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Critical Care
Published in: Critical Care 1/2019

Open Access 01-12-2019 | Heart Surgery | Research

Fluid management in patients undergoing cardiac surgery: effects of an acetate- versus lactate-buffered balanced infusion solution on hemodynamic stability (HEMACETAT)

Authors: Carmen A. Pfortmueller, Livia Faeh, Martin Müller, Balthasar Eberle, Hansjörg Jenni, Björn Zante, Josef Prazak, Lars Englberger, Jukka Takala, Stephan M. Jakob

Published in: Critical Care | Issue 1/2019

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Abstract

Background

Recent evidence suggests that acetate-buffered infusions result in better hemodynamic stabilization than 0.9% saline in patients undergoing major surgery. The choice of buffer in balanced crystalloid solutions may modify their hemodynamic effects. We therefore compared the inopressor requirements of Ringer’s acetate and lactate for perioperative fluid management in patients undergoing cardiac surgery.

Methods

Using a randomized controlled double-blind design, we compared Ringer’s acetate (RA) to Ringer’s lactate (RL) with respect to the average rate of inopressor administered until postoperative hemodynamic stabilization was achieved. Secondary outcomes were the cumulative dose of inopressors, the duration of inopressor administration, the total fluid volume administered, and the changes in acid-base homeostasis. Patients undergoing elective valvular cardiac surgery were included. Patients with severe cardiac, renal, or liver disease were excluded from the study.

Results

Seventy-five patients were randomly allocated to the RA arm, 73 to the RL. The hemodynamic profiles were comparable between the groups. The groups did not differ with respect to the average rate of inopressors (RA 2.1 mcg/kg/h, IQR 0.5–8.1 vs. RL 1.7 mcg/kg/h, IQR 0.7–8.2, p = 0.989). Cumulative doses of inopressors and time on individual and combined inopressors did not differ between the groups. No differences were found in acid-base parameters and their evolution over time.

Conclusion

In this study, hemodynamic profiles of patients receiving Ringer’s lactate and Ringer’s acetate were comparable, and the evolution of acid-base parameters was similar. These study findings should be evaluated in larger, multi-center studies.

