Ringer's Lactate Group Research Articles

Does the type of fluid affect rapidity of shock reversal in an anaesthetized-piglet model of near-fatal controlled haemorrhage? A randomized study

The optimal resuscitation fluid for the early treatment of severe bleeding patients remains highly debated. The objective of this experimental study was to compare the rapidity of shock reversal with lactated Ringer (LR) or hydroxyethyl starch (HES) 130/0.4 at the early phase of controlled haemorrhagic shock. To assess the influence of vascular permeability in this model, we measured plasma vascular endothelial growth factor (VEGF) levels during the experiment. Thirty-six anaesthetized and mechanically ventilated piglets were bled (<30 ml kg(-1)) to hold mean arterial pressure (MAP) at 40 mm Hg for more than 30 min and were resuscitated in two randomized groups: LR (n=14) or HES (n=14) at 1 ml kg(-1) min(-1) until MAP reached its baseline value of ±10%. MAP was maintained at its baseline value for 1 h. The time and fluid volume necessary to restore the baseline MAP value were measured. The time to restore the baseline MAP value of ±10% was significantly lower in the HES group (P<0.001). During the initial resuscitation phase, the infused volume was 279 (119) ml in the HES group and 1011 (561) ml in the LR group (P<0.0001). During the stabilization phase, the infused volume was 119 (124) ml in the HES group and 541 (506) ml in the LR group. Biological data and plasma VEGF levels were similar between the groups. Restoration of MAP was four times faster with HES than with LR in the early phase of controlled haemorrhagic shock. However, there was no evidence of increased vascular permeability.

Inflammatory activity modulation by hypertonic saline and pentoxifylline in a rat model of strangulated closed loop small bowel obstruction

BackgroundIntestinal obstruction is an abdominal disease associated to mortality, especially if complicated with sepsis. Resuscitation increases survival, although controversies remain concerning to therapeutic strategy. MethodsTo assess the effects of hypertonic saline and pentoxifylline on the inflammatory response and oxidative stress, Wistar rats underwent a laparotomy loop intestinal obstruction and ischemia. After 24 h, the intestinal segment was resected (IO) without any other treatment and resuscitation/pentoxifylline were administered according to the group: Ringer's lactate (RL); hypertonic saline (HS); pentoxifylline (PTX); Ringer's lactate with pentoxifylline (RL + PTX); hypertonic saline with pentoxifylline (HS + PTX) and the control group (CG) that was not submitted to ischemia and obstruction. Mean arterial pressure (MAP) was recorded 4 times, and euthanasia was done 3 h after the resuscitation to obtain lung tissue, for malondialdehyde (MDA) by thiobarbituric acid reactive substances (TBARS) method, inflammatory cytokines were assessed using ELISA and NF-κΒ by Western blotting. ResultsThe initial MAP levels were higher in the RL and HS groups than in the others; however, the last measurement was similar among all the groups. IL-1β, IL-6 and CINC-1 (Cytokine-Induced Neutrophil Chemoattractant-1) were lower in the HS, PTX and HS + PTX groups compared with the IO and RL groups. IL-10 was lower in the HS + PTX group than in the IO group. NF-κB in the HS, PTX and HS + PTX groups were lower than in the IO group; NF-κB in the HS + PTX group was lower than in the RL group. MDA in the lung was lower in the HS + PTX group compared with other groups. ConclusionHypertonic saline and pentoxifylline, both alone and in combination, attenuated oxidative stress and the activation of NF-κB, leading to a decrease in the inflammatory response.

A comparison of vasopressin, terlipressin, and lactated ringers for resuscitation of uncontrolled hemorrhagic shock in an animal model.

