Acid-Base Effects of a Bicarbonate-Balanced Priming Fluid during Cardiopulmonary Bypass: Comparison with Plasma-Lyte 148. A Randomised Single-Blinded Study

Morgan, T. J.; Power, Gerald; Venkatesh, Balasubramanian; Jones, Mark

doi:10.1177/0310057x0803600611

Cited by 25 publications

(25 citation statements)

References 52 publications

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“…We estimated that we would need 10 patients in each group, a total sample size of 20 patients, to have a power of 0.8 to detect a 2 mmol/l difference in base-excess between the two solutions. This is in line with the detection of a base-excess difference in other studies [7][8][9] . All patients underwent elective primary coronary revascularisation.…”

Section: Methodssupporting

confidence: 93%

Effect of Pump Prime on Acidosis, Strong-ion-difference and Unmeasured Ions during Cardiopulmonary Bypass

Liskaser

Story

Hayhoe

et al. 2009

Anaesth Intensive Care

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Changes in acid-base balance, particularly metabolic acidosis, are common in cardiac surgery with cardiopulmonary bypass (CPB) 1,2 . The mechanisms for such metabolic acidosis however, remain controversial. Those who use bicarbonate centred approaches to acid-base (patho)physiology conclude that dilution of bicarbonate is the underlying mechanism for acid-base changes following large volume infusion during CPB 3,4 . Using the Stewart approach to acid-base physiology 5 and fluid therapy 6 , our group 1,7 , and Himpe et al 8 and Morgan et al 9 , concluded that bypass associated metabolic acidosis may instead depend on the electrolytes and colloids in the CPB prime. One limitation of these studies was that CPB primes included constituents that are not measured in routine clinical chemistry; either colloids such as gelatin 1,8 or smaller organic molecules such as gluconate and acetate 7,9 . This limited the quantitative acid-base balance analysis possible with the Stewart approach 10 , because of the relatively large effects of unmeasured ions from the CPB prime solutions. Further, there is limited data on the changes in acid-base variables during the first 30 minutes of CPB 7-9 .The underlying mechanisms of acid-base changes associated with CPB might be easier to quantify using CPB primes that contain only electrolytes and anions routinely measured in clinical chemistry. We hypothesised that a CPB prime with lactate and chloride would be associated with less metabolic acidosis than a prime with only chloride, because of a difference in the measured strong-ion-difference. To test this hypothesis, we conducted a randomised, double-blinded trial of two different CPB primes: one containing 152 mmol/l of chloride and another SUMMARyWe tested the hypothesis that a cardiopulmonary bypass prime with lactate would be associated with less acidosis than a prime with only chloride anions because of differences in the measured strong-ion-difference. We randomised 20 patients to a 1500 ml bypass prime with either a chloride-only solution (Ringer's Injection; anions: chloride 152 mmol/l) or a lactated solution (Hartmann's solution; anions: chloride 109 mmol/l, lactate 29 mmol/l). Arterial blood was sampled before bypass and then two, five, 15 and 30 minutes after initiating bypass. We used repeated measures analysis of variance to compare groups. In both groups, the base-excess and measured strong-iondifference decreased markedly from baseline after two minutes of bypass. The chloride-only group had greater acidosis with lower base-excess and pH (P <0.05), greatest after five minutes of bypass (C5). Contrary to our hypothesis, however, the difference between the groups was not due to a difference in the measured strong-iondifference, P=0.88. At C5 when the difference in standard base-excess between the groups was greatest, 1.9 mmol/l (95% confidence interval: 0.1 to 3.6 mmol/l, P <0.05), the difference in the measured strong-ion-difference was only 0.2 mmol/l (95% confidence interval: -2.4 to 2.7 mmol/l, P >0.05). There was, how...

