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Despite the success of the treatment of diabetes mellitus, the incidence of diabetic ketoacidosis in recent years has not decreased. Its clinical manifestations Dreshfeld first described in 1886. Insulin began to be used in 1922. Mortality of this complication was 100 %. Widespread implementation of insulin therapy into the clinical practice reduced mortality by 30 %, and with improvement of treatment, including infusion therapy, there was a further reduction. The level of mortality of patients with diabetic ketoacidosis remains high (about 5 % in specialized centers). Prediction of the disease much worsens with age, in the development of coma and hypotension. The prevalence of diabetes mellitus is growing rapidly and currently ranges from 20 to 50 % of new-onset disease in young people. Violations of electrolytes are frequent in patients with this disease and may be the result of altered distribution of electrolytes associated with hyperglycemia-induced osmotic fluid shifts or general shortages caused by osmotic diuresis. Complications from damage to the target organs and therapies used in the treatment of diabetes can also contribute to electrolyte disturbances. We highlight the ways, in which specific electrolytes may be influenced by dysregulation in glucose homeostasis. High or normal plasma sodium concentration in the presence of hyperglycemia indicates a clinically significant deficit of the total body fluid. Sodium correction in patients with glycemia helps to evaluate shortage of sodium and water, and ensure adequate assessment required for tonicity during the course of rehydration therapy. Because children with diabetic ketoacidosis are at particularly high risk of such terrible complications, as swelling of the brain, then to some extent hypernatremia is acceptable during treatment to minimize this complication. Insulin deficiency, which often occurs in type 1 diabetes mellitus, is an important factor of potassium output from the cells. Changes in potassium level, caused by metabolic acidosis, are more significant in mineral acidosis (hyperchloremic, non-anion gap acidosis) than in the organic acidosis (large anion gap acidosis), which is present in diabetic ketoacidosis. In diabetic patients receiving non-selective β-blockers, increased adrenergic activity can exacerbate hyperkalemia, because unopposed α-receptor stimulation, promotes the release of potassium from the cells. Ketoacidosis occurs when the rate, at which hepatic ketoacid is generated, exceeds peripheral utilization and the concentration of ketoacid in the blood increases. Normalization of acid-base balance is made within a few days, as the correction of bicarbonate deficit occurs through its regeneration by kidneys. Patients with primary kidney diabetic ketoacidosis are not involved (with their normal function). Kidney compensate by higher ammonia discharge. Urinary osmolarity gap is measured in order to find out whether there is a corresponding increase in the excretion of ammonia, which leads to violations in acid-base status. Low urinary osmolarity gap in patients with persistent hyperchloremic acidosis provides leads to tubular dysfunction. Despite recent advances that allowed direct assessment of the levels of β-hydroxybutyrate, determining the concentration of ketone bodies often can not fully explain the increase in anion gap and in many patients may contribute to hyperlactatemia. Lactate level may be increased in response to increased adrenergic activity, even in the absence of tissue hypoperfusion. Chronic hyperglycemia leads to the development of «carbonyl stress» and accumulation of toxic dicarbonyl compounds, such as methyl glyoxal, etc. Epidemiological studies suggest that low magnesium intake is associated with increased risk of diabetes, while higher magnesium intake is associated with lower risk of developing diabetes. In patients with diabetic ketoacidosis, osmotic diuresis due to poor glycemic control leads to renal loss of magnesium. Hypomagnesemia can cause hypocalcemia, because magnesium deficiency may lead to lower parathyroid hormone release. Randomized studies of phosphate therapy in patients with diabetic ketoacidosis did not establish that this therapy provides clinical benefit. The dysregulation of glucose homeostasis leads to many direct and indirect effects on electrolyte and acid-base balance. Since the high prevalence of diabetes ensures that clinicians of every medical specialty will interact with these patients, familiarity with related electrolyte abnormalities is important.

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

Systemic fluid absorption frequently occurs during endoscopic prostatic surgery. The introduction of lasers allowed the use of normal saline (0.9% sodium chloride). We report 2 patients who developed hyperchloremic metabolic acidosis and isotonic hypervolemia during thulium laser enucleation of the prostate (ThuLEP) and required prolonged ventilation time, catecholamines, intensive care and prolonged hospitalization. A change to balanced electrolyte solutions in urology-as is already established in infusion and volume therapy-would be desirable, especially to avoid hyperchloremic metabolic acidosis.

OBJECTIVE Fluid replacement to correct dehydration, acidosis, and electrolyte abnormalities is the cornerstone of treatment for diabetic ketoacidosis (DKA), but little is known about optimal fluid infusion rates and electrolyte content. The objective of this study was to evaluate whether different fluid protocols affect the rate of normalization of biochemical derangements during DKA treatment. RESEARCH DESIGN AND METHODS The current analysis involved moderate or severe DKA episodes (n = 714) in children age RESULTS The rate of change of pH did not differ by treatment arm, but Pco2 increased more rapidly in the fast versus slow fluid infusion arms during the initial 4 h of treatment. The anion gap also decreased more rapidly in the fast versus slow infusion arms during the initial 4 and 8 h. Glucose-corrected sodium levels remained stable in patients assigned to 0.90% saline but decreased in those assigned to 0.45% saline at 4 and 8 h. Potassium levels decreased, while chloride levels increased more rapidly with 0.90% versus 0.45% saline. Hyperchloremic acidosis occurred more frequently in patients in the fast arms (46.1%) versus the slow arms (35.2%). CONCLUSIONS In children treated for DKA, faster fluid administration rates led to a more rapid normalization of anion gap and Pco2 than slower fluid infusion rates but were associated with an increased frequency of hyperchloremic acidosis.

Many clinical conditions, such as diabetes, hypoxia, chronic renal failure, cancer, severe trauma, and sepsis are accompanied by acidosis. The aim of the study was to study the changes in proteolytic activity of blood and tissues under conditions of chronic experimental non-gaseous acidosis and alkalosis, and comparison of them with the previously obtained indicators of the pituitary-adrenal system in chronic non-gaseous acidosis and alkalosis. Material and methods. The experiments were carried out on 60 intact white outbred male rats weighing 120-180 g, which were kept on a balanced diet of vivarium.Chronic non-gaseous hyperchloremic acidosis was simulated by daily intragastric administration with a probe for 30 days 20 mmol/kg NH4CL, and chronic non-gaseous alkalosis — 30 mmol/kg NaHCO3. The control animals were injected with the same amount of tap water. Euthanasia of animals was performed under light ether anesthesia by decapitation. Stabilization of blood was carried out with 3.8% sodium citrate solution. Results. Lysis of azoalbumin (breakdown of low molecular weight proteins), lysis of azocasein (breakdown of high molecular weight proteins) and lysis of azocol (lysis of collagen) in chronic non-gaseous alkalosis are almost no different from normal in the serum. However, in chronic non-gaseous acidosis, the lysis of azoalbumin increases in 3.6 times (control — 1.635±0.717 E440/h/ml, experiment — 5.985±0.812 E440/h/ml, p

Diabetic ketoacidosis (DKA) frequently requires emergency admission. The anion gap approach is conventionally used for the diagnosis and documenting the resolution of acidosis during treatment. However, it fails to detect hyperchloremic acidosis during the resolution and may result in the prolongation of treatment. To determine the role of the Stewart approach of acid-base disorder during DKA management for the prediction of an earlier resolution. A prospective comparative study was conducted between January 2017 and December 2017 at a single academic hospital in north India. Patients aged above 12 years with a diagnosis of DKA were randomly divided into two groups—the conventional group and the Stewart group, according to the approach used for DKA resolution. The primary outcome was the time duration required for resolution. The secondary outcomes were the therapeutic requirement of intravenous fluid, insulin, and potassium, Acute Physiology and Chronic Health Evaluation II (APACHE II) score at the time of resolution, and hospital stay. Forty-four DKA patients were equally distributed in the two groups with comparable baseline parameters. The Stewart group had early resolution of DKA (mean, 32.4±17.5 h versus 41.7±19.6 h; p value