AimThe aim of this study is to compare the effect of lactated ringer (LR), vasopressin (Vaso) or terlipressin (Terli) on uncontrolled hemorrhagic shock (UHS) in rats.Methods48 rats were divided into four treatment groups for UHS study. Vaso group was given bolus vasopressin (0.8 U/kg); the Terli group was given bolus terlipressin (15 mcg/kg); LR group was given LR and the sham group was not given anything. Mean arterial pressure (MAP), serum lactate level, plasma cytokine levels, lung injury and mortality are investigated for these different treatment groups.ResultsCompared with LR group, vasopressin and terlipressin-treated groups were associated with higher MAP, lowered mortality rates, less lung injury, lowered serum lactate level, less proinflammatory and more anti-inflammatory cytokine production at certain time points. Comparing between vasopressin and terlipressin treated groups, there is no statistical difference in mortality rates, lung injury, serum lactate level and cytokine level. However, there is a difference in the length of time in maintaining a restored level of MAP (80 to 110 mmHg). The terlipressin treated rats can maintain this restored level of MAP for 45 minutes, but the vasopressin treated rats can only maintain this restored level of MAP for 5 minutes before decreasing gradually to the MAP observed in LR group (40 mmHg).ConclusionEarly optimization of hemodynamics with terlipressin or vasopressin in an animal model of UHS was associated with improved hemodynamics and inflammatory cytokine profile than the LR control. Compared with vasopressin, terlipressin has the advantage of ease of use and sustained effects.

Amifostine enhances the antioxidant and hepatoprotective effects of UW and HTK preservation solutions.

To investigate whether amifostine contributes to the antioxidant and cytoprotective effects of histidine-tryptophan-ketoglutarate (HTK) and University of Wisconsin (UW) preservation solutions. Forty-eight Sprague Dawley male rats were equally divided into six groups: (1) ringer Lactate (RL) group; (2) RL + amifostine (RL + A) group; (3) HTK group; (4) HTK + A group; (5) UW group; and (6) UW + A group. Rats in the RL + A, HTK + A and UW + A groups were administered amifostine intraperitoneally at a dose of 200 mg/kg prior to laparotomy. The RL group was perfused with RL into the portal vein. The RL + A group were perfused with RL into the portal vein after amifostine administration. The HTK group received an HTK perfusion while the HTK + A group received an HTK perfusion after administration of amifostine. The UW group received a perfusion of UW, while the UW + A group received a UW perfusion after amifostine administration. Liver biopsy was performed to investigate histopathological, immunochemical [transferase mediated dUTP nick end labeling (TUNEL), inducible nitric oxide syntetase (iNOS)] and ultrastructural alterations. Biochemical alterations were determined by examining levels of alanine aminotransferase, alkaline phosphatase and nitric oxide in the perfusion fluid. Pathological sinusoidal dilatation and centrilobular hydropic alteration were significantly lower in the groups that received amifostine prior to preservation solution perfusion. Although the best results were obtained in the UW + A group, we did not observe a statistically significant difference between the UW + A and HTK + A groups. iNOS grades were significantly lower in the amifostine groups 12 h after treatment. When the amifostine groups were compared against each other, the iNOS grades obtained from the UW + A and HTK + A groups were similar while the RL + A group had a much poorer score. TUNEL assays demonstrated a lower apoptosis ratio in the amifostine groups than in the non-amifostine groups 12 h after treatment. No statistically significant difference was observed between the UW + A and HTK + A groups for apoptosis. Cellular ultrastructure was best preserved in the UW + A and HTK + A groups. Here, we show that preoperative administration of a single dose of amifostine is sufficient to minimize the preservation damage in hepatic cells.

