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Purpose Elevated serum bromide levels can cause dermatological, gastrointestinal, and neurological abnormalities. As bromide and chloride are both halogens, bromide may interfere with chloride assays, causing a falsely high serum chloride concentration and a low or negative anion gap. There is a paucity of data describing bromide toxicity from high doses of pyridostigmine bromide (PB). This case report describes a patient with an elevated bromide level with neurological symptoms from a therapeutic dose of PB. Summary A 37-year-old male with myasthenia gravis secondary to type B2 thymoma following thymectomy presented in myasthenic crisis. He required mechanical ventilation and was managed with steroids, intravenous immune globulin, plasmapheresis, and PB. On day 9, the patient experienced acute agitation. He had an anion gap of 2 mEq/L and a chloride concentration of 109 mEq/L. The plasma creatinine concentration was 0.63 to 1.15 mg/dL and urine output was 0.76 to 1.79 mL/kg/h throughout his admission. All other laboratory values were normal. The daily dose of PB was 660 mg on day 9, but the patient received 76 mg of intravenous PB over the first few days of his admission with the largest dose in 24 hours equal to 48 mg. On day 10, the patient's bromide level was 37 μg/mL. His agitation was initially managed with quetiapine, followed by PB dose reduction. To our knowledge, there are 2 cases in the literature of bromide toxicity secondary to PB. These patients experienced neurological symptoms with bromide levels of 88 to 90 μg/mL. Bromide concentrations of more than 12 μg/mL are associated with a higher risk of neuronal dysfunction demonstrated as disturbances on an electroencephalogram, and levels greater than 50 μg/mL are considered toxic. While our patient's bromide level was not as high as those previously reported, no other causes for his agitation were identified. Conclusion Elevated bromide levels from therapeutic PB can occur, and monitoring of these levels should be considered. [ABSTRACT FROM AUTHOR]

Background: Previous research found that serum chloride is an independent predictor of hospital mortality; its increase within 48 hours of admission was linked to a higher percentage of 0.9% saline administration. Furthermore, the number of days that a patient survived was negatively connected with the extent of the serum chloride elevation. So we aimed to predict the outcome among critically ill patients admitted to the surgical intensive care unit in Zagazig University Hospitals and its association with serum chloride fluctuations on admission and within 5 days of intensive care unit stay. Methods: This prospective cohort study was conducted on 300 critically ill patients with an age over 18 years old in the Surgical Intensive Care Unit (SICU), Faculty of Medicine, Zagazig University hospitals. Serum chloride level was measured on admission, 3rd day, and 5th day. According to chloride level on admission, the patients were classified into 3 groups: Group 1 included patients with chloride levels <95 mEq/L, Group 2 included patients with chloride levels 95-105 mEq/L, and Group 3 included patients with chloride levels > 105 mEq/L. Results: Longer periods of stay in the intensive care unit were correlated with higher serum chloride levels at admission (24.33 ± 26.87 days). On ICU admission, patients with hypochloremia had a high death rate (19.3%). Positive fluctuation of serum chloride after admission was linked to a high mortality rate (11.4%). Conclusion: Changes in the serum chloride level endanger the clinical outcome of critically ill patients in the form of longer periods of ICU stay and higher rates of mortality. [ABSTRACT FROM AUTHOR]

Diabetic ketoacidosis (DKA) is a life-threatening complication of type 1 diabetes mellitus (T1DM). Prerenal acute kidney injury (AKI) is associated with profound hypovolemia and reduced renal perfusion. Results regarding hyperchloremia-associated AKI in patients with DKA are conflicting; we therefore investigated the potential relationship between hyperchloremia status and the risk of developing AKI. This single-center cohort study included 113 newly diagnosed T1DM patients with DKA admitted to the pediatric intensive care unit. Laboratory parameters, including Na, K, urea, creatinine, and chloride levels, were retrospectively reviewed at the time of presentation and at 12, 24 and 36 h. AKI was defined using the eGFR according to the pediatric RIFLE classification criteria. Twenty-two (19.5%) of the 113 patients were in the AKI group. Two-way repeated-measures ANOVA showed significant (P values ≤ 0.01) time interaction effects within the groups based on the eGFR and the serum chloride, hyperchloremia, and phosphate levels. Serum chloride levels did not differ between the groups during the first 12 h (p > 0.05) but were significantly greater in the AKI group than in the non-AKI group at 24 h and 36 h (p < 0.01). The final DKA resolution time was significantly greater in the AKI group than in the non-AKI group [22.2 (9.5) vs. 17.0 (12.0) h, respectively; p = 0.03]. However, the groups had similar lengths of hospital stay [13.0 (8.0) days vs. 12.0 (4.0) days, respectively; p = 0.17]. Conclusions: Hyperchloremia may be iatrogenic rather than causative during treatment. This may worsen renal failure and prolong the recovery and treatment time for DKA patients. What is Known? • Acute kidney injury resulting from severe volume depletion is a common occurrence in diabetic ketoacidosis and typically requires significant volume replacement therapy. • In recent years, hyperchloremia has been associated with increased risks of AKI, morbidity, and mortality in some conditions, such as diabetic ketoacidosis. What is New? • The incidence of hyperchloremia increases over time during the treatment of diabetic ketoacidosis. • Hyperchloremia may be an iatrogenic element rather than a cause of acute kidney injury during the treatment of diabetic ketoacidosis. [ABSTRACT FROM AUTHOR]

Purpose The purpose of this therapeutic update is to provide pharmacists with a general overview of the pathophysiology of hyperchloremia and describe strategies to help prevent development of this electrolyte abnormality in hospitalized patients. Summary Hyperchloremia is an electrolyte abnormality associated with an increased incidence of acute kidney injury and metabolic acidosis. Intravenous (IV) fluids utilized for volume resuscitation, medication diluents, and total parental nutrition all may contribute to the development of hyperchloremia. Current evidence suggests that administration of balanced crystalloids for either fluid resuscitation or maintenance fluids may impact serum chloride levels and patient outcomes. In multiple randomized controlled trials, administering balanced crystalloids for fluid resuscitation in critically ill patient populations did not decrease mortality. However, further analyses of subpopulations within these trials have demonstrated that patients with sepsis may benefit from receiving balanced crystalloids for initial fluid resuscitation. Results from several small studies suggest that altering the composition of these IV fluids may help prevent development of hyperchloremia. Conclusion Management of hyperchloremia is preventative in nature and can be mitigated through management of resuscitation fluids, medication diluents, and total parenteral nutrition. Inpatient pharmacists should be aware of the potential risk of fluid-associated hyperchloremia and assist with optimal fluid management to prevent and manage hyperchloremia. [ABSTRACT FROM AUTHOR]

Maintenance intravenous fluids are the most frequently ordered medications for hospitalized children. Since the American Association of Pediatrics published national guidelines, there has been an increased reflexive use of isotonic solutions, especially 0.9% saline, as a prophylaxis against hyponatremia. In this educational review, we discuss the potential deleterious effects of using 0.9% saline, including the development of hyperchloremia, metabolic acidosis, acute kidney injury, hyperkalemia, and a proinflammatory state. Balanced solutions with anion buffers cause relatively minimal harm when used in most children. While the literature supporting one fluid choice over the other is variable, we highlight the benefits of balanced solutions over saline and the importance of prescribing fluid therapy that is individualized for each patient. [ABSTRACT FROM AUTHOR]

Oral poisoning can trigger diverse physiological reactions, determined by the toxic substance involved. One such consequence is hyperchloremia, characterized by an elevated level of chloride in the blood and leads to kidney damage and impairing chloride ion regulation. Here, we conducted a comprehensive genome-wide analysis to investigate genes or proteins linked to hyperchloremia. Our analysis included functional enrichment, protein–protein interactions, gene expression, exploration of molecular pathways, and the identification of potential shared genetic factors contributing to the development of hyperchloremia. Functional enrichment analysis revealed that oral poisoning owing hyperchloremia is associated with 4 proteins e.g. Kelch-like protein 3, Serine/threonine-protein kinase WNK4, Serine/threonine-protein kinase WNK1 and Cullin-3. The protein–protein interaction network revealed Cullin-3 as an exceptional protein, displaying a maximum connection of 18 nodes. Insufficient data from transcriptomic analysis indicates that there are lack of information having direct associations between these proteins and human-related functions to oral poisoning, hyperchloremia, or metabolic acidosis. The metabolic pathway of Cullin-3 protein revealed that the derivative is Sulfonamide which play role in, increasing urine output, and metabolic acidosis resulted in hypertension. Based on molecular docking results analysis it found that Cullin-3 proteins has the lowest binding energies score and being suitable proteins. Moreover, no major variations were observed in unbound Cullin-3 and all three peptide bound complexes shows that all systems remain compact during 50 ns simulations. The results of our study revealed Cullin-3 proteins be a strong foundation for the development of potential drug targets or biomarker for future studies. [ABSTRACT FROM AUTHOR]

Background: Acute kidney injury (AKI) is a recognized comorbidity in pediatric diabetic ketoacidosis (DKA), although the exact etiology is unclear. The unique physiology of DKA makes dehydration assessments challenging, and these patients potentially receive excessive amounts of intravenous fluids (IVF). We hypothesized that dehydration is over-estimated in pediatric DKA, leading to over-administration of IVF and hyperchloremia that worsens AKI. Methods: Retrospective cohort of all DKA inpatients at a tertiary pediatric hospital from 2014 to 2019. A total of 145 children were included; reasons for exclusion were pre-existing kidney disease or incomplete medical records. AKI was determined by change in creatinine during admission, and comparison to a calculated baseline value. Linear regression multivariable analysis was used to identify factors associated with AKI. True dehydration was calculated from patients' change in weight, as previously validated. Fluid over-resuscitation was defined as total fluids given above the true dehydration. Results: A total of 19% of patients met KDIGO serum creatinine criteria for AKI on admission. Only 2% had AKI on hospital discharge. True dehydration and high serum urea levels were associated with high serum creatinine levels on admission (p = 0.042; p < 0.001, respectively). Fluid over-resuscitation and hyperchloremia were associated with delayed kidney recovery (p < 0.001). Severity of initial AKI was associated with cerebral edema (p = 0.018). Conclusions: Dehydration was associated with initial AKI in children with DKA. Persistent AKI and delay to recovery was associated with hyperchloremia and over-resuscitation with IVF, potentially modifiable clinical variables for earlier AKI recovery and reduction in long-term morbidity. This highlights the need to re-address fluid protocols in pediatric DKA. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To determine if initial fluid resuscitation with balanced crystalloid (e.g., multiple electrolytes solution [MES]) or 0.9% saline adversely affects kidney function in children with septic shock. DESIGN: Parallel-group, blinded multicenter trial. SETTING: PICUs of four tertiary care centers in India from 2017 to 2020. PATIENTS: Children up to 15 years of age with septic shock. METHODS: Children were randomized to receive fluid boluses of either MES (PlasmaLyte A) or 0.9% saline at the time of identification of shock. All children were managed as per standard protocols and monitored until discharge/death. The primary outcome was new and/or progressive acute kidney injury (AKI), at any time within the first 7 days of fluid resuscitation. Key secondary outcomes included hyperchloremia, any adverse event (AE), at 24, 48, and 72 hours, and all-cause ICU mortality. INTERVENTIONS: MES solution (n = 351) versus 0.9% saline (n = 357) for bolus fluid resuscitation during the first 7 days. MEASUREMENTS AND MAIN RESULTS: The median age was 5 years (interquartile range, 1.3-9); 302 (43%) were girls. The relative risk (RR) for meeting the criteria for new and/or progressive AKI was 0.62 (95% CI, 0.49-0.80; p < 0.001), favoring the MES (21%) versus the saline (33%) group. The proportions of children with hyperchloremia were lower in the MES versus the saline group at 24, 48, and 72 hours. There was no difference in the ICU mortality (33% in the MES vs 34% in the saline group). There was no difference with regard to infusionrelated AEs such as fever, thrombophlebitis, or fluid overload between the groups. CONCLUSIONS: Among children presenting with septic shock, fluid resuscitation with MES (balanced crystalloid) as compared with 0.9% saline resulted in a significantly lower incidence of new and/or progressive AKI during the first 7 days of hospitalization. [ABSTRACT FROM AUTHOR]

