Free On-line Access

SPCI - Sociedade Portuguesa de Cuidados Intensivos

Revista Brasileira de Terapia Intensiva

AMIB - Associação de Medicina Intensiva Brasileira

OFFICIAL JOURNAL OF THE ASSOCIAÇÃO BRASILEIRA DE MEDICINA INTENSIVA AND THE SOCIEDADE PORTUGUESA DE CUIDADOS INTENSIVOS

ISSN: 0103-507X
Online ISSN: 1982-4335

Ícone Fechar

How to Cite


 

Park M, Calabrich A, Maciel AT, Zampieri FG, Taniguchi LU, Souza CE, et al. Caracterização físico-química da acidose metabólica induzida pela expansão volêmica inicial com solução salina a 0,9% em pacientes com sepse grave e choque séptico. Rev Bras Ter Intensiva. 2011;23(2):176-182

 

 

2011;23(2):176-182
Original Article - Clinical Research

http://dx.doi.org/10.1590/S0103-507X2011000200010

Physicochemical characterization of metabolic acidosis induced by normal saline resuscitation of patients with severe sepsis and septic shock

Caracterização físico-química da acidose metabólica induzida pela expansão volêmica inicial com solução salina a 0,9% em pacientes com sepse grave e choque séptico

Marcelo Park, Aknar Calabrich, Alexandre Toledo Maciel, Fernando Godinho Zampieri, Leandro Utino Taniguchi, Ciro Eduardo de Souza, Carlos Eduardo Barboza, Antonio Paulo Nassar Junior, Luciano César Pontes Azevedo

IIntensive Care Unit, Emergency Department, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - USP - São Paulo (SP), Brazil

Conflicts of interest: None.

Submitted on April 18, 2011
Accepted on June 10, 2011

Corresponding author:

Marcelo Park
Rua Francisco Preto, 46
Zip Code: 05623-010 - São Paulo (SP), Brazil.
Phone: 55 (11) 3069-6457
E-mail: mpark@uol.com.br

 

Abstract

OBJECTIVE: The aim of this study was to characterize and quantify metabolic acidosis that was caused by initial volume expansion during the reanimation of patients with severe sepsis and septic shock.
METHODS: A blood sample was drawn for physicochemical characterization of the patient's acid-base equilibrium both before and after volume expansion using 30 mL/kg 0.9% saline solution. The diagnosis and quantification of metabolic acidosis were based on the standard base excess (SBE).
RESULTS: Eight patients with a mean age of 58 ± 13 years and mean APACHE II scores of 20 ± 4 were expanded using 2,000 ± 370 mL of 0.9% saline solution. Blood pH dropped from 7.404 ± 0.080 to 7.367 ± 0.086 (p=0.018), and PCO 2 increased from 30 ± 5 to 32 ± 2 mmHg (p=0.215); SBE dropped from -4.4 ± 5.6 to -6.0 ± 5.7 mEq/L (p=0.039). The drop in SBE was associated with the acidifying power of two factors, namely, a significant increase in the strong ion gap (SIG) from 6.1 ± 3.4 to 7.7 ± 4.0 mEq/L (p = 0.134) and a non-significant drop in the apparent inorganic strong ion differences (SIDai) from 40 ± 5 to 38 ± 4 mEq/L (p = 0.318). Conversely, the serum albumin levels decreased from 3.1 ± 1.0 to 2.6 ± 0.8 mEq/L (p = 0.003) with an alkalinizing effect on SBE. Increased serum chloride levels from 103 ± 10 to 106 ± 7 mEq/L (p < 0.001) led to a drop in SIDai.
CONCLUSION: Initial resuscitation using 30 mL/kg of 0.9% saline solution for patients with severe sepsis and septic shock is associated with worsened metabolic acidosis, as measured by SBE. This worsened SBE can be ascribed to a serum increase in the levels of unmeasurable anions and chloride.

