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Is Is Hypercholerima Hypercholerima

Important ?Important ?Murat Sungur, MDMurat Sungur, MD

Erciyes University Medical SchoolErciyes University Medical SchoolDepartment of Internal Medcine.Department of Internal Medcine.

Division of Intensive Care Medicine.Division of Intensive Care [email protected]@erciyes.edu.tr

What is standard What is standard intravenous solution?intravenous solution?

Not Normal

Not Standard

An important anion in extracellular fluidAn important anion in extracellular fluid

Determinant of extracellular fluid volume with sodiumDeterminant of extracellular fluid volume with sodium

Responsible for acid base equilibrium, resting membrane potential Responsible for acid base equilibrium, resting membrane potential

and plasma oncotic pressureand plasma oncotic pressure

Exist in body as Potasium chloride and Sodium chloride Exist in body as Potasium chloride and Sodium chloride

Normal plasma concentration is 97-107mEq/L.Normal plasma concentration is 97-107mEq/L.

Absorbed in the first part of small intestine with bicarbonate Absorbed in the first part of small intestine with bicarbonate

eexchange. xchange.

Eliminated trough urine, feces and sweating Eliminated trough urine, feces and sweating

Chloride loadChloride load Chloride rich fluids: NS, colloidsChloride rich fluids: NS, colloids

Water loss (in excess of chloride)Water loss (in excess of chloride) Skin loses: fever, exerciseSkin loses: fever, exercise Extrarenal: diarrhea, burnsExtrarenal: diarrhea, burns Renal loses: DI, osmotic diuresis, diureticsRenal loses: DI, osmotic diuresis, diuretics

Increase in tubular chloride reabsorptionIncrease in tubular chloride reabsorption Renal tubular acidosisRenal tubular acidosis Early renal failureEarly renal failure Post hypocapniaPost hypocapnia Ureteral diversionsUreteral diversions

Troubles with using IV 0.9 % salineTroubles with using IV 0.9 % saline

Troubles with using IV 0.9 % salineTroubles with using IV 0.9 % saline

Recommendation 1 Because of the risk of inducing hyperchloraemic

acidosis in routine practice, when crystalloid resuscitation or replacement is indicated, balanced salt solutions e.g. Ringer’s lactate/acetate or Hartmann’s solution should replace 0.9% saline, except in cases of hypochloraemia e.g. from vomiting or gastric drainage.

Evidence level 1b1-6

We do not know if normal saline is We do not know if normal saline is harmful or nor even if it causes harmful or nor even if it causes hyperchloremic metabolic acidosishyperchloremic metabolic acidosis. .

Liu B, Finfer S: Intravenous fl uids in adults undergoing surgery [editorial].Br Med J 2009, 339:3-4.

1. Acidosis occurs with high volumes of normal saline infusion and it is related with chloride load. 2. There are no adequate studies showing that hyperchloremia is clinically important even though saline infusion have some side effects.Handy JM, Soni N: Physiological eff ects of hyperchloraemia and acidosis.Br J Anaesth 2008, 101:141-150

Plasma ElectroneutralityPlasma Electroneutrality

Normal SID = 40 – 42. < 40 acidosis> 42 alkalosis

Normal Saline InfusionNormal Saline Infusion

6000 ml normal 6000 ml normal saline infusionsaline infusion

Anesthesiol 1999, 90:1265-1270.

161161±±67 ml 67 ml crystalloidcrystalloid

Crit Care Med 2007; 35:2390–2394

Effects of given NaCl on unmeasured anions, albumin and base excess

Normal Saline InfusionNormal Saline Infusion

HES 130/0.4HES 130/0.4

Extrapolation from the studies:Extrapolation from the studies: 50 ml/kg HES = -3.5 Ba50 ml/kg HES = -3.5 Basese excess excess

Cardiovascular surgery patientsCardiovascular surgery patients HES + HES + NSNS or or HES + Ringer lactateHES + Ringer lactate

Chloride 110 vs. 112 mmol/L Chloride 110 vs. 112 mmol/L Maximum base excess difference 2 mmol/LMaximum base excess difference 2 mmol/L

Crit Care 2006, 10:176.

Chloride and Chloride and KidneysKidneys

Intrarenal infusionIntrarenal infusion

J Clin Invest 1983, 71:726-735

Renal Effects of Renal Effects of HyperchloremiaHyperchloremia


Intrarenal infusionIntrarenal infusion

J Clin Invest 1983, 71:726-735

Afferent arteriolar vasoconstriction Afferent arteriolar vasoconstriction and hyperchloreemiaand hyperchloreemia