Amelioration of hyperchloremic acidosis (Cl-Ac), a common complication in chronic kidney disease (CKD), could preserve renal function in chronic kidney disease (CKD). However, the development of Cl-Ac in CKD has not been clarified yet. The degree of Cl-Ac, which is indicated as the bicarbonate concentration decrease with serum chloride concentration increase (∆[HCO3–]Cl), was compared with the estimated glomerular filtration rate (eGFR) by using CKD patient records. In 307 records with metabolic acidosis, a spline curve obtained from the plot comparing ∆[HCO3–]Cl with eGFR showed that ∆[HCO3–]Cl did not change, increased, and decreased during eGFR decrease until 27, from 27 to 17.5, and from 17.5 mL/min/1.73 m2, respectively. By CKD progression, Cl-Ac progressed and regressed at the CKD stages G4 and G5, respectively. The regression would have reflected the shift of Cl-Ac to high anion gap acidosis.

OBJECTIVE Respiratory alkalosis (RA) and dilutional hyperchloremic acidosis (DHA) are the most common acid-base balance (ABB) disorders in patients with liver cirrhosis. The aims of this study were to clarify whether RA develops in relation to DHA via respiratory compensation of metabolic acidosis and whether spironolactone in combination with low-dose furosemide - diuretics known to ameliorate DHA - positively affects RA in liver cirrhosis patients. MATERIALS AND METHODS 59 patients with advanced cirrhosis were divided into two groups. Group D consisted of individuals (urine sodium concentration (UNa+) > 20 mmol/L) who responded to combination therapy consisting of spironolactone and low-dose furosemide. The non-D group consisted of individuals (UNa+ ≤ 20 mmol/L) who either did not respond to the treatment or who were not administered it. In both groups, we examined serum and urine concentrations of electrolytes and ABB parameters, including SNa+-SCl- and SNa+/SCl- values. RESULTS In group D, we found a statistically significant relationship between pCO2 and SHCO3-: r = 0.756 (p < 0.001) and between pCO2 and SNa+-SCl-: r = 0.522 (p = 0.001). Neither Salb nor the corrected anion gap were associated with changes in SHCO3- or pCO2 values. Although SHCO3- values were normal, abnormal pCO2 values were observed in one third of group D patients. Based on multivariable analysis, SHCO3- proved to be a statistically significant influencing factor on pCO2 values. CONCLUSION DHA contributes to the development of RA in individuals with liver cirrhosis. Reducing DHA by means of effective diuretic therapy comprising spironolactone and furosemide has a beneficial effect on RA in such patients.

Background Both saline and lactated Ringer’s solutions are commonly given to surgical patients. However, hyperchloremic acidosis consequent to saline administration may provoke complications. The authors therefore tested the primary hypothesis that a composite of in-hospital mortality and major postoperative complications is less common in patients given lactated Ringer’s solution than normal saline. Methods The authors conducted an alternating cohort controlled trial in which adults having colorectal and orthopedic surgery were given either lactated Ringer’s solution or normal saline in 2-week blocks between September 2015 and August 2018. The primary outcome was a composite of in-hospital mortality and major postoperative renal, respiratory, infectious, and hemorrhagic complications. The secondary outcome was postoperative acute kidney injury. Results Among 8,616 qualifying patients, 4,187 (49%) were assigned to lactated Ringer’s solution, and 4,429 (51%) were assigned to saline. Each group received a median 1.9 l of fluid. The primary composite of major complications was observed in 5.8% of lactated Ringer’s versus 6.1% of normal saline patients, with estimated average relative risk across the components of the composite of 1.16 (95% CI, 0.89 to 1.52; P = 0.261). The secondary outcome, postoperative acute kidney injury, Acute Kidney Injury Network stage I–III versus 0, occurred in 6.6% of lactated Ringer’s patients versus 6.2% of normal saline patients, with an estimated relative risk of 1.18 (99.3% CI, 0.99 to 1.41; P = 0.009, significance criterion of 0.007). Absolute differences between the treatment groups for each outcome were less than 0.5%, an amount that is not clinically meaningful. Conclusions In elective orthopedic and colorectal surgery patients, there was no clinically meaningful difference in postoperative complications with lactated Ringer’s or saline volume replacement. Clinicians can reasonably use either solution intraoperatively. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Background Acetazolamide is contraindicated in patients undergoing dialysis and should be used with caution in patients with chronic kidney disease (CKD). Here, we evaluate the effect of the concomitant use of aspirin by patient with CKD using acetazolamide. Case Report A 63-year-old man with CKD and multimorbidity presented at our Emergency Department (ED) with general weakness and dyspnea for 4 days. Work-up at the ED revealed severe metabolic acidosis and hyperammonemia, which were initially considered signs of sepsis due to an elevated C-reactive protein level and pyuria. However, subsequent blood work indicated hyperchloremic acidosis with low lactate levels. After reviewing his medical history, we suspected the concomitant use of acetazolamide and aspirin as the etiology. Weakness, acidosis, and hyperammonemia were resolved after the patient discontinued acetazolamide. Why Should an Emergency Physician Be Aware of This? Severe acidosis can be life threatening. Acetazolamide is known for causing mild metabolic acidosis, except in patients with severely impaired renal function. Here, we present a patient with mildly impaired renal function and concomitant aspirin use who developed severe metabolic acidosis and hyperammonemia after being prescribed acetazolamide. Regardless of the severity of the disease, patients with CKD should avoid taking acetazolamide concomitantly with aspirin.

Aim – determine a forms of metabolic acidosis (MetAc) after cardiac surgery with cardiopulmonary bypass (CPB). Estimate significance of MetAc in an early postoperative period.Material and methods. We included the 129 adult cardiac surgery patients. We studied the indicators of acid-base blood status, markers of systemic inflammation, an oxygen delivery and consumption, the hemodynamic parameters, the clinical course of the postoperative period.Results. The acid-base disorders were found in 73.6 % of cases. The metabolic acidosis was in 51.2 % of cases: the lactate acidosis was in 92.4 % and the hyperchloremic acidosis was in 7.6 %. The metabolic lactate acidosis was represented by two forms: 1. the acid-base disorders due to a low cardiac output syndrome with a decrease in oxygen delivery and contractility (14.7 %); 2. the lactate acidosis due to a systemic inflammatory response syndrome (49.2 % of cases). It is associated with a high delivery and a low oxygen extraction, increased cardiac output and a vasoplegia. Patients with these disorders had a higher level of leukocytosis after 24 hours of the end the operation, had a longer duration of respiratory support and a long ICU stay and hospital stay.Conclusion. The lactate acidosis is represented by two forms: the lactate acidosis associated with the low cardiac output syndrome and lactate acidosis associated with the systemic inflammatory response. The lactate acidosis is a predictor of adverse outcome after cardiac surgery with CPB and associated with a postoperative complications and a mortality.

Although the first clinical use of a fluid therapy based on sodium chloride dates back to the European cholera pandemic in 1831 (1), the first clinical study focused on the acid-base equilibrium in patients receiving NaCl 0.9% (or saline or normal saline) for volume expansion was published in 1999 and was entitled “Rapid Saline Infusion Produces Hyperchloremic Acidosis in Patients Undergoing Gynecologic Surgery” (2). This landmark study aimed at evaluating the effects of the administration of saline, a high chloride concentration crystalloid, in clinical practice.

