Brazilian Journal of Anesthesiology
https://bjan-sba.org/article/doi/10.1590/S0034-70942009000300005
Brazilian Journal of Anesthesiology
Scientific Article

Importância da hipercloremia no intraoperatório

The importance of intraoperative hyperchloremia

João Manoel Silva Junior; Eliete F Neves; Thassio C Santana; Ulisses P Ferreira; Yara N Marti; Jose Maria Correa Silva

http://dx.doi.org/10.1590/S0034-70942009000300005 Braz J Anesthesiol, vol.59, n3, p.304-313, 2009
PDF Português
PDF English
Downloads: 0
Views: 1354

Resumo

JUSTIFICATIVA E OBJETIVOS: A hipercloremia associada à acidose proporciona pior evolução dos pacientes se não identificada e tratada corretamente. O objetivo deste estudo foi verificar a importância da hipercloremia no intraoperatório. MÉTODO: Estudo de coorte prospectivo, durante cinco meses. Incluiu-se no estudo pacientes com idade igual ou maior que 18 anos submetidos a intervenções cirúrgicas com pós-operatório em unidade de terapia intensiva. Moribundos, diabéticos e com insuficiência renal foram excluídos. Os pacientes foram divididos em dois grupos: CH (hipercloremia) e SH (sem hipercloremia). A determinação de hipercloremia foi através de análise de curva ROC (Receiver Operating Characteristic), ou seja, o ponto com maior sensibilidade e especificidade para óbito foi escolhido como limite para diferenciar entre hipercloremia ou não. RESULTADOS: O estudo envolveu 393 pacientes. As concentrações séricas de cloro foram 111,9 ± 6,7 mEq.L-1, pH 7,31 ± 0,09 e diferença de bases de -5,6 ± 4,6 mmol.L-1. A área sob a curva ROC dos valores de cloro foi de 0,76 com ponto de corte de 114 mEq.L-1, sensibilidade = 85,7% e especificidade = 70,1%. Pacientes com cloro maior que 114 mEq.L-1 totalizaram 31,7% e foram determinados como grupo CH. O grupo CH apresentou maior mortalidade do que o grupo SH, 19,3% versus 7,4%, p = 0,001, acidose metabólica pH 7,27 (0,08) versus 7,32 (0,09) p = 0,001, diferença de bases -7,9 (3,8) mmol.L-1 versus -4,2 (4,6) mmol.L-1 p < 0,001, tempo cirúrgico 4,5 (1,8)h versus 3,6 (1,9)h p = 0,001 e quantidade de cristalóides no intra-operatório 4250 (2500-6000) mL versus 3000 (2000-5000) mL, p = 0,002. Não houve outras diferenças entre os grupos. CONCLUSÕES: Hipercloremia tem alta incidência no final do intra-operatório e esta associada à acidose metabólica, maior tempo cirúrgico, maiores quantidades de fluidos cristaloides e maior mortalidade no pós-operatório.

Palavras-chave

EQUILÍBRIO ÁCIDO BASE, EQUILÍBRIO HIDRO-ELETROLÍTICO, PROGNÓSTICO

Abstract

BACKGROUND AND OBJECTIVES: Hyperchloremia associated with acidosis is associated with worse patient evolution if it is not properly diagnosed and treated. The objective of this study was to determine the intraoperative importance of hyperchloremia. METHODS: This is a 5-month prospective study. Patients 18 years or older undergoing surgical procedures and admitted to the intensive care unit postoperatively. Terminal patients, diabetics, and with chronic renal failure were excluded. Patients were divided in two groups: CH (hyperchloremia) and SH (without hyperchloremia). Hyperchloremia was determined by analysis of the ROC (Receiver Operating Characteristic) curve, i.e., the point of greater sensitivity and specificity for death was chosen as the limit to differentiate hyperchloremia from normochloremia. RESULTS: Three hundred and ninety-three patients participated in the study. Serum levels of chloride were 111.9 ± 6.7 mEq.L-1, pH 7.31 ± 0.09, and base excess -5.6 ± 4.6 mmol.L-1. The area under the ROC curve of chloride levels was 0.76 with a cutting point of 114 mEq.L-1, sensitivity = 85.7%, and specificity = 70.1%. The CH group, with chloride levels of 114 mEq.L-1 or more was formed by 31.7% of the patients. Mortality was higher in the CH group than in SH, 19.3% versus 7.4%, p = 0.001, as well as the incidence f metabolic acidosis, pH 7.27 (0.08) versus 7.32 (0.09), p = 0.001, base excess -7.9 (3.8) mmol.L-1 versus -4.2 (4.6) mmol.L-1, p < 0.001, length of surgery 4.5 (1.8) h versus 3.6 (1.9) h, p = 0.001, and volume of intraoperative crystalloid administration, 4,250 (2,500 - 6,000) mL versus 3,000 (2,000 - 5,000) mL, p = 0.002. Other differences between both groups were not observed. CONCLUSIONS: The incidence of hyperchloremia at the end of surgery is elevated, and it is associated with metabolic acidosis, longer surgeries, greater volumes of crystalloids, and higher postoperative mortality.