Keywords: Ketosis; Intensive care units; Sepsis; Shock, septic/ therapy; Acid-base equilibrium; Saline solution, hypertonic/ therapeutic use

 

 

INTRODUCTION

In Brazil, approximately 26% of patients who are admitted to the intensive care unit (ICU) are diagnosed with sepsis or severe sepsis.(1) Antibiotics and volume expansion are often the first-line therapies for these patients.(2) Crystalloids, particularly 0.9% saline solution (normal saline), are commonly used for volume expansion.(3) Although 0.9% saline solution is considered to be a "physiological solution", infusing large volumes can cause metabolic disorders, particularly hyperchloremia-associated acidosis.(4-6)

The actual implications of metabolic acidosis in patients with severe sepsis and septic shock is currently uncertain;(7) however, metabolic acidosis and hyperchloremia at admission and unimproved metabolic acidosis that are associated with lactate and unmeasurable anions within 5 days of admission are related to an increased mortality rate.(8) Overall, in septic patients, improving metabolic acidosis as measured by standard base excess (SBE) is associated with less severe organ dysfunction(9) and a decreased risk of death.(10)

Acid-base equilibrium can be analyzed using various approaches with slightly different points of view showing the very same changes.(11) The physicochemical technique provides a quantification of the influence of both organic and non-organic components on pH.(12) In this method, strong ions (e.g., sodium, potassium, magnesium, calcium and chloride), unmeasurable anions, lactate, albumin and phosphates act to regulate metabolic pH control,(9,12) where as the partial pressure of carbon dioxide modulates respiratory pH control.(12)

Therefore, considering the widespread use of volume expansion with 30 mL/kg normal saline solution in patients with severe sepsis and septic shock,(2) we hypothesized that significant metabolic acidosis occurs after infusion of normal saline. Accordingly, the aim of this study was to perform a physicochemical characterization and quantification of metabolic acidosis caused by initial volume expansion in patients with severe sepsis and septic shock.

 

METHODS

This study was approved by the Ethics Committee of the Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, and all of the patients provided signed and informed consent. The study was conducted at the emergency department of the Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. The patients were sequentially selected according to the criteria of the Sepsis, Severe Sepsis and Septic Shock Consensus Conference.(13) Therefore, patients who presented at the emergency department with two out of four diagnostic features, as defined by the American College of Chest Physicians consensus, together with one out of two organ dysfunction criteria (lactate > 2 mEq/L or systolic blood pressure < 90 mmHg), were admitted to the study. The following exclusion criteria were applied: 1) pregnant women; 2) patients younger than 18 years; and 3) patients with severe hypotension requiring the immediate use of vasopressor drugs.

Brief medical histories and physical examinations (including body weights) were obtained. All of the patients who met the criteria for sepsis underwent a peripheral venous puncture for blood culture, blood chemistry, blood counts and coagulogram and an arterial puncture for measuring blood gas with lactate. In addition, a urine sample was obtained for urinalysis and culture, a chest radiograph was taken, and other cultures were performed as necessary. Via the venous puncture and at the emergency department physician's discretion, the patients were given their first antibiotic dose within one hour of the sepsis diagnosis. Patients with systolic blood pressure that was lower than 90 mmHg underwent immediate volume expansion with 30 mL/kg 0.9% saline solution within 30 minutes. For non-hypotensive patients, the venous puncture was maintained with normal saline for volume expansion (similar to the above-described method) at a later time if their plasma lactate levels exceeded 2 mEq/L. Within 10 minutes of the completion of the volume expansion procedure, a fresh arterial blood sample was drawn for blood gas and blood chemistry analysis.

Physicochemical analysis

We used the following standard equations to calculate the following physicochemical parameters:(12,14,15)

1. Standard base excess (SBE van Slyke equation; mEq/L) = 0.9287 × (HCO3- (mEq/L) - 24.4 + 14.83 × [pH - 7.4])

2. Strong ion difference apparent inorganic (SIDai; mEq/L) = Na+ (mEq/L) + K+ (mEq/L) + Ca2+ (mEq/L) + Mg2+ (mEq/L) − Cl (mEq/L)

3. Effective strong ion difference (SIDe; mEq/L) = 2.46 x 10-8 x PCO2 (mmHg) / 10-pH + (albumin (g/dL)) x (0.123 x pH - 0.631) + (phosphate (mg/dL) / 3 x pH - 0.469)

4. Strong ion gap (SIG; mEq/L) = SIDai - SIDe - lactate

5. Ionic albumin (mEq/L) = 10 x albumin (g/dL) x (0.123 x pH - 0.631)

6. Ionic phosphorus (Pi) (mEq/L) = (PO4 (mg/dL) x 10 / 30.97) x (0.309 x pH - 0.469)

Through the physicochemical interpretation of the metabolic component of acid-base equilibrium, changes in SBE can be explained by changes in lactate, SIG, SIDai, SIG, albumin and phosphate levels.(8,9,16-18) Based on this premise, any change in SBE between the two measurements can be explained by changes in these components; therefore, the SBE change that is ascribable to lactate, SIG, SIDai, albumin and phosphate is the difference between these ionic forms at the two evaluation times. The magnitude of the difference is related to the influence of each variable in relation to the final SBE.(16,19) Thus:

1. SBE ascribable to lactate = initial - normal lactate

2. SBE ascribable to SIG = initial - normal SIG

3. SBE ascribable to SIDai = initial - normal SIDai

4. SBE ascribable to albumin = initial - normal ionic albumin

5. SBE ascribable to phosphate = initial - normal ionic phosphorus

with all of the units in mEq/L.

