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Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 12  |  Issue : 3  |  Page : 719-723  

Evaluation of the metabolic profile of ringer lactate versus ringer acetate in nondiabetic patients undergoing major surgeries


Department of Anaesthesiology and Critical Care, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India

Date of Web Publication11-Sep-2018

Correspondence Address:
Dr. Manjulatha Kannan
Department of Anaesthesiology, Amrita Institute of Medical Sciences, Kochi - 682 041, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aer.AER_109_18

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   Abstract 

Background: Stress-induced neuroendocrine and metabolic changes lead to intraoperative hyperglycemia which is related to surgery and the type of intravenous fluids used. Aims: The primary objective was to assess the incidence of hyperglycemia with use of lactate versus acetate-based intravenous fluids in nondiabetics undergoing major surgeries. Incidence of lactatemia and metabolic acidosis were also assessed. Settings and Design: Prospective parallel group observational study conducted in a tertiary care institute. Subjects and Methods: A total of 208 nondiabetic patients undergoing major head and neck free flap or abdominal surgeries were included in the study. Group A received Ringer lactate, and Group B received Ringer acetate as intraoperative maintenance fluid. Intraoperative blood sugar, pH, and lactate levels were monitored. Statistical Tests Used: Chi-square test and independent “t” test were used for analysis. Results: Intraoperative hyperglycemia was more frequent in Group A than B (17.3 vs. 18.4%). Group B patients undergoing gastrointestinal (GI) surgeries showed higher blood glucose at 2, 4, 6, and 8 h when compared to flap surgeries. In Group A, significantly higher blood sugar values were noted at 2 and 8 h in those undergoing GI surgeries. Group B patients undergoing GI surgeries had significantly higher lactate levels at 6 and 8 h. Group B patients had significant acidosis when surgeries lasted >6 h. Conclusion: Nondiabetic patients undergoing major abdominal surgeries who received acetate-based fluids had relatively higher intraoperative blood sugar levels as compared to those receiving lactated solutions, but the incidence of hyperglycemia was comparable. When the duration of surgery exceeded 6 h, acetate-based solutions resulted in significantly higher lactate levels with progressive metabolic acidosis.

Keywords: Acetate, hyperglycemia, lactate, metabolic acidosis


How to cite this article:
Balakrishnan S, Kannan M, Rajan S, Purushothaman SS, Kesavan R, Kumar L. Evaluation of the metabolic profile of ringer lactate versus ringer acetate in nondiabetic patients undergoing major surgeries. Anesth Essays Res 2018;12:719-23

How to cite this URL:
Balakrishnan S, Kannan M, Rajan S, Purushothaman SS, Kesavan R, Kumar L. Evaluation of the metabolic profile of ringer lactate versus ringer acetate in nondiabetic patients undergoing major surgeries. Anesth Essays Res [serial online] 2018 [cited 2018 Dec 13];12:719-23. Available from: http://www.aeronline.org/text.asp?2018/12/3/719/240864


   Introduction Top


Surgery provokes major changes in the neuroendocrine, metabolic, and immune systems which result in the stress response.[1] Patients are exposed to multiple other factors such as, perioperative fasting, temperature fluctuations, use of multiple drugs besides tissue damage, and bleeding all of which adds to this stress response. The stress response results in the systemic release of adrenocorticotrophic hormone (ACTH), cortisol, catecholamine, aldosterone, arginine vasopressin (AVP), glucagon, acute-phase reactants, and cytokines to provide the host with energy along with retention of sodium and water to maintain cardiovascular homeostasis. This stress state can result in harmful effects on the patient such as hyperglycemia, cardiovascular instability (hypertension and tachycardia), and immunosuppression.[2]

Hyperglycemia in the perioperative period has been recognized as one of the risk factors for increased mortality and morbidity. We balance our anesthetic techniques to reduce the stress response and its deleterious effects. There are numerous studies which have looked into the blood glucose levels in diabetic patients undergoing cardiac surgery and in critically ill patients. Perioperative blood glucose is not routinely monitored in nondiabetic patients and has not been well studied. The choice of fluid is dependent on the underlying illness that a patient has. Lactate containing fluids are avoided in diabetic patients, and potassium-containing fluids are avoided in patients with renal failure. The aim of perioperative fluid therapy is to maintain tissue perfusion, cellular oxygenation and to maintain homeostasis of fluids and electrolytes.

Aim of study

The primary objective of this study was to compare the incidence of hyperglycemia with the use of lactate versus acetate based intravenous fluids in nondiabetic patients undergoing major surgeries of duration >3 h. Secondary objectives were to study the incidence of lactatemia and metabolic acidosis in these patients.