Poly-ADP-Ribose-Polymerase Inhibition Ameliorates Hind Limb Ischemia Reperfusion Injury in a Murine Model of Type 2 Diabetes

Diabetes is known to increase poly-ADP-ribose-polymerase (PARP) activity and posttranslational poly-ADP-ribosylation of several regulatory proteins involved in inflammation and energy metabolism. These experiments test the hypothesis that PARP inhibition will modulate hind limb ischemia reperfusion (IR) in a mouse model of type-II diabetes and ameliorate the ribosylation and the activity/transnuclear localization of the key glycolytic enzyme glyceraldehyde-3-phosphate dehydrogenase (GAPDH). db/db mice underwent 1.5 hours of hind limb ischemia followed by 1, 7, or 24 hours of reperfusion. The treatment group received the PARP inhibitor PJ34 (PJ34) over a 24-hour period; the untreated group received Lactated Ringer (LR) at the same time points. IR muscles were analyzed for indices of PARP activity, fiber injury, metabolic activity, inflammation, GAPDH activity/intracellular localization, and poly-ADP-ribosylation of GAPDH. PARP activity was significantly lower in the PJ34-treated groups than in the Lactated Ringer group at 7 and 24 hours of reperfusion. There was significantly less muscle fiber injury in the PJ34-treated group than in the Lactated Ringer-treated mice at 24 hours of reperfusion. PJ34 lowered levels of select proinflammatory molecules at 7 hours and 24 hours of IR. There were significant increases in metabolic activity only at 24 hours of IR in the PJ34 group, which temporally correlated with increase in GAPDH activity, decreased GAPDH poly-ADP-ribosylation, and nuclear translocation of GAPDH. PJ34 reduced PARP activity, GAPDH ribosylation, and GAPDH translocation; ameliorated muscle fiber injury; and increased metabolic activity after hind limb IR injury in a murine model of type-II diabetes. PARP inhibition might be a therapeutic strategy after IR in diabetic humans.

Reposição volêmica com hidroxietilamido ou solução de ringer lactato em cães com gastroenterite hemorrágica por parvovírus

Parvovirus is an infectious viral disease, highly contagious, affecting dogs causing acute enteritis. Dehydration is a minor problem and acute evolution, which is the main focus of treatment. The objective of this study was to evaluate two treatments volume replacement in dogs with confirmed diagnosis of parvovirus infection by antigen detection in stool by ELISA. A total of 15 dogs, mixed, male and female, aged from 3 to 6 months, these four they had died during treatment and 11 were included in the study. Patients were randomly divided into two groups: hydroxyethyl starch 130/0.4 (HES, n=6) and Group Ringer Lactate (RL, n=5), which received fluid resuscitation with hydroxyethyl starch 130/0.4 and Ringer’s solution lactate, respectively, based on calculations of fluid deficit. All animals received intravenously: cephalothin, metronidazole, ranitidine and metoclopramide. During hospitalization, every 12 hours were evaluated arterial blood gas, electrolyte dosing and clinical examination (heart rate, respiratory rate, rectal temperature, capillary refill time, vomiting, appetite, dehydration, weight gain, hematochezia, melena, hematemesis and presence abdominal pain) and 24 hours each blood count was performed. In group RL was increase in the values of PaO2 and decreases in hemoglobin, hematocrit, phosphorus and magnesium, and group HES, a decrease in the percentage of dehydration, hemoglobin, phosphorus and potassium. There were no differences in other parameters between the groups. Both treatments were effective in fluid replacement of patients, no difference in any variable analyzed.

English

The induction of general anaesthesia with propofol, however, has been associated with a decrease in systolic arterial blood pressure. Various measures to prevent hypotension include preloading with fluids (colloids and crystalloids) and use of vasopressors including ephedrine, dopamine, dobutamine, and metaraminol. The aim of the present study was to compare the three different regimes for the prevention of hypotension during induction of anaesthesia. MATERIALS AND METHODS: Ninety patients, classified as ASA physical status I or II, male/female, aged 20-50 years, body weight 45-85 kg, scheduled for various elective surgeries under general anaesthesia gave written informed consent to participate in this study. Patients were randomly allocated into one of three groups of 30 patients each to receive either normal saline Group C, ephedrine 70μg/kg, or Group E 10ml/kg Ringer Lactate Group RL prior to induction of anaesthesia with propofol (2mg/kg). Parameters analyzed were: heart rate and systemic arterial pressure noninvasively before induction, after propofol administration, immediate post intubation and then at 3min, 5min and at 10 post intubation. RESULTS: In all the groups there was an increase in the systemic arterial pressure post intubation; ephedrine> RL > control group. On comparing the groups at varied intervals the decrease was statistically significant in control group. (P<0.00).On comparing ephedrine group with RL decrease was statistically significant in the ephedrine group at 10mins. (P<0.01). CONCLUSION: We concluded, preoperative administration of ephedrine failed to prevent propofol-induced hypotension, but preoperative volume loading with 10ml/kg of ringer lactate successfully antagonised it, hence provide more haemodynamic stability.