Hypertension. 1998;32:1066-1070


Hyperchloremia and Hyperchloremia and VasoconstrictorsVasoconstrictors

Br. J. Pharmacol. (1993), 108, 106-110M

Normal Saline may be Normal Saline may be goodgood

Healthy Healthy volunteers. NS and volunteers. NS and LR infusionLR infusion

280

285

290

295

300

SF Ringerlaktat

Osm

olar

ite

7.3

7.35

7.4

7.45

SF RLp

H

Anesth Analg 1999;88:999 –1003

NS vs. Ringer LactateNS vs. Ringer Lactate

Ringer lactateRinger lactate Osmolarity: 273 mOsm/LOsmolarity: 273 mOsm/L Real osmolarity: 254 mOsm/LReal osmolarity: 254 mOsm/L

Not fully ionizedNot fully ionized

Normal salineNormal saline Osmolarity: 308 mOsm/LOsmolarity: 308 mOsm/L Fully ionizedFully ionized

During renal transplantationDuring renal transplantation


Serum potasium concentrationLR NS

•NS group•31 % acidosis requiring bicarbonate therapy

•LR group•None

Anesth Analg 2005;100:1518 –24


During renal transplantationDuring renal transplantation

Anesth Analg 2005;100:1518 –24

NS vs. PlasmalyteNS vs. Plasmalyte

Healthy volunteers. Crossover study. 2 L.Healthy volunteers. Crossover study. 2 L.

Ann Surg 2012;256:18–24

Metabolic effectsMetabolic effects

Ann Surg 2012;256:18–24

Ann Surg 2012;256:18–24

Ann Surg 2012;256:18–24

In ConclusionIn Conclusion

No significant differences in creatinine, Variations have been reported and only

slight differences in NGAL, not clinically relevant,

There is no convincing difference between isotonic saline strategies and balanced strategies in terms of renal function

Abdominal discomfort reported to be more often Abdominal discomfort reported to be more often in patients receiving NS as compared to LR. in patients receiving NS as compared to LR.

Anesth Analg 1999;88:999 –1003

Hyperchloremia and Hyperchloremia and Gastrointestinal SystemGastrointestinal System

Gastric mucosal Gastric mucosal perfusionperfusion

Postoperative pts.Postoperative pts. NS vs. Balanced fluidsNS vs. Balanced fluids


Anesth Analg 2001;93:811–6

Postoperative pts.Postoperative pts.

Anesth Analg 2003, 96:611-617.


Postoperative ptsPostoperative pts Liberal NS (>3 L) or restricted NS Liberal NS (>3 L) or restricted NS

(< 2 L)(< 2 L)

Lancet 2002; 359: 1812–18


ConclusionConclusion

There is not sufficient evidence from the available literature to suggest that hyperchloraemic acidosis has a clinically relevant effect on gastrointestinal function. Some degree of intraoperative

Crystalloid restriction and colloid use may, however, be associated with an improvement in gastrointestinal function and outcome.

Hyperchloremia and Hyperchloremia and CoagulationCoagulation

AAA repairAAA repair Randomized. NS or LR. Cl: 107 vs. 114, BE: - 2.2 vs – 3.8Randomized. NS or LR. Cl: 107 vs. 114, BE: - 2.2 vs – 3.8

0

200

400

600

800

1000

PRBC FFP Platelet

mL SF

RL*

Anesth Analg 2001;93:817–22)

Saudi J Anaesth. 2013 Jan-Mar; 7(1): 48–56

Saudi J Anaesth. 2013 Jan-Mar; 7(1): 48–56

ConclusionConclusion

There is little evidence that large volumes of isotonic saline have a significantly detrimental effect on coagulation, blood loss or transfusion.

Hyperchloremia and Hyperchloremia and MortalityMortality

Acidosis may be associated with Acidosis may be associated with mortality butmortality but

Type of acidosis is importantType of acidosis is important Difficult to establish relation with Difficult to establish relation with

hyperchloremia only. hyperchloremia only.

Rats. Experimental Sepsis model.Rats. Experimental Sepsis model. NS, LR or HESNS, LR or HES NS and RL leads higher chloride levels: 123 NS and RL leads higher chloride levels: 123

vs. 115vs. 115 BE is lower with NS.BE is lower with NS.

Crystalloid Colloid

Crit Care Med 2002; 30:300 –305


851 critically ill patients with lactate measurement851 critically ill patients with lactate measurement Mortality with acidosis: % 45, without acidosis % 26Mortality with acidosis: % 45, without acidosis % 26

Critical Care 2006, 10:R22


Base excess > 2, critically ill pts.Base excess > 2, critically ill pts.

SHOCK, Vol. 17, No. 6, pp. 459–462, 2002


175 critically ill pts.175 critically ill pts.


SOFA +chloride + albumin better for mortality prediction

Chloride and albumin levels are independent predictors of mortality.

Journal of Critical Care (2011) 26, 175–179


ResultsResults Hypercholoremic metabolic acidosis is a

side effect Mostly observed after the administration

of large volumes of isotonic saline as a crystalloid.

The effect remains moderate and relatively transient (24 to 48 hours), and is minimized with the use of colloids,

From the available literature, the evidence for adverse effects of hyperchloraemic acidosis on organ function, morbidity or mortality remains unanswered.

Health & Medicine

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