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.

A Hospital-Wide Open-Label Cluster Crossover Pragmatic Comparative Effectiveness Randomized Trial Comparing Normal Saline to Ringer's Lactate: Protocol and Statistical Analysis Plan of The FLUID Trial

BACKGROUND

Normal saline (NS) and Ringer's lactate (RL) are the most common crystalloids given to hospitalized patients. Despite concern about possible harm associated with NS (eg, hyperchloremic metabolic acidosis, impaired kidney function, and death), few large multicenter randomized trials focused on critically ill patients have compared these fluids. Uncertainty exists about the effects of these fluids on clinically important outcomes across all hospitalized patients.

OBJECTIVE

The FLUID trial is a pragmatic, multicenter, 2×2 cluster crossover comparative effectiveness randomized trial that aims to evaluate the effectiveness of a hospital-wide policy that stocks either NS or RL as the main crystalloid fluid in 16 hospitals across Ontario, Canada.

METHODS

All hospitalized adult and pediatric patients (anticipated sample size 144,000 patients) with an incident admission to the hospital over the course of each study period will be included. Either NS or RL will be preferentially stocked throughout the hospital for 12 weeks before crossing to the alternate fluid for the subsequent 12 weeks. The primary outcome is a composite of death and hospital readmission within 90 days of hospitalization. Secondary outcomes include death, hospital readmission, dialysis, reoperation, postoperative reintubation, length of hospital stay, emergency department visits, and discharge to a facility other than home. All outcomes will be obtained from health administrative data, eliminating the need for individual case reports. The primary analysis will use cluster-level summaries to estimate cluster-average treatment effects.

RESULTS

The statistical analysis plan has been prepared "a priori" in advance of receipt of the trial data set from ICES and any analyses.

CONCLUSIONS

We describe the protocol and statistical analysis plan for the evaluation of primary and secondary outcomes for the FLUID trial.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04512950; https://classic.clinicaltrials.gov/ct2/show/NCT04512950.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/51783.

The effect of 6% hydroxyethyl starch 130/0.4 preloading on the blood glucose levels in diabetic patients undergoing orthopedic surgery with spinal anesthesia: a randomized pilot study

BACKGROUND

Perioperative hyperglycemia can occur in surgical patients and may increase postoperative morbidity and mortality, especially in patients with diabetes. Therefore, we conducted the present study to evaluate whether the administration of 6% hydroxyethyl starch (HES)-130/0.4 increases blood glucose levels in patients with diabetes.

METHODS

Forty patients undergoing lower limb surgery under spinal anesthesia were randomly allocated into two groups according to the fluids administered 20 min before spinal anesthesia (Group L, lactated Ringer's solution; Group H, 6% HES-130/0.4). Patient characteristics, intraoperative variables, blood glucose levels, mean blood pressure (MBP), and heart rate (HR) were recorded at five time-points (0, 20, 60, 120, and 240 min).

RESULTS

A total of 39 patients were analyzed (Group L, n = 20; Group H, n = 19). The amount of intraoperative fluid was significantly higher in Group L than in Group H (718.2 ml vs. 530.0 ml, P = 0.010). There were no significant differences in the changes in blood glucose levels, HR, or MBP between the two groups (P = 0.737, P = 0.896, and P = 0.141, respectively). Serial changes in mean blood glucose levels from baseline also showed no significant differences between the groups (P = 0.764).

CONCLUSIONS

There were no significant changes in blood glucose levels when lactated Ringer's solution or 6% HES-130 was used. When compared to the lactated Ringer's solution, no evidence that 6% HES-130/0.4 produces hyperglycemia in diabetic patients could be found. Further evaluation of larger populations is needed.

Intravenous fluid therapy in patients with severe acute pancreatitis admitted to the intensive care unit: a narrative review

Patients with acute pancreatitis (AP) often require ICU admission, especially when signs of multiorgan failure are present, a condition that defines AP as severe. This disease is characterized by a massive pancreatic release of pro-inflammatory cytokines that causes a systemic inflammatory response syndrome and a profound intravascular fluid loss. This leads to a mixed hypovolemic and distributive shock and ultimately to multiorgan failure. Aggressive fluid resuscitation is traditionally considered the mainstay treatment of AP. In fact, all available guidelines underline the importance of fluid therapy, particularly in the first 24–48 h after disease onset. However, there is currently no consensus neither about the type, nor about the optimal fluid rate, total volume, or goal of fluid administration. In general, a starting fluid rate of 5–10 ml/kg/h of Ringer’s lactate solution for the first 24 h has been recommended. Fluid administration should be aggressive in the first hours, and continued only for the appropriate time frame, being usually discontinued, or significantly reduced after the first 24–48 h after admission. Close clinical and hemodynamic monitoring along with the definition of clear resuscitation goals are fundamental. Generally accepted targets are urinary output, reversal of tachycardia and hypotension, and improvement of laboratory markers. However, the usefulness of different endpoints to guide fluid therapy is highly debated. The importance of close monitoring of fluid infusion and balance is acknowledged by most available guidelines to avoid the deleterious effect of fluid overload. Fluid therapy should be carefully tailored in patients with severe AP, as for other conditions frequently managed in the ICU requiring large fluid amounts, such as septic shock and burn injury. A combination of both noninvasive clinical and invasive hemodynamic parameters, and laboratory markers should guide clinicians in the early phase of severe AP to meet organ perfusion requirements with the proper administration of fluids while avoiding fluid overload. In this narrative review the most recent evidence about fluid therapy in severe AP is discussed and an operative algorithm for fluid administration based on an individualized approach is proposed.