In recent decades, infusion solutions such as NaCl 0.9% and lactate Ringer's solution have been replaced in clinical practice. Since 2017, the national guidelines for perioperative infusion therapy in children recommend balanced isotonic solutions to maintain fluid balance. The composition of balanced infusion solutions varies with respect to their electrolyte content. Hyperchloremia may be mistaken for hypovolemia and may interfere with volume therapy in pediatric patients. Sterofundin ISO® balanced solution contains 127 mmol/L chloride and may cause hyperchloremic acidosis if administered in large volumes. Objectives: The purpose of this study was to compare the effects of Sterofundin ISO® (SF) therapy with the balanced isochloremic solution Deltajonin® (DJ) (106 mmol/L chloride) on the acid–base status in infants undergoing craniofacial surgery. Methods: This retrospective, non-blinded study included 100 infants undergoing craniectomy due to isolated nonsyndromic sagittal craniosynostosis. The first 50 infants received Sterofundin ISO®. Due to changes in national guidelines, the infusion was changed to the isoionic Deltajonin® in an additional 50 infants in 2017. Pre- and postoperative values of chloride, pH, base excess, bicarbonate, and albumin and phosphate were determined, and the strong-ion difference, strong-ion gap, anion gap, and weak acids were calculated. Results: Both groups were comparable in terms of their age, sex, underlying disease, preoperative electrolytes (except K at 3.9 ± 0.3 mmol/L (SF) vs. 4.1 ± 0.3 mmol/L (DJ) and lactate 8.7 ± 2.1 (SF) vs. 9.6 ± 2.6 mmol/L (DJ)). In the Sterofundin ISO® group, hyperchloremic metabolic acidosis was observed in 19 patients, whereas only 2 infants in the Deltajonin® group had hyperchloremic metabolic acidosis. The postoperative chloride level was 111 ± 2.7 mmol/L (SF) vs. 108 ± 2.4 mmol/L (DJ). The difference in anion gap was 12.5 ± 3.0 mmol/L (SF) vs. 14.6 ± 2.8 mmol/L (DJ), and the difference in SIDa (apparent strong-ion difference) was 30.9 mmol/L (SF) vs. 33.8 mmol/L (DJ). Conclusions: Hyperchloremic acidosis can be induced by the volume replacement with high-chloride-concentration crystalloids such as Sterofundin ISO®. This can be detected using the Stewart model. [ABSTRACT FROM AUTHOR]

Introduction: hyperchloremia and hypernatremia are common complications in critically ill children and have been associated with the development of acute kidney injury (AKI) and mortality. Objective: to estimate the incidence of hyperchloremia and hypernatremia during the first 72 hours of admission to a pediatric intensive care unit (PICU), and to evaluate their association with AKI and mortality. Material and methods: prospective cohort study, conducted over a period of 15 months. Patients with disorders in plasma levels of chloride (Cl-) or sodium (Na+), as well as with AKI at the time of admission, were excluded. Values > 110 mEq/L Cl- and > 145 mEq/L Na+ were considered as hyperchloremia and hypernatremia, respectively. A sample size of 255 patients was calculated. Statistical analysis. Odds Ratio (OR) and 95% confidence intervals (95% CI) were calculated for bivariate and multivariate analyses. Results: among 241 patients, the incidence of hyperchloremia was 12.4% (n = 30), and of hypernatremia 18.6% (n = 45). The frequency of AKI was 35.6%, and mortality was 14.1%. In logistic regression analysis, hypernatremia was associated with AKI (OR 2.7, 95% CI 1.3-5.7, p < 0.006), but not with mortality. While hyperchloremia was not identified as a risk for AKI or death. Conclusions: hyperchloremia and hypernatremia are common in critically ill pediatric patients, but only hypernatremia seems to confer a higher risk of complications. [ABSTRACT FROM AUTHOR]

Background : Hyperchloremia has been associated with acute kidney injury (AKI) in critically ill adult patients. Data is limited in pediatric patients. Our study sought to determine if an association exists between hyperchloremia and AKI in pediatric patients admitted to the intensive care unit (PICU). Methods: This is a single-center retrospective cohort study of pediatric patients admitted to the PICU for greater than 24 h and who received intravenous fluids. Patients were excluded if they had a diagnosis of kidney disease or required kidney replacement therapy (KRT) within 6 h of admission. Exposures were hyperchloremia (serum chloride ≥ 110 mmol/L) within the first 7 days of PICU admission. The primary outcome was the development of AKI using the Kidney Disease Improving Global Outcomes (KDIGO) criteria. Secondary outcomes included time on mechanical ventilation, new KRT, PICU length of stay, and mortality. Outcomes were analyzed using multivariate logistic regression. Results: There were 407 patients included in the study, 209 in the hyperchloremic group and 198 in the non-hyperchloremic group. Univariate analysis demonstrated 108 (51.7%) patients in the hyperchloremic group vs. 54 (27.3%) in the non-hyperchloremic group (p = <.001) with AKI. On multivariate analysis, the odds ratio of AKI with hyperchloremia was 2.24 (95% CI 1.39–3.61) (p =.001). Hyperchloremia was not associated with increased odds of mortality, need for KRT, time on mechanical ventilation, or length of stay. Conclusion: Hyperchloremia was associated with AKI in critically ill pediatric patients. Further pediatric clinical trials are needed to determine the benefit of a chloride restrictive vs. liberal fluid strategy. [ABSTRACT FROM AUTHOR]

Hyperchloremia has negative consequences, such as increased proinflammatory mediators, renal dysfunction, and mortality in patients with septic shock. However, data on the effects of hyperchloremia on COVID-19 infections are scarce. The study aimed to investigate the effects of hyperchloremia on inflammatory markers, serum creatinine, hemoglobin levels, and outcomes in critically ill COVID-19 patients. A retrospective review of all adult patients admitted to the ICU at King Fahd University Hospital with a moderate to severe COVID-19 infection from January 2020 to August 2021 was performed. Serum chloride levels, ferritin, lactate dehydrogenase (LDH), C-reactive protein (CRP), creatinine, and hemoglobin levels were collected on the first and third days of ICU admission. Demographic data, oxygen support modality, ICU length of stay (ICU LOS), renal replacement therapy (RRT), and deaths were collected. Of 420 patients, 255 were included; 97 (38%) had hyperchloremia, while 158 (62%) did not. Hyperchloremic patients had a higher percentage of increases in ferritin (54.6%), CRP (6.2%), and LDH (15.5%) between the first and third days of admission, compared to non-hyperchloremic patients (43.7%, 6.3%, and 5.7%, respectively). The decrease in hemoglobin levels was similar in both groups (p=0.103). There was a significant association between hyperchloremia and an increase in serum creatinine (p<0.0001). Sixty-six (68%) patients required endotracheal intubation in the hyperchloremic group (p=0.003). The mortality rate was significant in the hyperchloremic cohort (p=<0.0001). Hyperchloremia was significantly associated with increased risks of kidney injury, endotracheal intubation, and death. However, hyperchloremia was not associated with increased ferritin, CRP, or hemoglobin decreases in critically ill COVID-19 patients. [ABSTRACT FROM AUTHOR]

Purpose: Acute kidney injury (AKI) is an established complication of adult traumatic brain injury (TBI) and known risk factor for mortality. Evidence demonstrates an association between hyperchloremia and AKI in critically ill adults but studies in children are scarce. Given frequent use of hypertonic saline in the management of pediatric TBI, we believe the incidence of hyperchloremia will be high and hypothesize that it will be associated with development of AKI. Methods: Single-center retrospective cohort study was completed at an urban, level 1 pediatric trauma center. Children > 40 weeks corrected gestational age and < 21 years of age with moderate or severe TBI (presenting GCS < 13) admitted between January 2016 and December 2021 were included. Primary study outcome was presence of AKI (defined by pediatric Kidney Disease: Improving Global Outcomes criteria) within 7 days of hospitalization and compared between patients with and without hyperchloremia (serum chloride ≥ 110 mEq/L). Results: Fifty-two children were included. Mean age was 5.75 (S.D. 5.4) years; 60% were male (31/52); and mean presenting GCS was 6 (S.D. 2.9). Thirty-seven patients (71%) developed hyperchloremia with a mean peak chloride of 125 (S.D. 12.0) mEq/L and mean difference between peak and presenting chloride of 16 (S.D. 12.7) mEq/L. Twenty-three patients (44%) developed AKI; of those with hyperchloremia, 62% (23/37) developed AKI, while among those without hyperchloremia, 0% (0/15) developed AKI (difference 62%, 95% CI 42–82%, p < 0.001). Attributable risk of hyperchloremia leading to AKI was 62.2 (95% CI 46.5–77.8, p = 0.0015). Conclusion: Hyperchloremia is common in the management of pediatric TBI and is associated with development of AKI. Risk appears to be associated with both the height of serum chloride and duration of hyperchloremia. [ABSTRACT FROM AUTHOR]

