Intraoperative Fluid Management in ESRD Patients

Rationale for Using Balanced Crystalloids

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, 3
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 3

The ERAS Society guidelines recommend balanced crystalloids over 0.9% normal saline for resuscitation and to maintain intravascular volume 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 4

Use balanced crystalloids like Plasmalyte as the primary intraoperative fluid 3, 1
Target a mildly positive fluid balance (+1-2 L) by the end of surgery to protect remaining kidney function 5
Administer fluids based on objective measures of hypovolemia, titrated by bolus 2
Monitor for electrolyte abnormalities, particularly hyperkalemia 3
While balanced crystalloids are generally preferred, individualized assessment of electrolyte status is still important, particularly for potassium levels 4