Statistical analysis

The number of patients that were needed to find a significant decrease in SBE of at least 4 mEq/L between the measurements was based on a mean admission SBE of 8 mEq/L with a 3.5 mEq/L standard deviation.(8) Based on an alpha of 5% and a power of 80%, a sample size of 8 patients was required. A normal distribution was confirmed with the Shapiro-Silk test, and the data are presented as means ± standard deviation. The categorical data are presented as occurrences and percentages. The analysis of the variation between the measured values was performed with the paired Student's t-test. The equality of the variance was confirmed by the Levene test.(20) The software SPSS 17.0 for Windows (Chicago, Illinois, USA) was used for the calculations.

 

RESULTS

Eight patients were studied, and their clinical characteristics, required support and outcomes are shown in table 1. With regard to comorbidity, only one of the patients had systemic arterial hypertension, and the remaining 7 patients were healthy. At admission, the hemoglobin level was 12 ± 2 g/dL, and the white blood cell count was 15,590 ± 6,600 cells/mL. The patients were given a mean volume of 2,000 ± 370 mL of 0.9% saline solution over 30 minutes, as had been predetermined based on their weights.

Table 2 shows the pre- and post-volume expansion vital signs, blood chemistry, blood gas and physicochemical data. Given the pH drop and SBE drop in association with a non-significant increase in PCO2 (Table 2 and Figure 1-A) together with changes in several electrolyte and serum albumin levels, figure 1-B was generated to show the mEq/L variation of several SBE components. The influence of each SBE component is illustrated more clearly in figure 2-A in which several components are presented separately (for each determinant, the bar shows the mean SBE that is ascribable to that component). Finally, as the SIDai was highly relevant to pre- and post-volume expansion SBE, Figure 2-B shows the variation of the individual SIDai components.

 

DISCUSSION

In this study, a drop in pH was observed in association with an increased PCO2 and a drop in SBE following normal saline administration (Figure 1-A). This drop in SBE was ascribed to the acidifying power of the SIDai drop and SIG increase, which were counteracted by the alkalinizing effect of the drop in albumin (Figures 1-B and 2-A). Despite the numerical changes in the parameters, only SBE and albumin differed significantly (Table 2). With regard to the non-significant SIDai drop, several electrolyte levels were significantly different between the two assessment times (Table 2); however, as shown in figure 2-B, this variation was primarily due to significant increases in chloride, sodium and calcium with only slight changes in potassium and magnesium (Table 2).

A drop in pH during the course of severe sepsis and septic shock is common in patients.(7,8) Within days, an increase in arterial PCO2 often occurs.(8) In our patient sample, PCO2 was increased by about 2 mmHg during initial resuscitation (within 30 minutes) despite a stable respiratory rate (Table 2). This finding can be explained, at least in part, by a reduction in anxiety, improved blood pressure (which was significantly increased between the two assessment times; see Table 2) and improved systemic perfusion (which may have optimized the removal of CO2 from the tissues and, thereby, increased its partial blood pressure).

As measured by SBE, metabolic acidosis worsened significantly; however, as shown in figure 2-A, this drop in SBE could be ascribed to a combination of the SIDai acidifying component and SIG, which were counteracted by the alkalinizing effect of the drop in albumin levels. This drop in SIDai components is classically described as being produced by an increase in serum chloride as a result of volume expansion.(4-6) However, in endotoxemic rats, volume expansion explains only 30% of the increase in serum chloride levels, and the remaining increase is probably the result of a compartmental shift from intracellular into extracellular and extravascular into intravascular.(21) The lower change in sodium levels may be due to its large volume of distribution and concentration.(22) Interestingly, in our patients, we noted an increase in ionic calcium levels that may be explained by the drop in both serum albumin concentration and pH, which would promote a reduction in albumin's affinity for calcium. With regard to ionic calcium, despite its significant change between the two assessment times, this change had little influence on SBE (Figure 2-B).