Normal anion gap (non-gap) hyperchloremic acidosis with hypokalemia is a medical emergency. There are several causes of this metabolic phenomenon, of which distal renal tubular acidosis is among the very rare causes. In this report, we present an unusual case of a previously healthy woman who was admitted to the intensive care unit with a short history of severe muscle weakness. She had no significant past medical history and was not taking any regular medication. There was also no history of recent drug or herb ingestion. Investigations demonstrated a combination of severe hypokalemia, hyperchloremia, hypobicarbonatemia (non-gap metabolic acidosis), and relatively raised urinary potassium and urinary pH in the presence of severe hypokalemia and metabolic acidosis. Results suggested a diagnosis of distal renal tubular acidosis. The patient responded rapidly to a short course of electrolyte replacement therapy and the condition resolved spontaneously thereafter. This case highlights the fact that distal renal tubular acidosis can occur as a transient phenomenon in previously healthy individuals.

Intravenous fluid prescription is an essential part of postoperative care and may play a causal role in postoperative complications. The objective of the present study was to evaluate the relationship between intraoperative fluid administration and postoperative outcomes in a large cohort of pediatric patients. This analysis included a retrospective review of 172 patients who underwent gastroenterological surgery from January 2012 to September 2018 at an academic tertiary care hospital. Patients were evaluated based on the median amount of corrected crystalloids and subsequently dichotomized as low (25.89 mL/kg h). The primary outcome measure was the postoperative length of hospital stay (pLOS). Secondary outcome measures included the postoperative time to restore gastroenterological functions and postoperative complications. Patients who received larger amounts of crystalloids were more likely to have a lower intraoperative level of hemoglobin (P = .78) and an intraoperative blood transfusion (P = .27). There were trends toward lower incidence rates of hyperchloremic acidosis (P = .375) and metabolic acidosis (P = .54) in the high crystalloid administration cohort. The incidence of postoperative complications increased as the amount of administered fluid decreased (P = .046). The total length of hospital stay was shorter in patients who received high volumes of crystalloid fluid (19.5 [15.75–32.25] days) than in patients who received low volumes (22 [16–29.5] days, P = .283). Significant and multifaceted variability in crystalloid administration was noted among pediatric patients undergoing major surgery. High fluid administration was associated with favorable postoperative outcomes; these findings could be applied to improve patient safety and facilitate better quality of care.

One of the key elements of therapy for sepsis and septic shock is the fluid replacement. Current guidelines suggests an insfusion of at least 30 ml / kg of crystalloid in the first three hours, and if necessary, more. Preference is given to balanced crystalloid solutions, but the choice of a particular solution remains unclear. A randomized, controlled study of the “Ringer-Malat” balanced crystalloid solution was performed, compared with isotonic saline for primary resuscitation of septic shock patients. The study involved 48 patients randomized to ringer malate (experimental) and 0.9% sodium chloride (control) group. The 30-day mortality rate was not significantly different between the groups (20.0% and 21.4% respectively, p = 0.521), but the trend was noted for less time on vasopressor support (58.2 versus 74.3 hours, respectively, p = 0.072), higher delivery of oxygen (1064.26 vs. 612.38 ml / min, p

Background: Concerns have been raised regarding the use of various intravenous fluids resulting in hyperchloremic acidosis and associated acute kidney injury; however, this has primarily been in the context of resuscitation and critical care, and not ward-based medical or surgical patients who receive lower volumes of infusion fluid. We aimed to determine whether normal saline use is more likely to produce hyperchloremic metabolic acidosis than compound sodium lactate, in acute general medical and surgical patients. Methods: This was a retrospective study, conducted in 2015 in a metropolitan hospital in Melbourne, Australia, and of 1,158 sequentially admitted general medical and surgical patients receiving either intravenous normal saline or compound sodium lactate. Demographics, admission diagnosis, comorbidities, and medications were compared. Serum biochemistry results 24 - 48 h post-infusion were analyzed. Primary outcome was incidence of serum hyperchloremia post-infusion. In addition, mean shift in serum chloride concentration as well as mean normalized chloride concentration (mmol/L per day per L of infusion) were calculated. Acute kidney injuries and deaths during admission were also reported. Results: A total of 221 patients (169 medical and 52 surgical patients) were included for analysis (mean age 71.6 years, 72% female), with 174 normal saline and 61 compound sodium lactate infusions. No difference in hyperchloremia rate was found (normal saline vs. compound sodium lactate; n = 8 (4.6%) vs. n = 2 (3.3%), P = 1.0). Post-infusion serum chloride concentration was also not significantly different (99.0 ± 5.1 mmol/L vs. 100.0 ± 3.4 mmol/L, P = 0.1700) between infusion groups. Normal saline infusions resulted in an increase of mean normalized chloride concentration compared to compound sodium lactate (1.2 ± 4.0 mmol/L per day/L vs. -0.3 ± 1.5, P = 0.0121). Conclusions: We conclude that 2 - 3 L normal saline infusions in this population do not appear to be associated with hyperchloremic acidosis more frequently than compound sodium lactate infusions, allaying concerns of normal saline use in wards. World J Nephrol Urol. 2018;7(2):39-44 doi: https://doi.org/10.14740/wjnu339w

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Toluene is an aromatic hydrocarbon widely used as a solvent in industrial and commercial products including paints, adhesives, ink, and rubber. It is occasionally used as an inhalant drug for its intoxicating properties. While mostly known for producing neurologic effects, here we report a case of toluene induced acute lung injury. CASE PRESENTATION: A 61-year-old female with a medical history of alcohol abuse, depression, congestive heart failure with preserved ejection fraction presented with one week of weakness and shortness of breath. She had been seen twice in the week prior having tested negative for SARS-COV2. In the emergency department, O2 saturation was 70% with respiratory distress on room air requiring high flow nasal cannula support. Labs were notable for a potassium of 2.7 mmol/L, acute kidney injury, elevated transaminases, lactate of 2.8 mmol/L and leukocyte count of 9800/nL. CT showed diffuse bilateral ground glass opacities involving the lung parenchyma concerning for atypical including viral pneumonia. Upon admission to the ICU she developed worsening hypoxia and respiratory failure requiring intubation.A discussion with the patient's husband revealed she had a history of glue sniffing. She had recently been decreasing her alcohol intake and substituting this with an increased frequency of sniffing both permanent markers and modeling glue. This raised suspicion for chemical pneumonitis secondary to toluene induced acute lung injury. DISCUSSION: Toluene is a highly lipophilic molecule readily inhaled via the lungs and distributed widely throughout the body producing side effects like ethanol intoxication via interfering mainly with GABA receptors. Neurologic manifestations range from euphoria and hallucinations to cognitive dysfunction and ataxia with chronic use. It specifically causes renal tubular acidosis typically manifesting as a normal anion gap hyperchloremic acidosis with hypokalemia. It can also cause hepatic injury and cardiac automaticity and conduction abnormalities.Acute lung injury secondary to toluene has been described but less frequently reported. Toxicity can result in Reactive Airway Dysfunction Syndrome (RADS) from acute or chronic exposure to various chemical irritants. All hydrocarbons, including toluene, can cause chemical pneumonitis by direct contact with the pulmonary parenchyma and destroying alveolar and capillary membranes resulting in vascular permeability and edema. Symptoms may include cough, wheezing, respiratory distress, and hypoxia. Bilateral interstitial infiltrates may be delayed for several hours after the development of pneumonitis. There is no specific antidote for toluene toxicity. CONCLUSIONS: Treatment for toluene and many chemical induced pneumonitides consists of supportive care, supplemental oxygen, bronchodilators, inhaled and systemic glucocorticoids and may require intubation and admission to an ICU in severe cases. REFERENCE #1: Camara-Lemarroy CR, Rodriguez-Gutierrez R, Monreal-Robles R, Gonzalez-Gonzalez JG. Acute toluene intoxication–clinical presentation, management and prognosis: a prospective observational study. BMC Emerg Med. 2015;15:19. Published 2015 Aug 18. doi:10.1186/s12873-015-0039-0 REFERENCE #2: Alberts WM, do Pico GA. Reactive airways dysfunction syndrome. Chest. 1996;109(6):1618-1626. doi:10.1378/chest.109.6.1618 REFERENCE #3: Tormoehlen LM, Tekulve KJ, Nanagas KA. Hydrocarbon toxicity: A review. Clin Toxicol (Phila). 2014;52(5):479-489. doi:10.3109/15563650.2014.923904 DISCLOSURES: No relevant relationships by Ryan Lee, source=Web Response No relevant relationships by Dominic Valentino, source=Web Response

