1. Robert G. Hahn, MD, PhD Research Director, Södertälje Hospital; Professor of Anesthesiology, Linköping University; Associate professor, Karolinska institute, Sweden. BAXTER Satellite Symposium Why do balanced crystalloids change the paradigm?

2. Fluid therapy might be more difficult than you think! Fluid Management Crystalloid Colloid Balanced Unbalanced Natural Isotonic Saline Ringer´s Solution Plasma-Lyte Ringer’s Lactate Ringer’s Acetate Hartmann’s Human Albumin Blood Different fluids with different modes of action, and different side effects HES Dextran Gelatin Synthetic MD-IV-235 09-2013

3. …metabolic acidosis which increases breathing and serum potassium. ….impairs renal blood flow and GFR by 10-15%. …symptoms on 2-L infusion (slight mental confusion, abdominal pain)

4. Niels Van Regenmortel Balanced Crystalloids – from Evidence to Clinical Reality Robert Hahn Conclusion - alternatives to HES and saline Dileep Lobo Key Considerations to Make the Right Choice

6. * Isotonic saline Osmolar substances Isotonic saline (mOsm/L H 2 O) Extracellular (mOsm/L H 2 O) Plasma*Interstitial* Sodium (Na + )154142139 Potassium (K + )04.24 Calcium (Ca 2+ )01.31.2 Magnesium (Mg 2+ )00.80.7 Chloride (Cl - )154100 Bicarbonate (HCO 3 - )02428.3 Protein01.20.2 Others020.319.4 Total mOsm/l308295 Reference values taken from Guyton´s Textbook of Physiology. They are affected by many variables, including the patient population and the laboratory methods used

7. Ringer´s lactate Osmolar substances Ringer´´s lactate (mOsm/L) Extracellular (mOsm/L) Plasma*Interstitial* Sodium (Na + )131142139 Potassium (K + )54.24 Calcium (Ca 2+ )21.31.2 Magnesium (Mg 2+ )10.80.7 Chloride (Cl - )111100 Bicarbonate (HCO 3 - )30 (lactate)2428.3 Protein01.20.2 Others020.319.4 Total mOsm/l279295 Reference values are affected by many variables, including the patient population and the laboratory methods used

8. Sterofundin Osmolar substances Sterofundin (mOsm/L H 2 O) Extracellular (mOsm/L H 2 O) Plasma*Interstitial* Sodium (Na + )145142139 Potassium (K + )44.24 Calcium (Ca 2+ )2.51.31.2 Magnesium (Mg 2+ )00.80.7 Chloride (Cl - )127100 Bicarbonate (HCO 3 - )24 (acetate), 5 (malate)2428.3 Protein01.20.2 Others020.319.4 Total mOsm/l309295 Reference values are affected by many variables, including the patient population and the laboratory methods used

9. Plasma-Lyte Osmolar substances Plasma-Lyte (mOsm/L) Extracellular (mOsm/L) Plasma*Interstitial* Sodium (Na + )140142139 Potassium (K + )54.24 Calcium (Ca 2+ )01.31.2 Magnesium (Mg 2+ )1.50.80.7 Chloride (Cl - )98100 Bicarbonate (HCO 3 - )27 (acetate), 24 (gluconate) 2428 Protein01.20.2 Others020.319.4 Total mOsm/l295 Reference values are affected by many variables, including the patient population and the laboratory methods used

10. Acetate – a buffer similar to lactate, but can be metabolized in all body cells and not only in the liver (and kidney). * Metabolized to HCO 3 faster than lactate. * Requires only half as much O 2 as lactate to produce HCO 3. * Does not confuse serum lactate measurements in shock states. Gluconate – a food additive used to improve taste. * Occurs naturally in fruit juice and honey. * Daily production in intermediary metabolism 30 g per day (approximately 4 L of PlasmaLyte per day). * TOXNET: Non-toxic. Low priority for further work.

11. J Crit Care 2012; 27: 138-145. After 4-6 hours of Plasma-Lyte versus isotonic saline: Bicarbonate correction 8.4 versus 1.7 mmol/l After 6-12 hours of Plasma-Lyte versus isotonic saline: Bicarbonate correction 12.8 versus 6.2 mmol/l

12. Comparison between Ringer och NaCl i.v. Williams et al. Anesthesia & Analgesia 1999; 88: 999-103. 20 volunteers Ringer or NaCl 50 ml/kg i.v./1 h. Tiredness and ”problems to think” in 13/20 after NaCl, none after Ringer. Abdominal pain after NaCl in 10/20 volunteers, only 1/20 after Ringer. First void after 106 min for NaCl, 80 min for Ringer. pH fell 0.04 after NaCl.

13. NaCl during surgery Wilkes et al. Anesthesia & Analgesia 2001; 93: 811-816 Randomized to NaCl or Ringer, c:a 4 liters. 47 pat. > 60 years, major surgery. NaCl was followed by: –Metabolic acidosis (standard bicarbonate -5.5 mmol/L). –Poorer blood perfusion of the gut. –Half as high urinary flow. –Adverse events 379 versus 272. –Nausea and vomiting 23 versus 12 events. –Postoperative vomiting in 8 versus 3 patients.

14. 60 patients from 4 tertiary hospitals. Compared to Hartmann, PlasmaLyte was followed by: * Smaller base deficit (0.4 mmol/L) * Serum chloride levels lower. * Lactate levels lower (0.8 mmol/L) * Fewer complications

15. Summary isotonic saline vs. balanced fluids Isotonic saline gives rise to metabolic acidosis and inhibits kidney function – kidney injury? Various symptoms on infusion. More complications after surgery. Higher mortality? Plasma-Lyte is a slight/moderate improvement over buffered Ringer solutions – ”balance” is optimal.

16. Indications for isotonic saline Vomiting Head injury (or use PlasmaLyte) Pediatric surgery (or use PlasmaLyte) Hyponatraemia & hypochloraemia Together with erythrocytes (or use PlasmaLyte)

18. Robert G. Hahn, MD, PhD Research Director, Södertälje Hospital; Professor of Anesthesiology, Linköping University; Associate professor, Karolinska institute, Sweden. ABSTRACT SESSION

19. Serum urea/creatinine ratio predicts successful loop diuretic therapy in congestive heart failure Verbrugge F, Duchenne J, Dupont M, Mullens W Evaluation of CardioPAT autotransfusion system in elective cardiac surgery De Decker K, Bogaert T, Gooris T, Stockman B

20. Congestive heart failure Expanded heart chambers (BNP rise) Fluid retention due to impaired kidney perfusion (renin etc. high) Treated with fluid restriction, diuretics and vasodilators

21. J Am Coll Cardiol 2011; 58: 383-385

22. Evaluation of CardioPAT autotransfusion system in elective cardiac surgery De Decker K, Bogaert T, Gooris T, Stockman B