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CRITICAL CARE AND TRAUMA

Hyperchloremic Acidosis in the Critically Ill: One of the Strong-Ion Acidoses?

David A. Story, MD, FANZCA^*, Hiroshi Morimatsu, MD, and Rinaldo Bellomo, MD, FJFICM

From the Departments of *Anaesthesia and Intensive Care, Austin Health, and Department of Surgery, University of Melbourne, Austin Health, Heidelberg, Victoria, Australia.

Address correspondence and reprint requests to David A. Story, MD, Department of Anaesthesia, Austin Hospital, Studley Rd, Heidelberg, Victoria, 3084, Australia. Address e-mail to David.Story{at}austin.org.au.

Decreases in plasma bicarbonate are associated with hyperchloremic acidosis and lactic acidosis. According to the Stewart approach to acid-base physiology, the strong-ion difference regulates plasma bicarbonate, with chloride and lactate being the only strong anions routinely measured in clinical chemistry. We hypothesized that the plasma strong-ion difference, both with and without lactate, would have a stronger association with plasma bicarbonate than plasma chloride alone would have with bicarbonate. We used plasma acid-base data from 300 critically ill patients. The correlation with bicarbonate became progressively weaker (P < 0.001): all measured strong ions, r = 0.60; measured strong ions without lactate, r = 0.42; chloride alone, r = –0.27. In a subgroup of 26 patients with traditional hyperchloremic acidosis (base excess < –2mmol/L and anion gap <17 mmol/L), the measured strong-ion difference (without lactate) had a stronger correlation (P < 0.001) with bicarbonate than chloride had: r = 0.85 versus r = –0.60. We conclude that hyperchloremic acidosis and lactic acidosis are strong-ion acidoses. Hyperchloremia should be viewed relative to the plasma strong cations. A practical conclusion is that both managing and preventing acid-base disorders with IV fluid therapy involves manipulating each of the plasma strong ions, particularly sodium and chloride.

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