Background: In resuscitation, normal saline could cause hyperchloremic metabolic acidosis, while balanced electrolyte solution is a crystalloid fluid resembling blood plasma with lower chloride content. This study compared the effect of normal saline and balanced electrolyte solution Ringerfundin (BES) as the resuscitation fluid in diabetic ketoacidosis (DKA) patients. Parameters applied in this study were standard base excess (SBE) as resuscitation’s result indicator and strong ion difference (SID) to measure chloride’s influence in developing hyperchloremic acidosis.Methods: A prospective, randomized, single blind controlled trial was conducted at the Emergency Department of Cipto Mangunkusumo Hospital. Thirty subjects with blood sugar >250 mg/dl, arterial pH

AIM Hyperchloremic acidosis may have an important role as a precursor of acute kidney injury (AKI) in the hyperchloremic environment induced by chloride-rich fluids, but this remains unclear. We tested the hypothesis that hyperchloremic acidosis assessed by the Stewart approach is associated with postoperative AKI. METHODS A historical cohort study was conducted in adult patients who had normal renal function preoperatively and required admission to the intensive care unit after elective abdominal surgery. The Risk, Injury, Failure, Loss of kidney function, End stage kidney disease (RIFLE) classification was used for definition of AKI. RESULTS Of 206 patients (144 male, 69.9%) included in the study, 42 (20.4%) had postoperative AKI (AKI group) and 164 (79.6%) did not (non-AKI group). Base excess-chloride (BE-Cl) and strong ion difference (SID, approximated as Na-Cl) decreased, and the chloride level on postoperative day 1 increased compared with preoperative values in both groups (P < 0.05). In the AKI group, BE-Cl and SID were lower, and chloride was higher than in the non-AKI group (P < 0.05). The intraoperative load of chloride ions in fluids increased the risk of postoperative AKI (P < 0.01). In multivariate logistic regression analysis, postoperative BE-Cl < -7 mEq/L (i.e. SID

Intravenous fluid therapy is required for most surgical patients, but inappropriate regimens are commonly prescribed. The aim of this narrative review was to provide evidence-based guidance on appropriate perioperative fluid management. We did a systematic literature search of the literature to identify relevant studies and meta-analyses to develop recommendations. Of 275 retrieved articles, we identified 25 articles to inform this review. “Normal” saline (0.9% sodium chloride) is not physiological and can result in sodium overload and hyperchloremic acidosis. Starch colloid solutions are not recommended in surgical patients at-risk of sepsis or renal failure. Most surgical patients can have clear fluids and/or administration of carbohydrate-rich drinks up to 2 h before surgery. An intraoperative goal-directed fluid strategy may reduce postoperative complications and reduce hospital length of stay. Regular postoperative assessment of the patient’s fluid status and requirements should include looking for physical signs of dehydration or hypovolemia, or fluid overload. Both hypovolemia and salt and water overload lead to adverse events, complications and prolonged hospital stay. Urine output can be an unreliable indicator of hydration status in the postoperative surgical patient. Excess fluid administration has been linked to acute kidney injury, gastrointestinal dysfunction, and cardiac and pulmonary complications. There is good evidence supporting the avoidance of unnecessary fasting and the value of an individualized perioperative IV fluid regimen, with transition to oral fluids as soon as possible, to help patients recover from major surgery.

Introduction: Diabetic ketoacidosis (DKA) often becomes the primary focus and in turn masks a similar serious condition like hyperchloremic metabolic acidosis. Case report: A 20 years old female with type 1 diabetes mellitus presented to the emergency department (ED) with signs and symptoms corresponding to DKA. Initial pH, HCO3, Na and Cl concentrations were 6.83, 3.6 mmol/l, 143 mmol/l and 122 mmol/l respectively; anion gap 17.4 mmol/l and absent urinary ketones. DKA regime showed no improvement in the measured parameters nor the patient. The diagnosis changed to hyperchloremic high-anion gap acidosis and treatment modifications were made by adding sodium bicarbonate infusion. There was significant improvement in the clinical status of the patient and the calculated parameters. Discussion: Hyperchloremic acidosis is associated with a non-anion gap, decrease in plasma bicarbonate and increase in plasma chloride. Rarely, as with this case, it may present with a high-anion gap. The use of bicarbonate therapy has shown improvement in cases of non-anion gap acidosis however there is very little data to support its role in high-anion gap hyperchloremic metabolic acidosis. Keywords: Diabetic ketoacidosis, Hyperchloremia, Non-anion gap metabolic acidosis, High-anion gap metabolic acidosis

Intravenous fluid administration is an integral part of perioperative care for children undergoing surgery. The ultimate goal of intravenous fluid therapy is to maintain cardiovascular stability, euvolemia, normal electrolyte and acid base status. The volume and composition of the replacement fluids should be based on the preoperative patient condition, type of procedure and anticipated perioperative course. Neonates and infants poorly tolerate errors in fluid and electrolyte management. The chapter will mainly focus on distinctly different pediatric physiology, advantages of optimized perioperative fasting duration and assessment of volume status in neonates and children. In this chapter, we will review the various types of fluids, newer recommendations for perioperative fluid management in children to maintain normal physiology and to improve safety and efficacy. In addition, clinical situations requiring special consideration will be narrated briefly.

Chronic kidney disease (CKD) frequently causes metabolic acidosis. By stage 4 CKD approximately 40% of patients have metabolic acidosis. This is usually a hyperchloremic acidosis with a near-normal anion gap and normal S[K]. When the glomerular filtration rate (GFR) is less than 20 mL/min, a classic high anion gap metabolic acidosis ensues. Although a variety of defects in acid–base regulation have been reported, the predominant defect causing acidosis is an inadequate increase in ammonium excretion in the urine. A variety of complications are caused by this acidosis in conjunction with the other consequences of CKD: loss of muscle mass, loss of bone mineral, insulin resistance, and faster loss of GFR. Increased mortality is associated with the acidosis as well. Treatment of the acidosis may be with sodium bicarbonate, citrate, or diets high in fruits and vegetables. A few single-center trials have suggested that treatment of acidosis improves the progression of chronic kidney disease (CKD) and improves muscle function. Similar treatments have been evaluated in a few studies in patients with normal systemic pH and serum bicarbonate concentration. The rationale for such studies is based on some evidence of retained acid in selected patients with CKD.

