Rapid Saline Infusion Produces Hyperchloremic Acidosis in Patients Undergoing Gynecologic Surgery

Scheingraber, Stefan; Rehm, Markus; Sehmisch, Christiane; Finsterer, U

doi:10.1097/00000542-199905000-00007

Cited by 684 publications

(271 citation statements)

References 22 publications

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“…[57][58][59][60][61][62] In particular, hyperchloremic acidosis has been shown to reduce gastric blood flow and decrease gastric intramucosal pH in elderly surgical patients. 58 It has also been shown to reduce renal blood flow velocity and renal cortical tissue perfusion in healthy volunteers.…”

Section: Which Fluid Should I Use?mentioning

confidence: 99%

Fluid management and goal-directed therapy as an adjunct to Enhanced Recovery After Surgery (ERAS)

Miller

Roche

Mythen

2014

Can J Anesth/J Can Anesth

230

137

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Optimal perioperative fluid management is an important component of Enhanced Recovery After Surgery (ERAS) pathways. Fluid management within ERAS should be viewed as a continuum through the preoperative, intraoperative, and postoperative phases. Each phase is important for improving patient outcomes, and suboptimal care in one phase can undermine best practice within the rest of the ERAS pathway. The goal of preoperative fluid management is for the patient to arrive in the operating room in a hydrated and euvolemic state. To achieve this, prolonged fasting is not recommended, and routine mechanical bowel preparation should be avoided. Patients should be encouraged to ingest a clear carbohydrate drink two to three hours before surgery. The goals of intraoperative fluid management are to maintain central euvolemia and to avoid excess salt and water. To achieve this, patients undergoing surgery within an enhanced recovery protocol should have an individualized fluid management plan. As part of this plan, excess crystalloid should be avoided in all patients. For low-risk patients undergoing low-risk surgery, a ''zero-balance'' approach might be sufficient. In addition, for most patients undergoing major surgery, individualized goal-directed fluid therapy (GDFT) is recommended. Ultimately, however, the additional benefit of GDFT should be determined based on surgical and patient risk factors. Postoperatively, once fluid intake is established, intravenous fluid administration can be discontinued and restarted only if clinically indicated. In the absence of other concerns, detrimental postoperative fluid overload is not justified and ''permissive oliguria'' could be tolerated.Résumé La gestion périopératoire optimale des liquides est un élément important des programmes de récupération rapide après la chirurgie (RRAC). La gestion des liquides dans le cadre de la RRAC doit être vue comme un continuum au travers des phases pré-, per-et postopératoires. Chaque phase est importante pour améliorer la condition du patient et des soins sous-optimaux au cours d'une de ces phases peuvent miner les meilleures pratiques déployées tout au long de la RRAC. L'objectif de la gestion préopératoire des liquides est de faire en sorte que le patient entre en salle d'opération correctement hydraté et dans un état euvolémique. Pour y parvenir, un jeûne prolongé n'est pas recommandé et le nettoyage mécanique de l'intestin est à éviter. Les patients doivent être encouragés à absorber une boisson claire riche en hydrates de carbone, deux à trois heures avant la chirurgie. Les buts de la gestion peropératoire des liquides sont de maintenir une euvolémie centrale et d'éviter un excès de sel et d'eau. Pour y parvenir, les patients subissant une intervention chirurgicale dans le cadre d'un protocole de récupération rapide devraient avoir un programme personnalisé de gestion des liquides. Dans le cadre de ce plan, l'excès de cristalloïdes doit être évité chez tous les patients. Pour des patients à faible risque subissant une intervention c...

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Section: Which Fluid Should I Use?mentioning

confidence: 99%

Fluid management and goal-directed therapy as an adjunct to Enhanced Recovery After Surgery (ERAS)

Miller

Roche

Mythen

2014

Can J Anesth/J Can Anesth

230

137

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“…In fact, the concentration of chloride in 0.9 % saline is approximately 1.5 times that of normal plasma. Compared to low chloride solutions like Hartmann's, rapid infusion of 0.9 % saline results in acidosis due to reduced strong ion difference, reduced renal perfusion and glomerular filtration rate, a tendency towards reduced urinary output, and even a pronounced increase in body weight [5,6]. Recent data raise the possibility that administration of 0.9 % saline [7] may be harmful and suggest that using 'balanced' solutions with lower, more physiological, chloride concentrations than 0.9 % saline may be preferable [8][9][10].…”

mentioning

confidence: 99%

Crystalloid fluid therapy: is the balance tipping towards balanced solutions?