Lactated Ringers Does Not Reduce SIRS in Acute Pancreatitis Compared to Normal Saline: An Updated Meta-Analysis

BACKGROUND

We aimed to compare outcomes according to a Lactated Ringers (LR) versus Normal Saline (NS)-based strategy for acute pancreatitis.

METHODS

A database search through November 2020 was done to identify studies comparing LR to NS for fluid rehydration in AP. The primary endpoint was systemic inflammatory response syndrome (SIRS) at 24 h. Mantel-Haenszel pooled odds ratios (OR) and 95% confidence intervals were constructed using a random effects model. Heterogeneity was assessed using the I² statistic. Publication bias was assessed using funnel plots.

RESULTS

Six studies were included totaling 549 patients. No difference in the odds of developing SIRS was noted at 24 h (pooled OR 0.59, 95% CI 0.22-1.62, P = 0.31) between LR and NS. I² indices showed low heterogeneity between the groups, and a funnel plot showed no obvious publication bias. There was no difference between LR and NS found for SIRS at 48 and 72 h, mortality, and other secondary outcomes. LR was associated with a decreased need for ICU admission.

CONCLUSIONS

This updated meta-analysis does not support the previously published finding that the use of LR (rather than NS) leads to a statistically significant decreased odds of SIRS in acute pancreatitis.

Comparison of normal saline solution with low-chloride solutions in renal transplants: a meta-analysis

Background

Normal saline solution (NSS) has been the fluid of choice for renal transplant patients, but it can lead to hyperchloremic acidosis and hyperkalemia. This study was performed to compare the safety profile of low-chloride solutions with that of NSS in renal transplant patients.

Methods

We conducted a systemic review search on PubMed, Embase, and the Central Cochrane Registry. Randomized clinical trials (RCTs) and matched cohort studies involving NSS as the control arm and low-chloride solutions as an intervention arm were chosen. The standardized mean difference for continuous variables, the odds ratio (OR) for discrete variables, and a 95% confidence interval (CI) for effect sizes were used. A p-value of <0.05 was considered statistically significant. Analysis was performed using a random-effects model irrespective of heterogeneity, which was evaluated using I² statistics.

Results

Nine RCTs and one cohort study with a total of 726 patients were included. After transplantation, serum potassium was significantly lower in the low-chloride group (standardized mean difference compared to NSS group, –0.38 mEq/L; 95% CI, –0.66 to –0.11; p = 0.007). Similarly, postoperative chloride was lower in the low-chloride group (–2.41 mEq/L [–3.34 to –1.48], p < 0.001). No statistically significance was observed in delayed graft function (OR, 0.98 [0.56–1.69], p = 0.93), day 3 creatinine (–0.14 mg/dL [–0.46 to 0.18], p = 0.38), or day 7 urine output (–0.08 L [–0.29 to 0.12], p = 0.43).

Conclusion

Use of NSS during renal transplant leads to increased incidence of hyperchloremic acidosis with subsequent hyperkalemia, but clinical significance in the form of delayed graft function or postoperative creatinine remains comparable to that of low-chloride solutions.

Volume kinetic analysis of fluid retention after induction of general anesthesia

Background

Induction of general anesthesia increases the hemodilution resulting from infusion of crystalloid fluid, which is believed to be due to slower distribution caused by arterial hypotension. When normal distribution returns is not known.

Methods

An intravenous infusion of 25 mL kg^− 1 of Ringer’s lactate was infused over 30 min to 25 volunteers just after induction of general anesthesia for open abdominal hysterectomy. A two-volume model was fitted to the repeated measurements of the blood hemoglobin concentration and the urinary excretion using mixed-effects modelling software. Individual-specific covariates were added in sequence.

