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

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. Electronic supplementary material The online version of this article (10.1186/s13054-019-2423-8) contains supplementary material, which is available to authorized users.

Perioperative fluid management for major elective surgery

“…A recent trial comparing normal saline with buffered solutions in patients undergoing major abdominal surgery was terminated prematurely because of the increased need for vasopressor therapy in the saline group, possibly related to hyperchloraemic metabolic acidosis. Among balanced fluids, data are still lacking to guide selection of the optimal buffer (lactate or acetate).…”

The Surviving Sepsis Campaign: Fluid Resuscitation and Vasopressor Therapy Research Priorities in Adult Patients

“…3) What are the implications of acetate and gluconate contained in some balanced solutions? In cardiac surgery patients, an acetate-based balanced solution had similar hemodynamic effects compared with lactated ringers ( 57 ). However, significant infusion of acetate may contribute to vasoplegia and myocardial dysfunction in patients with kidney dysfunction ( 58 , 59 ).…”

The surviving sepsis campaign: fluid resuscitation and vasopressor therapy research priorities in adult patients

“… What are the implications of acetate and gluconate contained in some balanced solutions? In cardiac surgery patients, an acetate-based balanced solution had similar hemodynamic effects compared with lactated Ringer’s [ 57 ]. However, significant infusion of acetate may contribute to vasoplegia and myocardial dysfunction in patients with kidney dysfunction [ 58 , 59 ].…”