Keywords

ACID-BASE BALANCE, HYDROELECTROLYTIC BALANCE, PROGNOSIS

References

Haldane JBS. Experimental and therapeutic alterations of human tissue alkalinity. Lancet. 1924:537-538.

Scheingraber S, Rehm M, Sehmisch C. Rapid saline infusion produces hyperchloremic acidosis in patients undergoing gynecologic surgery. Anesthesiology. 1999;90:1265-1270.

Reid F, Lobo DN, Williams RN. (Ab)normal saline and physiological Hartmann's solution: a randomized double-blind crossover study. Clin Sci (Lond). 2003;104:17-24.

Constable PD. Hyperchloremic acidosis: the classic example of strong ion acidosis. Anesth Analg. 2003;96:919-922.

Greenberg A. Diuretic complications. Am J Med Sci. 2000;319:10-24.

Worthley LIG. Acid-base Balance and Disorders. Oh's Intensive Care Manual. 2003:873-883.

Prough DS, Bidani A. Hyperchloremic metabolic acidosis is a predictable consequence of intraoperative infusion of 0.9% saline. Anesthesiology. 1999;90:1247-1249.

Silva Jr JM, Rezende E, Campos EV. It Is Not Possible To Predict Elevated Arterial Lactate Level Using Measurement of Base Excess in Severe Sepsis Patients at Early Resuscitation Phase. Rev Bras Terap Intens. 2005;17:119-123.

Moreno RP, Metnitz PG, Metnitz B. Modeling in-hospital patient survival during the first 28 days after intensive care unit admission: a prognostic model for clinical trials in general critically ill patients. J Crit Care. 2008;23:339-348.

, . New classification of physical status. Anesthesiology. 1963;24:111.

Wilkes NJ, Woolf R, Mutch M. The effects of balanced versus saline-based hetastarch and crystalloid solutions on acid-base and electrolyte status and gastric mucosal perfusion in elderly surgical patients. Anesth Analg. 2001;93:811-816.

Waters JH, Gottlieb A, Schoenwald P. Normal saline versus lactated Ringer's solution for intraoperative fluid management in patients undergoing abdominal aortic aneurysm repair: an outcome study. Anesth Analg. 2001;93:817-822.

Bullivant EM, Wilcox CS, Welch WJ. Intrarenal vasoconstriction during hyperchloremia: role of thromboxane. Am J Physiol. 1989;256:F152-157.

Gustin P, Detry B, Cao ML. Chloride and inorganic phosphate modulate binding of oxygen to bovine red blood cells. J Appl Physiol. 1994;77:202-208.

Gustin P, Detry B, Robert A. Influence of age and breed on the binding of oxygen to bovine red blood cells in calves. J Appl Physiol. 1997;82:784-790.

Kellum JA, Bellomo R, Kramer DJ. Etiology of metabolic acidosis during saline resuscitation in endotoxemia. Shock. 1998;9:364-368.

Kellum JA, Song M, Venkataraman R. Effects of hyperchloremic acidosis on arterial pressure and circulating inflammatory molecules in experimental sepsis. Chest. 2004;125:243-248.

Kellum JA. Fluid resuscitation and hyperchloremic acidosis in experimental sepsis: improved short-term survival and acid-base balance with Hextend compared with saline. Crit Care Med. 2002;30:300-305.

Skellett S, Mayer A, Durward A. Chasing the base deficit: hyperchloremic acidosis following 0.9% saline fluid resuscitation. Arch Dis Child. 2000;83:514-516.

Brill SA, Stewart TR, Brundage SI. Base deficit does not predict mortality when secondary to hyperchloremic acidosis. Shock. 2002;17:459-462.

5dd67e7d0e8825ca2ec8fca6 rba Articles
Links & Downloads
2352-2291 (Electronic) 0104-0014 (Printed)
Braz J Anesthesiol ©2024 All rights reserved.

Braz J Anesthesiol

Share this page
Page Sections