the ERAS society in light of the recent evidence.

Evaluation of the Metabolic Profile of Ringer Lactate versus Ringer Acetate in Nondiabetic Patients Undergoing Major Surgeries

Background:

Stress-induced neuroendocrine and metabolic changes lead to intraoperative hyperglycemia which is related to surgery and the type of intravenous fluids used.

Aims:

The primary objective was to assess the incidence of hyperglycemia with use of lactate versus acetate-based intravenous fluids in nondiabetics undergoing major surgeries. Incidence of lactatemia and metabolic acidosis were also assessed.

Settings and Design:

Prospective parallel group observational study conducted in a tertiary care institute.

Subjects and Methods:

A total of 208 nondiabetic patients undergoing major head and neck free flap or abdominal surgeries were included in the study. Group A received Ringer lactate, and Group B received Ringer acetate as intraoperative maintenance fluid. Intraoperative blood sugar, pH, and lactate levels were monitored.

Statistical Tests Used:

Chi-square test and independent “t” test were used for analysis.

Results:

Intraoperative hyperglycemia was more frequent in Group A than B (17.3 vs. 18.4%). Group B patients undergoing gastrointestinal (GI) surgeries showed higher blood glucose at 2, 4, 6, and 8 h when compared to flap surgeries. In Group A, significantly higher blood sugar values were noted at 2 and 8 h in those undergoing GI surgeries. Group B patients undergoing GI surgeries had significantly higher lactate levels at 6 and 8 h. Group B patients had significant acidosis when surgeries lasted >6 h.

Conclusion:

Nondiabetic patients undergoing major abdominal surgeries who received acetate-based fluids had relatively higher intraoperative blood sugar levels as compared to those receiving lactated solutions, but the incidence of hyperglycemia was comparable. When the duration of surgery exceeded 6 h, acetate-based solutions resulted in significantly higher lactate levels with progressive metabolic acidosis.