Objective: To investigate the association of point‐of‐care biochemical variables obtained during CPR or within 24 hours of return of spontaneous circulation (ROSC) with patient outcomes. Design: Retrospective study. Setting: University teaching hospital. Animals: Ninety‐four dogs and 27 cats undergoing CPR according to the Reassessment Campaign on Veterinary Resuscitation guidelines. Interventions: None. Measurements and Main Results: Blood gas, acid–base, electrolyte, glucose, and plasma lactate values obtained during CPR or within 24 hours of ROSC were retrospectively evaluated and are described. The blood sample type and collection time with respect to CPR initiation and ROSC were recorded. Measured variables, collection times, and species were included in a multivariable logistic regression model to estimate the odds ratio (OR) and 95% confidence interval of ROSC, sustained ROSC (≥20 min), and survival to hospital discharge. Significance was set at P < 0.05. Seventy‐two venous blood samples obtained during CPR and 45 first venous and arterial blood samples obtained after ROSC were included in logistic regression analysis. During CPR, PvO2 (1.09 [1.036–1.148], P = 0.001) and venous standard base excess (SBE) (1.207 [1.094–1.331], P < 0.001) were associated with ROSC. PvO2 (1.075 [1.028–1.124], P = 0.002), SBE (1.171 [1.013–1.353], P = 0.032), and potassium concentration (0.635 [0.426–0.946], P = 0.026) were associated with sustained ROSC. Potassium concentration (0.235 [0.083–0.667], P = 0.007) was associated with survival to hospital discharge. Following ROSC, pH (69.110 [4.393–1087], P = 0.003), potassium concentration (0.222 [0.071–0.700], P = 0.010), and chloride concentration (0.805 [0.694–0.933], P = 0.004) were associated with survival to hospital discharge. Conclusions: Biochemical variables such as PvO2, SBE, and potassium concentration during CPR and pH, potassium, and chloride concentration in the postarrest period may help identify dogs and cats with lower odds for ROSC or survival to hospital discharge following CPR. [ABSTRACT FROM AUTHOR]

Aim: Hyperchloremia is related to the risks of several morbidities and mortality in seriously sick cases. The effect of hyperchloremia on the incidence of acute kidney injury (AKI) in trauma patients is not well known. Association of hyperchloremia and AKI within the first 72 hour of pediatric intensive care unit (PICU) admission in pediatric trauma patients was investigated. Materials and Methods: A total of 137 patients with major trauma were investigated retrospectively from tertiary hospital. Serum chloride levels = 110 mmol/L described as hyperchloremia. Clinical and laboratory data were compared between AKI and non-AKI. A multivariate logistic regression analysis was used to determine the association between hyperchloremia and AKI. Results: Totally 109 children were favorable for evaluation following the application of suitability criteria. On admission and at 72 hours, electrolyte measurements were similar between two groups, however chloride level was significantly higher in AKI group (112.33 ± 4.74 vs. 109.07 ± 4.90 mmol/L; p<0.01) at 72 hours. Ratio of hyperchloremia was remarkably more common in AKI group (p<0.01). Hyperchloremia at 72 hours was ensured as an independent risk factor for AKI of pediatric patients with major trauma in the multivariate logistic analysis. Conclusion: Hyperchloremia frequently seen among major trauma patients adopted to the PICU, and appear to be related to an increased risk for AKI within the first 72 hour of admission. [ABSTRACT FROM AUTHOR]

Background: Hypertonic sodium chloride (HTS) is used in intensive care unit (ICU) settings to manage cerebral edema, intracranial hypertension, and for the treatment of severe hyponatremia. It has been associated with an increased incidence of hyperchloremia; however, there is limited literature focusing on hyperchloremic risk in neurologically injured patients. Objective: The primary objective of this study was to determine risk factors associated with development of hyperchloremia in a neurocritical care (NCC) ICU population. Methods: This was a retrospective case-control study performed in an adult NCC ICU and included patients receiving HTS. The primary outcome was to evaluate patient characteristics and treatments associated with hyperchloremia. Secondary outcomes included acute kidney injury and mortality. Results: Overall, 133 patients were identified; patients who were hyperchloremic were considered cases (n = 100) and patients without hyperchloremia were considered controls (n = 33). Characteristics and treatments were evaluated with univariate analysis and a logistic regression model. In the multivariate model, APACHE II Score, initial serum osmolality, total 3% saline volume, and total 23.4% saline volume were significant predictors for hyperchloremia. In addition, patients with a serum chloride greater than 113.5 mEq/L were found to have a higher risk of acute kidney injury (AKI) (adjusted OR 3.15; 95% CI 1.10-9.04). Conclusions: This study demonstrated APACHE II Score, initial serum osmolality, and total 3% and 23.4% saline volumes were associated with developing hyperchloremia in the NCC ICU. In addition, hyperchloremia is associated with an increased risk of AKI. [ABSTRACT FROM AUTHOR]

Background: Isotonic fluids are becoming the standard for hydration and maintenance fluid therapy, but there is no consensus on the optional choice among the different types of isotonic solution.This study is a single-center, non-randomized controlled trial at Kobe University Hospital, Japan, between April 2021 and March 2023. The study included pediatric patients aged 1–19 years who underwent kidney biopsies. From April 2021 to March 2022, 0.9% sodium chloride (saline) was administered, and from April 2022 to March 2023, balanced crystalloids were used. The primary outcome was the occurrence of hyponatremia (< 137 mEq/L) after a kidney biopsy. Secondary outcomes included other electrolyte balances, blood gas parameters, creatinine-based estimated glomerular filtration rate (Cr-eGFR), and arginine vasopressin concentrations (UMIN Clinical Trial Registry: UMIN 000044330).Of 61 patients enrolled, 2 were excluded, leaving 34 in the saline group and 25 in the balanced crystalloid group. No hyponatremia occurred, and serum sodium concentrations were similar between both groups (138.7 vs. 138.9 mEq/L, P = 0.08). The saline group showed a greater increase in serum chloride (+ 1.7 vs. + 0.2, P < 0.01) and a greater decrease in HCO3− concentrations (− 0.6 vs. + 0.9, P < 0.01). There were minimal changes in pH (− 0.01 vs. − 0.01, P = 0.99) and Cr-eGFR (− 1.5 vs. + 1.1 mL/min/1.73 m2, P = 0.96) in both groups.During pediatric kidney biopsy, both saline and balanced crystalloids were effective in preventing hyponatremia. Although saline infusion results in higher serum chloride concentrations and lower blood HCO3− concentrations than balanced crystalloids infusion, the clinical significance was minimal.A higher resolution version of the Graphical abstract is available as Supplementary informationA higher resolution version of the Graphical abstract is available as Supplementary informationMethods: Isotonic fluids are becoming the standard for hydration and maintenance fluid therapy, but there is no consensus on the optional choice among the different types of isotonic solution.This study is a single-center, non-randomized controlled trial at Kobe University Hospital, Japan, between April 2021 and March 2023. The study included pediatric patients aged 1–19 years who underwent kidney biopsies. From April 2021 to March 2022, 0.9% sodium chloride (saline) was administered, and from April 2022 to March 2023, balanced crystalloids were used. The primary outcome was the occurrence of hyponatremia (< 137 mEq/L) after a kidney biopsy. Secondary outcomes included other electrolyte balances, blood gas parameters, creatinine-based estimated glomerular filtration rate (Cr-eGFR), and arginine vasopressin concentrations (UMIN Clinical Trial Registry: UMIN 000044330).Of 61 patients enrolled, 2 were excluded, leaving 34 in the saline group and 25 in the balanced crystalloid group. No hyponatremia occurred, and serum sodium concentrations were similar between both groups (138.7 vs. 138.9 mEq/L, P = 0.08). The saline group showed a greater increase in serum chloride (+ 1.7 vs. + 0.2, P < 0.01) and a greater decrease in HCO3− concentrations (− 0.6 vs. + 0.9, P < 0.01). There were minimal changes in pH (− 0.01 vs. − 0.01, P = 0.99) and Cr-eGFR (− 1.5 vs. + 1.1 mL/min/1.73 m2, P = 0.96) in both groups.During pediatric kidney biopsy, both saline and balanced crystalloids were effective in preventing hyponatremia. Although saline infusion results in higher serum chloride concentrations and lower blood HCO3− concentrations than balanced crystalloids infusion, the clinical significance was minimal.A higher resolution version of the Graphical abstract is available as Supplementary informationA higher resolution version of the Graphical abstract is available as Supplementary informationResults: Isotonic fluids are becoming the standard for hydration and maintenance fluid therapy, but there is no consensus on the optional choice among the different types of isotonic solution.This study is a single-center, non-randomized controlled trial at Kobe University Hospital, Japan, between April 2021 and March 2023. The study included pediatric patients aged 1–19 years who underwent kidney biopsies. From April 2021 to March 2022, 0.9% sodium chloride (saline) was administered, and from April 2022 to March 2023, balanced crystalloids were used. The primary outcome was the occurrence of hyponatremia (< 137 mEq/L) after a kidney biopsy. Secondary outcomes included other electrolyte balances, blood gas parameters, creatinine-based estimated glomerular filtration rate (Cr-eGFR), and arginine vasopressin concentrations (UMIN Clinical Trial Registry: UMIN 000044330).Of 61 patients enrolled, 2 were excluded, leaving 34 in the saline group and 25 in the balanced crystalloid group. No hyponatremia occurred, and serum sodium concentrations were similar between both groups (138.7 vs. 138.9 mEq/L, P = 0.08). The saline group showed a greater increase in serum chloride (+ 1.7 vs. + 0.2, P < 0.01) and a greater decrease in HCO3− concentrations (− 0.6 vs. + 0.9, P < 0.01). There were minimal changes in pH (− 0.01 vs. − 0.01, P = 0.99) and Cr-eGFR (− 1.5 vs. + 1.1 mL/min/1.73 m2, P = 0.96) in both groups.During pediatric kidney biopsy, both saline and balanced crystalloids were effective in preventing hyponatremia. Although saline infusion results in higher serum chloride concentrations and lower blood HCO3− concentrations than balanced crystalloids infusion, the clinical significance was minimal.A higher resolution version of the Graphical abstract is available as Supplementary informationA higher resolution version of the Graphical abstract is available as Supplementary informationConclusions: Isotonic fluids are becoming the standard for hydration and maintenance fluid therapy, but there is no consensus on the optional choice among the different types of isotonic solution.This study is a single-center, non-randomized controlled trial at Kobe University Hospital, Japan, between April 2021 and March 2023. The study included pediatric patients aged 1–19 years who underwent kidney biopsies. From April 2021 to March 2022, 0.9% sodium chloride (saline) was administered, and from April 2022 to March 2023, balanced crystalloids were used. The primary outcome was the occurrence of hyponatremia (< 137 mEq/L) after a kidney biopsy. Secondary outcomes included other electrolyte balances, blood gas parameters, creatinine-based estimated glomerular filtration rate (Cr-eGFR), and arginine vasopressin concentrations (UMIN Clinical Trial Registry: UMIN 000044330).Of 61 patients enrolled, 2 were excluded, leaving 34 in the saline group and 25 in the balanced crystalloid group. No hyponatremia occurred, and serum sodium concentrations were similar between both groups (138.7 vs. 138.9 mEq/L, P = 0.08). The saline group showed a greater increase in serum chloride (+ 1.7 vs. + 0.2, P < 0.01) and a greater decrease in HCO3− concentrations (− 0.6 vs. + 0.9, P < 0.01). There were minimal changes in pH (− 0.01 vs. − 0.01, P = 0.99) and Cr-eGFR (− 1.5 vs. + 1.1 mL/min/1.73 m2, P = 0.96) in both groups.During pediatric kidney biopsy, both saline and balanced crystalloids were effective in preventing hyponatremia. Although saline infusion results in higher serum chloride concentrations and lower blood HCO3− concentrations than balanced crystalloids infusion, the clinical significance was minimal.A higher resolution version of the Graphical abstract is available as Supplementary informationA higher resolution version of the Graphical abstract is available as Supplementary informationGraphical abstract: Isotonic fluids are becoming the standard for hydration and maintenance fluid therapy, but there is no consensus on the optional choice among the different types of isotonic solution.This study is a single-center, non-randomized controlled trial at Kobe University Hospital, Japan, between April 2021 and March 2023. The study included pediatric patients aged 1–19 years who underwent kidney biopsies. From April 2021 to March 2022, 0.9% sodium chloride (saline) was administered, and from April 2022 to March 2023, balanced crystalloids were used. The primary outcome was the occurrence of hyponatremia (< 137 mEq/L) after a kidney biopsy. Secondary outcomes included other electrolyte balances, blood gas parameters, creatinine-based estimated glomerular filtration rate (Cr-eGFR), and arginine vasopressin concentrations (UMIN Clinical Trial Registry: UMIN 000044330).Of 61 patients enrolled, 2 were excluded, leaving 34 in the saline group and 25 in the balanced crystalloid group. No hyponatremia occurred, and serum sodium concentrations were similar between both groups (138.7 vs. 138.9 mEq/L, P = 0.08). The saline group showed a greater increase in serum chloride (+ 1.7 vs. + 0.2, P < 0.01) and a greater decrease in HCO3− concentrations (− 0.6 vs. + 0.9, P < 0.01). There were minimal changes in pH (− 0.01 vs. − 0.01, P = 0.99) and Cr-eGFR (− 1.5 vs. + 1.1 mL/min/1.73 m2, P = 0.96) in both groups.During pediatric kidney biopsy, both saline and balanced crystalloids were effective in preventing hyponatremia. Although saline infusion results in higher serum chloride concentrations and lower blood HCO3− concentrations than balanced crystalloids infusion, the clinical significance was minimal.A higher resolution version of the Graphical abstract is available as Supplementary informationA higher resolution version of the Graphical abstract is available as Supplementary information [ABSTRACT FROM AUTHOR]

