Basic approaches and principles of controlled infusion therapy in patients with urgent surgical abdominal pathology

O.V. Kravets, E.N. Klygunenko


Over the past fifteen years, the number of urgent laparotomy is 36–58 % and is characterized by a mortality of 30–80 %. One of the main causes of this is hypovolemia, which causes hemodynamic disorders, tissue hypoxia and the development of multiple organ failure. The main method of its treatment is to fill the circulating blood volume deficiency, where the first choice drugs are crystalloids. It is easy to predict the effects of crystalloid solutions using the physico-chemical model of Stewart’s acid-alkaline equilibrium. Physiologically, all substances in the body are in a dissolved state. Enhancement or weakening of the dissociation of biological aqueous solutions regulate the dependent (H+, HCO3–) and independent (partial pressure of carbon dioxide (pCO2), strong ion difference (SID), total weak acid concentration (Atot)) variables. The regulation of the body’s aqueous media is subject to the three laws of electroneutrality, the equilibrium of dissociation and mass conservation. Based on the Stewart model, electrolyte disturbances can lead to a change in SID and Atot, which forms metabolic acidosis and alkalosis. The composition of cations in a balanced crystalloid solution should correspond to their physiological concentration in the plasma. In this case, the preservation of the physiological concentration of such a strong anion as Cl– in a crystalloid solution is possible only with an increase in the concentration of organic ions. Organic ions are lactate (lactic acid); acetate (acetic acid); malate (malic acid); gluconate (glucuronic acid); citrate (citric acid).These organic ions are moderately strong organic acids and belong to strong electrolytes. In the literature, organic ions are called donors of reserve alkalinity HCO3–. To date, evidence-based studies do not recommend the use of lactate because of: an increase in oxygen consumption during metabolism in the liver, which aggravates tissue hypoxia in conditions of initial oxygen deficiency; threat of intestinal cerebral edema and coagulopathy with excessive concentration of lactate; contraindications to use in shock, accompanied by lactic acidosis and liver failure. Acetate: rapidly stabilizes acid-alkaline disorders due to its rapid metabolism; can be used for violations of the liver; provides minimum oxygen consumption in the process of correction of metabolic acidosis; is an antihypoxant (representing the energy substrate of the Krebs cycle). Malate — can be used for violations of the liver; an antihypoxant (represen­ting the energy substrate of the Krebs cycle); has a detoxification and antioxidant effect. For safe clinical use of crystalloid solutions in patients with urgent abdominal cavity pathology, it is necessary to know: intravenous infusion of solutions causes a “mixing phenomenon” of two different fluids — infusion solution and plasma, which differ from each other in the values of SID and Atot. The main characteristic of the infusion solution is its SIDinf. Before starting the infusion, it is necessary to clearly understand the SID and Atot of the solution used. The total infusion volume changes the SID and Atot of the plasma, with the subsequent effect on the plasma pH. During the infusion therapy, the plasma values of SID and Atot will tend to subjugate SIDinf and Atot of the injected fluid. Crystalloid solutions do not contain albumins or phosphates, therefore, Atot of any crystalloid solution is 0. The characteristics of a balanced crystalloid solution are: SIDinf = 24 mEqL–1; compliance of the electrolyte content with their plasma concentration; the presence in the composition of organic ions, preventing an increase in the concentration of Cl– in the infusion solution and being donors of reserve alkalinity. According to the criteria for the ba­lance of crystalloid solutions, we distinguish: unbalanced crystalloid solutions (0.9% NaCl solution); partially balanced crystalloid solutions (Ringer’s lactate and Hartmann’s solutions); fully balanced solutions (plasmalyte, plasmalyte A, sterofundin, sterofundin ISO). The use of unbalanced solutions (0.9% NaCl solution) is dangerous due to the development of hyperchloremic acidosis. The use of partially balanced crystalloid solutions (Ringer’s lactate and Hartmann’s solutions) can form or aggravate lactate acidosis in conditions of tissue hypoxia and/or liver dysfunction. Infusion of balanced solutions — plasmalyte, plasmalyte A, sterofundin allows you to quickly adjust metabolic acidosis, but requires mandatory laboratory monitoring of the parameters of acid-base balance because of the threat of metabolic alkalosis. Introduction of a balanced solution sterofundin ISO has the highest safety profile, it enables to clinically apply the solution “blindly”.


infusion therapy; crystalloid solutions; acid-base balance; Stewart theory


The Royal College of Surgeons of England, Department of Health. RCS/DH; London: 2010. The Higher Risk Surgical Patient: Towards Improved Care for a Forgotten Group.

Emergency Surgery, Standards for Unscheduled Surgical Care, Guidance for Providers, Commissioners and Service Planners. — London: RCS, 2011.

Knowing the Risk; a Review of the Peri-operative Care of Surgical Patients // NCEPOD. — 2011.