Young

Joannidis

2014

Intensive Care Med

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Intravenous saline solutions were first introduced into clinical practice in the Sunderland cholera epidemic of 1831 [1]. More than 150 years later, not only is 0.9 % saline the most commonly used intravenous fluid in critically ill patients, it is also the fluid that has been administered to the largest number of critically ill patients in randomised controlled trials [2,3]. It is cheap and readily available, and more than a million litres of intravenous 0.9 % saline are administered to patients around the world every day [1]; however, although it is widely known as 'normal saline', 0.9 % saline is neither normal nor physiological [4]. In fact, the concentration of chloride in 0.9 % saline is approximately 1.5 times that of normal plasma. Compared to low chloride solutions like Hartmann's, rapid infusion of 0.9 % saline results in acidosis due to reduced strong ion difference, reduced renal perfusion and glomerular filtration rate, a tendency towards reduced urinary output, and even a pronounced increase in body weight [5,6]. Recent data raise the possibility that administration of 0.9 % saline [7] may be harmful and suggest that using 'balanced' solutions with lower, more physiological, chloride concentrations than 0.9 % saline may be preferable [8][9][10].The relationship between the serum chloride concentration and outcome appears to be 'U-shaped' so that values outside of the normal physiological range are associated with an increased risk of death [11]. Positive fluid balance is also associated with an increased risk of death [12]. Because chloride loading and volume loading often occur together the relative contributions of chloride overload and volume overload to the apparent increased mortality risk are uncertain. In this issue of Intensive Care Medicine, Shaw and colleagues examine, among other things, the association between the 'volume-adjusted chloride load' and in-hospital mortality in more than 100,000 patients with tachycardia (heart rate over 90 bpm) and at least one other systemic inflammatory response syndrome (SIRS) criterion [13]. The purpose of this was to demonstrate the association between chloride administration and outcome independent of administered fluid volume. In doing so, Shaw and colleagues were able to demonstrate, for the first time, an association between increasing amounts of chloride administered during crystalloid resuscitation and increased in-hospital mortality which persisted after controlling for the total volume of fluid administered [13], raising the possibility that the chloride content of resuscitation fluids might be a modifiable risk factor for adverse outcomes.This study adds to previous data which demonstrated an association between the use of chloride-rich fluids and adverse outcomes compared to the use of balanced solutions in surgical patients [9] and patients with sepsis [10] and is consistent with a single centre, open label, beforeand-after period pilot study which showed that a strategy Intensive Care Med

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“…The anion gap is a useful, if imperfect, tool for distinguishing metabolic acidosis such as keto-acidosis, lactic acidosis and uremic acidosis, that increase the anion gap from hyperchloremic acidosis, in which there is no increase in anion gap. Scheingraber et a/who showed the usefulness of assessing the anion gap in managing peri-operative metabolic acidosis has highlighted this fact (3,4).…”

Section: Discussionmentioning

confidence: 99%

Role of pump prime in the etiology of cardio-pulmonary bypass associated acidosis

Sanjay

Kilpadi

2002

Indian J Clin Biochem

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The development of metabolic acidosis during cardio-pulmonary bypass (CPB) is a well recognized but poorly explained phenomenon. It has been hypothesized that it is purely a development after the delivery of pump prime. A retrospective study was conducted at our hospital on 68 patients who underwent elective coronary artery bypass grafting (CABG). Sampling of arterial blood was performed at three time intervals: (T,) Baseline, prior to induction; (T2) 5 minutes after initiation of CPB and prior to administration of cardioplegia solution; (T3) during rewarming prior to weaning the patient off CPB. Measurements of Na § K § CI-, pH, pCO 2, HCO-3, Base excess, Anion gap, Strong ion difference at each collection point were performed. Results were analyzed in a quantitative manner. On delivery of pump prime, all patients' developed metabolic acidosis. However, it is very important to distinguish the metabolic acidosis as their management varies. Anion gap has been found to be useful in managing peri-operative metabolic acidosis.

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Rapid Saline Infusion Produces Hyperchloremic Acidosis in Patients Undergoing Gynecologic Surgery

Abstract: Infusion of approximately 30 ml x kg(-1) x h(-1) saline during anesthesia and surgery inevitably leads to metabolic acidosis, which is not observed after administration of lactated Ringer's solution. The acidosis is associated with hyperchloremia.

Cited by 684 publications

References 22 publications

Fluid management and goal-directed therapy as an adjunct to Enhanced Recovery After Surgery (ERAS)

Fluid management and goal-directed therapy as an adjunct to Enhanced Recovery After Surgery (ERAS)

Crystalloid fluid therapy: is the balance tipping towards balanced solutions?

Role of pump prime in the etiology of cardio-pulmonary bypass associated acidosis

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