Plasma acetate, gluconate and interleukin-6 profiles during and after cardiopulmonary bypass: a comparison of Plasma-Lyte 148 with a bicarbonate-balanced solution

Abstract

IntroductionAs even small concentrations of acetate in the plasma result in pro-inflammatory and cardiotoxic effects, it has been removed from renal replacement fluids. However, Plasma-Lyte 148 (Plasma-Lyte), an electrolyte replacement solution containing acetate plus gluconate is a common circuit prime for cardio-pulmonary bypass (CPB). No published data exist on the peak plasma acetate and gluconate concentrations resulting from the use of Plasma-Lyte 148 during CPB.MethodsThirty adult patients were systematically allocated 1:1 to CPB prime with either bicarbonate-balanced fluid (24 mmol/L bicarbonate) or Plasma-Lyte 148. Arterial blood acetate, gluconate and interleukin-6 (IL-6) levels were measured immediately before CPB (T1), three minutes after CPB commencement (T2), immediately before CPB separation (T3), and four hours post separation (T4).ResultsAcetate concentrations (normal 0.04 to 0.07 mmol/L) became markedly elevated at T2, where the Plasma-Lyte group (median 3.69, range (2.46 to 8.55)) exceeded the bicarbonate group (0.16 (0.02 to 3.49), P < 0.0005). At T3, levels had declined but the differential pattern remained apparent (Plasma-Lyte 0.35 (0.00 to 1.84) versus bicarbonate 0.17 (0.00 to 0.81)). Normal circulating acetate concentrations were not restored until T4. Similar gluconate concentration profiles and inter-group differences were seen, with a slower T3 decay. IL-6 increased across CPB, peaking at T4, with no clear difference between groups.ConclusionsUse of acetate containing prime solutions result in supraphysiological plasma concentrations of acetate. The use of acetate-free prime fluid in CPB significantly reduced but did not eliminate large acetate surges in cardiac surgical patients. Complete elimination of acetate surges would require the use of acetate free bolus fluids and cardioplegia solutions.Trial registrationAustralia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12610000267055

Modulation of Early Inflammatory Response by Different Balanced and Non-Balanced Colloids and Crystalloids in a Rodent Model of Endotoxemia

“…Although IL-6 levels did not differ significantly in this study the author concluded that one cannot rule out that these supra-physiological anion levels can be harmful [22]. Acetate has been shown to stimulate cytokine release such as IL-1, to cause carbohydrate intolerance and disturbance of fatty acid synthesis [23].…”

Diabetic ketoacidosis in adult patients: an audit of factors influencing time to normalisation of metabolic parameters

“…Those with a greater degree of acidosis received CSL more commonly than sodium chloride, presumably because of the perceived risk of worsening the acid–base status by promoting hyperchloraemic metabolic acidosis due to the lower chloride content in CSL. Another proposed hypothesis for the delay in resolution of DKA is that CSL contains lactate which requires additional metabolism in the liver . Data on lactate were not collected in this study and would be of interest in future studies.…”

Plasma-Lyte 148: A clinical review

“…Small quantities of acetate in dialysate solutions have been reported to cause supra-physiological acetate plasma concentrations (50 to 100 μmol/L)[47-49]. In addition, use of acetate solutions as a cardiopulmonary prime has also been reported to cause similar plasma concentrations in patients undergoing cardiac surgery[50], although it is unknown if such concentrations are associated with detrimental or adverse clinical outcomes.…”

“…The unmeasured anions were attributed to acetate and gluconate. Davies et al[50] observed that when PL 148 was administered as a cardiopulmonary bypass pump-prime fluid, there were supra-physiologic plasma levels of acetate and gluconate when compared to a bicarbonate pump prime solution. There were no significant differences in systemic inflammation (as measured by Interleukin-6 levels), and the authors advocated larger scale studies to more precisely assess this phenomenon.…”