Effect of Normal Saline versus PlasmaLyte on Coagulation and Metabolic Status in Patients Undergoing Neurosurgical Procedures

Abstract

Background The choice of intraoperative fluid in neurosurgical patients is important as we need to maintain adequate cerebral perfusion and oxygenation and also avoid cerebral edema. Normal saline (NS) is commonly used in neurosurgeries, but it leads to hyperchloremic metabolic acidosis, which may result in coagulopathy. Balanced crystalloid with physiochemical composition akin to that of plasma has favorable effects on metabolic profile and may avoid the problems associated with NS. Against this background, the present study aimed to compare the effects of NS versus PlasmaLyte (PL) on coagulation profile in patients undergoing neurosurgical procedures. Methods This prospective, randomized, double-blinded study was conducted in 100 adult patients scheduled to undergo various neurosurgical procedures. Patients were randomly allocated in two groups of 50 each to receive either NS or PL intraoperatively and postoperatively till 4 hours after the surgery. Hemoglobin, hematocrit, coagulation profile (PT, PTT, and INR), serum chloride, pH, blood urea, and serum creatinine were measured prior to induction (baseline) and 4 hours after completion of surgery. Results Demographic characteristics were statistically similar between the two groups. Coagulation profile parameters were comparable between the two groups at baseline as well as 4 hours after surgery. pH was significantly lower in the NS group as compared to the PL group at 4 hours after surgery. Postoperatively blood urea, serum creatinine, and serum chloride levels were significantly raised in the NS group as compared to the PL group. Hemoglobin and hematocrit values were similar between the two groups. Conclusion Coagulation profile parameters were normal and statistically similar with intraoperative infusion of NS versus PL in patients undergoing neurosurgical procedures. However, use of PL was associated with a better acid–base and renal profile in these patients.

Comparison of the efficacy of 0.9% normal saline with balanced crystalloid (Plasmalyte) in maintaining the metabolic profile in head injury patients undergoing evacuation of acute subdural haematoma – A randomised controlled trial

“…In two recent RCTs comparing Plasmalyte and NS in neurosurgical patients, including only TBI patients, the authors found that Plasmalyte maintained the metabolic profile better than 0.9% saline. [ 2 16 ] Our results were in agreement with these two studies. In a subgroup analysis of the BaSICS RCT conducted on TBI patients, the authors found that using BCs was associated with a higher 90-day mortality.…”

“…[ 1 ] Although 0.9% normal saline (NS) has been traditionally favoured in neurosurgical patients, its supraphysiological chloride content can lead to hyperchloremic metabolic acidosis and acute kidney injury (AKI) when infused in larger volumes (>2 l). [ 2 3 ] This, coupled with renal ischaemia and reduced glomerular filtration rate (GFR), heightens the risk of AKI. In addition, physiological derangements produced by overzealous IV fluid administration may necessitate further crystalloid and blood product infusions, establishing a vicious cycle.…”

Effect of Fluid Therapy on Acid–Base Balance in Patients Undergoing Clipping for Ruptured Intracranial Aneurysm: A Prospective Randomized Controlled Trial

“…In another study, authors observed that chloride levels in the 0.9 % saline group were persistently higher than the Plasmalyte A group throughout the study period. 9,12 Similarly, rise in chloride levels (up to 115 mEq/L) was noted in patients undergoing surgery for supratentorial tumors when NS was used. 7 In literature, 0.9 % saline is known to cause hyperchloremic metabolic acidosis.…”

“…In a similar study in neurosurgical population, creatinine was significantly elevated in NS group at 4 hours after surgery. 9 The urine NGAL and serum cystatin C emerged as biomarkers of AKI in medical literature. 10,11 Urine NGAL is an early biomarker of AKI seen to rise as early as 6 hours after insult.…”

“…6 Few studies compared BSS with 0.9% saline, and BSS was found to maintain better metabolic parameters like acidbase balance and electrolyte levels in neurosurgical patients with brain tumors. [7][8][9] However, there is no study comparing these two fluids in perioperative fluid management of patients with ruptured aSAH. We hypothesize that BSS will give better perioperative acid-base balance parameters like pH, bicarbonate, anion gap, and preserved renal functions.…”