Studies in non-cardiac surgery populations have suggested that the use of 0.9% saline may increase bleeding compared to buffered crystalloids, although this has not been confirmed in other studies. In this post-hoc, subgroup analysis (study 1) and prospective, single-centre nested cohort (study 2) from the SPLIT (0.9% saline vs. PL-148 for ICU fluid therapy) trial, the investigators hypothesised that patients receiving Plasma-Lyte 148 would require fewer blood products and have less post-operative bleeding than those receiving saline.
In the United States, 10–25% of all blood product transfusions are administered to patients who have received cardiac surgery (Ferraris & Ferraris, 1995; Hartmann et al., 2006; Makar et al., 2010). Reducing the need for blood products may be possible through the appropriate use of intravenous (IV) fluids, with animal and some surgical studies suggesting that buffered crystalloids may reduce the need for blood product transfusions versus saline (Waters et al., 2001; Brummel-Ziedins et al., 2006; Kiraly et al., 2006; Shaw et al., 2012). However, prior to the SPLIT study, such comparisons had not been performed in a cardiac surgery population.
Plasma-Lyte 148 (PL-148) is a buffered crystalloid fluid that is calcium-free and has electrolyte levels that more closely mimic human plasma than saline. The authors of this study hypothesised that the use of PL-148 would result in a lower requirement for blood products and less post-operative bleeding following cardiac surgery compared with 0.9% saline (Reddy et al., 2017).
In the first study, the authors performed a post-hoc analysis of the prospective, investigator-initiated, multicentre, blinded, cluster-randomised, double-crossover SPLIT study. In SPLIT, 2,262 patients were enrolled and blinded saline or PL-148 was used for four alternating 7-week blocks at the ICU level. From these patients, 954 cardiac surgery patients were identified and included within study 1 with 475 receiving PL-148 and 479 receiving 0.9% saline.
The primary outcome was the proportion of patients who received blood products (packed red blood cells [PRBCs], fresh frozen plasma [FFP], platelets, or cryoprecipitate) during the first 3 days in the ICU (Figure 1) (Reddy et al., 2017).
Unexpectedly, the use of PL-148 in cardiac surgery patients was associated with a significant increase in the need for blood and blood products than the use of saline. Patients receiving PL-148 also required a significantly higher volume of PRBC, FFP and platelets (Reddy et al., 2017).
In study 2, the authors used chest drain losses as a surrogate marker for bleeding among cardiac surgery patients enrolled in the SPLIT study within a single study centre. This pre-planned secondary analysis analysed 2,251 patients and included 131 patients receiving PL-148 and 120 receiving 0.9% saline.
The primary outcome of this study was chest drain output and no significant differences were observed between the groups (566 mL with PL-148 vs. 547 mL with saline; P=0.60). However, as observed in study 1, patients receiving PL-148 required significantly more blood or blood products than those receiving saline (30.5% vs. 18.3%; OR = 1.96; 95% CI = 1.08–3.54; P=0.03) (Reddy et al., 2017).
The results of this study suggest that the use of buffered crystalloid fluids, such as PL-148, may increase the need for blood products in patients who have undergone cardiac surgery, although no differences were observed in chest drain losses/bleeding (Reddy et al., 2017). This is contrary to the author’s hypothesis and differs to previous research in different patient populations (Shaw et al., 2012; Krajewski et al., 2015). Given the post-hoc nature of this study, and the pre-study administration of crystalloid fluids to patients, further studies are required to confirm the association between PL-148 and increased blood product use in cardiac surgery patients.
Catch-up on the debate surrounding hydroxyethyl starch use as we take you on an interactive journey through its changing fortunes. Do you think current restrictions will be enough to change clinical practice?
Brummel-Ziedins K, Whelihan MF, Ziedins EG, Mann KG. The resuscitative fluid you choose may potentiate bleeding. J Trauma. 2006;61(6):1350–8.
Ferraris VA, Ferraris SP. Limiting excessive postoperative blood transfusion after cardiac procedures. A review. Tex Heart Inst J. 1995;22(3):216–30.
Hartmann M, Sucker C, Boehm O, Koch A, Loer S, Zacharowski K. Effects of cardiac surgery on hemostasis. Transfus Med Rev. 2006;20(3):230–41.
Kiraly LN, Differding JA, Enomoto TM, Sawai RS, Muller PJ, Diggs B, 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. J Trauma. 2006;61(1):57–64.
Krajewski ML, Raghunathan K, Paluszkiewicz SM, Schermer CR, Shaw AD. Meta-analysis of high- versus low-chloride content in perioperative and critical care fluid resuscitation. Br J Surg. 2015;102(1):24–36.
Makar M, Taylor J, Zhao M, Farrohi A, Trimming M, D’Attellis N. Perioperative Coagulopathy, Bleeding, and Hemostasis During Cardiac Surgery. A Comprehensive Review. ICU Director. 2010;1:1–27.
Reddy SK, Bailey MJ, Beasley RW, Bellomo R, Mackle DM, Psirides AJ, et al. J Cardiothorac Vasc Anesth. 2017;31(5):1630–8.
Shaw AD, Bagshaw SM, Goldstein SL, Scherer LA, Duan M, Schermer CR, et al. Major complications, mortality, and resource utilization after open abdominal surgery: 0.9% saline compared to Plasma-Lyte. Ann Surg. 2012;255(5):821–9.
Waters JH, Gottlieb A, Schoenwald P, Popovich MJ, Sprung J, Nelson DR. Normal saline versus lactated Ringer's solution for intraoperative fluid management in patients undergoing abdominal aortic aneurysm repair: an outcome study. Anesth Analg. 2001;93(4):817–22.
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