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Section: Methodssupporting

confidence: 93%

Effect of Pump Prime on Acidosis, Strong-ion-difference and Unmeasured Ions during Cardiopulmonary Bypass

Liskaser

Story

Hayhoe

et al. 2009

Anaesth Intensive Care

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“…Gluconate may protect against post ischemic cardiac dysfunction and oxidative injury[73], however there is lack of data on acetate and gluconate levels after PL 148 administration in most surgical settings. In a phase II clinical trial of PL 148 vs a bicarbonate-based cardiopulmonary bypass prime solution, there was a significant increase in unmeasured anions levels after PL 148 administration, which was still present, albeit in smaller concentrations prior to cessation of CPB[74]. Liskaser et al[19] reported similar findings.…”

Section: Discussionmentioning

confidence: 88%

Plasma-Lyte 148: A clinical review

Weinberg

Collins

Mourik

et al. 2016

WJCCM

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AIMTo outline the physiochemical properties and specific clinical uses of Plasma-Lyte 148 as choice of solution for fluid intervention in critical illness, surgery and perioperative medicine.METHODSWe performed an electronic literature search from Medline and PubMed (via Ovid), anesthesia and pharmacology textbooks, and online sources including studies that compared Plasma-Lyte 148 to other crystalloid solutions. The following keywords were used: “surgery”, “anaesthesia”, “anesthesia”, “anesthesiology”, “anaesthesiology”, “fluids”, “fluid therapy”, “crystalloid”, “saline”, “plasma-Lyte”, “plasmalyte”, “hartmann’s”, “ringers” “acetate”, “gluconate”, “malate”, “lactate”. All relevant articles were accessed in full. We summarized the data and reported the data in tables and text.RESULTSWe retrieved 104 articles relevant to the choice of Plasma-Lyte 148 for fluid intervention in critical illness, surgery and perioperative medicine. We analyzed the data and reported the results in tables and text.CONCLUSIONPlasma-Lyte 148 is an isotonic, buffered intravenous crystalloid solution with a physiochemical composition that closely reflects human plasma. Emerging data supports the use of buffered crystalloid solutions in preference to saline in improving physicochemical outcomes. Further large randomized controlled trials assessing the comparative effectiveness of Plasma-Lyte 148 and other crystalloid solutions in measuring clinically important outcomes such as morbidity and mortality are needed.

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“…Gluconate has also been incorporated into some enteral and parenteral pharmaceutical preparations. The principal benefit of bicarbonate-balanced fluids demonstrated thus far, apart from avoidance of exogenous anions, is the ability to achieve a well balanced acid-base status across CPB [8]. Also, there is now evidence that added sodium bicarbonate may exert a renal protective effect in CPB [29].…”

Section: Discussionmentioning

confidence: 99%

“…A potential complication [2] of CPB is metabolic acidosis, which is influenced by the CPB circuit priming fluid [3,4]. Attempts to prevent metabolic acidosis have entailed alterations to circuit prime fluids, including partial replacement of chloride by rapidly metabolised anions such as L-lactate [5,6], acetate and gluconate [3,7], or else by bicarbonate [8]. Plasma-Lyte 148 (Baxter, Toongabbie, NSW, Australia) is a crystalloid CPB prime fluid in common use in Australia and New Zealand (personal communication, Andrew McLaren, Baxter, Australia) in about 7% of surveyed units in the UK [9] and in some units in North America [10].…”

Section: Introductionmentioning

confidence: 99%

“…One litre of Plasma-Lyte 148 contains 27 mmol acetate and 23 mmol gluconate. In a recent Phase II evaluation of Plasma-Lyte 148 versus a bicarbonate balanced prime, CPB commencing with Plasma-Lyte 148 prime was associated with an immediate surge in unmeasured anions of >10 mEq/L, with residual elevations still present just prior to CPB cessation [8]. Liskaser and colleagues have reported a similar phenomenon [3].…”

Section: Introductionmentioning

confidence: 99%

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

et al. 2011

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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

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Acid-Base Effects of a Bicarbonate-Balanced Priming Fluid during Cardiopulmonary Bypass: Comparison with Plasma-Lyte 148. A Randomised Single-Blinded Study

Cited by 25 publications

References 52 publications

Effect of Pump Prime on Acidosis, Strong-ion-difference and Unmeasured Ions during Cardiopulmonary Bypass

Effect of Pump Prime on Acidosis, Strong-ion-difference and Unmeasured Ions during Cardiopulmonary Bypass

Plasma-Lyte 148: A clinical review

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

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