Effect of Chloride in Determining Fluid Responsiveness Using Stewart Approach

INTRODUCTION: Fluid responsiveness is crucial concept in management of critically ill patients. Studies have shown that dyschloremia, serum chloride levels not within the limits of normal, has major impact on clinical outcomes in critical illnesses. OBJECTIVES: To assess the influence of Chloride guided fluid resuscitation on acidbase homeostasis in critically ill patients, by using Stewart approach. MATERIALS AND METHODS: The study was conducted in ICU of Fortis Escorts Heart Institute, Okhla, Delhi. All Adult patients admitted in ICU, were assessed within 24 hours for fluid responsiveness and thereby fluid resuscitation was done using Stewart approach of ABG, based on chloride level in ABG. Normal chloride level in ABG was considered in the range of 97–107 mmol/L. Values less than range indicated Metabolic alkalosis and values higher than 107 mmol/L indicated non anion gap metabolic acidosis by Stewart Approach. Fluid responsiveness will also be confirmed with the dynamic measures of ultrasound. Exclusion criteria are–: 1. Acetazolamide use. 2. Addisons disease. 3. Renal tubular Acidosis. 4. Illiostomies, fistulae. 5. Ureteral diversion. 6. Pancreaticoduodenal fistula. RESULTS: We found significant correlation between Chloride levels in ABG and fluid responsiveness of all critically ill patients admitted in ICU within 24 hours. DISCUSSIONS/CONCLUSIONS: Chloride is the major strong anion in blood, accounting for approximately one-third of plasma tonicity, for 97 to 98% of all strong anionic charges and for two-thirds of all negative charges in plasma.(1) over the years, chloride has become the forgotten ion. With progress in our understanding of acid-base and chloride channel physiology, the chloride ion is regaining its prominence.(2) Within the Stewart approach, chloride is the dominant negative strong ion in plasma and a key contributor to the strong ion difference (SID), one of three independent variables that determine the hydrogen ion concentration. Hyperchloraemia is quite commonly encountered in intensive care unit (ICU) patients(3) and plays an important role in the pathogenesis of metabolic acidosis. Data from various observational investigation demonstrate that temporary hyperchloremia may even occur in 75% of ICU patients during the first 24 h of ICU stay. However, despite a rather high prevalence in critically ill patients, few outcome-related data regarding systemic chloride levels exist. This study aims to provide an overview on chloride physiology and to reflect chloride guided fluid resuscitation for better outcome of critically ill patients.