Background: On the basis of increased mortality associated with hyperchloremia among critically ill patients, we investigated the effect of occurrence of early hyperchloremia on death or disability at 90 days in patients with intracerebral hemorrhage (ICH). Methods: We analyzed the data from Antihypertensive Treatment of Cerebral Hemorrhage 2 trial, which recruited patients with spontaneous ICH within 4.5 h of symptom onset. Patients with increased serum chloride levels (110 mmol/L or greater) at either baseline or 24, 48, or 72 h after randomization were identified. We further graded hyperchloremia into one occurrence or two or more occurrences within the first 72 h. Two logistic regression analyses were performed to determine the effects of hyperchloremia on (1) death within 90 days and (2) death or disability at 90 days after adjustment for potential confounders. Results: Among the total of 1,000 patients analyzed, hyperchloremia within 72 h was seen in 114 patients with one occurrence and in 154 patients with two or more occurrences. Patients with one occurrence of hyperchloremia (odds ratio [OR] 2.5, 95% confidence interval [CI] 1.1–5.5) and those with two or more occurrences (OR 2.6, 95% CI 1.3–5.0) had significantly higher odds of death within 90 days after adjustment for age, race and ethnicity, National Institutes of Health Stroke Scale score strata, hematoma volume, presence or absence of intraventricular hemorrhage, cigarette smoking, previous stroke, and maximum hourly dose of nicardipine. Patients with two or more occurrences of hyperchloremia (OR 3.4, 95% CI 2.1–5.6) had significantly higher odds of death or disability at 90 days compared with patients without hyperchloremia after adjustment for the abovementioned potential confounders. Conclusions: The independent association between hyperchloremia and death or disability at 90 days suggests that avoidance of hyperchloremia may reduce the observed death or disability in patients with ICH. Clinical Trial Registration: ClinicalTrials.gov: NCT01176565. [ABSTRACT FROM AUTHOR]

Background/aim: While chloride (Cl) is the most abundant anion in the serum, it is unfortunately one of the most commonly disregarded laboratory test results routinely drawn upon admission into the medical intensive care unit (MICU). We aimed to investigate the relation between in-hospital mortality, different pathologies requiring admission to the MICU, serum Cl levels, and other biochemical tests in a tertiary center. Materials and methods: The prospective study included data from 373 patients admitted to the ICU of a tertiary care center between 2017 and 2019. Data of patients under 18, pregnant patients or patients who were in the MICU for under 48 h were excluded. Comorbidity status, complete blood count, biochemistry tests, and blood gas analysis results of all patients included in the study were collected and recorded. Univariate and multivariate analyses were performed with the obtained data. Results: Of the patients included in the study, 158 (42.4%) were discharged, and 215 (57.6%) died. In the receiver operator characteristics curve analysis performed to determine the discriminating power of Cl levels with a cut-off value of >98 mEq/L in relation to mortality, its sensitivity was found to be 84% and specificity 60%. According to Kaplan-Meier analysis results, mortality rate was higher (60% vs 46%) and survival time was lower (19.0 ± 1.46 vs. 23.0 ± 4.36 days; p = 0.035) in the patient group with high Cl levels compared to the patient group with normal or low Cl levels. In the Cox regression analysis, it was found that the survival time of the patients hospitalized in the MICU was associated with the variables of Cl, presence of cancer diagnosis and pCO2 (hazard ratio: 1.030 (1.008-1.049), 2.260 (1.451-3.500), and 1.020 (1.003-1.029); p < 0.05, respectively). Conclusion: Mortality in MICU patients were found to increase in association with higher Cl levels at admission, presence of cancer disease, and higher pCO2 levels. In addition, it should not be ignored that there may be an important relationship between renal failure and hyperchloremia in MICU patients. [ABSTRACT FROM AUTHOR]

Background: 0.9% saline commonly used for resuscitation of septic patients might induce biochemical changes leading to detrimental effects. Ringer's lactate being a balanced crystalloid might be beneficial in such a scenario. Objectives: We undertook this study to explore in detail the effect of these fluids in the resuscitation of septic patients, and risks and benefits these two fluids would have on the overall prognosis of patients. Methods: This was an open-label randomized controlled trial undertaken in emergency medical services attached to the department of medicine at a tertiary care teaching hospital. One hundred sixty adult (⩾18 years old) medical patients admitted with the diagnosis of sepsis fulfilling eligibility criteria were included. They were randomly assigned to receive 0.9% saline or ringer's lactate. These fluids were given for the initial 24 h only, and after then, the type of fluid given was based on treating physician discretion. Various biochemical parameters were measured at baseline and various time points during the hospital stay. The primary outcome was to find out the incidence of hyperchloremia at 24 h from the time of randomization and during the hospital stay. The secondary outcomes were incidence of acute kidney injury, need for renal replacement therapy; differences in pH, bicarbonate, serum lactate, coagulation parameters, sequential organ failure assessment scores at various time points; and hospital/30-day mortality. Results: The baseline characteristics in both groups were comparable. At admission, each group had a serum chloride value which was comparable (p value: 0.595); however, at 24 and 48 h, a statistically significant difference was noticed, with 0.9% saline group having a higher mean serum chloride value (113.66 ± 10.04 v/s 108.98 ± 8.04 mEq/L, p value: 0.001 at 24 h) and (114.75 ± 9.51 v/s 111.12 ± 7.84 mEq/L, p value: 0.022 at 48 h). At 24 and 48 h post-randomization, the incidence of hyperchloremia was significantly higher in the 0.9% saline group (at 24 h, 0.9% saline: 75.0% v/s Ringer's lactate: 48.8%, p value: 0.001 and at 48 h, 0.9% saline: 77.2% v/s Ringer's lactate: 60.3%, p value: 0.022), although there was no difference in the incidence of hyperchloremia recorded during the hospital stay. Acute kidney injury incidence at 24 and 48 h post-randomization was significantly higher in the 0.9% saline group (at 24 h, 0.9% saline: 23.8% v/s Ringer's lactate: 10.0%, p value: 0.020 and at 48 h, 0.9% saline: 29.1% v/s Ringer's lactate: 15.4%, p value: 0.039). No significant differences in other secondary outcomes were observed. Conclusion: Higher incidence of hyperchloremia and a higher rate of acute kidney injury at 24 and 48 h after randomization were noted in the 0.9% saline group. [ABSTRACT FROM AUTHOR]

Background: A few previous clinical studies have shown that chloride (Cl) contributes to the progression and development of hypertension or proteinuria. Therefore, we aimed to determine whether hyperchloremia is associated with hypertension or proteinuria in patients with chronic kidney disease (CKD) and to define the relationships between the reduction in serum Cl concentration associated with CKD treatment and improvements in hypertension and/or proteinuria. Methods: We performed a retrospective observational study of new or referred patients with CKD who had hyperchloremia, moderate proteinuria, renal dysfunction, and hypertension. Patients taking medication for metabolic acidosis or with a history of dialysis were excluded. The participants' systolic and diastolic blood pressure (BP), serum sodium (Na) and Cl concentrations, and urinary protein (UP) concentration were measured at baseline and after 1 month of CKD treatment. Results: Fifty-one patients with CKD were included in the study. Their serum Cl concentration independently correlated with sBP and UP at baseline (P = 0.022 and P = 0.033, respectively). After 1 month's CKD treatment, their serum Na and Cl concentrations, sBP, and UP were significantly lower. The change in sBP during the month (ΔsBP) correlated with the change in serum Cl (ΔCl) (P = 0.012) but not with the change in serum Na. Multivariate analysis showed that ΔsBP was independently associated with ΔCl (P = 0.029). Conclusions: Hyperchloremia is an independent predictor of hypertension and proteinuria for patients with CKD. [ABSTRACT FROM AUTHOR]

Introduction: Diabetic ketoacidosis (DKA) is characterized by hyperglycemia, ketogenesis, and increased anion gap metabolic acidosis. Such derangements are accompanied by volume depletion as well as electrolyte disturbances. Resuscitation using traditional saline in DKA patients can exacerbate electrolyte abnormalities, in particular the production of hyperchloremia. Severe hypovolemia can result in acute kidney injury (AKI). The link between hyperchloremia and AKI is controversial. This study aimed to assess the relationship between hyperchloremia and AKI in pediatric patients with DKA and its impacts on clinical outcomes. Methods: This cross-sectional study was conducted on 70 children with DKA admitted to the pediatric intensive care unit in which all patients were subjected to detailed medical history taking and full clinical examination. Daily assessment of Na, K, urea, creatinine, chloride, arterial blood gases, and albumin/creatinine ratio (ACR) was done. AKI was defined as pRIFLE stage I and F. Results: Hyperchloremia was detected in 65.7% of patients at admission and in 52.9% after 24 h (p = 0.17). AKI was documented in 28% of patients. At admission hyperchloremia was detected in 56% of patients without AKI versus 90% of patients with AKI (p = 0.007). After 24 h, hyperchloremia was detected in 48.4% patients without versus 100% of patients with AKI. Chloride was significantly positively correlated to duration of admission, creatinine, ACR, and negatively correlated to eGFR. Conclusion: The development of AKI in patients with DKA was accompanied by hyperchloremia, increased time to DKA resolution, and longer hospital stay. A higher resolution version of the Graphical abstract is available as Supplementary information [ABSTRACT FROM AUTHOR]

The article presents a case study of a 60-year-old man with mental confusion and signs of dehydration. Topics include attending physician then requesting whole blood sodium measured using a point-of care device; and patient describing in the case study presenting with hypertonic dehydration resulting in electrolyte abnormalities most notable for hypernatremia and hyperchloremia.