   Subjects and Methods Top


The present study was conducted at a tertiary care hospital in South India in the Department of Anesthesiology during the period from December 2014 to August 2016. This was a prospective parallel group observational study. After the Hospital Ethical Committee approval was obtained, nondiabetic patients with preoperative glucose random blood sugar <140 mg/dl or fasting blood sugar <110 mg/dl and postprandial blood sugar <140 mg/dl were selected to be included in the study. Patients were allocated to one of the two study groups. Group A patients received Ringer Lactate as the maintenance fluid while Group B patients received only Ringer acetate (Kabilyte, Fresenius Kabi R) as the maintenance fluid.

The patients were allotted into either Group A or Group B based on the choice of fluid of the covering consultant anesthesiologist. A search of the literature did not reveal any studies comparing Ringer lactate with Ringer acetate in nondiabetic patients. As there was no similar study published, an initial pilot study was done with 10 patients in each group. Based on the results of the pilot study for obtaining 80% power and 95% confidence interval a minimum sample size of 211 was required in each group.

All patients who were nondiabetic and were to undergo elective prolonged surgeries of >3 h were included in the study. The other inclusion criteria were age between 18 and 80 years, the American Society of Anesthesiologists (ASA) physical status 1–3 patients undergoing nephrectomy, gastrectomy, colectomy, open prostatectomy, nephroureterectomy, ureteric reimplantation, and free flap surgeries were included. Diabetic patients, patients undergoing emergency surgery, pregnant women and patients with renal failure and liver disease were excluded from the study.

All patients were administered general anesthesia, and the need for epidural anesthesia was decided based on the type of surgeries the patients were to undergo. Patients undergoing gastrointestinal (GI) surgical procedures had received general anesthesia with epidural whereas patients undergoing laparoscopic surgeries or flap surgeries did not receive an epidural. An arterial line was secured, and an arterial blood sample was obtained to have baseline blood glucose, lactate, and acid-base status. Arterial blood gas (ABG) was then collected every 2 h until the end of surgery.

Half of the total deficit was corrected in the 1st hour of surgery and the remaining half of the deficit was corrected in the next 2 h. The maintenance fluids were administered to maintain mean arterial pressure (MAP) >65–70 mmHg and urine output >0.5 ml/kg/h. Blood loss exceeding the maximum allowable loss was assessed and replaced with three times the volume of loss by maintenance fluid used as per the study group the patient belonged to. After replacement with crystalloids if the patients' MAP was still found low blood and blood products or 0.45% saline with 20% albumin or inotropes and vasopressors were used to maintain the normal hemodynamic status.

ABG was repeated every 2 h as per the protocol, and the blood glucose, lactates, and acid-base status of the patients were documented. Blood glucose value of >180 mg/dl were considered as hyperglycemia and treated with an insulin bolus. The insulin dose was calculated by blood sugar value/100 and was administered as bolus. Blood sugars were rechecked after 1 h if insulin was used. Insulin infusion was instituted for sugar value >200 mg/dl and the total amount of insulin used in each patient was calculated at the end of surgery. Blood lactate and acidosis were also assessed from the ABG and it was documented.

Numerical variables were expressed as a mean and standard deviation, whereas categorical variables were expressed as frequency and percentages. To obtain association of categorical variables such as acidosis between the Ringer Lactate and Ringer acetate groups, Chi-square test was applied. To compare the statistical significance of numerical variables such as glucose and lactate with groups and subsets, independent “t” test was applied. The statistical analysis was performed using SPSS software Version 20.0 for Windows (IBM Corporation ARMONK, NY, USA).


   Results Top


The data of 217 patients were analysed [Figure 1]. The two groups had comparable demographic characters such as age, weight, sex, ASA physical status, and type of surgery or type of anesthesia. We analyzed the blood glucose levels between the two groups. It was found that only 17.3% (n = 18) in Group A had a blood glucose level of >180 mg/dl, whereas in Group B 18.4% (n = 19) had a glucose level >180 mg/dl. This difference was not statistically significant (P = 0.831) [Figure 2]. The blood glucose levels of the patients in the two groups were studied two hourly. There was no statistically significant difference between the two groups [Table 1].
Figure 1: Flow diagram

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Figure 2: Comparison of incidence of hyperglycemia between the groups

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Table 1: Two hourly comparison of blood glucose between the two groups