Intravenous fluids for reducing the duration of labour in low risk nulliparous women

Intravenous fluids for reducing the duration of labour in low risk nulliparous women

Effects of resuscitation fluids on endothelial glycocalyx (EG) and coagulation in severe hemorrhagic shock (HS)

To study the effects of resuscitation fluids on changes in coagulation and EG in HS, we studied venules of cremaster muscle of anesthetized rats subjected to 1h of HS (40% of blood volume, HEM only) followed by 1h resuscitation with Hextend (HEX), Ringer's lactate (RL), or fresh frozen plasma (FFP). EG thickness was estimated using dextrans of different molecular weights labeled with FITC or Texas Red. Blood gases, hematocrit, cell count, coagulation tests (ROTEM) were performed. EG thickness was 50% lower in HEM, RL and HEX groups. EXTEM: clotting time [CT] was longer for RL compared to other groups. Clot strength [G] in HEM was higher at post‐resuscitation compared to baseline. FIBTEM: maximal clot elasticity [MCE], maximum clot formation [MCF], thrombin generation and G were lower in RL and HEX groups than the others. Resuscitation with FFP was superior in reverting coagulopathy (no differences in CT, G and MCE compared to Sham) and restoring EG thickness. Resuscitation with RL and HEX reestablished mean arterial pressure and tissue perfusion but caused EG shedding and altered coagulation by reducing clot strength and elasticity, and diluting coagulation factors, in contrast to FFP. We showed that ROTEM can indentify changes in coagulation function in massive blood loss and HS‐associated coagulopathy in a rat model that also displayed microvascular changes.Supported by US Army Medical Research &amp; Materiel Command.

The effect of fluid overload in the presence of an epidural on the strength of colonic anastomoses

BackgroundDespite the beneficial effects of epidurals in intra-abdominal surgery, the incidence of anastomotic leak remains controversial when used. Moreover, studies have also shown that fluid overload may be deleterious to anastomoses. The purpose of this paper is to evaluate the effects of varying intraoperative fluid protocols, in the presence of an epidural, on the burst pressure strength of colonic anastomoses. MethodsAn epidural was installed in 18 rabbits, divided into three groups. Group 1 received 30 mL/kg/h Ringer's lactate, Group 2 received 100 mL/kg/h Ringer's lactate, and Group 3 received 30 mL/kg/h Pentaspan. Two colo-colonic anastomoses were performed per rabbit. On postoperative day 7 the anastomoses were resected and their burst pressures measured as a surrogate for anastomotic leak. ResultsWhen comparing the average burst pressures of all three groups, there was a significant difference (P = 0.04). The anastomoses in the 100 mL/kg/h Ringer's lactate group were shown to be the weakest, with 64% of the anastomoses having burst under 120 mm Hg. The rabbits hydrated with Pentaspan had the highest strength, with no anastomoses bursting under 120 mm Hg. This translated into significant burst pressure differences (P = 0.02) between Group 2 and Group 3. ConclusionThese results suggest that fluid overload with a crystalloid, in the presence of an epidural, may be deleterious to the healing of colonic anastomoses, creating a higher risk of anastomotic leak. Intraoperative resuscitation should thus focus on goal-directed euvolemia with appropriate amounts of colloids and/or crystalloids to prevent the risk of weakening anastomoses, especially in patients with epidurals.

Effect of Hypericum perforatum on intraperitoneal adhesion formation in rats.

