Anybody using Plasmalyte routinely?

[VentdependenT]

There is a trend at my institution to use plasmalyte in cases requiring large amounts of fluid.

Anybody using this stuff on a regular basis?

It seems like the ideal solution. No worries about developing hyopnatremia (as in LR) or hyperchloremic acidosis (as in 0.9NS). Plus its got a lil' bit of gluconate (which should turn into bicarb) and acetate (supposedly decrease renal loss of bicarb).

Dunno about the price difference.

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[Jeff05]

we use plasmalyte exclusively.

it IS the ideal solution.

 

[jetproppilot]

Nope.

But sounds like we need to look into it.

 

[InductionAgent]

We use Plasmalyte at the VA hospital and Normosol (a similar neutral pH, Na+140 entity) at the county hospital. I use those as my default fluids. I'm not sure if there's an evidence base, but it seems like a good idea. Also, they're not much more expensive to my knowledge.

Exceptions in which I use 0.9% NS are situations requiring close K+ control (e.g. peds, renal failure). Also I use normal saline for intracranial neuro cases in which slightly hypertonic fluid is preferable. Finally, if I get a low (but not frightening) sodium on a blood gas (consistent with ADH response to pain), I often switch my fluids to 0.9% NS.

 

[Planktonmd]

We use Plasmalyte at the VA hospital and Normosol (a similar neutral pH, Na+140 entity) at the county hospital. I use those as my default fluids. I'm not sure if there's an evidence base, but it seems like a good idea. Also, they're not much more expensive to my knowledge.

Exceptions in which I use 0.9% NS are situations requiring close K+ control (e.g. peds, renal failure). Also I use normal saline for intracranial neuro cases in which slightly hypertonic fluid is preferable. Finally, if I get a low (but not frightening) sodium on a blood gas (consistent with ADH response to pain), I often switch my fluids to 0.9% NS.

😕
I have never seen anybody develop hyponatremia intraoperatively as a response to pain!

 

[dhb]

we use plasmalyte exclusively.

it IS the ideal solution.

we do too

 

[InductionAgent]

😕
I have never seen anybody develop hyponatremia intraoperatively as a response to pain!

I've read more than once that pain is a stimulus for ADH release and with that can come hyponatremia. I can't think of too many other reasons why a patient with normal renal function receiving isotonic fluid would develop hyponatremia. I've certainly seen plenty of it on blood gases.

But in any case, whatever the reason the hyponatremia exists, I prefer to give 0.9% NS over isotonic fluid in those circumstances.

 

[thegasman]

nuthin normal about normal saline. Plasmalyte is where its at. It is a little more expensive though so for short low volume cases I usually just use LR. But if it is a big case or I am giving a lot of fluid (or running blood) plasmalyte it is.

 

[JP2005]

we use it here for our livers

 

[militarymd]

perioperative hyponatremia is a VERY common electrolyte abnormality...IF you do big cases....not going to see it if all you do all day are hernia repairs....or if you don't check labs...or if you don't see your patients post op...and don't check their labs...

I've read more than once that pain is a stimulus for ADH release and with that can come hyponatremia. I can't think of too many other reasons why a patient with normal renal function receiving isotonic fluid would develop hyponatremia. I've certainly seen plenty of it on blood gases.

But in any case, whatever the reason the hyponatremia exists, I prefer to give 0.9% NS over isotonic fluid in those circumstances.

 

[Frank Rizzo]

We use Plasmalyte at the VA hospital and Normosol (a similar neutral pH, Na+140 entity)

How similar is it? I'm asking because we dont' even have plasmalyte available to us... never used it. I do use normosol quite frequently in large cases.

 

[Planktonmd]

perioperative hyponatremia is a VERY common electrolyte abnormality...IF you do big cases....not going to see it if all you do all day are hernia repairs....or if you don't check labs...or if you don't see your patients post op...and don't check their labs...

🙄

You see it if your patients have severe perioperative PAIN caused by crappy anesthesia and crappier post op pain management.

 

[coprolalia]

No, but I've seen the results of medicine residents in the ICU massively resuscitating patients with normal saline. Want to talk about fcuked-up labs...

-copro

 

[epidural man]

I know nothing about this stuff.....sounds good though.

