Robert G. Hahn, MD, PhD

Research Director, Södertälje Hospital; Professor of Anesthesiology, Linköping University; Associate professor, Karolinska institute, Sweden.

BAXTER Satellite Symposium

Why do balanced crystalloids change the paradigm?

Fluid therapy might be more difficult than you think!

Fluid Management

Crystalloid Colloid

BalancedUnbalanced Natural

Isotonic SalineRinger´s Solution

Plasma-LyteRinger’s LactateRinger’s Acetate

Hartmann’s

Human AlbuminBlood

Different fluids with different modes of action, and different side effects

HESDextranGelatin

Synthetic

MD-IV-235 09-2013

…metabolic acidosis which increases breathing and serum potassium.

….impairs renal blood flow and GFR by 10-15%.

…symptoms on 2-L infusion (slight mental confusion, abdominal pain)

Niels Van RegenmortelBalanced Crystalloids – from Evidence to Clinical Reality

Robert Hahn Conclusion - alternatives to HES and saline

Dileep Lobo Key Considerations to Make the Right Choice

*

Isotonic saline

Osmolar substances

Isotonic saline(mOsm/L H2O) Extracellular (mOsm/L H2O)

Plasma* Interstitial*

Sodium (Na+) 154 142 139

Potassium (K+) 0 4.2 4

Calcium (Ca2+) 0 1.3 1.2

Magnesium (Mg2+) 0 0.8 0.7

Chloride (Cl-) 154 100 100

Bicarbonate (HCO3-) 0 24 28.3

Protein 0 1.2 0.2

Others 0 20.3 19.4

Total mOsm/l 308 295 295

Reference values taken from Guyton´s Textbook of Physiology. They are affected by many variables, including the patient population and the laboratory methods used

Ringer´s lactate

Osmolar substances

Ringer´´s lactate (mOsm/L) Extracellular (mOsm/L)

Plasma* Interstitial*

Sodium (Na+) 131 142 139

Potassium (K+) 5 4.2 4

Calcium (Ca2+) 2 1.3 1.2

Magnesium (Mg2+) 1 0.8 0.7

Chloride (Cl-) 111 100 100

Bicarbonate (HCO3-) 30 (lactate) 24 28.3

Protein 0 1.2 0.2

Others 0 20.3 19.4

Total mOsm/l 279 295 295Reference values are affected by many variables, including the patient population and the laboratory methods used

Sterofundin

Osmolar substances

Sterofundin (mOsm/L H2O) Extracellular (mOsm/L H2O)

Plasma* Interstitial*

Sodium (Na+) 145 142 139

Potassium (K+) 4 4.2 4

Calcium (Ca2+) 2.5 1.3 1.2

Magnesium (Mg2+) 0 0.8 0.7

Chloride (Cl-) 127 100 100

Bicarbonate (HCO3-) 24 (acetate), 5 (malate) 24 28.3

Protein 0 1.2 0.2

Others 0 20.3 19.4

Total mOsm/l 309 295 295

Reference values are affected by many variables, including the patient population and the laboratory methods used

Plasma-Lyte

Osmolar substances Plasma-Lyte (mOsm/L) Extracellular (mOsm/L)

Plasma* Interstitial*

Sodium (Na+) 140 142 139

Potassium (K+) 5 4.2 4

Calcium (Ca2+) 0 1.3 1.2

Magnesium (Mg2+) 1.5 0.8 0.7

Chloride (Cl-) 98 100 100

Bicarbonate (HCO3-) 27 (acetate),

24 (gluconate) 24 28

Protein 0 1.2 0.2

Others 0 20.3 19.4

Total mOsm/l 295 295 295Reference values are affected by many variables, including the patient population and the laboratory methods used

Acetate – a buffer similar to lactate, but can be metabolized in all body cells and not only in the liver (and kidney). * Metabolized to HCO3 faster than lactate. * Requires only half as much O2 as lactate to produce HCO3.* Does not confuse serum lactate measurements in shock states.

Gluconate – a food additive used to improve taste.* Occurs naturally in fruit juice and honey. * Daily production in intermediary metabolism 30 g per day

(approximately 4 L of PlasmaLyte per day).* TOXNET: Non-toxic. Low priority for further work.

J Crit Care 2012; 27: 138-145.

After 4-6 hours of Plasma-Lyte versus isotonic saline:

Bicarbonate correction 8.4 versus 1.7 mmol/l

After 6-12 hours of Plasma-Lyte versus isotonic saline:

Bicarbonate correction 12.8 versus 6.2 mmol/l

Comparison between Ringer och NaCl i.v.Williams et al. Anesthesia & Analgesia 1999; 88: 999-103.

• 20 volunteers Ringer or NaCl 50 ml/kg i.v./1 h.

• Tiredness and ”problems to think” in 13/20 after NaCl, none after Ringer.

• Abdominal pain after NaCl in 10/20 volunteers, only 1/20 after Ringer.

• First void after 106 min for NaCl, 80 min for Ringer.

• pH fell 0.04 after NaCl.

NaCl during surgery Wilkes et al. Anesthesia & Analgesia 2001; 93: 811-816

• Randomized to NaCl or Ringer, c:a 4 liters.• 47 pat. > 60 years, major surgery.• NaCl was followed by:

– Metabolic acidosis (standard bicarbonate -5.5 mmol/L).– Poorer blood perfusion of the gut.– Half as high urinary flow.– Adverse events 379 versus 272.– Nausea and vomiting 23 versus 12 events.– Postoperative vomiting in 8 versus 3 patients.

60 patients from 4 tertiary hospitals.Compared to Hartmann, PlasmaLyte was followed by:

* Smaller base deficit (0.4 mmol/L)* Serum chloride levels lower.* Lactate levels lower (0.8 mmol/L)* Fewer complications

Summary isotonic saline vs. balanced fluids

• Isotonic saline gives rise to metabolic acidosis and inhibits kidney function – kidney injury?

• Various symptoms on infusion.• More complications after surgery.• Higher mortality?

Plasma-Lyte is a slight/moderate improvement

over buffered Ringer solutions – ”balance” is optimal.

Indications for isotonic saline

• Vomiting• Head injury (or use PlasmaLyte)

• Pediatric surgery (or use PlasmaLyte)

• Hyponatraemia & hypochloraemia• Together with erythrocytes (or use PlasmaLyte)

Robert G. Hahn, MD, PhD

Research Director, Södertälje Hospital; Professor of Anesthesiology, Linköping University; Associate professor, Karolinska institute, Sweden.

ABSTRACT SESSION

Serum urea/creatinine ratio predicts successful loop diuretic therapy incongestive heart failureVerbrugge F, Duchenne J, Dupont M, Mullens W

Evaluation of CardioPAT autotransfusion system in elective cardiac surgeryDe Decker K, Bogaert T, Gooris T, Stockman B

Congestive heart failureExpanded heart chambers (BNP rise)Fluid retention due to impaired kidney perfusion (renin etc. high)

Treated with fluid restriction, diuretics and vasodilators

J Am Coll Cardiol2011; 58: 383-385

Evaluation of CardioPAT autotransfusion system in elective cardiac surgeryDe Decker K, Bogaert T, Gooris T, Stockman B