Clinical physiology aspects of chloremia in fluid therapy: a systematic review

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Clinical physiology aspects of chloremia in fluid therapy: a systematic review David Astapenko1,2* , Pavel Navratil2,3, Jiri Pouska4,5 and Vladimir Cerny1,2,6,7,8,9

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

Background This systematic review aims to summarize the state-ofthe-art knowledge about the role of chloride and chloremia in the context of infusion therapy with special emphasis on the population of patients receiving intensive and perioperative care. Infusion therapy involving the administration of ionor glucose-containing solutions (crystalloid solutions) is one of the most widely used procedures in clinical * Correspondence: [email protected] 1 Department of Anesthesiology, Resuscitation and Intensive Care Medicine, University Hospital Hradec Kralove, Sokolská 581, 500 05 Hradec Kralove, Czech Republic 2 Faculty of Medicine in Hradec Kralove, Charles University, Prague, Czech Republic Full list of author information is available at the end of the article

medicine; in the field of anesthesiology and intensive care medicine, crystalloid solution administration is almost a universal strategy in all patients. While having been employed in medicine for almost 190 years, no studies focused largely on their safety were published before 1999. In international and intercontinental comparisons, the choice of crystalloid solutions in clinical practice is highly variable. Apart from thei