IntroductionThe aim of this study was to evaluate the efficacy of Hypericum perforatum for prevention of adhesion formation in rats.Material and methodsTwenty-four female wistar rats underwent left uterine horn adhesion model. Rats were randomised into 4 groups. Group 1 (Control): Closure of abdominal incision without any agent administration. Group 2: Closure of incision after administration of intraperitoneal (i.p.) Ringer's lactate solution. Group 3: Closure of incision after administration of i.p. olive oil (diluent of H. perforatum). Group 4: Hypericum perforatum extract (Ecodab®) was administered i.p. before the closure of incision. Fourteen days later, relaparatomy was performed and surgical adhesion scores, inflammation and fibrosis scores were noted. Groups were compared according to these scores.ResultsThere was statistical significant difference between ringer's lactate group and olive oil group according to surgical adhesion score (p = 0.009). However, groups were not different according to inflammation and fibrosis scores (p > 0.05).ConclusionsDespite antiinflammatory, antioxidants and antimicrobial properties of H. perforatum, our results revealed no positive effect of H. perforatum on the prevention of intraperitoneal adhesion formation.

The effect of 6% Hydroxyethyl starch vs. Ringer's lactate on acute kidney injury after renal ischemia in rats

To compare fluid replacement therapy with Hydroxyethyl starch 6% (HES) versus Ringer's lactate (RL) in a rodent model of non-septic renal ischemia. Forty male Wistar rats were randomized to receive HES 2 ml.kg(-1).hr(-1) or RL 5 ml.kg(-1).hr(-1) that underwent 30 minutes of renal ischemia followed by reperfusion. Twelve hours after kidney ischemia, the kidneys were evaluated for histological changes. Serum NGAL levels were obtained at different times of the experimental protocol. Rodents in the HES group had a median (IQR) grade of renal injury 3 (3 to 5) compared to 2 (2 to 4) in the RL group (p=0.03). NGAL levels were not associated with the severity of kidney injury. Hydroxyethyl starch administration caused more kidney injury than Ringer's lactate in a non-infectious model of renal hypoperfusion.

Evaluation of hemostatic changes using thromboelastography after crystalloid or colloid fluid administration during major orthopedic surgery

The effects of Ringer lactate, 6% hydroxyethyl starch (130/0.4) or 4% succinylated gelatin solutions on perioperative coagulability were measured by thromboelastography (TEG). Seventy-five patients (ASA I-III) who were to undergo major orthopedic procedures performed under epidural anesthesia were included in the study. Patients were randomly divided into three groups of 25 each for the administration of maintenance fluids: group RL (Ringer lactate), group HES (6% hydroxyethyl starch 130/0.4), and group JEL (4% gelofusine solution). Blood samples were obtained during the perioperative period before epidural anesthesia (t1, baseline), at the end of the surgery (t2), and 24 h after the operation (t3). TEG data, reaction time (R), coagulation time (K), angle value (α), and maximum amplitude (MA) were recorded. TEG parameters changed from normal values in all patients. In group RL, R and K times decreased compared to perioperative values while the α angle and MA increased (P < 0.05). In group HES, R and K times increased, however, the α angle and MA decreased (P < 0.05). In group JEL, R time increased (P < 0.05), but K time, α angle and MA did not change significantly. In the present study, RL, 6% HES (130/0.4) and 4% JEL solutions caused changes in the coagulation system of all patients as measured by TEG, but these changes remained within normal limits.

