A case of pseudohyperchloraemia caused by sodium nitrate ingestion.

Emergency department presentations of sodium nitrate poisoning are increasing in frequency. Point-of-care blood gas analysis is useful for identifying methaemoglobinaemia and other abnormalities in such patients. Topically applied nitrate is known to positively interfere with chloride measurement in both point-of-care instruments and automated analysers of the clinical chemistry laboratory. In this article, the authors describe a case of pseudohyperchloraemia caused by sodium nitrate, which was consumed orally for the purpose of suicide. Consistent with the established pattern of interference, the ABL800 (Radiometer Medical, Brønshøj Copenhagen) blood gas analyser produced spuriously high chloride results, whilst the Alinity (Abbott Diagnostics, Abbot Park, Illinois) automated analyser resulted in chloride measurements comparable to those of inductively coupled mass spectrometry (ICP-MS). Both instruments, measure chloride with ion-selective electrodes (ISEs). The ABL800 (Radiometer) uses a membrane electrode, which is vulnerable to permeation by lipophilic nitrate ions, whereas the Alinity (Abbott) employs a silver chloride redox electrode system that is resistant to precipitation of silver nitrate due to its relatively high solubility. These mechanistic differences likely explain why nitrate interferes with some point-of-care devices but does not appear to affect the results of automated analysers.

Urinary chloride concentration as a prognostic marker in critically ill patients.

AIM: Associations have been reported among serum chloride concentration, mortality and incidence of acute kidney injury (AKI) in intensive care units (ICU). This study aimed to examine associations among urinary chloride, mortality, and AKI incidence in ICU patients. METHODS: A retrospective observational study was conducted among medical-surgical ICU in a tertiary hospital wherein 170 consecutive ICU patients were evaluated from October 2015 to March 2016 and 116 patients were enrolled. Serial data of serum and urine electrolytes from day 1 to day 4 of ICU admission were examined. The primary and secondary outcomes were ICU mortality and incidence of AKI in the ICU, respectively. RESULTS: Among the 116 enrolled patients, 15 (13%) died during their ICU stay. Although serum and urinary sodium and potassium on day 1 did not significantly differ between ICU survivors and non-survivors, urinary chloride concentration on day 1 was significantly lower in non-survivors. Receiver operating characteristic analysis showed that the cutoff value of day 1 urinary chloride concentration for prediction of ICU mortality was 53 mEq/L. The lower urinary chloride concentration group on day 1 showed a significantly lower survival rate, even in long-term follow-up, compared with the higher urinary chloride group. Addition of day 1 urinary chloride concentration improved prediction of AKI incidence in the ICU by Sequential Organ Failure Assessment score alone. CONCLUSION: Lower urinary chloride concentration was associated with increased mortality and incidence of AKI in the ICU. Further investigation is necessary to clarify the mechanism of urinary chloride regulation.

Increase in chloride from baseline is independently associated with mortality in critically ill children.

PURPOSE: To determine if there is an association between mortality and admission chloride levels and/or increases in the chloride level in critically ill children. METHODS: We performed a retrospective cohort study of all patients admitted to the paediatric intensive care unit (PICU) from January 2014 to December 2015. Patients were excluded for the following reasons: (1) age < 90 days or > 18 years, (2) admission to the cardiac intensive care unit, (3) no laboratory values upon admission to the PICU, (4) history of end-stage renal disease, (5) a disorder of chloride transport, and (6) admission for diabetic ketoacidosis. The patients were stratified on the basis of admission chloride levels (hypochloraemia, < 96 mEq/L; normochloraemia, 96-109 mEq/L; and hyperchloraemia, ≥ 110 mEq/L) and dichotomised on the basis of an increase in chloride in the first day (< 5 mEq/L, ≥ 5 mEq/L). Our primary outcome was in-hospital mortality. RESULTS: A total of 1935 patients [55% female, median age 6.3 years IQR (1.9-13.4)] were included. The overall mortality was 4% (n = 71) and day 2 AKI occurred in 17% (n = 333. Hypochloraemia, hyperchloraemia, and an increase in serum chloride ≥ 5 mEq/L occurred in 2%, 21%, and 12%, respectively. After adjusting for confounders, increase in chloride ≥ 5 mEq/L was associated with a 2.3 (95% CI 1.03-5.21) greater odds of mortality. CONCLUSIONS: An increase in serum chloride level in the first day of admission is common and an independent risk factor for mortality in critically ill children. Further studies are warranted to identify how chloride disturbances contribute to mortality risk in critically ill children.

