Journal of Acute Care

Register      Login

VOLUME 1 , ISSUE 2 ( May-August, 2022 ) > List of Articles

Original Article

Balanced Salt Solution in Type-2 Diabetes Mellitus undergoing Off-pump Coronary Artery Bypass Grafting: Ringer Lactate vs Plasmalyte®

Kedar Bangal, Sriram Korukonda, C Reddy Sampath K, Raghu Bheemiah

Keywords : Blood sugar, Electrolyte balance, Insulin, Potassium, Renal dysfunction, Systemic inflammatory response syndrome, Tracheotomy

Citation Information : Bangal K, Korukonda S, Sampath K CR, Bheemiah R. Balanced Salt Solution in Type-2 Diabetes Mellitus undergoing Off-pump Coronary Artery Bypass Grafting: Ringer Lactate vs Plasmalyte®. 2022; 1 (2):51-55.

DOI: 10.5005/jp-journals-10089-0020

License: CC BY-NC 4.0

Published Online: 31-12-2022

Copyright Statement:  Copyright © 2022; The Author(s).


Background: Coronary artery bypass grafting (CABG) is a surgical option for patients with significant coronary artery disease (CAD) who are not suitable candidates for percutaneous interventions. Cardiopulmonary bypass (CPB) with cardiac arrest (on-pump) provides a surgical field free of motion and blood, allowing safe anastomosis construction. Off-pump CABG (OPCABG) avoids serious complications associated with CPB such as stroke, renal dysfunction, and systemic inflammatory response syndrome. Intravenous fluids are administered to maintain the circulation blood volume and cardiac output during surgical manipulation of the heart during OPCABG. This study was performed to compare the effects of Ringer's lactate (RL) and Plasmalyte® (PL) on the acid base status and electrolyte balance in patients suffering from type-2 diabetes mellitus (T2-DM) undergoing elective OPCABG surgery. Methods: After obtaining ethical approval and informed consent, this study was performed on patients with type-2 DM undergoing elective OPCABG. Patients undergoing CABG on CPB, concomitant procedures, emergency, renal dysfunction, conversion to CPB were excluded. OPCABG was performed as per the standard institutional protocol. Intraoperative management of DM was done using recommended guidelines namely maintenance of blood sugar between 140 and 180 mg% and insulin infusion titrated to achieve the blood glucose in the desired range. Serum potassium was maintained between 4 and 5 mmol/L. Arterial blood gases and lactate levels were determined at two hourly intervals throughout the perioperative period. Comparison of serum lactate levels, base deficit levels, potassium levels, and pH values was done by paired t-test. Outcome measures included low-output state, renal dysfunction, bleeding, tracheotomy, ICU stay, hospital stay, and mortality. Results: There were 50 patients in the group with 25 in each group. None of the patients was converted to on-pump and complete data were available to all patients. At 12th postoperative hour, lactate was significantly lower (p < 0.014) and serum potassium levels were significantly higher (p < 0.018) in PL group. When compared to the PL group, the base excess levels were significantly higher (p < 0.035) in ringer lactate group at 24th postoperative hour. Excepting for this, there were no significant differences in any of the measured parameters, outcomes, length of ICU stay, and hospital stay in the two groups. Conclusion: In well-controlled patients of type-2 DM with precise perioperative monitoring and management of blood glucose and serum potassium, there were no significant differences in outcomes between RL and PL in diabetic patients undergoing OPCABG.