Fluid management in diabetic-acidosis--Ringer's lactate versus normal saline: a randomized controlled trial

To determine if Ringer's lactate is superior to 0.9% sodium chloride solution for resolution of acidosis in the management of diabetic ketoacidosis (DKA). Parallel double blind randomized controlled trial. Patients presenting with DKA at Kalafong and Steve Biko Academic hospitals were recruited for inclusion in this study if they were >18 years of age, had a venous pH >6.9 and ≤7.2, a blood glucose of >13 mmol/l and had urine ketones of ≥2+. All patients had to be alert enough to give informed consent and should have received <1 l of resuscitation fluid prior to enrolment. Fifty-seven patients were randomly allocated, 29 were allocated to receive 0.9% sodium chloride solution and 28 to receive Ringer's lactate (of which 27 were included in the analysis in each group). An adjusted Cox proportional hazards analysis was done to compare the time to normalization of pH between the 0.9% sodium chloride solution and Ringer's lactate groups. The hazard ratio (Ringer's compared with 0.9% sodium chloride solution) for time to venous pH normalization (pH = 7.32) was 1.863 (95% CI 0.937-3.705, P = 0.076). The median time to reach a pH of 7.32 for the 0.9% sodium chloride solution group was 683 min (95% CI 378-988) (IQR: 435-1095 min) and for Ringer's lactate solution 540 min (95% CI 184-896, P = 0.251). The unadjusted time to lower blood glucose to 14 mmol/l was significantly longer in the Ringer's lactate solution group (410 min, IQR: 240-540) than the 0.9% sodium chloride solution group (300 min, IQR: 235-420, P = 0.044). No difference could be demonstrated between the Ringer's lactate and 0.9% sodium chloride solution groups in the time to resolution of DKA (based on the ADA criteria) (unadjusted: P = 0.934, adjusted: P = 0.758) This study failed to indicate benefit from using Ringer's lactate solution compared to 0.9% sodium chloride solution regarding time to normalization of pH in patients with DKA. The time to reach a blood glucose level of 14 mmol/l took significantly longer with the Ringer's lactate solution.

Hydroxyethyl Starch Resuscitation Reduces the Risk of Intra-Abdominal Hypertension in Severe Acute Pancreatitis

This study aimed to address whether hydroxyethyl starch (HES) is beneficial for intra-abdominal pressure (IAP) in severe acute pancreatitis (SAP) in early stages. Forty-one patients with SAP were randomized to HES group (n = 20) and the Ringer's lactate (RL) group (n = 21). The groups received 6% HES 130/0.4 for 8 days and RL solution without colloid, respectively. The primary end point was the IAP. The secondary end points were fluid balance, major organ complications, the Acute Physiology and Chronic Heath Evaluation II score, and the serum levels of C-reactive protein, interleukin-6, and interleukin-8. The characteristics of baseline data were similar in the 2 groups. In the HES group, the IAP was significantly lower in 2 to 7 days, and fewer patients received mechanical ventilation (15.0% vs 47.6%). A negative fluid balance was observed earlier in the HES group than in the RL group (2.5 ± 2.2 vs 4.0 ± 2.5 days). Fluid resuscitation with HES in the early stages of SAP can decrease the risk of intra-abdominal hypertension and reduce the use of mechanical ventilation.

Fluid Replacement in Craniofacial Pediatric Surgery

Pediatric craniofacial surgery requires large amounts of intravenous fluid replacement that may alter the ionic composition of body compartments. Normal (0.9%) saline (NS) and Ringer's lactate (RL) solutions are commonly used, with different advantages and disadvantages. Our hypothesis was that there would be more acidosis with NS but with no advantage of NS over RL regarding the incidence of hyponatremia. Our objective was to determine whether acid-base and electrolyte outcomes could guide fluid management in this group of patients. A retrospective study of 122 children younger than 5 years who underwent craniofacial surgery was performed: 63 received only NS (NS group) and 59 received RL (RL group). Blood gases, plasma sodium, and potassium concentrations were analyzed during 2 different periods: 1 to 2 hours from anesthetic induction (P-1) and 2 to 4 hours from anesthetic induction (P-2). Statistical comparisons were made with χ test and t-test, as appropriate. Acidosis was more frequent in NS group than in RL patients during P-1 and P-2: 66% and 80% in the NS group versus 26% and 37% in the RL group. Severe acidosis (pH ≤ 7.25) was also more frequently in those receiving NS (39%) than RL (8%); and so was a base excess of -5 or less: NS = 53% and RL = 16%. The incidence of hyponatremia (Na < 135 mmol/L) was similar in both groups: 40% (NS) and 26% (RL) during P-1 and 52% (NS) and 50% (RL) during P-2. In young children undergoing craniofacial surgery, RL may be a preferred crystalloid over NS because metabolic acidosis is less frequent, with no increased incidence of hyponatremia.