Hyperchloraemia in sepsis.

Chloride represents-quantitatively-the most prevalent, negatively charged, strong plasma electrolyte. Control of chloride concentration is a probable major mechanism for regulating the body's acid-base balance and for maintaining homeostasis of the entire internal environment. The difference between the concentrations of chloride and sodium constitutes the major contributor to the strong ion difference (SID); SID is the key pH regulator in the body, according to the physicochemical approach. Hyperchloraemia resulting from either underlying diseases or medical interventions is common in intensive care units. Recent studies have demonstrated the importance of hyperchloraemia in metabolic acidosis and in other pathophysiological disorders present in sepsis. The aim of this narrative review is to present the current knowledge about the effects of hyperchloraemia, in relation to the underlying pathophysiology, in septic patients.

Hiponatremia adquirida en el hospital: ¿influye el tipo de fluidoterapia en los niños ingresados a cuidados intensivos? / Hospital-acquired hyponatremia: Does the type of fluid therapy affect children admitted to intensive care?

Resumen: Introducción: Este estudio tuvo por objetivo valorar las diferencias entre el tipo de fluidoterapia ini cial utilizada (sueros isotónicos o hipotónicos) en el desarrollo de hiponatremia, valores de cloro y to lerancia de las vías venosas. Pacientes y Método: Estudio retrospectivo de cohortes en una Unidad de Cuidados Intensivos Pediátricos (UCIP) de un hospital terciario. Se incluyeron niños menores de 15 años ingresados durante el primer semestre de los años 2010 y 2013, que recibieron fluidoterapia in travenosa, excluyéndose los sometidos a cirugía cardiaca, trasplantados renales y aquellos con ingreso inferior a 24 h. Se recogieron datos epidemiológicos, de comorbilidad y relacionados con el ingreso, tipo de suero recibido, valores de sodio y cloro en las primeras 72 h y la incidencia de extravasaciones de vías periféricas. Resultados: Se incluyeron 111 niños: 68 (61,3%) recibieron líquidos hipotónicos y 43 (38,7%) isotónicos. No hubo diferencias respecto a la patología y gravedad, ni tampoco en el volumen de líquidos recibido. Entre los pacientes que recibieron sueros hipotónicos, 28 (41,2%) pre sentaron hiponatremia, siendo esta moderada (Na <130 mEq/kg) en 11 de ellos, en comparación con 8 niños (18,6%) entre los que recibieron sueros isotónicos, registrando hiponatremia moderada solo en un caso (p=0,027). No se registró ningún caso de hipernatremia, ni hubo diferencias en los valores de cloro plasmático. Tampoco se objetivó mayor frecuencia de pérdida del acceso venoso utilizando la fluidoterapia isotónica (4,7% vs. 7,4%, p=0,704). Conclusión: El uso de líquidos iniciales isotóni cos en niños hospitalizados en UCIP se asocia con menor incidencia y gravedad de hiponatremia, sin cambio en la cloremia y es bien tolerado por las vías venosas periféricas.