Background: Serum chloride (Cl−) is one of the most essential extracellular anions. Based on emerging evidence obtained from patients with kidney or heart disease, hypochloremia has been recognized as an independent predictor of mortality. Nevertheless, excessive Cl− can also cause death in severely ill patients. This study aimed to investigate the relationship between hyperchloremia and high mortality rate in patients admitted to the surgical intensive care unit (SICU). Methods: We enrolled 2131 patients from the Multiparameter Intelligent Monitoring in Intensive Care III database version 1.4 (MIMIC-III v1.4) from 2001 to 2012. Selected SICU patients were more than 18 years old and survived more than 72 h. A serum Cl− level ≥ 108 mEq/L was defined as hyperchloremia. Clinical and laboratory variables were compared between hyperchloremia (n = 664) at 72 h post-ICU admission and no hyperchloremia (n = 1467). The Locally Weighted Scatterplot Smoothing (Lowess) approach was utilized to investigate the correlation between serum Cl- and the thirty-day mortality rate. The Cox proportional-hazards model was employed to investigate whether serum chlorine at 72 h post-ICU admission was independently related to in-hospital, thirty-day and ninety-day mortality from all causes. Kaplan-Meier curve of thirty-day and ninety-day mortality and serum Cl− at 72 h post-ICU admission was further constructed. Furthermore, we performed subgroup analyses to investigate the relationship between serum Cl− at 72 h post-ICU admission and the thirty-day mortality from all causes. Results: A J-shaped correlation was observed, indicating that hyperchloremia was linked to an elevated risk of thirty-day mortality from all causes. In the multivariate analyses, it was established that hyperchloremia remained a valuable predictor of in-hospital, thirty-day and ninety-day mortality from all causes; with adjusted hazard ratios (95% CIs) for hyperchloremia of 1.35 (1.02 ~ 1.77), 1.67 (1.28 ~ 2.19), and 1.39 (1.12 ~ 1.73), respectively. In subgroup analysis, we observed hyperchloremia had a significant interaction with AKI (P for interaction: 0.017), but there were no interactions with coronary heart disease, hypertension, and diabetes mellitus (P for interaction: 0.418, 0.157, 0.103, respectively). Conclusion: Hyperchloremia at 72 h post-ICU admission and increasing serum Cl− were associated with elevated mortality risk from all causes in severely ill SICU patients. [ABSTRACT FROM AUTHOR]

Background: Chloride (Cl) is required for the regulation of blood pressure, renal function, gastrointestinal homeostasis and decarboxylation/gas transport. "Dyschloremia" or levels of serum Cl beyond the normal range, is a frequent occurrence in intensive care units and seems to be mostly caused by iatrogenic procedures (i.e. intravenous infusion of fluids rich in Cl). Hypochloremia and hyperchloremia seem to be related to high risk of death in specified intensive care unit (ICU) groups, although the data is inconclusive. Hyperchloremia may be associated with higher hemodynamic unstable changes and need for vasopressors, in addition to hyperchloremic metabolic acidosis (e.g., following major surgeries). Nonetheless, the direct or indirect mediation of these effects is still uncertain. Additionally, new research suggests that individuals with advanced hyperchloremia have a higher risk of acute renal damage and require renal replacement treatment. Objective: The purpose of this study was to describe significant chloride-related outcomes in critical illness and to evaluate their relevance for everyday clinical practice and therapeutic alternatives. Conclusion: One may conclude that the concern about understanding the impact of chloride disorders on negative outcomes is rising; there seems to be a link between chloride disorders and negative outcomes, particularly death, in the ICU setting; one could theorize the need to rationalize the use of solutions with electrolyte components separate from the physiological solutions; and consider the presence or the development of hyperchloremia as a prognostic factor, without taking into consideration the severity of the critical patient. [ABSTRACT FROM AUTHOR]

Introduction: Patients with DKA generally present with a high anion gap metabolic acidosis (AG > 16) due to the presence of ketones but may also develop a narrow anion gap metabolic acidosis related to hyperchloremia. This study attempts to determine the incidence of hyperchloremic metabolic acidosis (before starting IV fluids) in children with DKA and to evaluate the impact of hyperchloremic metabolic acidosis on acute kidney injury and cerebral edema and inturn on mortality and duration of PICU stay. Methods: This was a prospective study conducted in the Department of Paediatrics, VIMS, Bellary between May 2016 to December 2017 and a total of 32 patients with DKA were enrolled in the study. Along with routine investigations, ABG and serum chloride levels were measured at the time of admission for categorization into normochloremic (high anion-gap) metabolic acidosis and hyperchloremic (normal anion-gap) metabolic acidosis. Incidence of hyperchloremic metabolic acidosis and its impact on the development of acute kidney injury and cerebral edema was taken as the primary outcome of the study. Mortality rate and duration of PICU stay were taken as a secondary outcome. Results: Hyperchloremic metabolic acidosis was observed in 18.8% of the study group. Acute kidney injury was seen in 38.4% of children who had normochloremic metabolic acidosis and in 83.3% of children with hyperchloremia. About 50% patients developed cerebral edema in the hyperchloremia group and only 3.8% developed cerebral edema in normochloremic group. These differences were statistically significant. Mortality rate in normochloremic and hyperchloremic metabolic acidosis was 3.8% and 50% respectively. Conclusions: Hyperchloremia at presentation in DKA is a risk factor for increased mortality. This fact should be born in mind while treating patients aggressively with chloride-containing fluids. Simple investigations like ABG and serum chloride levels can direct careful management of DKA and appropriate selection of IV fluids. [ABSTRACT FROM AUTHOR]

Hyperchloremia leads to adverse effects like increase in pro-inflammatory mediators, anaemia and renal dysfunction. Aim of this study is to determine the association of hyperchloremia with rise in C-reactive protein (CRP), serum ferritin, lactate dehydrogenase (LDH), serum creatinine and anaemia in COVID-19 patients in intensive care unit (ICU). It was a single-centre study, 62 COVID-19 patients participated. Change in CRP, serum ferritin, LDH, serum creatinine, haemoglobin between day one and day three of ICU admission were noted. Outcome in terms of in-hospital mortality was noted. Hyperchloremia (>106mmol/L) or rise in chloride by > 5mmol/L was seen in 13/62 (20.96%) patients. It was not associated with a rise in CRP, ferritin, LDH, creatinine, drop in hemoglobin within 72 hours or in-hospital mortality. 44/62 (71%) patients survived and were discharged from hospital. Multivariate logistic regression showed that if age and gender are also considered, there is a 25 times higher chance of having had a significant ferritin rise (> 95 ng/mL) in 72 hours of ICU admission among those who died. (p=0.01). Hyperchloremia (>106mmol/L) or a rise in chloride by > 5mmol/L in 72 hours of ICU admission was not associated with a significant increase in CRP, LDH, ferritin, serum creatinine within 72 hours of ICU admission or mortality in moderate-severe COVID-19 patients. If age and gender are taken into consideration, there is a 25 times higher chance of having had a significant ferritin rise (> 95 ng/mL) in 72 hours of ICU admission among those who died. [ABSTRACT FROM AUTHOR]

Background: The superiority of either the traditional or Stewart based approach to acid-base balance has focused primarily on analyzing metabolic acidemia, with little attention given to patients with neutral pH. In this study, we evaluate metabolic disturbances in patients in the immediate postoperative period focusing on patients with neutral pH, while comparing the Stewart and traditional approach. Methods: We conducted a single center retrospective observational cohort study. Over a 17-month period, data on arterial blood gas analysis, electrolytes, and albumin on the morning after surgery were retrieved from patients admitted to the postsurgical high dependency unit (HDU). Albumin-corrected anion gap (AG), apparent (SIDa) and effective strong ion difference (SIDe), and strong ion gap (SIG) were calculated. Results: Out of 1207 HDU admissions, 400 cases had a complete set of laboratory-data including albumin of which 281 presented with neutral pH (7.35 ≤ pH ≤ 7.45), 64 with acidemia (pH < 7.35) and 55 with alkalemia (pH > 7.45). In pH neutral patients, the following acidifying disturbances were found: SIDa was lowered in 101 (36%), and SIG was raised in 60 (21%). Base excess (BE) was decreased in 16 (6%) and corrected AG raised in 107 (38%). The alkalizing effect of hypoalbuminemia was present in 137 (49%). Out of 134 cases with normal BE and corrected AG, SIDa was lowered in 58 (43%). Out of 136 cases with normal SIDa and SIG, none had lowered BE and 28 increased AG (21%). Length of stay was significantly longer in patients with hypoalbuminemia, lowered SIDa, and increased corrected AG, but not decreased BE (hypoalbuminemia: 16 days vs. 10 days, P < 0.001; low SIDa: 15 days vs. 12 days, P = 0.015; increased AG: 16 days vs. 11 days, P < 0.001; low BE: 14 days vs. 13 days, P = 0.736). Conclusions: Metabolic disturbances, characterized mainly by the presence of lowered SIDa, increased AG, and hypoalbuminemia, are frequent in our population with apparent neutral acid-base balance based on pH and base excess. These changes on the morning after surgery are associated with increased length of stay. [ABSTRACT FROM AUTHOR]