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On comparing blood glucose, based on the type of surgery patient underwent (i.e., GI vs. free flap), Group B patients who underwent GI surgeries showed significantly higher blood glucose levels at 2 h (136.59 ± 27.62, P = 0.002), 4 h (144 ± 30.30, P = 0.027), 6 h (151.32 ± 30.89, P = 0.017) and 8 h (161.83 ± 22.17, P = 0.009) [Table 2] whereas Group A patients who underwent GI surgeries, showed significantly higher blood sugar values only at 2 h (133.63 ± 31.04, P = 0.03) and at 8 h (182.15 ± 40.09, P = 0.007) as shown in [Table 3].
Table 2: Glucose levels in different surgeries based on duration in Group B

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Table 3: Glucose levels in different surgeries based on duration in Group A

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Lactate levels were compared between the two groups. It was again noted that patients in group B undergoing GI surgeries had a significantly higher lactate levels at 6 h (2.86 ± 1.58, P = 0.005) and at 8 h (3.69 ± 1.93, P = 0.002) as shown in [Figure 3]. In Group A, patients a similar rise in lactate levels were not observed in patients undergoing GI surgery [Figure 4].
Figure 3: Lactate levels in Group B undergoing different surgeries

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Figure 4: Lactate levels in Group A undergoing different surgeries

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When Group A and Group B were compared to assess the influence of fluids on acid-base profile, Group B showed significant acidosis in patients whose surgeries lasted >6 h (18.6%, P = 0.027) as in [Table 4].
Table 4: Comparison of acidosis between the two groups

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   Discussion Top


Stress response to surgery and anesthesia may be aggravated by multiple factors such as preoperative fasting, temperature fluctuations, use of drugs, tissue damage, and bleeding. The stress response results in the systemic release of ACTH, cortisol, catecholamine, aldosterone, AVP glucagon, acute phase reactants, and cytokines in an effort to provide the host with energy along with retention of sodium and water to maintain cardiovascular homeostasis. This high-stress state can result in harmful outcomes for the patient.

We observed a significantly higher blood glucose levels in the patients receiving acetate based solution undergoing GI surgery when compared to patients undergoing reconstructive flap surgeries. In the patients receiving lactate-based solution higher blood sugars were noted in the patients undergoing GI surgeries, but the occurrence was less frequent. When the incidence of hyperglycemia (blood glucose level >180 mg/dl) was compared between the two groups, there was no significant difference between the two groups.

Hyperglycemia in the perioperative period results in increased morbidity and mortality outcome after surgery.[2],[3] We balance our anesthetic techniques to reduce the stress response and its deleterious side effects. Intraoperative blood glucose in nondiabetic patients undergoing elective major surgery under general anesthesia have been studied, and it has been found that dextrose containing fluids as opposed to ringer lactate increases the incidence of hyperglycemia in this subset of patients.[4] The choice of fluid is dependent on the underlying illness the patient has. Ringer Lactate is the most common maintenance fluid used in the perioperative period but always with the fear of lactates being converted to glucose especially in diabetic patients. However, in our study, it was found that there was no significant difference in the incidence of hyperglycemia based on the duration of surgery in the two groups.

Gastrointestinal surgeries are associated with increased stress response as well as higher fluid shifts, blood losses, and hence greater hemodynamic fluctuations when compared to flap surgeries which are more superficial surgeries. Higher blood glucose levels were seen in patients undergoing GI surgeries in both the groups, though a significantly higher level of glucose was observed in patients receiving ringer acetate. This was also noticed by Kumar et al.[5] in their study where progressively higher blood glucose was noticed in the Kabilyte group. Acetate has a role in carbohydrate and fat metabolism and can rarely cause a slight increase in glucose level.[6] These results were similar to the previous study done by Maitra et al.[7] which showed that maintenance fluid therapy with dextrose-containing solution resulted in a higher incidence of hyperglycemia when compared to Ringer's Lactate. The choice of fluids along with the type of surgery the patient undergoes influences the blood glucose level in this subset of patients.

The secondary objective of our study was to look at lactate levels and the metabolic acidosis. We observed a higher lactate level in patients undergoing GI surgery with duration >6 h receiving ringer acetate solution. There was also a higher incidence of acidosis in the Ringer acetate group undergoing prolonged surgeries.

Higher lactate levels in Ringer acetate group are different from the previous studies conducted by Kumar et al.[8] in donor hepatectomy and Hadimioglu et al.[7] in kidney transplantation. Kumar et al.[8] concluded that the acetated fluids had higher bicarbonate, lesser base deficit, glucose, and chloride as well as lower lactate than Ringer's lactate with normal saline. Hadimioglu [9]et al. compared three fluids normal saline, Ringer's lactate, and plasmalyte and found that the best metabolic profile is with plasmalyte. The contradicting result in our study cannot be explained.