Trial registration

Clinicaltrials.gov NCT02895659. Registered 16 September 2016.
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Literature
1.
Challand C, Struthers R, Sneyd JR, Erasmus PD, Mellor N, Hosie KB, Minto G. Randomized controlled trial of intraoperative goal-directed fluid therapy in aerobically fit and unfit patients having major colorectal surgery. Br J Anaesth. 2012;108(1):53–62.PubMed
2.
Magder S, Potter BJ, Varennes BD, Doucette S, Fergusson D. Fluids after cardiac surgery: a pilot study of the use of colloids versus crystalloids. Crit Care Med. 2010;38(11):2117–24.PubMed
3.
Schumacher J, Klotz K-F. Fluid therapy in cardiac surgery patients. Appl Cardiopulm Pathophysiol. 2009;13(1):138–42.
4.
Kramer A, Zygun D, Hawes H, Easton P, Ferland A. Pulse pressure variation predicts fluid responsiveness following coronary artery bypass surgery. Chest. 2004;126(5):1563–8.PubMed
5.
Suzuki S, Woinarski NC, Lipcsey M, Candal CL, Schneider AG, Glassford NJ, Eastwood GM, Bellomo R. Pulse pressure variation-guided fluid therapy after cardiac surgery: a pilot before-and-after trial. J Crit Care. 2014;29(6):992–6.PubMed
6.
Sponholz C, Schelenz C, Reinhart K, Schirmer U, Stehr SN. Catecholamine and volume therapy for cardiac surgery in Germany--results from a postal survey. PLoS One. 2014;9(8):e103996.PubMedPubMedCentral
7.
Verheij J, van Lingen A, Raijmakers PG, Rijnsburger ER, Veerman DP, Wisselink W, Girbes AR, Groeneveld AB. Effect of fluid loading with saline or colloids on pulmonary permeability, oedema and lung injury score after cardiac and major vascular surgery. Br J Anaesth. 2006;96(1):21–30.PubMed
8.
Jacob M, Fellahi JL, Chappell D, Kurz A. The impact of hydroxyethyl starches in cardiac surgery: a meta-analysis. Crit Care. 2014;18(6):656.PubMedPubMedCentral
9.
Bayer O, Schwarzkopf D, Doenst T, Cook D, Kabisch B, Schelenz C, Bauer M, Riedemann NC, Sakr Y, Kohl M, et al. Perioperative fluid therapy with tetrastarch and gelatin in cardiac surgery--a prospective sequential analysis*. Crit Care Med. 2013;41(11):2532–42.PubMed
10.
Hans GA, Ledoux D, Roediger L, Hubert MB, Koch JN, Senard M. The effect of intraoperative 6% balanced hydroxyethyl starch (130/0.4) during cardiac surgery on transfusion requirements. J Cardiothorac Vasc Anesth. 2015;29(2):328–32.PubMed
11.
Pfortmueller C, Funk GC, Potura E, Reiterer C, Luf F, Kabon B, Druml W, Fleischmann E, Lindner G. Acetate-buffered crystalloid infusate versus infusion of 0.9% saline and hemodynamic stability in patients undergoing renal transplantation: prospective, randomized, controlled trial. Wien Klin Wochenschr. 2017;129(17–18):598–604. https://​doi.​org/​10.​1007/​s00508-017-1180-4. [Epub 2017 Mar 2]PubMedPubMedCentral
12.
Pfortmueller CA, Funk GC, Reiterer C, Schrott A, Zotti O, Kabon B, Fleischmann E, Lindner G. Normal saline versus a balanced crystalloid for goal-directed perioperative fluid therapy in major abdominal surgery: a double-blind randomised controlled study. Br J Anaesth. 2018;120(2):274–83.PubMed
13.
Kuze S, Ito Y, Miyahara T. Expiration of radioactive carbon dioxide by rats after administration of isotopic lactate and acetate. Acta Medica Biologica. 1986;34:93–102.
14.
Chang-Seng L, Lowenstein J. Metabolic control of the circulation: effects of acetate and pyruvate. J Clin Investig. 1978;62:1029–38.
15.
Knowles SE, Jarrett IG, Filsell OH, Ballard FJ. Production and utilization of acetate in mammals. Biochem J. 1974;142(2):401–11.PubMedPubMedCentral
16.
Nitenberg A, Huyghebaert MF, Blanchet F, Amiel C. Analysis of increased myocardial contractility during sodium acetate infusion in humans. Kidney Int. 1984;26(5):744–51.PubMed
17.
Suokas A, Kupari M, Heikkila J, Lindros K, Ylikahri R. Acute cardiovascular and metabolic effects of acetate in men. Alcohol Clin Exp Res. 1988;12(1):52–8.PubMed
18.
Doucet JJ, Hall RI. Limited resuscitation with hypertonic saline, hypertonic sodium acetate, and lactated Ringer’s solutions in a model of uncontrolled hemorrhage from a vascular injury. J Trauma. 1999;47(5):956–63.PubMed
19.
Uusaro A, Ruokonen E, Takala J. Splanchnic oxygen transport after cardiac surgery: evidence for inadequate tissue perfusion after stabilization of hemodynamics. Intensive Care Med. 1996;22(1):26–33.PubMed
20.
Jakob SM, Ruokonen E, Takala J. Assessment of the adequacy of systemic and regional perfusion after cardiac surgery. Br J Anaesth. 2000;84(5):571–7.PubMed
21.