Results

Distribution of infused fluid was interrupted during the first 20 min of the infusions. During this time 16.6 mL kg^− 1 of lactated Ringer’s had been infused, of which virtually all remained in the circulating blood. Thereafter, the fluid kinetics was similar to that previously been found in awake volunteers except for the elimination rate constant (k₁₀), which remained to be very low (0.86 × 10^− 3 min^− 1). Redistribution of infused fluid from the interstitium to the plasma occurred faster (higher k₂₁) when the arterial pressure was low. No covariance was found between the fixed parameters and preoperatively concentrated urine, the use of sevoflurane or propofol to maintain the anesthesia, or the plasma concentrations of two degradation products of the endothelial glycocalyx, syndecan-1 and heparan sulfate.

Conclusions

Induction of general anesthesia interrupted the distribution of lactated Ringer’s solution up to when 16.6 mL kg^− 1 of crystalloid fluid had been infused. Plasma volume expansion during this period of time was pronounced.

Trial registration

Controlled-trials.com (ISRCTN81005631) on May 17, 2016 (retrospectively registered).

Ringer's Lactate Prevents Early Organ Failure by Providing Extracellular Calcium

OBJECTIVE

Ringer's lactate may improve early systemic inflammation during critical illnesses like severe acute pancreatitis, which are associated with hypocalcemia. Ringer's lactate is buffered and contains lactate and calcium. We, thus analyzed extracellular calcium or lactate's effects on the mechanisms, intermediary markers, and organ failure in models mimicking human disease with nonesterified fatty acid (NEFA) elevation.

METHODS

Meta-analyses and experimental studies were performed. Experimentally, extracellular calcium and lactate were compared in their interaction with linoleic acid (LA; a NEFA increased in human severe pancreatitis), and its subsequent effects on mitochondrial depolarization and cytosolic calcium signaling resulting in cell injury. In vivo, the effect of LA was studied on organ failure, along with the effect of calcium or lactate (pH 7.4) on severe acute pancreatitis-associated organ failure. A meta-analysis of human randomized control trials comparing Ringer's lactate to normal saline was done, focusing on necrosis and organ failure.

RESULTS

Calcium reacted ionically with LA and reduced lipotoxic necrosis. In vivo, LA induced organ failure and hypocalcemia. During severe pancreatitis, calcium supplementation in saline pH 7.4, unlike lactate, prevented hypocalcemia, increased NEFA saponification, reduced circulating NEFA and C-reactive protein , reduced pancreatic necrosis adjacent to fat necrosis, and normalized shock (carotid pulse distension) and blood urea nitrogen elevation on day 1. This, however, did not prevent the later increase in serum NEFA which caused delayed organ failure. Meta-analysis showed Ringer's lactate reduced necrosis, but not organ failure, compared with normal saline.

CONCLUSION

Hypocalcemia occurs due to excess NEFA binding calcium during a critical illness. Ringer's lactate's early benefits in systemic inflammation are by the calcium it provides reacting ionically with NEFA. This, however, does not prevent later organ failure from sustained NEFA generation. Future studies comparing calcium supplemented saline resuscitation to Ringer's lactate may provide insights to this pathophysiology.

Choice of crystalloid fluid in the treatment of hyperglycemic emergencies: a systematic review protocol

BACKGROUND

Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are life-threatening complications of diabetes mellitus which require prompt treatment with large volume crystalloid fluid administration. A variety of crystalloid fluids is currently available for use and differs in their composition and ion concentrations. While there are potential pros and cons for different crystalloid fluids, it remains unknown if any particular fluid confers a clinical outcome benefit over others in the treatment of hyperglycemic emergencies.

METHODS

A systematic search of MEDLINE, Embase, and the Cochrane Library of Systematic Reviews will be conducted to identify eligible studies, which will include observational and interventional studies involving adult and pediatric patients admitted to the hospital with either DKA or HHS. The interventions will include intravenous treatment with 0.9% saline versus other buffered (Ringer's lactate, Hartmann's, etc.), and non-buffered (0.45% saline) crystalloid fluids. The primary outcome is mortality at the latest follow-up time point. Secondary outcomes will include mortality at specific time points, length of hospital stay, development of acute kidney injury, requirement for renal replacement therapy, altered level of consciousness, and the time to normalization of several serum biochemical parameters. Where appropriate, meta-analyses will be performed for the outcomes and conducted separately for adult and pediatric patient populations.

DISCUSSION

DKA and HHS are dangerous complications of diabetes mellitus and account for significant morbidity and mortality. Given the importance of crystalloid fluid administration in the management of these conditions, a systematic synthesis of the existing evidence base will identify potential evidence gaps and may help guide future clinical practice.

