Can a patient with End-Stage Renal Disease (ESRD) receive Plasmalyte (balanced crystalloid solution) as an intraoperative fluid?

Plasmalyte for Intraoperative Fluids in ESRD Patients

Yes, patients with End-Stage Renal Disease (ESRD) can safely receive Plasmalyte as intraoperative fluid therapy, and it may be preferred over 0.9% saline due to lower risk of hyperchloremic metabolic acidosis and adverse renal events.

Rationale for Using Balanced Crystalloids in ESRD

• Balanced crystalloid solutions like Plasmalyte have an electrolyte composition closer to plasma, which helps maintain acid-base balance and reduces the risk of hyperchloremia 1
• The use of 0.9% saline is associated with hyperchloremic metabolic acidosis, which can have a negative impact on perioperative electrolyte management, end-organ function, and survival 2
• Solutions with high chloride content (like 0.9% saline) can negatively impact renal function, resulting in decreased kidney perfusion, increased extravascular fluid accumulation, and increased vasopressor requirements 2
• Even in patients with ESRD who are dependent on dialysis, maintaining acid-base balance during surgery is important for overall hemodynamic stability 3

Evidence Supporting Balanced Crystalloids

• The SMART trial (15,802 ICU patients) showed that patients who received 0.9% saline had a significantly higher incidence of major adverse kidney events within 30 days compared to those who received balanced crystalloids (15.4% vs 14.3%) 4
• The SALT trial demonstrated that patients who received balanced crystalloids had lower 30-day in-hospital mortality and lower incidence of renal replacement therapy or renal dysfunction compared to those who received 0.9% saline 2
• The 2023 ERAS Society guidelines recommend balanced crystalloids over 0.9% normal saline for resuscitation and to maintain intravascular volume 2

Special Considerations for ESRD Patients

• ESRD patients have significant alterations in fluid, electrolyte, and acid-base equilibrium that require special perioperative considerations 3
• Patients with ESRD should ideally have hemodialysis within 24 hours before elective surgery to optimize electrolyte balance and volume status 5
• Intraoperative fluid management should be carefully monitored in ESRD patients to avoid volume overload, which can lead to pulmonary edema and heart failure 3
• The potassium content in balanced solutions like Plasmalyte (5 mmol/L) is generally not a concern, as studies have shown that even in patients prone to hyperkalemia, the use of balanced solutions does not lead to significant increases in potassium levels compared to 0.9% saline 2

Fluid Management Algorithm for ESRD Patients

1. Preoperative preparation:

   • Ensure hemodialysis is performed within 24 hours before elective surgery 5
   • Check baseline electrolytes, especially potassium and bicarbonate levels 5

2. Intraoperative fluid choice:

   • Use balanced crystalloids like Plasmalyte as the primary intraoperative fluid 2, 1
   • Target a mildly positive fluid balance (+1-2 L) by the end of surgery to protect remaining kidney function 2
   • Administer fluids based on objective measures of hypovolemia, titrated by bolus 2

3. Monitoring:

   • Use arterial lines for real-time blood pressure measurement and frequent arterial blood gas sampling 2
   • Carefully record fluid balance throughout surgery 2
   • Monitor for electrolyte abnormalities, particularly hyperkalemia 2

Potential Pitfalls and Caveats

• Avoid excessive fluid administration, as ESRD patients have limited ability to excrete fluid and are at higher risk for volume overload 3
• Be cautious with the total volume of any intravenous fluid administered, as ESRD patients may require earlier post-operative dialysis if large volumes are given 6
• Consider the timing of the next scheduled dialysis session when planning fluid management strategy 5
• While balanced crystalloids are generally preferred, individualized assessment of electrolyte status is still important, particularly for potassium levels 2

In summary, Plasmalyte is an appropriate and potentially beneficial choice for intraoperative fluid therapy in ESRD patients. Its balanced composition helps maintain acid-base equilibrium better than 0.9% saline, which is particularly important in the perioperative management of these complex patients.