Here is a little stuff from the FDA about it

"PLASMA-LYTE A Injection pH 7.4 is a sterile, nonpyrogenic isotonic solution in a single dose container for intravenous administration. Each 100 mL contains 526 mg of Sodium Chloride, USP (NaCl); 502 mg of Sodium Gluconate (C6H11NaO7); 368 mg of Sodium Acetate Trihydrate, USP (C2H3NaO2•3H2O); 37 mg of Potassium Chloride, USP (KCl); and 30 mg of Magnesium Chloride, USP (MgCl2•6H2O). It contains no antimicrobial agents. The pH is adjusted with sodium hydroxide. The pH is 7.4 (6.5 to 8.0).

PLASMA-LYTE A Injection pH 7.4 administered intravenously has value as a sousrce of water, electrolytes, and calories. One liter has an ionic concentration of 140 mEq sodium, 5 mEq potassium, 3 mEq magnesium, 98 mEq chloride, 27 mEq acetate, and 23 mEq gluconate. The osmolarity is 294 mOsmol/L (calc). Normal physiologic osmolarity range is 280 to 310 mOsmol/L. Administration of substantially hypertonic solutions may cause vein damage. The caloric content is 21 lcal/L.

PLASMA-LYTE A Injection pH 7.4 produces a metabolic alkalinizing effect. Acetate and gluconate ions are metabolized ultimately to carbon dioxide and water, which requires the consumption of hydrogen cations."

They say it is compatible with mixing it with RBC's. Why can't I mix LR with RBC's (something I do all the time)?

 

[urge]

They say it is compatible with mixing it with RBC's. Why can't I mix LR with RBC's (something I do all the time)?

Calcium. LR has calcium, plasmalyte does not.

I have mixed blood and LR too. I have given calcium through a transfusion line also. As long as you keep it running it will not clot. Leave it standing for a while and it will.

 

[VentdependenT]

You guys think that Acetate or Gluconate does anything (just like the lactate in LR)?

I mean, your kidneys are just gonna piss out extra bicarb anyhoots.

I just put all my peeps in the SICU on it who need crystalloid infusions. Why? Because then I can teach the nurses/residents who ask why? Oh, and for the patient of course.

 

[powermd]

I like the concept, but in practice I don't see much utility for plasmlyte. The stuff costs $7/bag, which is outrageous for such minimal benefit. We use it only in liver transplants, but sparingly, because the goal is almost always to be able to close the abdomen at the end. If you *really* need volume in these cases, the answer is usually PRBC and FFP, not crystalloid. Most of our livers get less than 3L plasmalyte, but 10-15 U PRBC and 6-8 FFP.

I've yet to have hyponatremia from LR or "pain under anesthesia" wtf?? Maybe I just do a good job titrating opioids, or don't check lytes often enough to notice. We'll use LR even in our ESRD patients here. I've yet to see one get massively hyperkalemic from 3 L LR for a transplant.

 

[VentdependenT]

I like the concept, but in practice I don't see much utility for plasmlyte. The stuff costs $7/bag, which is outrageous for such minimal benefit. We use it only in liver transplants, but sparingly, because the goal is almost always to be able to close the abdomen at the end. If you *really* need volume in these cases, the answer is usually PRBC and FFP, not crystalloid. Most of our livers get less than 3L plasmalyte, but 10-15 U PRBC and 6-8 FFP.

I've yet to have hyponatremia from LR or "pain under anesthesia" wtf?? Maybe I just do a good job titrating opioids, or don't check lytes often enough to notice. We'll use LR even in our ESRD patients here. I've yet to see one get massively hyperkalemic from 3 L LR for a transplant.

Dude, your average liver gets 10 and 8? Holy christ I wish we had your transplant guys. Our average liver: 60 and 60

 

[nutmegs]

Dude, your average liver gets 10 and 8? Holy christ I wish we had your transplant guys. Our average liver: 60 and 60

:blink:
cell saver?

 

[VentdependenT]

:blink:
cell saver?

I dunno. It just continually dumps into our belmont. I've had cases where we've had TWO of the big cell saver machines running with the big canisters and all 4 cansiters would fill up from exsanguination. The perfusionist was moving so fast he looked like a friggen ron of japan chef.

You ever see a veno-veno bypass line? Well, the perfusion dudes where having to hook up to that to push more blood in with us. We just couldn't get it in fast enough even with two double lumen cordis runnen wide open a belmont up to as high as it goes (liter per minute I think), a level one with someone working it with NASCAR efficiency, and another body pressure bagging in stuff.

Great cases they are these Rush livers!

 

[dhb]

I dunno. It just continually dumps into our belmont. I've had cases where we've had TWO of the big cell saver machines running with the big canisters and all 4 cansiters would fill up from exsanguination. The perfusionist was moving so fast he looked like a friggen ron of japan chef.

