Avaliação da administração de Plasmalyte 148 ou solução salina a 0,9 no equilíbrio ácido-base em pacientes submetidos à neurocirurgia: ensaio clínico randomizado
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2023-04-13
Autores
Thom, Murilo Moreira
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Universidade Estadual Paulista (Unesp)
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Introdução: A escolha do fluido utilizado para reposição volêmica é um desafio em neurocirurgia. Objetivo do estudo: Avaliou-se os efeitos do Plasmalyte 148 ou da solução salina a 0,9% sobre o equilíbrio ácido-base e hidroeletrolítico em pacientes submetidos à cirurgia intracraniana. Delineamento: Ensaio clínico randomizado controlado duplo-cego. Cenário: Este estudo foi realizado no Hospital das Clínicas da Faculdade de Medicina de Botucatu no período de janeiro de 2019 a fevereiro de 2020. Pacientes: Adultos submetidos a cirurgia intracraniana. Intervenções: Os pacientes foram randomizados para receber Plasmalyte 148 ou solução salina a 0,9% a 2 ml.kg-1.h1. O volume de fluidos foi ajustado de acordo com a pressão arterial média e a variação da pressão de pulso. Medições: Foram coletadas amostras de gasometria arterial e eletrólitos plasmáticos. O resultado da análise do pH sanguíneo ao término da cirurgia foi considerado como o desfecho primário. Os desfechos secundários foram a dosagem de HCO3-, excesso de bases e eletrólitos plasmáticos, lactato, glicemia, extubação em sala operatória, tempo de internação hospitalar e em unidade de terapia intensiva, déficit neurológico novo e mortalidade. Resultados principais: Trinta e três e trinta e cinco pacientes nos grupos Plasmalyte 148 e solução salina a 0,9%, respectivamente, completaram o estudo. Os volumes totais (mediana [quartis]) de cristaloides administrados foram 2.227 (1.416, 3.000) e 3.000 (2.000, 4.000) nos grupos Plasmalyte 148 e solução salina a 0,9%, respectivamente (p = 0,107). Ao término do procedimento cirúrgico, os valores médios (desvio padrão) de pH, HCO3-, excesso de bases e cloreto foram 7,39 ± 0,04 e 7,35 ± 0,05 (p < 0,001), 22,5 ± 1,8 e 20,6 ± 2,2 mmol.l-1 (p < 0,001), -1,6 ± 2,3 e -3,9 ± 2,6 (p < 0,001) e 109,1 ± 6,6 e 113,9 ± 4,5 mmol.l-1 (p = 0,001) nos grupos Plasmalyte 148 e salina a 0,9%, respectivamente. O cálcio iônico sérico foi reduzido no grupo Plasmalyte 148 em comparação com o grupo salina a 0,9% (1,14 ± 0,04 versus 1,17 ± 0,05 mmol.l-1; p = 0,040). Não houve diferenças entre os grupos quanto aos demais desfechos secundários. Conclusões: Para situações habituais de neurocirurgias eletivas sem grandes demandas de reposição volêmica, o uso do Plasmalyte 148 está associado a maiores valores de pH sanguíneo, bicarbonato arterial e excesso de bases, e mais baixos de cloro plasmático ao término da cirurgia, embora o pH permaneça dentro da faixa fisiológica normal em ambos os grupos, não implicando em acidose. Considerações finais: Não havendo diferença na incidência de distúrbios ácidobase ou eletrolíticos entre os grupos, entendemos que essa vantagem teórica do Plasmalyte não lhe garante relevância clínica suficiente para recomendar seu uso rotineiro sobre a amplamente utilizada, estudada, barata e segura solução salina a 0,9% em neurocirurgia.
