The Importance of Intraoperative Hyperchloremia

Silva, João Manoel da; Neves, Eliete F; Santana, Thassio C; Ferreira, Ulisses P; Marti, Yara N; Silva, Jose Maria Correa

doi:10.1590/s0034-70942009000300005

Cited by 23 publications

(6 citation statements)

References 16 publications

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“…We are unaware of any other study on the prevalence of hyperchloremia or hypochloremia in the critical care setting, although there is one study on the incidence of hyperchloremia in the intraoperative setting [16]. This study showed that 31.7% of the study population was hyperchloremic, a prevalence approximately 1.9 times greater than the rate observed in our study.…”

Section: Discussioncontrasting

confidence: 69%

The Incidence and Prognostic Value of Hypochloremia in Critically Ill Patients

Tani

Morimatsu

Takatsu

et al. 2012

The Scientific World Journal

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Little is known on the clinical effects of chloride on critically ill patients. We conducted this retrospective, observational study in 488 critically ill patients to investigate the incidence of chloride abnormalities, effects of hypochloremia in acid-base disorders, and association between chloride and clinical outcome. The study involved retrieval of arterial blood gas analyses, biochemical and demographical data from electrical records as well as quantitative acid-base analyses. For statistical analysis, the patients were stratified into three groups according to their chloride level (normal range: 98–106 mEq/L). The distribution of chloride levels was hyperchloremia 16.6%, normochloremia 74.6%, and hypochloremia 8.8%. The hypochloremic group was significantly alkalemic (P < 0.0001) and has significantly higher apparent strong ion difference (SIDa) (P < 0.0001) compared to the two other groups. The hypochloremic group had significantly longer stays in the ICU and hospital (P < 0.0001) with higher mortality (P < 0.0001). However, multiple regression analysis showed that chloride was not an independent factor of poorer outcome. In conclusion, the acid-base characteristics of the hypochloremic patients were alkalemia coexisting with higher SIDa. And although it was not an independent prognostic factor, hypochloremia was related to poorer outcome in critically ill settings.

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Section: Discussioncontrasting

confidence: 69%

The Incidence and Prognostic Value of Hypochloremia in Critically Ill Patients

Tani

Morimatsu

Takatsu

et al. 2012

The Scientific World Journal

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“…However, fluid overload and saline consequences have been shown in the literature [24], which eliminates the preference for a liberal fluid management. The adverse effects of volume overload are more evident in the lungs, where fluid resuscitation can lead to acute pulmonary edema compromising gas exchange and making the patients more susceptible to infections.…”

Section: Discussionmentioning

confidence: 99%

The effect of excess fluid balance on the mortality rate of surgical patients: a multicenter prospective study

et al. 2013

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IntroductionIn some studies including small populations of patients undergoing specific surgery, an intraoperative liberal infusion of fluids was associated with increasing morbidity when compared to restrictive strategies. Therefore, to evaluate the role of excessive fluid infusion in a general population with high-risk surgery is very important. The aim of this study was to evaluate the impact of intraoperative fluid balance on the postoperative organ dysfunction, infection and mortality rate.MethodsWe conducted a prospective cohort study during one year in four ICUs from three tertiary hospitals, which included patients aged 18 years or more who required postoperative ICU after undergoing major surgery. Patients who underwent palliative surgery and whose fluid balance could change in outcome were excluded. The calculation of fluid balance was based on preoperative fasting, insensible losses from surgeries and urine output minus fluid replacement intraoperatively.ResultsThe study included 479 patients. Mean age was 61.2 ± 17.0 years and 8.8% of patients died at the hospital during the study. The median duration of surgery was 4.0 (3.2 to 5.5) h and the value of the Simplified Acute Physiology Score (SAPS) 3 score was 41.8 ± 14.5. Comparing survivors and non-survivors, the intraoperative fluid balance from non-survivors was higher (1,950 (1,400 to 3,400) mL vs. 1,400 (1,000 to 1,600) mL, P <0.001). Patients with fluid balance above 2,000 mL intraoperatively had a longer ICU stay (4.0 (3.0 to 8.0) vs. 3.0 (2.0 to 6.0), P <0.001) and higher incidence of infectious (41.9% vs. 25.9%, P = 0.001), neurological (46.2% vs. 13.2%, P <0.001), cardiovascular (63.2% vs. 39.6%, P <0.001) and respiratory complications (34.3% vs. 11.6%, P <0.001). In multivariate analysis, the fluid balance was an independent factor for death (OR per 100 mL = 1.024; P = 0.006; 95% CI 1.007 to 1.041).ConclusionsPatients with excessive intraoperative fluid balance have more ICU complications and higher hospital mortality.