Intravenous crystalloid therapy is one of the most ubiquitous aspects of hospital and critical care medicine. In recent years, there has been increasing focus on the electrolyte composition, and particularly chloride content, of crystalloid solutions. This has led to increasing clinical adoption of balanced solutions, containing substrates for bicarbonate generation and consequently a lower chloride content, in place of 0.9% saline. In this article we review the physiochemical rationale for avoidance of 0.9% saline and the effects of hyperchloremic acidosis on renal physiology. Finally, we review the current evidence and rationale for use of balanced solutions greater than 0.9% saline in acutely ill patients in a variety of clinical settings, as well as considering the role for sodium bicarbonate in preventing or correcting metabolic acidosis. In conclusion, there is a strong physiological rationale for avoidance of iatrogenic hyperchloremic acidosis from 0.9% saline administration in acutely unwell patients and an association with adverse renal outcomes in several studies. However, evidence from large definitive multicenter randomized trials is not yet available to establish the dose-relationship between 0.9% saline administration and potential harm and inform us if some 0.9% saline use is acceptable or if any exposure confers harm.

Background: Fluid replacement to correct acidosis and electrolyte abnormalities is the cornerstone of treatment of diabetic ketoacidosis (DKA). We evaluated the rates of change in pH, pCO2, anion gap, Na, K, and Cl in children randomized to four DKA fluid treatment protocols. Methods: From a large study conducted by The Pediatric Emergency Care Applied Research Network we used data from 714 children Results: The median age, sex, and baseline laboratory characteristic of the patients did not differ by treatment arm. The rate of change of pH did not differ by the arm, however the rate of rise of pCO2 was more rapid in the fast vs. slow fluid arms during the initial 4 h. The rate of decrease in anion gap was more rapid in the fast vs. slow arms during the initial 4 h and 8 h (p Conclusions: In children treated for DKA, faster fluid administration led to more rapid normalization of anion gap and pCO2 than slower fluid rates. However, more rapid fluid rates were associated with increased frequency of hyperchloremic acidosis. Disclosure A. Rewers: None. N.D. Kuppermann: Other Relationship; Self; InsuCalc. M.J. Stoner: None. A. Garro: None. K. Quayle: None. J.E. Bennett: None. S. Myers: None. J.K. McManemy: None. L.E. Nigrovic: None. J.L. Trainor: None. L. Tzimenatos: None. M. Kwok: None. C.S. Olsen: None. T.C. Casper: None. S. Ghetti: None. N. Glaser: Consultant; Self; Bristol-Myers Squibb Company. Other Relationship; Self; Insucalc. Funding Eunice Kennedy Shriver National Institute of Child Health and Human Development

INTRODUCTION: The ideal asanguineous intravenous fluid for volume resuscitation in children is controversially debated and clinical practice guidelines are scarce. Administration of large amounts of normal saline has been associated with complications including hyperchloremic acidosis, dysnatremia, neurologic damage, and fatality. AIM: We examined the current practice of intravenous fluid and blood product administration in acutely ill and injured children among pediatric acute care physicians in Switzerland. METHODS: For this descriptive, cross-sectional study, pediatric emergency departments, pediatric and neonatal intensive care units were surveyed by means of an online questionnaire. RESULTS: Sixty of 66 departments and 47 of 87 participants returned the survey. Normal saline (NS) was most commonly administered (n = 42/46, 91.3%) and twice as many times as balanced electrolyte solutions (n = 20/46, 43.5%). The mean fluid volumes ranged from 7.9 to 19.1 mL/kg. Hypertonic saline/NS were selected most often for shock with severe head injury. Half of participants administered colloids (48.9%). Packed red blood cells (97.7%) and fresh frozen plasma (88.4%) were most frequently given blood products. CONCLUSION: There is a distinct practice variation in intravenous fluid and blood product administration in children in Switzerland. Although NS is most frequently given, we observed a trend toward the use of balanced electrolyte solutions. Prospective studies are warranted to compare NS with balanced electrolyte solution (BES) in the pediatric acute care setting. We suggest that pediatric fluid administration guidelines and mass transfusion protocols are implemented to standardize this frequent intervention and minimize complications.

Context and Aims: Off-pump coronary artery bypass graft (OPCABG) is a form of CABG surgery. It is performed without the use of cardiopulmonary bypass machine as a surgical treatment for coronary heart disease. Acute kidney injury (AKI) is one of the common postoperative complications of OPCABG. Previous studies suggest important differences related to intravenous fluid (IVF) chloride content and renal function. We hypothesize that perioperative use of chloride restricted IVFs may decrease incidence and severity of postoperative AKI in patients undergoing OPCABG. Methods: Six hundred patients were randomly divided into two groups of 300 each. In Group A (n = 300), chloride liberal IVFs, namely, hydroxyethyl starch (130/0.4) in 0.9% normal saline (Voluven), 0.9% normal saline, and Ringer's lactate were used for perioperative fluid management. In Group B (n = 300), chloride-restricted IVFs, namely, hydroxyethyl starch (130/0.4) in balanced colloid solution (Volulyte) and balanced salt crystalloid solution (PlasmaLyte A), were used for perioperative fluid management. Serum creatinine values were taken preoperatively, postoperatively at 24 h and at 48 h. Postoperative AKI was determined by AKI network (AKIN) criteria. Results: In Group A, 9.2% patients and in Group B 4.6% patients developed Stage-I AKI determined by AKIN criteria which was statistically significant (P < 0.05). Conclusion: Perioperative use of chloride restricted IVF was found to decrease incidence of postoperative AKI. The use of chloride liberal IVF was associated with hyperchloremic metabolic acidosis.

Intravenous fluid administration has been occurring for well over one hundred years for a variety of pediatric disease processes. Surprisingly, clinicians have yet to agree upon a standardized intravenous solution. There is ongoing debate regarding the administration of isotonic versus hypotonic fluids as maintenance solutions. In this article, we will review what is known about different maintenance solutions, discuss the potential complications with their use, and summarize the available evidence to help guide clinicians in their choice of maintenance fluids for their patients.

The purpose of the study: estimate the frequency of registration of different types of acid-base state disorders in children with acute infectious diarrhea; to determine the clinical features of acute intestinal infections that occur with metabolic acidosis (MA) and without it to choose the tactics of effective correction. Мaterials and methods : retrospective cohort study was conducted of 246 patients hospitalized in a hospital with clinic of acute infectious diarrhea. Results of the study : laboratory-confirmed acidosis, were recorded in 40.7% (95% CI 34.6–46.8), 100/246 children, incl. With a pH below 7.25 in 9.3% (95% CI 5–7–12.9), 23/246. The condition of alkalosis revealed in 4.9% (95% CI 2.2–7.6) of 12/246 examined. Hyperchloremic acidosis had a place in 81% (95% CI 73.3–88.7), 81/100 patients, with a high anionic deficiency in 19% (95% CI 11.3–26.7), 19/100, P