  1. GBD 2017 Causes of Death Collaborators. Global, regional, and national age–sex–specific mortality for 282 causes of death in 195 countries and territories, 1980–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 2018;392(10159):1736. DOI: 10.1016/S0140-6736(18)32203-7
  2. GBD 2017 DALYs and HALE Collaborators. Global, regional, and national disability–adjusted life–years (DALYs) for 359 diseases and injuries and healthy life expectancy (HALE) for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 2018;392(10159):1859. DOI: 10.1016/S0140-6736(18)32335-3
  3. Gorter PM, Olijhoek JK, Van der Graaf Y, et al. Prevalence of metabolic syndrome in patients with coronary heart disease, cerebrovascular disease, peripheral arterial disease or abdominal aortic aneurysm. Atherosclerosis 2004;173(2):363–369. DOI: 10.1016/j.atherosclerosis.2003.12.033
  4. Palmer BF. A physiologic-based approach to the evaluation of a patient with hyperkalemia. Am J Kidney Dis 2010;56(2):387–393. DOI: 10.1053/j.ajkd.2010.01.020
  5. Tzamaloukas AH, Ing TS, Elisaf MS, et al. Abnormalities of serum potassium concentration in dialysis-associated hyperglycemia and their correction with insulin: a unique clinical/physiologic exercise in internal potassium balance. Int Urol Nephrol 2010;42(4):1015–1022. DOI: 10.1007/s11255-010-9831-7
  6. Inzucchi SE, Lipska KJ, Mayo H, et al. Metformin in patients with type-2 diabetes and kidney disease: a systematic review. JAMA 2014;312(24):2668–2675. DOI: 10.1001/jama.2014.15298
  7. Ranucci M, De Toffol B, Isgrò G, et al. Hyperlactatemia during cardiopulmonary bypass: determinants and impact on postoperative outcome. Crit Care 2006;10(6):R167. DOI: 10.1186/cc5113
  8. Ranucci M, Isgro G, Carlucci C, et al. Central venous oxygen saturation and blood lactate levels during cardiopulmonary bypass are associated with outcome after pediatric cardiac surgery. Crit Care 2010;14(4):R149. DOI: 10.1186/cc9217
  9. Inoue S, Kuro M, Furuya H. What factors are associated with hyperlactatemia after cardiac surgery characterized by well-maintained oxygen delivery and a normal postoperative course? A retrospective study. Eur J Anaesthesiol 2001;18(9):576–584. DOI: 10.1046/j.1365-2346.2001.00893.x
  10. Atalla HA, Abulkassem MS, Abo Elenine KM. Assessment of intraoperative use of Ringer acetate in patients with liver cirrhosis. Alexandria J Anaesth Intensive Care 2005;8(2):75–82.
  11. Surabhi S, Kumar M. Comparison of ringer's lactate and plasmalyt-a as cardiopulmonary bypass prime for bypass associated acidosis in valve replacement surgeries. Ann Card Anaesth 2021;24(1):36–41. DOI: 10.4103/aca.ACA_104_19
  12. Gu YJ, Boonstra PW. Selection of priming solutions for cardiopulmonary bypass in adults. Multimed Man Cardiothorac Surg 2006;2006(109). DOI: 10.1510/mmcts.2005.001198
  13. American Diabetes Association. 2. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes–2018. Diabetes Care 2018;41(Suppl 1):S13-S27. DOI: 10.2337/dc18-S002
  14. Moghissi ES, Korytkowski MT, DiNardo M, et al. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Diabetes Care 2009;32(6):1119–1131. DOI: 10.2337/dc09-9029
  15. Kim JY, Joung KW, Kim KM, et al. Relationship between a perioperative intravenous fluid administration strategy and acute kidney injury following off-pump coronary artery bypass surgery: an observational study. Crit Care 2015;19:350. DOI: 10.1186/s13054-015-1065-8
  16. Yunos NM, Bellomo R, Hegarty C, et al. Association between a chloride-liberal vs chloride-restrictive intravenous fluid administration strategy and kidney injury in critically ill adults. JAMA 2012;308(15):1566–1572. DOI: 10.1001/jama.2012.13356
  17. Meyer E. A review of renal protection strategies. South Afr J Anaesth Analg 2015;21(2):1– 4. DOI: 10.1080/22201181.2015.9
  18. McCluskey SA, Karkouti K, Wijeysundera D, et al. Hyperchloremia after noncardiac surgery is independently associated with increased morbidity and mortality: a propensity-matched cohort study. Anesth Analg 2013;117(2):412–421. DOI: 10.1213/ANE.0b013e318293d81e
  19. 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(5):821–829. DOI: 10.1097/SLA.0b013e31825074f5
  20. Young JB, Utter GH, Schermer CR, et al. Saline versus Plasma-Lyte A in initial resuscitation of trauma patients: a randomized trial. Ann Surg 2014;259(2):255–262. DOI: 10.1097/SLA.0b013e318295feba
  21. Poole-Wilson PA. Acidosis and contractility of heart muscle. Ciba Found Symp 1982;87:58–76. DOI: 10.1002/9780470720691.ch4
  22. Morgan TJ. The ideal crystalloid – What is ’balanced’? Curr Opin Crit Care 2013;19(4):299–307. DOI: 10.1097/MCC.0b013e3283632d46
  23. Vashisth A, Saleem Y, Darbari A, et al. Comparative study to assess the effect of priming solutions (Plasmalyte-A and Ringer Lactate) on Acid–base balance during cardiopulmonary bypass for adult cardiac surgery. Res Cardiovasc Med 2022;11(2):49–53. DOI: 10.4103/rcm.rcm_65_21
  24. Mahler SA, Conrad SA, Wang H, et al. Resuscitation with balanced electrolyte solution prevents hyperchloremic metabolic acidosis in patients with diabetic ketoacidosis. Am J Emerg Med 2011;29(6):670–674. DOI: 10.1016/j.ajem.2010.02.004
  25. Shin WJ, Kim YK, Bang JY, et al. Lactate and liver function tests after living donor right hepatectomy: a comparison of solutions with and without lactate. Acta Anaesthesiol Scand 2011;55(5):558–564. DOI: 10.1111/j.1399-6576.2011.02398.x
  26. Hadimioglu N, Saadawy I, Saglam T, et al. The effect of different crystalloid solutions on acid-base balance and early kidney function after kidney transplantation. Anesth Analg 2008;107(1):264–269. DOI: 10.1213/ane.0b013e3181732d64
PDF Share
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.