Plasma-Lyte A is a calcium-free,
balanced crystalloid solution that very closely resembles serum electrolyte concentrations (Na 140
mEq/L, Cl 98 mEq/L, acetate 27 mEq/L, gluconate 23 mEq/L, K 5.0 mEq/L, Mg 3.0
mEq/L, pH 7.4 and 294 mOsm/L). It
is also compatible with blood product transfusions.
Plasma-Lyte A is a resuscitation fluid,
not a maintenance fluid. Once euvolemic and resuscitated, change to D5LR (preferably)
or LR.
Resuscitation of critically
injured and ill patients has classically been with isotonic fluids. 0.9% NaCl
and Ringer’s Lactate (LR) have traditionally been our options. LR, however, becomes hypotonic
after infusion making it an inappropriate solution for acute volume
resuscitation in traumatic brain injury secondary to increased brain edema.
0.9% NaCl has classically been used in TBI as it remains isotonic and will not
cause hyponatremia during resuscitation.
Continued resuscitation with 0.9% NaCl
leads to many untoward side effects in the multiply injured trauma patients,
such as:
1.
Hyperchloremic
metabolic acidosis[1-8]
2.
Renal artery
vasoconstriction and reduced renal cortical blood flow[3-5]
3.
Coagulopathy[9-12]
4.
Decreased and
delayed urine output [9]
5.
Poor acid base
status[3-5, 13]
Plasma-Lyte A is not associated
with these complications and, importantly, will not cause hyponatremia, causes less
hypomagnesemia, allows more rapid clearance of base deficit and return to
normal acid-base status and one can transfuse blood products with it. A recent randomized controlled trial
demonstrated these benefits. [13]
We are recommending all acutely
ill surgical patients and seriously injured trauma patients (Trauma Alerts and
Trauma Alert-Reds), regardless of TBI, be resuscitated with Plasma-Lyte A.
Obviously the TBI patient with elevated intra-cranial pressure warranting
cranial pressure therapy can be switched to a hypertonic maintenance fluid at
any time. Plasma-Lyte A can be used in renal failure as well because there are
only 5 mEq/L of K in a liter of solution.
Plasma-Lyte A is NOT
indicated in:
1.
Severe TBI
requiring intracranial pressure reduction therapy with hypertonic saline
solution
2.
Renal failure
with severe hyperkalemia.
Reference List:
1.
Kellum JA, Song
M, Almasri E. Hyperchloremic acidosis increases circulating inflammatory
molecules in experimental sepsis. Chest. 2006;130:962–967.
2.
Kellum JA, Song
M, Li J. Lactic and hydrochloric acids induce different patterns of
inflammatory response in LPS-stimulated RAW 264.7 cells. Am J Physiol Regul
Integr Comp Physiol. 2004;286:R686–R692.
3.
Bullivant EM,
Wilcox CS, Welch WJ. Intrarenal vasoconstriction during hyperchloremia: role of
thromboxane. Am J Physiol. 1989;256:F152–F157.
4.
Hansen PB,
Jensen BL, Skott O. Chloride regulates afferent arteriolar contraction in
response to depolarization. Hypertension. 1998;32:1066–1070.
5.
Imig JD,
Passmore JC, Anderson GL, Jimenez AE. Chloride alters renal blood flow
autoregulation in deoxycorticosterone-treated rats. J Lab Clin Med.
1993;121:608–613.
6.
Hadimioglu N,
Saadawy I, Saglam T, Ertug Z, Dinckan A. The effect of different crystalloid
solutions on acid-base balance and early kidney function after kidney
transplantation. Anesth Analg. 2008;107:264–269.
7.
McFarlane C, Lee
A. A comparison of Plasmalyte 148 and 0.9% saline for intra-operative fluid
replacement. Anaesthesia. 1994;49:779–781.
8.
Reid F, Lobo DN,
Williams RN, et al. (Ab) normal saline and physiological Hartmann’s solution: a
randomized double-blind crossover study. Clin Sci (Lond). 2003;104:17–24.
9.
Chowdhury AH,
Cox EF, Francis ST, et al. A randomized, controlled, doubleblind crossover
study on the effects of 2-L infusions of 0.9% saline and plasmalyte(R) 148 on
renal blood flow velocity and renal cortical tissue perfusion in healthy
volunteers. Ann Surg. 2012;256:18–24.
10.
Shaw AD, Bagshaw
SM, Goldstein SL, et al. Major complications, mortality, and resource
utilization after open abdominal surgery: 0.9% saline compared to Plasma-Lyte.
Ann Surg 2012;255:821-829
11.
Kiraly LN et al.
Resuscitation With Normal Saline (NS) vs. Lactated Ringers (LR) Modulates
Hypercoagulability and Leads to Increased Blood Loss in an Uncontrolled
Hemorrhagic Shock Swine Model Young JB et al.
12.
Saline Versus
Plasma-Lyte A in Initial Resuscitation of Trauma Patients- A randomized
Controlled Trial. Ann of Surgery. 259:255-262.