The finding of a higher incidence of acidosis in the ringer acetate group in our study is contradictory to the previous study conducted by Hofmann-Kiefer et al.[10] who found that acetated and lactated solutions did not show any superior acid-base profile over each other. One of the reasons could be the lower pH range of the Ringer acetate solution which is 4.0–8.0 when compared to Ringer lactate which is 6–7.5. The more physiological pH of Ringer lactate may have resulted in less acidosis in this group.

Limitations of our study are that the use of steroids and use of vasopressors or inotropes have not been assessed and analyzed. These drugs could also increase the blood glucose level by stimulating glycolysis and gluconeogenesis. Preoperative volume status of the patient was not assessed as the central line was inserted only after induction of GA, and it was not inserted in all patients. This might have an influence on the blood glucose and lactate levels in patients. Being a tertiary referral hospital, we cater to a large group of patients who have multiple medical problems, and so it has been difficult to get enough numbers of nondiabetic patients coming for surgeries to have an adequately powered study. Blood loss and the use of blood products have not been analyzed in the study. Only GI surgeries and free flap surgeries were included in the study, further research involving larger number of patients undergoing different surgeries is needed to know the influence of fluids used and the surgeries on the metabolic profile in nondiabetic patients.

Our study thus revealed ringer lactate has a better metabolic profile when compared to acetate-based solutions in nondiabetic patients without liver dysfunction. So Ringer lactate can be used safely in nondiabetic patients undergoing major surgeries with a normal metabolic profile and at a reduced cost. However further studies should be conducted in a larger population considering different types of surgeries to support this study results.


   Conclusion Top


Nondiabetic patients undergoing major abdominal surgeries who received acetate based fluids had relatively higher intraoperative blood sugar levels as compared to those receiving lactate based solutions, but the incidence of hyperglycemia was not significantly different between groups. When the duration of surgery exceeded 6 h, use of acetate-based solutions resulted in significantly higher lactate levels with progressive metabolic acidosis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Desborough JP, Hall GM. Endocrine response to surgery. In: Kaufman L, editor. Anaesthesia Review. Vol. 10. Edinburg: Churchill Livingstone; 1993. p. 131-48.  Back to cited text no. 1
    
2.
Scholl R, Bekker A, Babu R. Neuroendocrine and immune responses to surgery. Internet J Anaesth 2012;30:1-8.  Back to cited text no. 2
    
3.
Tilak V, Schoenberg C, Castro AF 3rd, Sant M. Factors associated with increases in glucose levels in the perioperative period in non-diabetic patients. Open J Anaesth 2013;3:176-85.  Back to cited text no. 3
    
4.
Desborough JP. The stress response to trauma and surgery. Br J Anaesth 2000;85:109-17.  Back to cited text no. 4
    
5.
Kumar AK, Pratyusha AC, Kavita J, Ramachandran G. Comparative study of effect of intra-operative administration of ringer's lactate, sterofund in, plasmalyte-A and kabilyte on ionic and acid base status. Med Pulse Int J Anesthesiol 2017;4:59-67.  Back to cited text no. 5
    
6.
Zander R. Fluid Management. Bibliomed-Medizinsche Verlagsgesellschaft; 2008.p21, 30. Available from: https://www.physioklin.de/fileadmin/userupload/./fluid_management_1109. [Last accessed on 2018 Jun 30].  Back to cited text no. 6
    
7.
Maitra S, Kirtania J, Pal S, Bhattacharjee S, Layek A, Ray S. Intraoperative blood glucose levels in non-diabetic patients undergoing elective major surgery under general anaesthesia receiving different crystalloid solutions for maintenance fluid. Anesth Essays Res 2013;7:183-8.  Back to cited text no. 7
  [Full text]  
8.
Kumar L, Seetharaman M, Rajmohan N, Ramamurthi P, Rajan S, Varghese R, et al. Metabolic profile in right lobe living donor hepatectomy: Comparison of lactated ringer's solution and normal saline versus acetate based balanced salt solution – A pilot study. Indian J Anaesth 2016;60:719-25.  Back to cited text no. 8
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9.
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;107:264-9.  Back to cited text no. 9
    
10.
Hofmann-Kiefer KF, Chappell D, Kammerer T, Jacob M, Paptistella M, Conzen P, et al. Influence of an acetate-and a lactate-based balanced infusion solution on acid base physiology and hemodynamics: An observational pilot study. Eur J Med Res 2012;17:21.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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