Haemodynamic and renal effects of resuscitation of dogs from haemorrhagic shock with hypertonic saline or Lactated Ringer's solution combined with whole blood

Despite numerous studies on haemorrhagic shock treatment, the choice of fluid and the rate of administration is a subject of controversy. Early haemodynamic effects, neuroendocrine response and renal function following acute sodium load with either hypertonic saline (HS) or Lactated Ringer's (LRS) were investigated in a model of controlled haemorrhagic shock. Six anaesthetized dogs were bled 30% of calculated blood volume, i.e., 27 ml/kg b.w. over 15 min and left untreated for 30 min. Afterward, the dogs were treated with either HS 4 ml/kg b.w. or LRS 81 ml/kg b.w., followed by whole blood. After a resting period of at least 30 days, the dogs underwent a similar second shock experiment, but with the second solution. Haemodynamics, renal effects and neuroendocrine response were studied during shock and at 15, 30, 45 and 60 min after administration of HS or LRS and 30 and 60 min after the addition of whole blood. LRS treatment resulted in significantly higher cardiac filling pressures and cardiac performance indexes than HS but, following whole blood administration, there were no differences between treatments, except that pulmonary capillary wedge pressure was higher in the LRS group. Urinary output and glomerular filtration rate index were restored to normal values by both treatments; however, they were significantly higher in the LRS group until whole blood was administered. LRS and HS restored plasma norepinephrine to baseline values with no difference between the treatments. Both solutions improved haemodynamics and renal function but their effects were short lived and whole blood was required for a favourable outcome, regardless of the initial solution used. In contrast to LRS, HS did not overload the cardiovascular system.

A comparison of Ringer's lactate and acetate solutions and resuscitative effects on splanchnic dysoxia in patients with extensive burns

We compared the effects of Ringer's lactate (RL) and acetate (RA) solutions on parameters of splanchnic dysoxia such as PgCO 2 (PCO 2 of gastric mucosa) and pH i (pH of gastric mucosa) using a gastric tonometer, in addition to blood markers such as the serum arterial level of lactate, base excess, ketone body ratio, and antithrombin during the first 72 h of the resuscitation period in patients with burns covering 30% or more of their body surface. A prospective study was conducted in the university tertiary referral centers. There were no significant differences in the average age, TBSA (total burn surface area), and resuscitative fluid volume during the first and second 24 h between the two groups. In the RA group, PCO 2 gap values calculated employing the formula: PgCO 2 − PaCO 2 (arterial PCO 2), and pH gap calculated by: pH a (arterial pH) − pH i, improved to the normal ranges at 24 h postburn, which was significantly faster than in the RL group. On the other hand, there were no significant differences in blood parameters between the two groups over the course. These results suggest that fluid resuscitation with RA may more rapidly ameliorate splanchnic dysoxia, as evidenced by gastric tonometry, compared to that with RL.

RAP Trial: Ringer's Lactate and Packed Red Blood Cell Transfusion, An in Vitro Study and Chart Review.

