Physiological response to fluid resuscitation with Ringer lactate versus Plasmalyte in critically ill burn patients

Abstract

The metabolic consequences in vivo of various balanced solutions are poorly known in critically ill patients. The main objective of this study was to describe the metabolic consequences of Plasmalyte versus Ringer lactate (RL) in critically ill burn patients, with a special focus on the plasma clearance of buffer anions (i.e., gluconate, acetate, and lactate). We conducted a randomized trial between August 2017 and October 2018 in a tertiary teaching hospital in Paris, France. Patients with burn total body surface area >30% were randomized to receive Plasmalyte or RL. The primary end point was the base excess 24 h after inclusion. The secondary end points were acetate, gluconate, and lactate plasma concentration, the strong ion difference (SID). Twenty-eight patients were randomized. Twenty-four hours after inclusion, plasma BE was not significantly different in the Plasmalyte and RL groups {−0.9 [95% confidence interval (95% CI): −1.8–0.9] vs. −2.1 [95% CI: −4.6–0.6] mmol/L, respectively, P = 0.26}. Plasma gluconate concentration was higher in the Plasmalyte group ( P < 0.001), with a maximum level of 1.86 (95% CI: 0.98–4.0) mmol/L versus 0 (95% CI: 0–0.15) mmol/L. Plasma acetate and lactate were not significantly different. Ionized calcium level was lower in the Plasmalyte group ( P = 0.002). Hemodynamics did not differ between groups. To conclude, the alkalinizing effect of Plasmalyte was less important than expected with no difference in base excess compared with RL, in part due to gluconate accumulation. Acetate and lactate did not significantly accumulate. Plasmalyte led to significantly lower ionized calcium levels. NEW & NOTEWORTHY During fluid resuscitation in burns the alkalinizing effect of Plasmalyte was less important than expected, with no difference in base excess compared with Ringer lactate (RL), in part due to gluconate accumulation. Acetate and lactate did not significantly accumulate. Plasmalyte led to significantly lower ionized calcium levels.

Comparison of Balanced Crystalloid Solutions: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

“…The balanced crystalloids that were studied include Plasmalyte (Plasma-Lyte 148/Plasma-Lyte A), Kabilyte, Normosol-R, Ringer’s Lactate, Ringerfundin/Ringer’s Acetate, Hartmann’s solution, Ringer’s Bicarbonate, Sterofundin, and novel balanced solutions (see Table 2 for a summary of commercially available fluids and their electrolyte concentrations). Of the included studies, 16 were performed in the perioperative setting ( n = 1142 participants) ( 16 – 20 , 23 , 25 , 26 , 28 , 30 – 32 , 35 , 36 , 38 , 39 ), six in the ICU ( n = 427 participants) ( 21 , 27 , 29 , 33 , 34 , 37 ), one in the emergency department (ED; n = 90 participants) ( 24 ), and one in healthy volunteers ( n = 14 participants) ( 22 ). Five studies involved pediatric patients ( n = 298 participants) ( 16 , 17 , 25 , 38 , 39 ), whereas the remainder focused on adult participants.…”

“…Five studies involved pediatric patients ( n = 298 participants) ( 16 , 17 , 25 , 38 , 39 ), whereas the remainder focused on adult participants. Volumes of study fluid received ranged from 380 mL ( 17 ) to 19,626 mL ( 37 ) (median, 2,000 mL and interquartile range, 2,812.5 mL). The duration of study fluid administration also varied widely from 1 hour ( 29 ) to 5 days ( 37 ).…”

“…The duration of study fluid administration also varied widely from 1 hour ( 29 ) to 5 days ( 37 ). Most studies ( n = 19) reported only short-term metabolic outcomes ( 16 – 22 , 24 – 27 , 29 – 32 , 34 , 37 – 39 ), while a few ( n = 5) reported longer term clinical outcomes ( 23 , 28 , 33 , 35 , 36 ). Six studies were available as abstract only ( 21 , 25 , 27 , 33 , 34 , 38 ).…”

Lactate versus acetate buffered intravenous crystalloid solutions: a scoping review

“…Seventeen clinical trials were conducted in a surgical setting with the intervention administered intraoperatively. 21,23e27,29e33,36e41 The remaining five clinical trials were conducted in burn units, 20,34,35 in an emergency department, 28 and in an ICU. 22 All four observational studies evaluated fluid therapy in a surgical setting.…”

“…45e48 Indication for use was specified in 12 studies, 20e23, 28,32e35,37,40,47 one of which compared the use of buffered solutions as pre-hydration before epidural anaesthesia, 32 and one specifically evaluated the use of solutions as replacement therapy, 47 one as maintenance therapy, 33 and five as predominantly resuscitation therapy. 20,22,28,34,35 Four studies evaluated the use of lactate-vs acetate-buffered solutions for cardiopulmonary bypass (CPB) pump prime. 21,23,37,40 The remaining 14 studies, all investigating intraoperative use of buffered solutions, did not provide details on the specific indication for the use of i.v.…”