Introduction: The choice of fluid used for volume replacement is a challenge in neurosurgery. Study objective: The effects of Plasmalyte 148 or 0.9% saline solution on acid-base and hydro-electrolyte balance in patients undergoing intracranial surgery were evaluated. Design: Double-blind randomized controlled clinical trial. Setting: This study was conducted at the Clinical Hospital of Botucatu Medical School from January 2019 to February 2020. Patients: Adults undergoing intracranial surgery. Interventions: Patients were randomized to receive either Plasmalyte 148 or 0.9% saline at 2 ml.kg-1.h-1. Fluid volume was adjusted according to mean arterial pressure and pulse pressure variation. Measurements: Arterial blood gas and plasma electrolyte samples were collected. Blood gas pH analysis result at the end of surgery was considered as primary endpoint. The secondary outcomes were HCO3-, base excess and plasma electrolytes, lactate, glycemia, extubating in the operating room, length of hospital and intensive care unit stay, new neurological deficit and mortality. Main results: Thirty-three and thirty-five patients in the Plasmalyte 148 and 0.9% saline groups, respectively, completed the study. The total volumes (median [quartiles]) of crystalloids administered were 2227 (1416, 3000) and 3000 (2000, 4000) in the Plasmalyte 148 and 0.9% saline groups, respectively (p = 0.107). At the end of the surgical procedure, the mean values (standard deviation) of pH, HCO3, Base Excess and chloride were 7.39 ± 0.04 and 7.35 ± 0.05 (p < 0.001), 22.5 ± 1.8 and 20.6 ± 2.2 mmol.l-1 (p < 0.001), -1.6 ± 2.3 and -3.9 ± 2.6 (p < 0.001) and 109.1 ± 6.6 and 113.9 ± 4.5 mmol.l-1 (p = 0.001) in Plasmalyte 148 and 0.9% saline groups, respectively. Serum ionic calcium was reduced in the Plasmalyte 148 group compared to the 0.9% saline group (1.14 ± 0.04 versus 1.17 ± 0.05 mmol.l-1; p = 0.040). There were no differences between the groups regarding the other secondary outcomes. Conclusions: For usual elective neurosurgery situations without major volume replacement demands, the use of Plasmalyte 148 is associated with higher blood pH, arterial bicarbonate and base excess, and lower plasma chloride values at the end of surgery, although pH remains within the normal physiologic range in both groups, not implying acidosis. Final considerations: As there is no difference in the incidence of acid-base or electrolyte disturbances between groups, we understand that this theoretical advantage of Plasmalyte 148 does not guarantee enough clinical relevance to recommend its routine use over the widely used, studied, cheap and safe 0.9% saline in neurosurgery.
Introduction: The choice of fluid used for volume replacement is a challenge in neurosurgery. Study objective: The effects of Plasmalyte 148 or 0.9% saline solution on acid-base and hydro-electrolyte balance in patients undergoing intracranial surgery were evaluated. Design: Double-blind randomized controlled clinical trial. Setting: This study was conducted at the Clinical Hospital of Botucatu Medical School from January 2019 to February 2020. Patients: Adults undergoing intracranial surgery. Interventions: Patients were randomized to receive either Plasmalyte 148 or 0.9% saline at 2 ml.kg-1.h-1. Fluid volume was adjusted according to mean arterial pressure and pulse pressure variation. Measurements: Arterial blood gas and plasma electrolyte samples were collected. Blood gas pH analysis result at the end of surgery was considered as primary endpoint. The secondary outcomes were HCO3-, base excess and plasma electrolytes, lactate, glycemia, extubating in the operating room, length of hospital and intensive care unit stay, new neurological deficit and mortality. Main results: Thirty-three and thirty-five patients in the Plasmalyte 148 and 0.9% saline groups, respectively, completed the study. The total volumes (median [quartiles]) of crystalloids administered were 2227 (1416, 3000) and 3000 (2000, 4000) in the Plasmalyte 148 and 0.9% saline groups, respectively (p = 0.107). At the end of the surgical procedure, the mean values (standard deviation) of pH, HCO3, Base Excess and chloride were 7.39 ± 0.04 and 7.35 ± 0.05 (p < 0.001), 22.5 ± 1.8 and 20.6 ± 2.2 mmol.l-1 (p < 0.001), -1.6 ± 2.3 and -3.9 ± 2.6 (p < 0.001) and 109.1 ± 6.6 and 113.9 ± 4.5 mmol.l-1 (p = 0.001) in Plasmalyte 148 and 0.9% saline groups, respectively. Serum ionic calcium was reduced in the Plasmalyte 148 group compared to the 0.9% saline group (1.14 ± 0.04 versus 1.17 ± 0.05 mmol.l-1; p = 0.040). There were no differences between the groups regarding the other secondary outcomes. Conclusions: For usual elective neurosurgery situations without major volume replacement demands, the use of Plasmalyte 148 is associated with higher blood pH, arterial bicarbonate and base excess, and lower plasma chloride values at the end of surgery, although pH remains within the normal physiologic range in both groups, not implying acidosis. Final considerations: As there is no difference in the incidence of acid-base or electrolyte disturbances between groups, we understand that this theoretical advantage of Plasmalyte 148 does not guarantee enough clinical relevance to recommend its routine use over the widely used, studied, cheap and safe 0.9% saline in neurosurgery.
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Neurocirurgia, Fluidoterapia, Soluções cristaloides, Eletrólitos, Equilíbrio ácido-base, Neurosurgery, Fluid therapy, Crystalloid solutions, Electrolytes, Acid-base balance