Abstract 2105Poster Board II-82 Background:The Canadian Blood Services and the American Association of Blood Banks state that intravenous solution administered with packed red blood cells (pRBC) must be isotonic and must not contain calcium or glucose. This recommendation is based on in vitro investigations demonstrating that calcium containing solutions can initiate in vitro coagulation in citrated blood (Ryden 1975, Dickson 1980, Lorenzo 1998). Recently this recommendation has been challenged by in vitro studies that combined AS-3 pRBC with Ringer's Lactate (RL) (Albert 2009). Currently there are anaesthetists that use RL with pRBC for intra-operative transfusions. The purpose of this study was to evaluate whether RL, as compared with normal saline (NS), can safely be used in transfusion therapy. Methods:Eleven units of AS-3 pRBC were obtained for this study. In part A, multiple dilutions of blood with RL or NS were assessed for clot, both visually using a 20 micron filter and molecularly using F1+2 ELISA. In part B, blood was run through a standard gravity filter with NS or RL, to simulate both ward and intra-operative transfusion practice. The blood was then assessed for clot at times 30, 60, 120, and 240 minutes. In part C, patients who received intra-operative transfusions of pRBC with RL were identified. These charts were reviewed for evidence of transfusion reactions including: TRALI, arterial or venous thrombosis, coagulopathy and mortality. Results:In part A, none of the filters had evidence of visible clot, nor evidence of thrombin generation at supraphysiologic levels, >300 pmol/L (Ota 2008, Pelzer 1991). In part B, there was no visible evidence of clot at the preselected time points. Over four hours the NS + blood group F1+2 levels ranged from 12- 267 pmol/L, and the RL + blood F1+2 levels ranged from 14-218 pmol/L. In the transfusion set primed with blood and then RL added, a simulation of common operating room transfusion practice, the F1+2 ELISA levels ranged from 13-435 pmol/L. There were no statistically significant difference in the ELISA F1+2 between the NS and RL groups (NS + blood vs. RL + blood p= 0.547, NS + blood vs. blood +RL p= 0.663). Nine patients totaling 36 units of pRBC transfused with RL were reviewed. The transfusion times ranging from 15-95 minutes, with an average transfusion time of 30 minutes per unit of pRBC. There was no evidence of transfusion related adverse events identified. Discussion:In addition to our results confirming recent studies that demonstrate in vitro compatibility of pRBC with RL, our study is the first comprehensive study involving visual clot, molecular clot and intra-operative transfusion of pRBC with RL. We have utilized a 20 micron filter, whereas previous studies utilized 40 micron filters. Further, in contrast to other studies we are the first to investigate the effects of both the concentration of RL with blood and the transfusion duration; no other study has looked at four hour transfusions with RL. Conclusion:Our study adds credibility to the hypothesis that RL is safe for clinical transfusion, including intra-operative and ward transfusion practice. Although new evidence now challenges international transfusion guidelines, a larger study should be conducted before transfusion with RL is adopted into widespread clinical practice. Disclosures:No relevant conflicts of interest to declare.

Ringer’s lactate is compatible with the rapid infusion of AS-3 preserved packed red blood cells

Ringer's lactate (RL) may be preferable to normal saline (NS) for large volume resuscitation. Authorities recommend against its mixture with packed red blood cells (PRBC) due to a theoretical risk of clotting. The purpose of this study was to test whether RL, as compared with NS, leads to a risk of clotting when used to dilute AS-3 preserved PRBC in a clinically relevant model. Following Ethics Board approval, eight units of unused, unexpired AS-3 preserved PRBC were obtained. Four sets of two parallel studies were performed, comparing RL with NS as the diluent for PRBC. The mixtures were infused using gravity flow through standard blood filter tubing and fluid warmer, to simulate an intraoperative blood transfusion. A series of progressively more dilute samples was collected. These were filtered and analyzed macroscopically, then using enzyme-linked immunosorbent assay to quantify the amount of F1+2 (the breakdown products of thrombin generation). No filters in any of the NS and RL mixtures contained evidence of clot or debris. In the NS group, the F1+2 levels ranged from 2.7 to 38.0 pmol x L(-1). In the RL group, the F1+2 levels ranged from 3.2 to 289.7 pmol x L(-1). All of these values were below the physiologic levels determined in previous studies. In this simulation of intraoperative blood transfusion, RL did not lead to visible or molecular evidence of activation of the clotting cascade. The current study challenges recommendations that AS-3 PRBC should not be mixed with RL for rapid transfusion.