Horwood J., Ratnam S., Maw A. Decisions to operative: the ASA grade 5 dilemma // Ann. R. Coll. Surg. Engl. — 2011. — 93 (5). — 365-369. [Pub. Med.]

Saunders D.I., Murray D., Pichel A.C., Varley S., Peden C.J. UK Emergency Laparotomy Network. Variations in mortality after emergency laparotomy: the first report of the UK Emergency Laparotomy Network // Br. J. Anaesth. — 2012. — 109 (3). — 368-75. doi: 10.1093/bja/aes165. [Pub. Med.] [Cross. Ref.]

Stewart P.A. Modern quantitative acid-base chemistry // Can. J. Physiol. Pharmacol. — 1983. — 61. — 1444-61.

Kellum J.A., Elbers P.W.G. Stewart’s Textbook of Acid-Base. — 2nd ed. — Barking, UK: Lulu Enterprises UK Ltd., 2009.

Lloyd P., Freebairn R. Using quantitative acid-base analysis in the ICU // Crit. Care Resusc. — 2006 — 8. — 19-30. [Pub. Med.]

Gilfix B.M., Bique M., Magder S. A physical chemical approach to the analysis of acid-base balance in the clinical setting // J. Crit. Care. — 1993. — 8. — 187-97. [Pub. Med.]

Berend K., de Vries A.P., Gans R.O. Physiological approach to assessment of acid-base disturbances // N. Engl. J. Med. — 2014. — 371. — 1434-45. doi: 10.1093/bja/aes165. [Pub. Med.] [Cross. Ref.]

Seifter J.L. Integration of acid-base and electrolyte disorders // N. Engl. J. Med. — 2014. — 371. — 1821-31.

Figge J.J. Integration of acid-base and electrolyte disorders // N. Engl. J. Med. — 2015. — 372. — 390. [Pub. Med.]

Rocktaeschel J., Morimatsu H., Uchino S., Goldsmith D., Poustie S., Story D., Gutteridge G., Story D.A., Vaja R., Poustie S.J., McNicol L. Fencl-Stewart analysis of acid-base changes immediately after liver transplantation // Crit. Care Resusc. — 2008. — 10. — 23. [Pub. Med.]

Story D.A. Filling the (strong ion) gap // Crit. Care Med. — 2008. — 36. — 998-9. [Pub. Med.]

Yunos N.M., Kim I.B., Bellomo R., Bailey M., Ho L., Story D., Gutteridge G.A., Hart G.K. The biochemical effects of restricting chloride-rich fluids in intensive care // Crit. Care Med. — 2011. — 39. — 2419-24. [Pub. Med.]

Guidet B., Soni N., Della R.G. et al. A balanced view of balanced solutions // Crit. Care. — 2010. — 14. — 325. [Pub. Med.]

Kaplan L.J., Kellum J.A. Fluids, pH, ions and electrolytes // Curr. Opin. Crit. Care. — 2010. — 16. — 323-31. [Pub. Med.]

Deng L.Q. Influence of transfusion of lactated Rin­ger’s solution onarterial blood lactate concentration and acid base balance duringorthotopic liver transplantation // Chin. J. Mod. Nurs. — 2008. — 14. — 1754. doi: 10.1093/bja/aes165. [Pub. Med.] [Cross. Ref.]

Tellan G., Antonucci A., Marandola M. et al. Postoperative metabolicacidosis: use of three different fluid therapy models // Chir. Ital. — 2008. — 60. — 33-40. [Pub. Med.] [Cross. Ref.]

Nuraei N., Khajenouri R., Soleimani M., Dabbagh A. The effects ofintraoperative normal saline versus lactated ringer solutionon clinicaloutcomes and laboratory findings in renal transplant patients // Tehran. Univ. Med. J. — 2010. — 68. — 872-7. [Pub. Med.]

Ramanathan S., Masih A.K., Ashok U., Arismendy J., Turndorf H. Concentrationsof lactate and pyruvate in maternal and neonatalblood with different intravenous fluids used for prehydration before epidural anesthesia // Anesth. Analg. — 1984. — 63. — 69-74. [Pub. Med.]

O’Malley C.M., Frumento R.J., Hardy M.A. et al. A randomized, doubleblindcomparison of lactated Ringer’s solution and 0.9 % NaClduring renal transplantation // Anesth. Analg. — 2005. — 100. — 1518-24. [Pub. Med.]

Khajavi M.R., Etezadi F., Moharari R.S. et al. Effects of normal saline vs.lactated ringer’s during renal transplantation // Ren. Fail. — 2008. — 30. — 535-9. doi: 10.4103/0019-5049.123332. [Pub. Med.] [Cross. Ref.]

Hadimioglu N., Saadawy I., Saglam T., Ertug Z., Din­ckan A. The effect of different crystalloid solutions on acid-base balance and earlykidney function after kidney transplantation // Anesth. Analg. — 2008. — 107. — 264-9. doi: 10.1093/bja/aes165. [Pub. Med.] [Cross. Ref.]