You ever see a veno-veno bypass line? Well, the perfusion dudes where having to hook up to that to push more blood in with us. We just couldn't get it in fast enough even with two double lumen cordis runnen wide open a belmont up to as high as it goes (liter per minute I think), a level one with someone working it with NASCAR efficiency, and another body pressure bagging in stuff.

Great cases they are these Rush livers!

Seems like your local butcher would be a better option than your surgeons... A lot of people do livers with minimal transfusions.

 

[pd4emergence]

I dunno. It just continually dumps into our belmont. I've had cases where we've had TWO of the big cell saver machines running with the big canisters and all 4 cansiters would fill up from exsanguination. The perfusionist was moving so fast he looked like a friggen ron of japan chef.

You ever see a veno-veno bypass line? Well, the perfusion dudes where having to hook up to that to push more blood in with us. We just couldn't get it in fast enough even with two double lumen cordis runnen wide open a belmont up to as high as it goes (liter per minute I think), a level one with someone working it with NASCAR efficiency, and another body pressure bagging in stuff.

Great cases they are these Rush livers!

Venty,
Livers can be fun. The liver guys where I trained where the sh it. Every once in a while we would have a blood bath but usually only about a loss of 500cc-1000cc. I only had one go on veno-veno bypass and that was because the patient had known IHSS and it was planned. I usually only had to give 4-6 units of blood, it was almost overkill to even have the rapid infuser in there. I had one liver where I only gave 2 units of blood. These cases were just plain fun. The patients were usually extubated the next day in the ICU and they were on the floor in 3-4 days. When my cirrhosis kicks in this is where I plan to go.

 

[VentdependenT]

Venty,
Livers can be fun. The liver guys where I trained where the sh it. Every once in a while we would have a blood bath but usually only about a loss of 500cc-1000cc. I only had one go on veno-veno bypass and that was because the patient had known IHSS and it was planned. I usually only had to give 4-6 units of blood, it was almost overkill to even have the rapid infuser in there. I had one liver where I only gave 2 units of blood. These cases were just plain fun. The patients were usually extubated the next day in the ICU and they were on the floor in 3-4 days. When my cirrhosis kicks in this is where I plan to go.

Yeah...that sounds nice. But I'm done with livers. I never want to see another one.

 

[InductionAgent]

I've yet to have hyponatremia from LR or "pain under anesthesia" wtf?? .

Taken from Barash Clinical Anesthesia Fifth Edition

"Anesthesia, surgery, and trauma elicit a generalized endocrine metabolic response characterized by an increase in the plasma levels of cortisol, ADH, renin, catecholamines, and endorphines."

Here's the journal articles they cite:

Weissman C: The metabolic response to stress: An overview and update. Anesthesiology 73:308, 1990.

Woolf PD: Hormonal responses to trauma. Crit Care Med 20: 216, 1992

In some cases the ADH response probably outweighs the cortisol and RAA response in terms of sodium balance.

Pain is just one of many factors in perioperative stress involved in ADH release. I've pushed plenty of fentanyl in some cases in which I've seen hyponatremia.

 

[fakin' the funk]

I like the concept, but in practice I don't see much utility for plasmlyte. The stuff costs $7/bag, which is outrageous for such minimal benefit.

I thought LR and NS cost like $10-15/bag...? 😕

 

[InductionAgent]

I thought LR and NS cost like $10-15/bag...? 😕

If you're willing to pay $15 for a bag of NS, I have a bridge in New York I'd like to sell you.

 

[Noyac]

Taken from Barash Clinical Anesthesia Fifth Edition

"Anesthesia, surgery, and trauma elicit a generalized endocrine metabolic response characterized by an increase in the plasma levels of cortisol, ADH, renin, catecholamines, and endorphines."

Here's the journal articles they cite:

Weissman C: The metabolic response to stress: An overview and update. Anesthesiology 73:308, 1990.

Woolf PD: Hormonal responses to trauma. Crit Care Med 20: 216, 1992

In some cases the ADH response probably outweighs the cortisol and RAA response in terms of sodium balance.

Pain is just one of many factors in perioperative stress involved in ADH release. I've pushed plenty of fentanyl in some cases in which I've seen hyponatremia.

YOu can stop arguing this point IA. It's true and well supported. They can believe it or not. But I haven't seen it. Its rare. 👍

 

[Noyac]

I thought LR and NS cost like $10-15/bag...? 😕

I think our charge to the hospital is $.79

The pt charge is more like $79.

Mostly a guess but I'll bet I'm in the ballpark.