Background: This systematic review discusses a clinical physiology aspect of chloride in fluid therapy. Crystalloid solutions are one of the most widely used remedies. While generally used in medicine for almost 190 years, studies focused largely on their safety have only been published since the new millennium. The most widely used solution, normal saline, is most often referred to in this context. Its excessive administration results in hyperchloremic metabolic acidosis with other consequences, including higher mortality rates. Methods: Original papers and review articles eligible for developing the present paper were identified by searching online in the electronic MEDLINE database. The keywords searched for included hyperchloremia, hypochloremia, and compound words containing the word "chloride," infusion therapy, metabolic acidosis, renal failure, and review. Results: A total of 21,758 papers published before 31 May 2020 were identified; of this number, 630 duplicates were removed from the list. Upon excluding articles based on their title or abstract, 1850 papers were screened, of which 63 full-text articles were assessed. Conclusions: According to the latest medical concepts, dyschloremia (both hyperchloremia and hypochloremia) represents a factor indisputably having a negative effect on selected variables of clinical outcome. As infusion therapy can significantly impact chloride homeostasis of the body, the choice of infusion solutions should always take into account the potentially adverse impact of chloride content on chloremia and organ function. [ABSTRACT FROM AUTHOR]

Objective: Hyperchloremia is associated with worsened outcomes in various clinical situations; however, data are limited in patients with diabetic ketoacidosis (DKA). The purpose of this study was to determine the effect of hyperchloremia on time to DKA resolution. Methods: We conducted a retrospective cohort study of adult patients admitted with incident DKA from January 2013 through October 2017 and stratified by the development of hyperchloremia versus maintaining normochloremia. The primary outcome was time to final DKA resolution. Secondary outcomes included time to initial DKA resolution, incidence of acute kidney injury (AKI) on admission, in-hospital development of AKI, and hospital length of stay (LOS). Results: Of the 102 patients included, 52 developed hyperchloremia. Patients with hyperchloremia had longer times to final DKA resolution compared to those with normochloremia (median 22.3 [interquartile range, IQR, 15.2-36.9] vs 14.2 [IQR 8.8-21.1] hours; P = .001). Time to initial DKA resolution was also longer in patients who developed hyperchloremia compared to those who did not (median 16.3 vs 10.9 hours; P = .024). More patients with hyperchloremia developed in-hospital AKI (26.9% vs 8.0%; P = .01). Median hospital LOS was significantly longer in the hyperchloremia cohort (P < .001). On Cox regression analysis, time to DKA resolution was significantly longer with each 1 mmol/L increase in serum chloride (HR 0.951; P < .001). Conclusion: The presence of hyperchloremia in patients with DKA was associated with increased time to DKA resolution, risk of in-hospital AKI, and hospital LOS. Further evaluation of the avoidance or treatment of hyperchloremia in DKA is needed. [ABSTRACT FROM AUTHOR]

Background: Hypernatremia has been associated with mortality in neurocritically ill patients, with and without traumatic brain injury (TBI). These studies, however, lack concomitant adjustment for hyperchloremia as a physiologically co-occurring finding despite the associations with hyperchloremia and worse outcomes after trauma, sepsis, and intracerebral hemorrhage. The objective of our study was to examine the association of concomitant hypernatremia and hyperchloremia with in-hospital mortality in moderate–severe TBI (msTBI) patients. Methods: We retrospectively analyzed prospectively collected data from the OPTIMISM-study and included all msTBI patients consecutively enrolled between 11/2009 and 1/2017. Time-weighted average (TWA) sodium and chloride values were calculated for all patients to examine the unadjusted mortality rates associated with the burden of hypernatremia and hyperchloremia over the entire duration of the intensive care unit stay. Multivariable logistic regression modeling predicting in-hospital mortality adjusted for validated confounders of msTBI mortality was applied to evaluate the concomitant effects of hypernatremia and hyperchloremia. Internal bootstrap validation was performed. Results: Of the 458 patients included for analysis, 202 (44%) died during the index hospitalization. Fifty-five patients (12%) were excluded due to missing data. Unadjusted mortality rates were nearly linearly increasing for both TWA sodium and TWA chloride, and were highest for patients with a TWA sodium > 160 mmol/L (100% mortality) and TWA chloride > 125 mmol/L (94% mortality). When evaluated separately in the multivariable analysis, TWA sodium (per 10 mmol/L change: adjusted OR 4.0 [95% CI 2.1–7.5]) and TWA chloride (per 10 mmol/L change: adjusted OR 3.9 [95% CI 2.2–7.1]) independently predicted in-hospital mortality. When evaluated in combination, TWA chloride remained independently associated with in-hospital mortality (per 10 mmol/L change: adjusted OR 2.9 [95% CI 1.1–7.8]), while this association was no longer observed with TWA sodium values (per 10 mmol/L change: adjusted OR 1.5 [95% CI 0.51–4.4]). Conclusions: When concomitantly adjusting for the burden of hyperchloremia and hypernatremia, only hyperchloremia was independently associated with in-hospital mortality in our msTBI cohort. Pending validation, our findings may provide the rationale for future studies with targeted interventions to reduce hyperchloremia and improve outcomes in msTBI patients. [ABSTRACT FROM AUTHOR]

Background: Serum chloride derangements are associated with poor clinical outcomes, including acute kidney injury (AKI) and mortality. We sought to determine the association between persistent hyperchloremia and renal recovery in critically ill children with AKI. Methods: We performed a retrospective cohort study of all patients with day 2 AKI admitted to a large academic pediatric intensive care unit from January 2014 to December 2015. After applying exclusion criteria, 348 patients were categorized as (1) hyperchloremia on both day 2 and day 7 (PersistentCl), (2) hyperchloremia on day 2 with normochloremia on day 7 (RecoveredCl), (3) normochloremia on day 2 with hyperchloremia on day 7 (DelayedCl), and (4) no hyperchloremia on day 2 nor day 7 (NormalCl). Hyperchloremia was defined as ≥ 110 mEq/L. The primary outcome was renal recovery on day 7, defined as the absence of AKI criteria. Secondary outcomes included discharge renal recovery, mortality, duration of mechanical ventilation, and hospital length of stay. Results: Day 7 renal recovery rates for PersistentCl, RecoveredCl, DelayedCl, and NormalCl were 37%, 66%, 71%, and 52% respectively. PersistentCl had lower odds of day 7 renal recovery (aOR = 0.29; 95% CI, 0.14 to 0.60; p = 0.0009), lower odds of discharge renal recovery (aOR = 0.22; 95% CI, 0.11 to 0.48; p = 0.0001), and higher odds of mortality (aOR = 3.50; 95% CI, 1.11 to 11.10; p = 0.03) when compared with RecoveredCl after adjusting for confounders. Conclusions: Persistent hyperchloremia is independently associated with impaired renal recovery as well as higher mortality. Prospective studies are indicated to determine if serum chloride represents a modifiable risk factor for poor outcomes. [ABSTRACT FROM AUTHOR]

In this article, the second in a new series designed to improve acute care nurses' understanding of laboratory abnormalities, the author continues her discussion of important values in the basic metabolic panel (see Back to Basics, January, for a discussion of sodium and fluid balance). Here she addresses the electrolytes potassium and chloride as well as blood urea nitrogen and creatinine, four values that are best considered together because they both reflect and impact renal function as well as acid--base homeostasis. Important etiology, clinical manifestations, and treatment concerns are also presented. Three case studies are used to integrate select laboratory diagnostic tests with history and physical examination findings, allowing nurses to develop a thorough, focused plan of care for electrolyte abnormalities and kidney disorders commonly encountered in the medical--surgical setting. [ABSTRACT FROM AUTHOR]

Background: Recent reports have demonstrated that among patients with subarachnoid hemorrhage (SAH) treated with hypertonic NaCl, resultant hyperchloremia has been associated with the development of acute kidney injury (AKI). We report a trial comparing the effect of two hypertonic solutions with different chloride contents on the resultant serum chloride concentrations in SAH patients, with a primary outcome aimed at limiting chloride elevation. Methods: A low ChloridE hyperTonic solution for brain Edema (ACETatE) trial is a single-center, double-blinded, double-dummy, randomized pilot trial comparing bolus infusions of 23.4% NaCl and 16.4% NaCl/Na-acetate for the treatment of cerebral edema in patients with SAH. Randomization occurred when patients developed hyperchloremia (serum Cl− ≥ 109 mmol/L) and required hyperosmolar treatment. Results: We enrolled 59 patients, of which 32 developed hyperchloremia and required hyperosmolar treatment. 15 patients were randomized to the 23.4% NaCl group, and 17 patients were randomized to the 16.4% NaCl/Na-acetate group. Although serum chloride levels increased similarly in both groups, the NaCl/Acetate group showed a significantly lower Cl− load at the end of the study period (978mEq vs. 2,464mEq, p < 0.01). Secondary outcome analysis revealed a reduced rate of AKI in the Na-acetate group (53.3% in the NaCl group vs. 11.8% in the Na-acetate group, p = 0.01). Both solutions had similar effects on ICP reduction, but NaCl/Acetate treatment had a more prominent effect on immediate post-infusion Na+ concentrations (increase of 2.2 ± 2.8 vs. 1.4 ± 2.6, (p < 0.01)). Proximal tubule renal biomarkers differed in concentration between the two groups. Conclusions: Our pilot trial showed the feasibility and safety of replacing 23.4% NaCl infusions with 16.4% NaCl/Na-acetate infusions to treat cerebral edema in patients with SAH. The degree of hyperchloremia was similar in the two groups. 16.4% NaCl/Na-acetate infusions led to lower Cl− load and AKI rates than 23.4% NaCl infusions. Further multi-center studies are needed to corroborate these results. Trial registration: clinicaltrials.gov # NCT03204955, registered on 6/28/2017 [ABSTRACT FROM AUTHOR]

Purpose: To determine the effects of the sodium content of maintenance fluid therapy on cumulative fluid balance and electrolyte disorders.Methods: We performed a randomized controlled trial of adults undergoing major thoracic surgery, randomly assigned (1:1) to receive maintenance fluids containing 154 mmol/L (Na154) or 54 mmol/L (Na54) of sodium from the start of surgery until their discharge from the ICU, the occurrence of a serious adverse event or the third postoperative day at the latest. Investigators, caregivers and patients were blinded to the treatment. Primary outcome was cumulative fluid balance. Electrolyte disturbances were assessed as secondary endpoints, different adverse events and physiological markers as safety and exploratory endpoints.Findings: We randomly assigned 70 patients; primary outcome data were available for 33 and 34 patients in the Na54 and Na154 treatment arms, respectively. Estimated cumulative fluid balance at 72 h was 1369 mL (95% CI 601-2137) more positive in the Na154 arm (p < 0.001), despite comparable non-study fluid sources. Hyponatremia < 135 mmol/L was encountered in four patients (11.8%) under Na54 compared to none under Na154 (p = 0.04), but there was no significantly more hyponatremia < 130 mmol/L (1 versus 0; p = 0.31). There was more hyperchloremia > 109 mmol/L under Na154 (24/35 patients, 68.6%) than under Na54 (4/34 patients, 11.8%) (p < 0.001). The treating clinicians discontinued the study due to clinical or radiographic fluid overload in six patients receiving Na154 compared to one patient under Na54 (excess risk 14.2%; 95% CI - 0.2-30.4%, p = 0.05).Conclusions: In adult surgical patients, sodium-rich maintenance solutions were associated with a more positive cumulative fluid balance and hyperchloremia; hypotonic fluids were associated with mild and asymptomatic hyponatremia. [ABSTRACT FROM AUTHOR]