Impact of balanced versus unbalanced fluid resuscitation on clinical outcomes in critically ill children: protocol for a systematic review and meta-analysis

BACKGROUND

Isotonic crystalloid fluid bolus therapy is used in critically ill children to restore or maintain hemodynamic stability. However, the ideal choice of crystalloid remains to be determined. The most easily available and most frequently used crystalloid is 0.9% saline, an unbalanced crystalloid, that has been associated with hyperchloremic metabolic acidosis and acute kidney injury (AKI). Balanced fluids such as Ringer's lactate (RL) were developed to be closer to the composition of serum. However, they are more expensive and less readily available than 0.9% saline. Few trials have found RL to be associated with more favorable outcomes, but pediatric data is limited and inconsistent. The objective of the present systematic review is to review existing literature to determine the effect of balanced versus unbalanced fluid bolus therapy on metabolic acidosis in critically ill children.

METHODS

Using the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) guidelines, we will conduct a systematic review to retrieve all controlled trials and observational studies comparing balanced and unbalanced resuscitative fluids in critically ill children from age 28 days to 18 years old in any resuscitation settings. Search strategy was developed in collaboration with an experienced clinical research librarian. The primary outcome is the incidence and/or time to resolution of metabolic acidosis. Secondary outcomes included the incidence of hyperchloremia, AKI, duration of renal replacement therapy, vasopressors, mechanical ventilation, total volume of rehydration needed per day, extracorporeal membrane oxygenation, and length of stay and mortality. Study screening, inclusion, data extraction, and assessment of risk of bias will be performed independently by two authors. We intend to perform a meta-analysis with studies that are compatible on the basis of population and outcomes.

DISCUSSION

Isotonic crystalloid fluid bolus therapy is a ubiquitous treatment in resuscitation of critically ill pediatric patients and yet there is no clear recommendation to support the choice of balanced versus unbalanced fluid. The present review will summarize current available data in the literature and assess whether recommendations can be generated regarding the choice of crystalloids or otherwise identify knowledge gaps which will open the door to a large-scale randomized controlled trial (RCT).

Comparison of the Effects of Albumin 5% versus Ringer's Lactate on Blood Loss and Coagulation after Vascular Surgery Using Thromboelastography

AIM

Comparing the effects of Albumin 5% versus Ringer's lactate on blood loss and coagulation after vascular surgery using.

METHODS

In this randomised study, 60 patients, aged (18-60 years) ASA physical status (I-III) undergoing vascular surgery were included in the study and randomly allocated into two groups using a random number generator, to receive either Human albumin or Ringer lactate after obtaining written informed consent. Group A received 1-2 ml per minute of human albumin 5% combined with normal saline (0.9%). Group B received Ringer's lactate only as of the main solution. Variables were measured after administration of fluids as postoperative measures. The amount of blood needed for testing was 4 ml drawn before the operation and at the end of surgery with a citrate tube (blue tube) from the venous line or using a regular needle. The standard time of 15 minutes was considered to begin processing.

RESULTS

There was no statistically significant difference observed between both groups regarding demographic data, surgical wound drainage, haemoglobin level, hematocrit level and coagulation profile. Regarding ROTEM thermoelectrometry variables showed that there was no statistically significant difference was found between the two groups In-TEM variables (Ex-TEM Clotting time, TEM Clot Formation Time) but In-TEM Alpha Angel measured in degrees showed a Statistically significant difference between the two groups. P < 0.001 and Ex-TEM Maximum Clotting Firmness MCF values measured in mm, there was a statistically significant difference between the two groups P = 0.045.

CONCLUSION

This study concluded that the use of human albumin (5%) in vascular surgeries before reaching the trigger point for blood transfusion didn't improve blood loss or coagulation profile compared to the use of ringer lactate only. Therefore, ringer lactate can be used as a good replacement for human albumin. Ringer lactate is readily available and inexpensive while human albumin may be costly.

Effect of 6% hydroxyethyl starch-450 and low molecular weight dextran on blood sugar levels during surgery under subarachnoid block: A prospective randomised study

Dextrans and hydroxyethyl starches produce significant levels of free glucose residues following metabolism. The following study was designed to compare 6% hydroxyethyl starch-450 with Dextran 40, both used as preloading fluids, for their potential to raise peri-operative blood glucose levels. After taking an informed consent, 180 non-diabetic adult patients, posted for elective surgery under spinal anaesthesia, were randomly divided into three groups, to receive Ringer’s Lactate 20 ml/kg (group 1), Dextran 40,10 ml/kg (group 2) and Hestar 6%-450, 10 ml/kg (group 3), over half an hour, prior to the subarachnoid block, as preloading fluid, and serial capillary blood glucose measurements were taken thereafter at regular intervals up to 240 minutes from the baseline reading. All the three preloading fluids, including Ringer’s Lactate used as control, were seen to significantly increase the capillary blood glucose levels intra-operatively (P < 0.05), but the rise with Dextran-40 was seen to be sustained and highly significant (P < 0.001). We thus conclude that, Dextran40 causes a sustained and significant rise in peri-operative blood glucose levels.