Aoki K., Yoshino A., Yoh K., Sekine K.,Yamazaki M., Aikawa N. Acomparison of Ringer’s lactate and acetate solutions and resuscitativeeffects on splanchnic dysoxia in patients with extensive burns // Burns. — 2010. — 36. — 1080-5. doi: 10.1093/bja/aet487. [PMC free article][Pub. Med.] [Cross. Ref.]

Shin W.J., Kim Y.K., Bang J.Y., Cho S.K., Han S.M., Hwang G.S. Lactate andliver function tests after living donor right hepatectomy: acomparisonof solutions with and without lactate // Acta Anaesthesiol. Scand. — 2011. — 55. — 558-64. doi: 10.1093/bja/aet487. [Pub. Med.] [Cross. Ref.]

Mahler S.A., Conrad S.A., Wang H., Arnold T.C. Resuscitation withbalanced electrolyte solution prevents hyperchloremic metabolicacidosis in patients with diabetic ketoacidosis // Am. J. Emerg. Med. — 2011. — 29. — 670-4. [Pub. Med.]

Wu B.U., Hwang J.Q., Gardner T.H. et al. Lactated Ringer’s solutionreduces systemic inflammation compared with saline in patientswith acute pancreatitis // Clin. Gastroenterol. He­patol. — 2011. — 9. — 710-7. doi: 10.4103/0019-5049.123332. [PMC free article] [Pub. Med.] [Cross. Ref.]

Heidari S.M., Saryazdi H., Shafa A., Arefpour R. Comparison of theeffect of preoperative administration of Ringer’s solution, normalsaline and hypertonic saline 5 % on postoperative nausea andvomiting: a randomized, double blinded clinical study // Pak. J. Med. Sci. — 2011. — 27. — 771-4. doi: 10.1093/bja/aet487. [Pub. Med.] [Cross. Ref.]

Hasman H., Cinar O., Uzun A., Cevik E., Jay L., Co­mert B. A randomizedclinical trial comparing the effect of rapidly infused crystalloids onacid-base status in dehydrated patients in the emergency department // Int. J. Med. Sci. — 2012. — 9. — 59-64. [Pub. Med.]

Modi M.P., Vora K.S., Parikh G.P., Shah V.R. Acomparative study of impact of infusion of Ringer’s lactate solution versus normal saline onacid-base balance and serum electrolytes during live relatedrenal transplantation // Saudi J. Kidney Dis. Transpl. — 2012. — 23. — 135-7. [Pub. Med.]

Reid F., Lobo D.N., Williams R.N., Rowlands B.J., Allison S.P. (Ab)normalsaline and physiological Hartmann’s solution: a randomizeddouble-blind crossover study // Clin. Sci (Lond). — 2003. — 104. — 17-24. [Pub. Med.]

Gunnerson K.J., Saul M., He S., Kellum J.A. Lactate versus non-lactatemetabolic acidosis: a retrospective outcome evaluation of criticallyill patients // Crit. Care. — 2006. — 10. — R22. [Pub. Med.]

Brummel-Ziedins K., Whelihan M.F., Ziedins E.G., Mann K.G. The resuscitativefluid you choose may potentiate bleeding // J. Trauma. — 2006. — 61. — 1350-8. [Pub. Med.]

Petraitiene R., Petraitis V., Witt J.R. III et al. Galactomannan antigenemiaafter infusion of gluconate-containing Plasma-Lyte — J. Clin. Microbiol. — 2011. — 49. — 4330-2. [Pub. Med.]

Zadak Z., Hyspler R., Hronek M., Ticha A. The energetic and metaboliceffect of Ringerfundin (B. Braun) infusion and comparison withPlasma-Lyte (Baxter) in healthy volunteers // Acta Medica (Hradec Kralove). — 2010. — 53. — 131-7.

Shaw A.D., Bagshaw S.M., Goldstein S.L. et al. Major complications, mortality, and resource utilization after open abdominal surgery: 0.9 % saline compared to Plasma-Lyte // Ann. Surg. — 2012. — 255. — 821-9. doi: 10.1093/bja/aet487 [PMC free article] [Pub. Med.] [Cross. Ref.]

Yunos N.M., Bellomo R., Hegarty C., Story D., Ho L., Bailey M. Associationbetween a chloride-liberal vs chloride-restrictive intravenous fluidadministration strategy and kidney injury in critically ill adults // JAMA. — 2012. — 308. — 1566-72. doi: 10.12356/bja/aet432 [PMC free article][Pub. Med.] [Cross. Ref.]



  • There are currently no refbacks.

Copyright (c) 2017 EMERGENCY MEDICINE

Creative Commons License
This work is licensed under a Creative Commons Attribution 4.0 International License.


© Publishing House Zaslavsky, 1997-2018


 Яндекс.МетрикаSeo анализ сайта Рейтинг