Background: The plasma ionized calcium concentration (cCa2+) represents the biologically active form of calcium and is the preferred method for evaluating calcium status in animals. Different pH‐corrective equations have been developed for human plasma, but the validity of the equations for bovine plasma is unknown. Hypothesis: We hypothesized that pH‐corrective equations for bovine plasma would be similar to those used for human plasma; cCa2+ was dependent on the plasma concentrations of total calcium (cTCa), chloride (cCl), L‐lactate (cLactate), and albumin (cAlbumin); and the in vitro and in vivo cCa2+‐pH relationships would differ. Animals: Ten healthy calves (in vitro study), 1426 critically ill calves. Methods: The in vitro plasma log10(cCa2+)‐pH relationship was determined by CO2 tonometry of 465 plasma samples. Plasma cCl was altered by equivolume dilution of plasma with 3 electrolyte solutions of different cCl. The in vivo plasma cCa2+‐pH relationship was investigated and validated using clinicopathologic data extracted from the medical records of 950 (model development) and 476 (model validation) critically ill calves. Results: pH‐corrective equations for bovine plasma were similar to those used for human plasma. Plasma cCa2+ increased in vitro with increases in plasma cCl. Plasma cCa2+ in critically ill calves was associated with plasma cTCa, blood pH, plasma cCl, serum cMg, and cL‐lactate (R2 = 0.69) but not plasma cAlbumin. Conclusions and Clinical Importance: Calculation of cCa2+ from cTCa in calf plasma or serum requires adjustment for at least pH and cCl when 1 or both are outside the reference range. [ABSTRACT FROM AUTHOR]

Introduction: Dextromethorphan hydrobromide is widely available as an over-the-counter cough suppressant. A semi-synthetic opioid displaying N-methyl-d-aspartate receptor antagonism, it is commonly abused for recreational purposes. Spuriously elevated serum chloride concentrations are a well-described phenomenon in the setting of dextromethorphan hydrobromide toxicity, but evidence to suggest the development of tolerance is limited to case reports. Case: A 32-year-old male known to chronically ingest dextromethorphan hydrobromide for recreational purposes presented to regional hospitals on 179 occasions over 110 months and was treated for dextromethorphan toxicity on 163/174 (93.7%) of these visits. He reported a subjective need to increase his dosing over time to achieve the same degree of intoxication. Measured serum chloride over this period (n = 217) ranged from 98 to 138 mEq/L (median 115 mEq/L, IQR 110–123 mEq/L). Measured concentrations over the 110-month period progressively rose, with a fitted plot of 111.15 + 0.00232x describing the rise in measured chloride. Though not formally assessed, anion gaps tended to become progressively more negative over the observed period. Discussion: We report a patient with persistent dextromethorphan hydrobromide abuse at escalating doses whose mean serum chloride concentration increased, on average, by 0.00232 mEq/L every day over a 110-month period. This case demonstrates progressive spurious hyperchloremia secondary to bromide interference in hospital-based chloride assays, supporting the patient's reported need to dose escalate to the same desired effect. Although this artefactual laboratory finding is a well-documented result of bromide ingestion, it may be useful in identifying patterns of dextromethorphan hydrobromide use that suggest tolerance. [ABSTRACT FROM AUTHOR]

Acute kidney injury (AKI) is a major public health problem that complicates 10 – 40% of hospital admissions. Importantly, AKI is independently associated with increased risk of progression to chronic kidney disease, end-stage renal disease, cardio- vascular events, and increased risk of in-hospital and long-term mortality. The chloride content of intravenous fluid has garnered much attention over the last decade, as well as its association with excess use and adverse outcomes, including AKI. Numerous studies show that changes in serum chloride concentration, independent of serum sodium and bicarbonate, are associated with increased risk of AKI, morbidity, and mortality. This comprehensive review details the complex renal physiology regarding the role of chloride in regulating renal blood flow, glomerular filtration rate, tubuloglomerular feed- back, and tubular injury, as well as the findings of clinical research related to the chloride content of intravenous fluids, changes in serum chloride concentration, and AKI. Chloride is underappreciated in both physiology and pathophysiology. Although the exact mechanism is debated, avoidance of excessive chloride administration is a reason- able treatment option for all patients and especially in those at risk for AKI. Therefore, high-risk patients and those with “incipient” AKI should receive balanced solutions rather than normal saline to minimize the risk of AKI. [ABSTRACT FROM AUTHOR]

Objectives: Although the potential dangers of hyperchloremia from resuscitation fluids continue to emerge, no study to date has considered the contribution of medication diluents to cumulative volume and hyperchloremia. This study compares saline versus dextrose 5% in water as the primary medication diluent and the occurrence of hyperchloremia in critically ill patients.Design: Prospective, open-label, sequential period pilot study.Setting: Medical ICU of a large academic medical center.Patients: Adult patients admitted to the medical ICU were eligible for inclusion. Patients who were admitted for less than 48 hours, less than 18 years old, pregnant, incarcerated, or who had brain injury were excluded.Interventions: Saline as the primary medication diluent for 2 months followed by dextrose 5% in water as the primary medication diluent for 2 months.Measurements and Main Results: A total of 426 patients were included, 216 in the saline group and 210 in the dextrose 5% in water group. Medication diluents accounted for 63% of the total IV volume over the observation period. In the saline group, 17.9% developed hyperchloremia compared with 10.5% in the dextrose 5% in water group (p = 0.037), which was statistically significant in multivariable analysis (odds ratio, 0.50; 95% CI, 0.26-0.94; p = 0.031). In the saline group, 34.2% developed acute kidney injury versus 24.5% in the dextrose 5% in water group (p = 0.035); however, this was not statistically significant when adjusting for baseline covariates. No other significant differences in dysnatremias, insulin requirements, glucose control, ICU length of stay, or ICU mortality were observed.Conclusions: This study identified that medication diluents contribute substantially to the total IV volume received by critically ill patients. Saline as the primary medication diluent compared with dextrose 5% in water is associated with hyperchloremia, a possible risk factor for acute kidney injury. [ABSTRACT FROM AUTHOR]

Background: The optimal fluid management in critically ill children is currently under investigation with several studies suggesting that hyperchloremia, chloride load, and the use of chloride-rich fluids contribute to worse outcomes.Methods: This is a single-center retrospective cohort study of Pediatric Intensive Care Unit patients from 2008 to 2016 requiring continuous renal replacement therapy (CRRT). Patients were excluded if they had end-stage renal disease, a disorder of chloride transport, or concurrent provision of extracorporeal membrane oxygenation therapy.Results: Patients (n = 66) were dichotomized into two groups (peak chloride (Cl) ≥ 110 mmol/L vs. peak Cl < 110 mmol/L prior to CRRT initiation). Hyperchloremia was present in 39 (59%) children. Baseline characteristics were similar between groups. Fluid overload at CRRT initiation was more common in patients with hyperchloremia (11.5% IQR 3.8-22.4) compared to those without (5.5% IQR 0.9-13.9) (p = 0.04). Mortality was significantly higher in patients with hyperchloremia (n = 26, 67%) compared to those without (n = 8, 29%) (p = 0.006). Patients with hyperchloremia had 10.9 times greater odds of death compared to those without hyperchloremia, after adjusting for percent fluid overload, PRISM III score, time to initiation of CRRT, height, and weight (95% CI 2.4 to 49.5, p = 0.002).Conclusions: Hyperchloremia is common among critically ill children prior to CRRT initiation. In this population, hyperchloremia is independently associated with mortality. Further studies are needed to determine the impact of hyperchloremia on all critically ill children and the impact of chloride load on outcomes. [ABSTRACT FROM AUTHOR]

Purpose: Research on intravenous fluid therapy and its side effects, volume, sodium, and chloride overload, has focused almost exclusively on the resuscitation setting. We aimed to quantify all fluid sources in the ICU and assess fluid creep, the hidden and unintentional volume administered as a vehicle for medication or electrolytes.Methods: We precisely recorded the volume, sodium, and chloride burdens imposed by every fluid source administered to 14,654 patients during the cumulative 103,098 days they resided in our 45-bed tertiary ICU and simulated the impact of important strategic fluid choices on patients' chloride burdens. In septic patients, we assessed the impact of the different fluid sources on cumulative fluid balance, an established marker of morbidity.Results: Maintenance and replacement fluids accounted for 24.7% of the mean daily total fluid volume, thereby far exceeding resuscitation fluids (6.5%) and were the most important sources of sodium and chloride. Fluid creep represented a striking 32.6% of the mean daily total fluid volume [median 645 mL (IQR 308-1039 mL)]. Chloride levels can be more effectively reduced by adopting a hypotonic maintenance strategy [a daily difference in chloride burden of 30.8 mmol (95% CI 30.5-31.1)] than a balanced resuscitation strategy [daily difference 3.0 mmol (95% CI 2.9-3.1)]. In septic patients, non-resuscitation fluids had a larger absolute impact on cumulative fluid balance than did resuscitation fluids.Conclusions: Inadvertent daily volume, sodium, and chloride loading should be avoided when prescribing maintenance fluids in view of the vast amounts of fluid creep. This is especially important when adopting an isotonic maintenance strategy. [ABSTRACT FROM AUTHOR]

Objective: To assess the prevalence of acute kidney injury in patients with subarachnoid hemorrhage patients.Design: Retrospective analysis of all subarachnoid hemorrhage admissions.Settings: Neurocritical care unit.Patients: All patients with a diagnosis of subarachnoid hemorrhage between 2009 and 2014.Interventions: None.Measurements and Main Results: Of 1,267 patients included in this cohort, 16.7% developed acute kidney injury, as defined by Kidney Disease Improving Global Outcome criteria (changes in creatinine only). Compared to patients without acute kidney injury, patients with acute kidney injury had a higher prevalence of diabetes mellitus (21.2% vs 9.8%; p < 0.001) and hypertension (70.3% vs 50.5%; p < 0.001) and presented with higher admission creatinine concentrations (1.21 ± 0.09 vs 0.81 ± 0.01 mg/dL [mean ± SD], respectively; p < 0.001). Patients with acute kidney injury also had higher mean serum chloride and sodium concentrations during their ICU stay (113.4 ± 0.6 vs 107.1 ± 0.2 mmol/L and 143.3 ± 0.4 vs 138.8 ± 0.1 mmol/L, respectively; p < 0.001 for both), but similar chloride exposure. The mortality rate was also significantly higher in patients with acute kidney injury (28.3% vs 6.1% in the non-acute kidney injury group [p < 0.001]). Logistic regression analysis revealed that only male gender (odds ratio, 1.82; 95% CI, 1.28-2.59), hypertension (odds ratio, 1.64; 95% CI, 1.11-2.43), diabetes mellitus (odds ratio, 1.88; 95% CI, 1.19-2.99), abnormal baseline creatinine (odds ratio, 2.48; 95% CI, 1.59-3.88), and increase in mean serum chloride concentration (per 10 mmol/L; odds ratio, 7.39; 95% CI, 3.44-18.23), but not sodium, were associated with development of acute kidney injury. Kidney recovery was noted in 78.8% of the cases. Recovery reduced mortality compared to non-recovering subgroup (18.6% and 64.4%, respectively; p < 0.001).Conclusions: Critically ill patients with subarachnoid hemorrhage show a strong association between hyperchloremia and acute kidney injury as well as acute kidney injury and mortality. [ABSTRACT FROM AUTHOR]