Metabolic acidosis frequently is present in surgical patients; however, different types of metabolic acidosis (hyperlactatemia, hyperchloremia, and others) may have different relationships to perioperative outcomes. We hypothesized that in postoperative surgical patients, distinctive types of metabolic acidosis would correlate differently with the outcomes of high-risk surgeries.A prospective, multicenter observational study was performed in 3 different tertiary care hospitals. Patients who required postoperative admission to the intensive care unit (ICU) were included in this study. Patients with a short life expectancy (those with untreated cancer and limited treatment), hepatic failure, renal failure, or a diagnosis of diabetes were excluded. Patients were classified at ICU admission according to the presence and type of metabolic acidosis into 4 groups: those without acidosis, those with a base excess-4 mmol/L and albumin-corrected anion gap ≤12 mmol/L (hyperchloremic), those with a base excess-4 mmol/L and increased albumin-corrected anion gap12 mmol/L, and those with a base excess-4 mmol/L and hyperlactatemia2 mmol/L. Furthermore, patients were reclassified 12 hours after admission to the ICU to verify the metabolic acidosis behavior and outcome differences among the groups.The study included 618 patients. The incidence of acidosis at ICU admission was 59.1%; 23.9% presented with hyperchloremia, 21.3% with hyperlactatemia, 13.9% with increased anion gap, and 40.9% of the patients presented without metabolic acidosis. Patients whose metabolic acidosis persisted for 12 hours had an incidence of ICU complications rates in hyperlactatemia group of 68.8%, increased anion gap of 68.6%, hyperchloremic of 65.8%, and those without acidosis over 12 hours of 59.3%. A Cox regression model for postoperative 30-day mortality showed: in hyperlactatemic acidosis, hazard ratio (HR) = 1.74, 95% confidence interval (CI) = 1.02-2.96; increased anion gap acidosis, HR = 1.68, 95% CI = 0.85-3.81; hyperchloremic acidosis, HR = 1.47, 95% CI = 0.75-2.89, and 10.3% of 30-day mortality rate in patients without acidosis. An adjusted survival curve by Cox regression found a worse 30-day survival in the hyperlactatemic group compared with the other groups (P = .03). Furthermore, in multiple comparisons among groups, patients with hyperlactatemic acidosis were more likely to develop renal dysfunction (P.001) up to the seventh day postoperatively.We found that among patients with different types of acidosis, patients who developed hyperlactatemic metabolic acidosis postoperatively showed greater rates of renal dysfunction within 7 days and hyperlactatemic acidosis represented an independent factor on 30-day mortality in high-risk surgical patients.

Intracranial hypertension (ICH) is the most important modifiable factor with predictive negative value in brain injury patients. Osmotherapy is the most important first level specific measure in the treatment of ICH. Mannitol 20%, and 3, 7.5, 10, and 23% hypertonic sodium chloride are the most commonly used osmotic agents in the neurocritical care setting. Currently, controversy about the best osmotic agent remains elusive. Therefore, over the past few years, half-molar sodium lactate has been introduced as a new osmotic agent to be administered in the critically ill. Lactate is able to prevent hyperchloremia, as well as its adverse effects such as hyperchloremic acidosis, systemic inflammation, and acute kidney injury. Furthermore, lactate may also be used by glia as energy substrate in brain injury patients. Half-molar sodium lactate would also have a more potent and long-lasting effect decreasing intracellular osmolarity and by inhibiting neuronal volume control mechanisms. Pioneering researches in patients with traumatic brain injury have shown a more significant effect than mannitol on the control of ICH. In addition, in this group of patients this solution appears to be beneficial in preventing episodes of ICH. However, future research is necessary to corroborate or not these promising results.

Metabolic acidosis results from an increase in the concentration of a strong anion. Metabolic acidosis is divided into hyperchloremic metabolic acidosis and high anion gap acidosis based on the changes in the anion gap. Hyperchloremic metabolic acidosis is the result of chloride retention, excessive loss of sodium relative to chloride, or excessive gain of chloride relative to sodium. Clinical signs are related to the underlying disease that accompanies the metabolic acidosis. Treatment of hyperchloremic acidosis is based on addressing the underlying disease process.

Intravenous fluids should be regarded with the same consideration as other pharmacologically active agents. Perioperative fluid management is an important component of the treatment to restore and/or maintain adequate cerebral blood flow and cerebral perfusion pressure. The distribution of these infused synthetic fluids in our patients depends on their volume and composition and also the patient’s underlying physiology. Unnecessary volumes, or infusion of hypotonic fluids, results in cerebral edema, influencing the strong ion difference that may in turn affect the acid-base balance. Also, the electrolyte composition has far-reaching consequences, such as chloride rich solutions that contribute toward hyperchloremic acidosis and impaired renal blood flow. Synthetic colloid solutions and mannitol are not without their own limitations, for example, they may also contribute toward acute kidney injury. This chapter discusses treatment choices with different fluid types in specific neurosurgical situations. Perioperative fluid management in these settings should be tailored to suit a patient’s clinical condition and underlying pathophysiology. In general, hypotonic fluids should be avoided, with isotonic fluids being preferred. Personalized fluid management strategies should be guided by dynamic variables that assess fluid responsiveness.

Background: Renal function tends to deteriorate in a hyperchloremic acidifying environment, which is reflected by a decrease in the difference between sodium and chloride. Objectives: To examine the effect of furosemide administered under hyperchloremic acidosis on intraoperative oliguria and acute kidney injury in patients with preoperatively normal renal function. Methods: In patients undergoing abdominal or orthopedic surgeries (April 2010–November 2018), we retrospectively identified patients who preoperatively had a normal renal function but experienced intraoperative oliguria under hyperchloremic acidosis (a sodium-chloride difference < 30 mEq/L) without dehydration. We compared the perioperative urine output and the incidence of postoperative acute kidney injury between patients who intraoperatively received an initial dose of 5 mg of furosemide (the furosemide group) and patients who did not intraoperatively receive furosemide (the control group). Results: We identified 62 patients in the furosemide group and 48 patients in the control group. The furosemide group intraoperatively received 0.11 ± 0.06 mg/kg of furosemide (range 0.06–0.39 mg/kg). Compared to the control group, the furosemide group had greater urine output (mL/kg/h) in the operating room (1.1 ± 0.7 vs. 0.3 ± 0.1, p < 0.01) and on postoperative day 1 (1.2 ± 0.5 vs. 1.1 ± 0.4, p = 0.02). The incidence of postoperative acute kidney injury was lesser in the furosemide group than that in the control group (8.0 vs. 27.0%, p < 0.01; multivariate OR 0.18; 95% CI 0.05–0.61; p < 0.01). Conclusions: In surgery patients under hyperchloremic acidosis, furosemide (0.1 mg/kg) resolved intraoperative oliguria and reduced the incidence of postoperative acute kidney injury.

Introduction Metabolic acidosis is common post cardiac surgery. The incidence of hyperchloremic metabolic acidosis (HCMA) post cardiac surgery was 56% in our previous audit . There was a huge correlation with the use colloid 4 % gelatin in these patients. The purpose of the present audit was to assess the current incidence of HCMA and contributing factors as part of quality improvement. Methods A prospective audit, data collected from all cardiac surgical patients over a period of two months. Incidence of HCMA on admission to ICU and its course over the first 24 hours was analysed. The duration of CPB, amount of cardioplegia used, perioperative chloride level and amount and type of perioperative fluids used were analysed. Results On Admission to ITU, 30 patients (56%) had metabolic acidosis, of whom19 (63%) patients were hyperchloremic, giving an incidence of HCMA as 36% .Hyperchloremia without acidosis was seen in 43% patients, making the overall incidence of hyperchloremia on admission as 55%. Hyperchloremia persisted in 61% patients on day 1 post surgery. No relation was found between perioperative fluids used and hyperchloremia. Maintenance fluid had changed to hartmann's solution & use of colloid 4% gelatin had decreased by 75% following the previous audit. Among the patients with persistent hyperchloremia, 57% had CPB time greater than 120 minutes and 61% had more than 2 litres of cardioplegia. Discussion HCMA post cardiac surgery has been related to the CPB prime and perioperative fluids. Our CPB prime is normochloremic and there was no relation between hyperchloremia and the intravenous fluids used. There was a direct relationship between hyperchloremia and the duration of CPB and the volume of cardioplegia used because cardioplegia contains 160 mmols/L of chloride. Thus, we conclude that increasing volumes of cardioplegia used with longer cardiopulmonary bypass times might be a significant contributor to increasing incidence of hyperchloremic metabolic acidosis. This is the first report implicating cardioplegia in the pathogenesis of HCMA.