Abstract: Introduction: The objective of this study was to evaluate the association between the type of initial fluid therapy used (isotonic or hypotonic solutions) and the development of hyponatremia, the plas ma chlorine values and the tolerance of venous access. Patients and Method: Retrospective cohort study in a Pediatric Intensive Care Unit (PICU) of a high complexity hospital. There were included children younger than 15 years old hospitalized during the first semester of 2010 and 2013 who recei ved intravenous maintenance fluid therapy, excluding patients undergoing cardiac surgery, kidney transplant and admissions that lasted less than 24 hours. Epidemiological, comorbidity and admis sion-related data were collected, including type of solution received, sodium and chlorine values in the first 72 hours of hospitalization and the incidence of extravasation of peripheral intravenous lines. Results: 111 children were included; 68 children (61.3%) were treated with hypotonic solutions and 43 (38.7%) with isotonic solutions. There were no differences in pathology and severity, and also in the volume of fluid received. Among the patients who received hypotonic solutions, 28 (41.2%) de veloped hyponatremia, wich was moderate (Na <130 mEq/Kg) in 11 cases, compared with 8 children (18.6%) who received isotonic solutions, with only one case of moderate hyponatremia (p = 0.027). No cases of hypernatremia were recorded, and there were no differences in plasma chlorine values. There was also no increased frequency of venous access loss in patients treated with isotonic solutions (4.7% versus 7.4%, p = 0.704). Conclusion: Treatment with initial isotonic solutions in children hos pitalized in PICU is associated with a lower incidence and severity of hyponatremia, without changes in the plasma chlorine values and it is well tolerated by peripheral intravenous lines.

Choice of fluids in the perioperative period of kidney transplantation. / Elección de fluidos en el periodo perioperatorio del trasplante renal.

Normal saline has traditionally been the resuscitation fluid of choice in the perioperative period of kidney transplantation over balanced potassium solutions. However, the problems arising from hyperchloraemia triggered by the infusion of normal saline have led to studies being conducted that compare this solution with balanced solutions. From this narrative review it can be concluded that the use of balanced crystalloids containing potassium in the perioperative period of kidney transplantation can be considered safe. These solutions do not affect serum potassium levels any more than normal saline, whilst maintaining a better acid-base balance in these patients.

Maintenance fluid therapy in a tertiary hospital: A prevalence study. / Fluidoterapia de mantenimiento administrada en un hospital terciario: estudio de prevalencia.

OBJECTIVE: To assess the types of maintenance fluids used in our hospital, comparing their volume and composition to the standards recommended by the guidelines. MATERIAL AND METHODS: Observational, cross-sectional study. Volume and type of fluid therapy administered during 24h to patients admitted to various hospital departments were recorded. Patients receiving fluid therapy because of water-electrolyte imbalance were excluded. RESULTS: Out of 198 patients registered, 74 (37.4%) were excluded because they did not meet the criteria for inclusion. Mean administered volume was 2,500cc/day. Mean daily glucose dose was 36g per 24h (SD: 31.4). The most frequent combination included normal saline solution (NSS) and glucose 5% (64.4%). Mean daily dose of sodium and chlorine was, respectively, 173mEq (SD: 74.8) and 168mEq (SD: 75), representing a surplus daily dose of +87.4mEq and +85mEq. Potassium, magnesium and calcium daily deficit was, respectively, -50mEq, -22mEq and -21mEq per day. Buffer administration was exceptional, bicarbonate (2.29%), acetate (1.29%), lactate (1.15%) and gluconate (1.10%) being the buffering agents most frequently used. CONCLUSION: NNS is the most frequently used solution. In contrast to excess doses of sodium and chlorine, there is a great deficit of other ions, buffering agents and caloric intake in the fluid therapy regimens that are usually prescribed.

False hyperchloraemia in a dog secondary to ingestion of horse feed supplemented with potassium bromide.

BACKGROUND: A dog was presented for acute abdominal distension after inadvertent access to a large amount of dry dog food and possibly horse feed consisting of chaff, pony cubes and vitamin, mineral and yeast supplements. RESULTS: A marked hyperchloraemia and decreased anion gap on blood electrolyte analysis prompted a review of the patient's history for potential ingestion of bromide. It was revealed that the horse feed was supplemented with potassium bromide. The serum bromide level was 23.6 mmol/L. The dog recovered uneventfully. CONCLUSION: This case report highlights the importance of knowing common interferents of chemical analysis techniques.