BACKGROUND: Hyperchloremia is the most common cause of metabolic acidosis in critically ill patients. The sodium-chloride difference (Na+-Cl-) and chloride/sodium ratio (Cl-/Na+) may simply evaluate the role of hyperchloremia in acid-base disturbances. OBJECTIVE: To determine if sodium-chloride difference and chloride/ sodium ratio measured at 24 h of admission are mortality predictors at 30 days in patients with septic shock. MATERIAL AND METHOD: A prospective cohort, longitudinal, descriptive and analytic study was done including patients diagnosed with septic shock according to the guidelines of the Surviving Sepsis Campaign in 2012, admitted to the Intensive Care Unit in the period comprising from June 2015 to June 2016. RESULTS: The multivariate analysis showed that the Na+-Cl- difference less than 31 mEq/L increases the risk of death in patients with septic shock at 30 days, OR 15.26 (95% CI 1.56-148.49) p=0.019. CONCLUSION: The decrease in the Na+-Cl- difference below 31 mEq/L conditioned by hyperchloremia increases the risk of death at 30 days in the patient with septic shock. [ABSTRACT FROM AUTHOR]

Objective: Intravenous fluids are broadly categorized into colloids and crystalloids. The aim of this review is to present under a clinical point of view the characteristics of intravenous fluids that make them more or less appropriate either for maintaining hydration when enteral intake is contraindicated or for treating hypovolemia.Methods: We considered randomized trials and meta-analyses as well as narrative reviews evaluating the effects of colloids or crystalloids in patients with hypovolemia or as maintenance fluids published in the PubMed and Cochrane databases.Results: Clinical studies have not shown a greater clinical benefit of albumin solutions compared with crystalloid solutions. Furthermore, albumin and colloid solutions may impair renal function, while there is no evidence that the administration of colloids reduces the risk of death compared with resuscitation with crystalloids in patients with trauma, burns or following surgery. Among crystalloids, normal saline is associated with the development of hyperchloremia-induced impairment of kidney function and metabolic acidosis. On the other hand, the other commonly used crystalloid solution, the Ringer's Lactate, has certain indications and contraindications. These matters, along with the basic principles of the administration of potassium chloride and bicarbonate, are meticulously discussed in the review.Conclusions: Intravenous fluids should be dealt with as drugs, as they have specific clinical indications, contraindications and adverse effects. [ABSTRACT FROM AUTHOR]

Background: Abnormal chloride levels are commonly observed in critically ill patients, but their clinical relevance remains a matter of debate. We examined the association between abnormal chloremia and ICU and hospital mortality. To further refine findings and integrate them into the ongoing discussion on the detrimental effects of chloride-rich solutions, the impact of strong ion difference (SID) on the same end points was assessed. Methods: Retrospective cohort study in an academic tertiary intensive care unit on 8830 adult patients who stayed at least 24 h in the ICU was carried out. Patients admitted after elective cardiac surgery were treated as a separate subgroup ( n = 2350). Analyses were performed using multivariable logistic regression. All statistical models were extensively adjusted for confounders, including comorbidity, admission diagnosis, other electrolytes and acid-base parameters. Results: Severe hyperchloremia (>110 mmol/L), but not low (SID) was significantly associated with increased mortality in the ICU (odds ratio vs. normochloremia 1.81; 95 % CI 1.32-2.50; p < 0.001) and the hospital (odds ratio 1.49; 95 % CI 1.14-1.96; p = 0.003). Hyperchloremia and low (SID) were encountered in the majority of patients admitted after cardiac surgery (in 86.9 and 47.2 %, respectively), but were not negatively associated with mortality. Conclusions: In the ICU, hyperchloremia at admission was associated with negative outcome. On the other hand, decreased strong ion difference did not have an impact on mortality, precluding a simple extrapolation of these findings to the ongoing discussion on the detrimental effects of chloride-rich solutions. This notion is fueled by the finding that hyperchloremia after cardiac surgery, frequently encountered and probably fluid-induced, did not seem to be deleterious. [ABSTRACT FROM AUTHOR]

Purpose: The recommended method for elucidating the effects of strong ions other than lactate on acid-base balance is to calculate the non-lactate strong ion difference (SIDnl). A relationship between HCO and SIDnl in hyperchloremic patients has already been demonstrated; in the present study, the relationships between SIDnl, the apparent strong ion difference (SIDa), and mortality at intensive care unit (ICU) admission were investigated. Methods: In our two-center study, 2691 patients admitted to the ICU were retrospectively evaluated, including 1069 critically ill patients. These patients were divided into three subgroups according to their SIDnl levels at admission to the ICU: low (<38 mmol L), normal (38-40 mmol L), and high (>40 mmol L). Patient age, gender, diagnosis, blood gas values, length of ICU stay, and mortality were recorded. Results: The low-SIDnl group included 768 patients (71.8 %), the normal-SIDnl group consisted of 127 patients (11.9 %), and the high-SIDnl group contained 174 patients (16.3 %). There was no significant difference in lactate levels among the SIDnl groups ( p = 0.635). In a multivariate logistic regression model, likelihood of mortality was increased 1.24-fold (1.20-1.28), 2.56-fold (1.61-4.08) and 2.55-fold (1.003-6.47) by APACHE II, lactate level ≥2mmol L and low SIDnl ( p < 0.001, p < 0.001, and p = 0.049, respectively). Conclusions: SIDnl can be used to determine the effects of strong ions other than lactate on SIDa values and acid-base balance. Furthermore, a low SIDnl at ICU admission can be a prognostic indicator of mortality. [ABSTRACT FROM AUTHOR]

Objective: This study aims to describe the effect of 0.9% saline (NS) versus 0.45% saline (half NS) when used during recovery phase of diabetic ketoacidosis (DKA) in children. Methods: A retrospective analysis of all children (1-18 years old) with DKA admitted in the pediatric intensive care unit (PICU) from 2005 to 2009 was undertaken. The primary end point was effect on serum electrolytes and acidosis. Results: Compared to 47 patients who received only NS (group A) throughout the recovery period and 33 patients who received NS but were switched to half NS (group B) at some point during recovery, 41 who received only half NS (group C) had a significant decrease in corrected serum sodium (P < .01). Hyperchloremia leading to nonanion gap acidosis was significantly greater in NS groups A and B than in half NS group C (P < .01). This led to increased duration of insulin infusion and length of stay in the PICU in the NS groups. Conclusions: Hyperchloremia resulting in nonanion gap acidosis can occur and may prolong the duration of insulin infusion and length of PICU stay in patients receiving NS as post-bolus rehydration fluid. Alternatively, the use of half NS may result in a decrease in serum-corrected sodium. Providers need to be vigilant toward this while using higher or lower sodium chloride when managing children with DKA. Larger trials are required to study the clinical significance of the results of this study. [ABSTRACT FROM AUTHOR]

A 77-year-old male was admitted to hospital after suffering a pelvic bone fracture in a road traffic accident and was incidentally found to have IgG-kappa-type multiple myeloma with hypercalcemia. The patient was also noted to be hypokalemic and had low HCO3), with possible damage to the distal tubules in the kidneys. When the treatment was begun with bortezomib/dexamethasone/elcatonin and sodium bicarbonate (NaHCO3) in normal saline (equivalent to a daily sodium dose of 200 millimoles per liter [mmol/L]), the patient was in a state of poor oral fluid intake. The patient developed hypernatremia and hyperchloremia, with a peak serum sodium and chloride levels of 183 mmol/L and 153 mmol/L, respectively, at the sixth day after the start of treatment. Following the switch of the intravenous infusions from normal saline to soldem 1 and soldem 3 solutions, these high-electrolyte levels gradually returned to normal over the next 7 days. Although the patient showed disturbed consciousness (Japan Coma Scale = JCS-I-3) during the period of electrolyte abnormality, he eventually fully recovered without sequelae. In this patient, we successfully managed the severe hypernatremia/hyperchloremia, caused by the combined effects of intravenous saline burden in a state of poor oral fluid intake, during the treatment for IgG-kappa type multiple myeloma. [ABSTRACT FROM AUTHOR]

Background Metabolic acidosis is an important abnormality in ill and injured dogs and cats. Objectives To describe the incidence, nature, and etiology of metabolic acidosis in dogs and cats that had arterial or venous blood gases measured for any reason at a university teaching hospital. Animals Dogs and cats at the Veterinary Medical Teaching Hospital. Methods Acid base parameters and electrolyte and lactate concentrations in dogs and cats measured during a 13-month period were retrospectively retrieved from a computer database. Metabolic acidosis was defined as a standardized base excess ( SBE) in dogs of <−4 mmol/L and in cats <−5 mmol/L. Results A total of 1,805 dogs and cats were included; of these, 887 (49%) were classified as having a metabolic acidosis (753 dogs and 134 cats). Primary metabolic acidosis was the most common disorder in dogs, whereas mixed acid base disorder of metabolic acidosis and respiratory acidosis was most common in cats. Hyperchloremic metabolic acidosis was more common than a high anion gap ( AG) metabolic acidosis; 25% of dogs and 34% of cats could not be classified as having either a hyperchloremic metabolic acidosis or a high AG metabolic acidosis. Conclusions and Clinical Importance Metabolic acidosis was found commonly in this patient population and was associated with a wide variety of disease processes. Mixed acid base disorders occur frequently and routine categorization of metabolic acidosis based on the presence of high AG or hyperchloremia may be misleading in a large proportion of cases. [ABSTRACT FROM AUTHOR]

The article investigates the effects of chloride-rich intravenous fluid restriction on critically ill patients. Results show that after the intervention, severe metabolic acidosis and severe acidemia incidence decreased, but it also led to increased incidence of severe metabolic alkalosis and alkalemia. Data from a tertiary intensive care in Australia reveal that restricting chloride-rich fluids affects electrolyte and acid-base status and the choice of fluids modulates acid-base status.