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“…Chloride plays a pivotal role in many body functions including acid-base balance, muscular activity, osmosis, and immunomodulation (2). Despite its physiological importance, chloride has captured little attention by the scientific community until recently (3) when chloride-rich solutions were associated with hyperchloremic metabolic acidosis (4, 5) and short-term mortality after non-cardiac surgery (6, 7). The precise mechanisms of hyperchloremic metabolic acidosis are somewhat controversial: 1) HCO 3 - dilution (8); 2) chloride as a key contributor to the decrease in strong ion difference influencing the dissociation of water with H + generation (Stewart approach) (9); and 3) the unbalanced dilution of the buffer system (HCO 3 - but not CO 2 ) (10).…”

Section: Introductionmentioning

confidence: 99%

Association of Hyperchloremia With Hospital Mortality in Critically Ill Septic Patients

Neyra

Canepa-Escaro²,

et al. 2015

Critical Care Medicine

181

153

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Objective Hyperchloremia is frequently observed in critically ill patients in the intensive care unit (ICU). Our study aimed to examine the association of serum chloride (Cl) levels with hospital mortality in septic ICU patients. Design Retrospective cohort study. Setting Urban academic medical center ICU. Patients ICU adult patients with severe sepsis or septic shock who had Cl measured on ICU admission were included. Those with baseline estimated glomerular filtration rate < 15 ml/min/1.73 m2 or chronic dialysis were excluded. Intervention: None. Measurements and Main Results Of 1940 patients included in the study, 615 (31.7%) had hyperchloremia (Cl ≥ 110 mEq/L) on ICU admission. All-cause hospital mortality was the dependent variable. Cl on ICU admission (Cl0), Cl at 72 h (Cl72), and delta Cl (ΔCl = Cl72 – Cl0) were the independent variables. Those with Cl0 ≥ 110 mEq/L were older and had higher cumulative fluid balance, base deficit, and sequential organ failure assessment scores. Multivariate analysis showed that higher Cl72 but not Cl0 was independently associated with hospital mortality in the subgroup of patients with hyperchloremia on ICU admission [adjusted odds ratio (OR) for Cl72 per 5 mEq/L increase = 1.27, 95% CI (1.02–1.59), P = 0.03]. For those who were hyperchloremic on ICU admission, every within-subject 5 mEq/L increment in Cl72 was independently associated with hospital mortality [adjusted OR for ΔCl 5 mEq/L = 1.37, 95% CI [1.11–1.69], P = 0.003]. Conclusions In critically ill septic patients manifesting hyperchloremia (Cl ≥110 mEq/L) on ICU admission, higher Cl levels and within-subject worsening hyperchloremia at 72 h of ICU stay were associated with all-cause hospital mortality. These associations were independent of base deficit, cumulative fluid balance, acute kidney injury, and other critical illness parameters.

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The Importance of Intraoperative Hyperchloremia

Abstract: The incidence of hyperchloremia at the end of surgery is elevated, and it is associated with metabolic acidosis, longer surgeries, greater volumes of crystalloids, and higher postoperative mortality.

Cited by 23 publications

References 16 publications

The Incidence and Prognostic Value of Hypochloremia in Critically Ill Patients

The Incidence and Prognostic Value of Hypochloremia in Critically Ill Patients

The effect of excess fluid balance on the mortality rate of surgical patients: a multicenter prospective study

Association of Hyperchloremia With Hospital Mortality in Critically Ill Septic Patients

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