To determine the severity, duration, and contributing factors for metabolic acidosis after deep hypothermic circulatory arrest (DHCA).Retrospective observational study.University hospital.Eighty-seven consecutive patients undergoing elective thoracic aortic surgery with DHCA.Regression analysis was used to test for relationships between the severity of metabolic acidosis and clinical and laboratory variables.Minimum pH averaged 7.27±0.06, with 76 (87%) having a pH7.35; 55 (63%), a pH7.30; and 7 (8%), a pH7.20. The mean duration of metabolic acidosis was 7.9±5.0 hours (range: 0.0 - 26.8), and time to minimum pH after DHCA was 4.3±2.0 hours (1.0 - 10.0 hours). Hyperchloremia contributed to metabolic acidosis in 89% of patients. The severity of metabolic acidosis correlated with maximum lactate (p0.0001) and hospital length of stay (LOS) (r = 0.22, p0.05), but not with DHCA time, DHCA temperature, duration of vasoactive infusions, or ICU LOS. Patient BMI was the sole preoperative predictor of the severity of postoperative metabolic acidosis.This retrospective analysis involved short-term clinical outcomes related to pH severity and duration, which indirectly may have included the impact of sodium bicarbonate administration.Metabolic acidosis was common and severe after DHCA and was attributed to both lactic and hyperchloremic acidosis. DHCA duration and temperature had little impact on the severity of metabolic acidosis. The severity of metabolic acidosis was best predicted by the BMI and had minimal effects on short-term outcomes. Preventing hyperchloremic acidosis has the potential to decrease the severity of metabolic acidosis after DHCA.

Background The administration of potassium solutions may result in hyperpotassemia during surgery; normal saline solution (NSS) traditionally used in renal transplant may cause hyperchloremic acidosis. Objective To compare the safety of Lactated Ringer's (LR) against NSS in renal transplantation. Search strategy A systematic review was completed on Central Cochrane Registry – controlled trials, Medline, Lilacs, EBSCO and Embase, accessing review articles and contacting expert clinicians. There was no language restriction. Selection criteria Randomized controlled trials on adult patients undergoing renal transplantation. Data collection and analysis Independent trial selection, quality assessment and data extraction were performed. The mean differentials were estimated with a 95% confidence interval (95% CI). Heterogeneity was evaluated with statistic I-square (I2) and the fixed and random effect models were used. Results Four trials with a total of 237 patients were included. At the end of surgery, the potassium differential was non-significant (means difference (MD: −0.26 mEq/L; CI 95%: −0.58 to 0.05 p = 0.10; I2 = 75%); the pH was lower in the NSS group (MD: 0.06; CI 95%: 0.05–0.08; p Conclusions The use of RL vs. NSS during the renal transplantation perioperative period results in lower potassium and chloride levels and a higher pH, with no significant Creatinine changes.

Renal tubular acidosis (RTA) is essentially characterized by normal anion gap and hyperchloremic metabolic acidosis. It is important to understand that despite knowing the disease for 60-70 years, complexities in the laboratory tests and their interpretation still make clinicians cautious to diagnose and label types of tubular disorder. Hence, we are writing this mini-review to emphasize on the step wise approach to RTA with some understanding on its basic etiopathogenesis. This will definitely help to have an accurate interpretation of urine and blood reports in correlation with the clinical condition. RTA can be a primary or secondary defect and results either due to abnormality in bicarbonate ion absorption or hydrogen ion secretion. Primary defects are common in children due to gene mutation or idiopathic nature while secondary forms are more common in adults. We are focusing and explaining here in this review all the clinical and laboratory parameters which are essential for making the diagnosis of RTA and excluding the extrarenal causes of hyperchloremic, normal anion gap metabolic acidosis.

In the acute care setting, the type and amount of fluid administered has a significant impact on patient outcomes. In particular, 0.9% saline infusions are known to cause or exacerbate hyperchloremia. The studies presented evaluate possible complications from 0.9% saline infusions. These studies compared administration of 0.9% saline with lactated ringer or plasmalyte in the acute care setting. In each trial, the patients who were randomized to receive 0.9% saline infusions had a more severe acidosis from increased serum chloride levels. From the available data, chloride-restrictive intravenous fluid such as plasmalyte appears to reduce acid-base disturbances and improve patient outcomes.

Background Fluid maintenance and resuscitation is an important strategy during major surgeries. There has been a debate on the choice of crystalloids over the past decades. 0.9% saline (normal saline) is more likely to cause hyperchloremic acidosis when compared to balanced crystalloids with low chloride content. Meta-analyses comparing these two kinds of crystalloids have been performed in renal transplantations. We aim to compare the safety of balanced crystalloids to normal saline among adult patients undergoing non-renal surgery. Methods Relevant articles were searched through PubMed, Embase and the Cochrane Library. Nine randomized controlled trials (including 871 participants) comparing balanced crystalloids to normal saline on adult patients undergoing non-renal surgery were finally included. Possible effects were calculated using meta-analysis. Results Patients in the normal saline group had significantly lower postoperative pH (MD: 0.05; 95% CI: 0.04–0.06; p 2 = 82%) and base excess (MD: 2.04; 95% CI: 1.44–2.65; p 2 = 87%). The postoperative serum chloride level was significantly higher in the normal saline group (MD: −4.79; 95% CI: −8.13∼-1.45; p = .005; I 2 = 95%). Conclusion Comparing to normal saline, balanced crystalloids are more beneficial in keeping postoperative electrolytes and acid-base balance among adult patients undergoing non-renal surgery. Future researches should pay more attention to meaningful clinical outcomes concerning the safety of balanced crystalloids and normal saline.

Background Acid–base disturbances are frequently observed in critically ill patients at the intensive care unit. To our knowledge, the acid–base profile of patients with acute-on-chronic liver failure (ACLF) has not been evaluated and compared to critically ill patients without acute or chronic liver disease. Results One hundred and seventy-eight critically ill patients with liver cirrhosis were compared to 178 matched controls in this post hoc analysis of prospectively collected data. Patients with and without liver cirrhosis showed hyperchloremic acidosis and coexisting hypoalbuminemic alkalosis. Cirrhotic patients, especially those with ACLF, showed a marked net metabolic acidosis owing to increased lactate and unmeasured anions. This metabolic acidosis was partly antagonized by associated respiratory alkalosis, yet with progression to ACLF resulted in acidemia, which was present in 62% of patients with ACLF grade III compared to 19% in cirrhosis patients without ACLF. Acidemia and metabolic acidosis were associated with 28-day mortality in cirrhosis. Patients with pH values

Resume L’apport excessif de chlore et l’hyperchloremie qu’elle provoque sont associes a une acidose metabolique. Elle s’observe avec les solutes non balances comme le serum sale isotonique, premiere cause d’acidose metabolique en reanimation. L’hyperchloremie est egalement associee a des perturbations de l’hemostase, a un etat pro-inflammatoire, eventuellement a un risque d’insuffisance renale et a une surmortalite en reanimation. L’usage des solutes balances est recommande.

