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|NI FEATURE: THE EDITORIAL DEBATE III-- PROS AND CONS
|Year : 2018 | Volume
| Issue : 5 | Page : 1299-1300
Balance the fluid….
Ganne Sesha Umamaheswara Rao
Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India
|Date of Web Publication||17-Sep-2018|
Dr. Ganne Sesha Umamaheswara Rao
Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences, Bangalore - 560 029, Karnataka
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Umamaheswara Rao GS. Balance the fluid…. Neurol India 2018;66:1299-300
The goals of intraoperative fluid therapy during the performance of a craniotomy are to maintain normal haemodynamic status, maintain a lax brain, ensure that the milieu interieur is not disturbed and also that blood coagulation is not affected. Traditionally, 0.9% normal saline (NS) is used intraoperatively during craniotomy as it is an isotonic solution. The composition of normal saline, however, differs in many ways from the composition of plasma. The concentration of chloride is higher than in plasma. Electrolytes such as potassium, calcium, and magnesium, and bicarbonate buffer are lacking. The osmolality and concentration of sodium are marginally higher than those of plasma. An intravenous infusion of NS tends to increase the serum sodium concentration and the osmolality slightly and cause metabolic acidosis. Uncompensated acidosis has many untoward effects on the human body such as sympathetic stimulation and reduced myocardial contractility.
Several studies attempted to avoid the metabolic acidosis caused by NS by using different compositions of intraoperative fluid. Ringer's lactate has been used as an alternative to NS during abdominal aortic aneurysm surgery. When normal saline was used as the primary intraoperative solution, significantly more acidosis was seen on completion of surgery. Though it did not change the outcome of the patients, the requirement for bicarbonate to achieve predetermined measurements of base deficit was higher. No such acidosis was evident when Ringer's lactate was used. The apprehension that Ringer's lactate would rise the serum lactate or blood glucose level has not been supported by any studies. Two fluid regimens - 25 patients receiving half NS with soda bicarb (sodium bicarbonate) and 25 patients receiving NS in combination with Ringer's lactate – were compared in neurosurgical patients. No significant difference was found either in the blood gases or brain relaxation. Yet another study from the same centre compared Ringer's lactate with 1.3% soda bicarb in half normal saline during intraoperative haemorrhage and found that the latter solution maintained better acid-base status and better haemodynamic stability. One metaanalysis comparing studies using normal saline with buffered fluids concluded that the administration of buffered fluids to adult patients during surgery is safe and effective. The use of buffered fluids is associated with less metabolic derangement, in particular, hyperchloraemia and metabolic acidosis.
Plasmalyte is a further development over Ringer's acetate. The osmolality and chloride content of Plasmalyte agree more closely with the composition of plasma [Table 1].
Several studies attest to the superiority of Plasmalyte in maintaining a stable metabolic status when used as intraoperative fluid. A randomized clinical study examined the effects of NS, Ringer's lactate and Plasmalyte in 90 patients. A volume of 20 mL/kg was infused over 2 hours. Normal saline caused acidosis, which was significant in patients who have underlying metabolic disturbances. Normal saline, Ringer's lactate and Plasmalyte were compared with regard to acid-base balance and potassium and lactate levels in patients undergoing kidney transplantation. All three crystalloid solutions could be safely used during uncomplicated, short-duration renal transplants; however, the best metabolic profile is maintained in patients who received Plasmalyte.
Another important issue that needs to be taken care of during the intraoperative fluid therapy is its effect on blood coagulation. In patients undergoing multi-level lumbar spinal fusion, one study compared the effect of plasmalyte and NS on coagulation assessed by rotation thromboelastometry (ROTEM) and acid-base balance. In contrast to plasmalyte, fluid therapy with 0.9% saline resulted in transient hyperchloremic acidosis while coagulation and the amount of blood loss were similar between the groups.
Several large, long-term, outcome-based, randomized controlled trials with Plasmalyte have been published in the recent years.
In a multiple-crossover trial comparing balanced-crystalloids (lactated Ringer's solution or Plasma-Lyte A) with saline among adults who were treated with intravenous crystalloids in the emergency department and were subsequently hospitalized outside an intensive care unit, the number of hospital-free days did not differ between the balanced-crystalloid and saline groups. Balanced crystalloids, however, resulted in a lower incidence of major adverse kidney events within 30 days than saline. In critically-ill patients also, the use of balanced crystalloids for intravenous administration resulted in a lower rate of the composite outcome of death from any cause, new renal-replacement therapy, or persistent renal dysfunction than the use of saline.
Plasmalyte contains small amounts of Aspergillus galactomannan, which can cause false-positive results in broncho-alveolar lavage (BAL) specimens.
In this issue of Neurology India, Day et al., publish a study that compares normal saline with Plasmalyte as intraoperative maintenance fluid during craniotomy for excision of brain tumors. Like the findings of the earlier studies, they find that the acid-base status and renal profile were better with Plasmalyte. Two novel findings of this study are the absence of any significant difference in the intraoperative brain relaxation between the groups, and a significantly lower level of neutrophil gelatinase-associated lipocalin (NGAL), a biomarker of kidney injury in the Plasmalyte group.
Thus, the age old belief that 0.9% sodium chloride is isotonic and is the best fluid for intraoperative fluid replacement is shaken up by the finding that it can cause hyperchloremic acidosis and affect the renal function, especially in patients with preexisting renal disease. Neurosurgical procedures are typically long; thus, this concern should play an important role in the choice of the intraoperative fluid. While Ringer's lactate may offset metabolic acidosis, it still has the disadvantage of being mildly hypotonic and when given in large quantities, as is done in prolonged neurosurgical procedures, may reduce the serum osmolality. It has been conclusively proven in experimental studies that a minor change in crystalloid osmotic pressure can cause more brain oedema than a major change in colloid osmotic pressure. In this context, Plasmalyte, which has existed in the market for several years, promises to be an ideal fluid for intraoperative replacement, as shown in the current small sample study. However, some large multicenter randomized trials in neurosurgical patients are warranted to prove its effect on serum osmolality and brain oedema in patients undergoing brain tumor surgery.
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