Takala J, Dellinger RP, Koskinen K, St Andre A, Read M, Levy M, Jakob SM, Mello PV, Friolet R, Ruokonen E. Development and simultaneous application of multiple care protocols in critical care: a multicenter feasibility study. Intensive Care Med. 2008;34(8):1401–10.PubMed
22.
Yelland LN, Sullivan TR, Voysey M, Lee KJ, Cook JA, Forbes AB. Applying the intention-to-treat principle in practice: guidance on handling randomisation errors. Clin Trials. 2015;12(4):418–23.PubMedPubMedCentral
23.
McHugh ML. The chi-square test of independence. Biochem Med. 2013;23(2):143–9.
24.
Potura E, Lindner G, Biesenbach P, Funk GC, Reiterer C, Kabon B, Schwarz C, Druml W, Fleischmann E. An acetate-buffered balanced crystalloid versus 0.9% saline in patients with end-stage renal disease undergoing cadaveric renal transplantation: a prospective randomized controlled trial. Anesth Analg. 2015;120(1):123–9.PubMed
25.
Iseki K, Onoyama K, Maeda T, Shimamatsu K, Harada A, Fujimi S, Omae T. Comparison of hemodynamics induced by conventional acetate hemodialysis, bicarbonate hemodialysis and ultrafiltration. Clin Nephrol. 1980;14(6):294–8.PubMed
26.
Mansell MA, Nunan TO, Laker MF, Boon NA, Wing AJ. Incidence and significance of rising blood acetate levels during hemodialysis. Clin Nephrol. 1979;12(1):22–5.PubMed
27.
Holbert RD, Pearson JE, Gonzalez FM. Effect of sodium acetate infusion on renal function in the dog. Arch Int Pharmacodyn Ther. 1976;219(2):211–22.PubMed
28.
Kirkendol PL, Starrs J, Gonzalez FM. The effects of acetate, lactate, succinate and gluconate on plasma pH and electrolytes in dogs. Trans Am Soc Artif Intern Organs. 1980;26:323–7.PubMed
29.
Liang CS, Lowenstein JM. Metabolic control of the circulation. Effects of acetate and pyruvate. J Clin Invest. 1978;62(5):1029–38.PubMedPubMedCentral
30.
Kveim M, Nesbakken R. Acetate metabolizing capacity in man. J Oslo City Hosp. 1980;30:101–4.PubMed
31.
Pfortmueller CA, Fleischmann E. Acetate-buffered crystalloid fluids: current knowledge, a systematic review. J Crit Care. 2016;35:96–104.PubMed
32.
Conahan ST, Dupre A, Giaimo ME, Fowler CA, Torres CS, Miller HI. Resuscitation fluid composition and myocardial performance during burn shock. Circ Shock. 1987;23(1):37–49.PubMed
33.
Pfortmueller CA, Uehlinger D, von Haehling S, Schefold JC. Serum chloride levels in critical illness-the hidden story. Intensive Care Med Exp. 2018;6(1):10.PubMedPubMedCentral
34.
Kellum JA, Song M, Venkataraman R. Effects of hyperchloremic acidosis on arterial pressure and circulating inflammatory molecules in experimental sepsis. Chest. 2004;125(1):243–8.PubMed
35.
Chowdhury AH, Cox EF, Francis ST, Lobo DN. A randomized, controlled, double-blind crossover study on the effects of 1-L infusions of 6% hydroxyethyl starch suspended in 0.9% saline (Voluven) and a balanced solution (Plasma Volume Redibag) on blood volume, renal blood flow velocity, and renal cortical tissue perfusion in healthy volunteers. Ann Surg. 2014;259(5):881–7.PubMed
36.
Chowdhury AH, Cox EF, Francis ST, Lobo DN. A randomized, controlled, double-blind crossover study on the effects of 2-L infusions of 0.9% saline and plasma-lyte(R) 148 on renal blood flow velocity and renal cortical tissue perfusion in healthy volunteers. Ann Surg. 2012;256(1):18–24.PubMed
37.
Ferguson BS, Rogatzki MJ, Goodwin ML, Kane DA, Rightmire Z, Gladden LB. Lactate metabolism: historical context, prior misinterpretations, and current understanding. Eur J Appl Physiol. 2018;118(4):691–728.PubMed
38.
Rohrig R, Wegewitz C, Lendemans S, Petrat F, de Groot H. Superiority of acetate compared with lactate in a rodent model of severe hemorrhagic shock. J Surg Res. 2014;186(1):338–45.PubMed
39.
Gille J, Klezcewski B, Malcharek M, Raff T, Mogk M, Sablotzki A, Taha H. Safety of resuscitation with Ringer’s acetate solution in severe burn (VolTRAB)--an observational trial. Burns. 2014;40(5):871–80.PubMed
40.
Cropsey C, Kennedy J, Han J, Pandharipande P. Cognitive dysfunction, delirium, and stroke in cardiac surgery patients. Semin Cardiothorac Vasc Anesth. 2015;19(4):309–17.PubMed
41.
Metadata
Title
Fluid management in patients undergoing cardiac surgery: effects of an acetate- versus lactate-buffered balanced infusion solution on hemodynamic stability (HEMACETAT)
Authors
Carmen A. Pfortmueller
Livia Faeh
Martin Müller
Balthasar Eberle
Hansjörg Jenni
Björn Zante
Josef Prazak
Lars Englberger
Jukka Takala
Stephan M. Jakob
Publication date
01-12-2019
Publisher
BioMed Central
Published in
Critical Care / Issue 1/2019
Electronic ISSN: 1364-8535
DOI
https://doi.org/10.1186/s13054-019-2423-8

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