Background The infusion of crystalloid solutions is a fundamental part of the management of critically ill patients. These solutions are used to maintain the balance of water and essential electrolytes and replace losses when patients have limited gastrointestinal intake. They also act as carriers for intravenous infusion of medication and red cells. The most commonly used solution, 0.9% saline, has equal concentrations of Na + and Cl − even though the plasma concentration of Na + normally is 40 meq/L higher than that of Cl − . The use of this fluid thus can produce a hyperchloremic acidosis in a dose-dependent manner, but it is not known whether this has clinical significance. Approach The first part of this article deals with the significance of Na + and Cl − in normal physiology. This begins with examination of their roles in the regulation of osmolality, acid–base balance, and generation of electrochemical gradients and why the concentration of Cl − normally is considerably lower than that of Na + . The next part deals with how their concentrations are regulated by the gastrointestinal tract and kidney. Based on the physiology, it would seem that solutions in which the concentration of Na + is "balanced" by a substance other than Cl − would be advantageous. The final part examines the evidence to support that point. Conclusions There are strong observational data that support the notion that avoiding an elevated Cl − concentration or using fluids that reduce the rise in Cl − reduces renal dysfunction, infections, and possibly even mortality. However, observational studies only can indicate an association and cannot indicate causality. Unfortunately, randomized trials to date are far too limited to address this crucial issue. What is clear is that appropriate randomized trials will require very large populations. It also is not known whether the important variable is the concentration of Cl − , the difference in concentrations of Na + and Cl − , or the total body mass of Cl − .

This case report presents a 49 year-old female with type 1 diabetes admitted to the intensive care unit with acute respiratory failure and severe diabetic ketoacidosis with an initial measurement of blood glucose level of 1,200 mg L⁻¹, pH 6.78, serum HCO₃ ⁻ 3.2 mmoL L⁻¹ and BE -31.2 mmoL L⁻¹. Analysis of the blood gasometric parameters with the Stewart approach and the traditional Henderson-Hasselbalch concept enabled the discovery of metabolic acidosis caused by unidentified anions (mainly ketons). A treatment protocol with intensive fluid management with 0.9% NaCl, intensive intravenous insulin therapy, and potassium supplementation was administered. Analysis of the gasometric parameters after 12 hours of treatment according to the Stewart approach compared to the Henderson-Hasselbalch concept disclosed that metabolic acidosis caused by the unidentified anions has resolved almost completely and been replaced by metabolic hyperchloremic acidosis. The hyperchloremic acidosis was caused by the intensive fluid resuscitation with 0.9% NaCl, which contains a high chloride load, exceeding the chloride levels observed in human serum. Fluid management with balanced fluids other than saline was continued, together with intravenous insulin infusion, potassium supplementation, and 5% glucose administration. Analysis of this case study revealed the advantages of the Stewart approach to acid base abnormalities compared to the traditional Henderson-Hasselbalch concept. The Stewart approach allows the diagnosis of the exact causes of severe life-threatening metabolic acidosis and the appropriate modification of the therapeutic mangement of patients with diabetic ketoacidosis.

Background:In an incidental finding, during a study of plasma chemistry after crystalloid infusion, participants reported subjective cognitive changes, particularly slower thinking, after saline but not Hartmann’s (Ringer’s lactate) solution. The authors tested the hypothesis that saline infusion would produce greater adverse cognitive changes than Plasmalyte infusion.Methods:The authors conducted a randomized, cross-over, multiple blinded study of healthy adult volunteers. On separate days, participants received 30 ml/kg over 1 h of either 0.9% saline or Plasmalyte with the order randomly allocated. Plasma chemistry was tested on venous samples. As part of a battery of cognitive tests our primary endpoint was the reaction time index after infusion.Results:The authors studied 25 participants. Plasma chloride was greater after saline than after Plasmalyte: mean difference 5.4 mM (95% CI, 4.1–6.6 mM; P < 0.001). Saline was also associated with greater metabolic acidosis: base-excess 2.5 mM more negative (95% CI, 1.9–3.0 mM more negative; P < 0.001). There was no evidence of a difference in the reaction time index between the two interventions: mean reaction time index 394 ms (SD, 72) after saline versus 385 ms (SD, 55) after Plasmalyte. Difference: saline 9 ms slower (95% CI, 30 ms slower to 12 ms faster; P = 0.39). There were minimal differences in the other cognitive and mood tests.Conclusions:Despite expected differences in plasma chemistry, the authors found that measures of cognition did not differ after infusions of Plasmalyte or saline.

Objective: The traditional approach for acid base interpretation is based on Handerson-Hasselbalch formula and includes Base Excess (BE), bicarbonate (HCO3), albumin corrected anion gap. The Physicochemical approach is centered on the Carbon Dioxide tension (PCO2), the strong ion difference (SID), strong ion gap (SIG) = SID apparent-SID effective and totally weak acids (Atot). The study aims to compare between the traditional approach and the physicochemical approach in acid base disorder interpretation. Design: Prospective observational study in an adult Intensive Care Unit (ICU) recruiting six hundred and sixty one patients. Methods: Arterial blood samples were analyzed to measure pH, PaCO2 sodium, potassium, chloride and lactate. Venous blood samples were analyzed to measure ionized calcium, magnesium, phosphorous and albumin. These samples were interpreted by both techniques. Results: Normal HCO3 and BE were detected by traditional approach in 49 cases of which SIG acidosis was detected in 22 cases (46%) and Hyperchloremic acidosis was detected in 29 cases (60%) by physicochemical method. SIG was elevated in 72 cases (58%) of 124 cases with high anion gap acidosis. SIDeff and BE were strongly correlated, r = 0.8, p 0.0001, while SIG and Albumin corrected Anion Gap (ALAG) were moderately correlated r = 0.56, p Conclusion: Both approaches are important for interpretation of the acid base status. Traditional approach identifies the diagnostic description without many calculations and detects body compensatory response to acid base disorders. Physicochemical approach is essential to identify the exact causation and the severity of the acid base disorders.

Massive ketosis in a neonate or young infant is a key to the diagnosis of a classic organic aciduria. The initial episode may begin with vomiting, anorexia, and lethargy, but progresses rapidly to life-threatening acidosis, dehydration, coma, and apnea. A clinical clue to the diagnosis is metabolic acidosis with vomiting. Some infants with organic aciduria have been thought to have pyloric stenosis; similarly these infants are often thought to have sepsis. Septic infants can certainly be acidotic, but they are not ketotic. Testing of the urine for ketones is a must in all ill infants. Routine clinical chemistry reveals low pH, low bicarbonate, and an increased anion gap. The urine pH is low. Hyperchloremic acidosis and a normal anion gap mean intestinal losses or a renal tubular acidosis from other causes, the former with acidic urine and the latter with alkaline urine. Quantitative organic acid analysis by gas chromatography-mass spectrometry is essential in differential diagnosis which may be faster achieved by acylcarnitine (MS/MS) analysis.

Background Citrate, the currently preferred anticoagulant for continuous veno-venous hemofiltration (CVVH), may influence acid-base equilibrium. Methods The effect of 2 different citrate solutions on acid-base status was assessed according to the Stewart-Figge approach in two consecutive cohorts of critically ill adult patients. The first group received Prismocitrate 10/2 (PC10/2; 10 mmol citrate/L). The next group was treated with Prismocitrate 18/0 (PC18; 18 mmol citrate/L). Both groups received bicarbonate-buffered fluids in post-dilution. Results At similar citrate flow, the metabolic acidosis present at baseline in both groups was significantly attenuated in PC18 patients but persisted in PC10/2 patients after 24 h of treatment (median pH 7,42 vs 7,28; p = 0.0001). Acidosis in the PC10/2 group was associated with a decreased strong ion difference and an increased strong ion gap (respectively 43 vs. 51 mmol/L and 17 vs. 12 mmol/L, PC10/2 vs. PC18; both p = 0.001). Chloride flow was higher in PC10/2 than in PC18 subjects (25.9 vs 14.3 mmol/L blood; p Conclusion Correction of acidosis was blunted in patients who received 10 mmol citrate/L as regional anticoagulation during CVVH. This could be explained by differences in chloride flow between the applied citrate solutions inducing hyperchloremic acidosis.