The increase in unmeasurable anions that was measured with SIG apparently also contributed to the drop in SBE. This finding is difficult to explain but is consistent with the findings of Marques et al.(23) in which a chloride reduction from 111 to 107 mEq/L in the dialysis fluid of chronic renal patients was associated with improved SBE because of reduced SIG with no change in SIDai. The authors hypothesized that this finding was due to a compartmental redistribution of chloride and unmeasurable anions, thus causing a Gibbs-Donnan effect, in which weak acids that are composed of macromolecules drive inter-molecular repulsion and prevent their passage through biological membranes.

Another interesting finding in our study was the drop in albumin levels after the initial resuscitation. In previous case studies of critically ill patients in general and in septic patients in particular, albumin levels changed little in the days following the initial resuscitation.(7,8,17) Considering the brief interval between our measurement, the most important factor in generating hypoalbuminemia was likely dilution, although hypoalbuminemia in septic patients has other recognized causes, including a possible imbalance between liver albumin synthesis and loss into the interstitial space due to increased capillary permeability,(24) particularly during the acute phase of sepsis,(25) in association with reduced lymphatic albumin clearance.

Metabolic acidosis in association with hyperchloremia is common in critically ill patients and is associated with poorer prognosis in critically ill patients in general(26) and in septic patients in particular.(8) Recently, an interesting notion was proposed in which hyperchloremic acidosis renders the kidneys at least partially incapable of eliminating SIDai (i.e., chloride).(27)

Our findings should be interpreted as an explanation of the acid-base changes that follow volume resuscitation. This finding adds no negative ideas related to volume expansion or related to the use of 0.9% saline solution; these results merely concern how the changes should be interpreted and, in the future, how the organ dysfunction responsible for these changes should be addressed.

There were some limitations to this study, including 1) a lack of a control group, 2) a lack of long-term follow-up and 3) a relatively small sample size. However, our primary focus was the physicochemical characterization of volume expansion using normal saline in septic patients, and this goal was met with this study.

 

CONCLUSIONS

The initial resuscitation of patients with severe sepsis and septic shock using 30 mL/kg 0.9% saline solution is associated with worsened metabolic acidosis, as assessed with SBE. This worsened SBE is physicochemically complex and may be ascribed to an increase in the levels of unmeasurable anions and chloride with the latter being responsible for the drop in SIDai. The rapid decrease in serum albumin concentration apparently mitigates the acidifying effects of expansion with normal saline.

 

REFERÊNCIAS

1. Silva E, Pedro Mde A, Sogayar AC, Mohovic T, Silva CL, Janiszewski M, Cal RG, de Sousa EF, Abe TP, de Andrade J, de Matos JD, Rezende E, Assunção M, Avezum A, Rocha PC, de Matos GF, Bento AM, Corrêa AD, Vieira PC, Knobel E; Brazilian Sepsis Epidemiological Study. Brazilian Sepsis Epidemiological Study (BASES study). Crit Care. 2004;8(4):R251-60.

2. Levy MM, Dellinger RP, Townsend SR, Linde-Zwirble WT, Marshall JC, Bion J, et al. The Surviving Sepsis Campaign: results of an international guideline-based performance improvement program targeting severe sepsis. Intensive Care Med. 2010;36(2):222-31.

3. Finfer S, Liu B, Taylor C, Bellomo R, Billot L, Cook D, Du B, McArthur C, Myburgh J; SAFE TRIPS Investigators. Resuscitation fluid use in critically ill adults: an international cross-sectional study in 391 intensive care units. Crit Care. 2010;14(5):R185.

4. Waters JH, Gottlieb A, Schoenwald P, Popovich MJ, Sprung J, Nelson DR. 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(4):817-22.

5. Todd SR, Malinoski D, Muller PJ, Schreiber MA. Lactated Ringer's is superior to normal saline in the resuscitation of uncontrolled hemorrhagic shock. J Trauma. 2007;62(3):636-9.

6. Reid F, Lobo DN, Williams RN, Rowlands BJ, Allison SP. (Ab)normal saline and physiological Hartmann's solution: a randomized double-blind crossover study. Clin Sci (Lond). 2003;104(1):17-24.

7. Maciel AT, Noritomi DT, Park M. Metabolic acidosis in sepsis. Endocr Metab Immune Disord Drug Targets. 2010;10(3):252-7. Review.

8. Noritomi DT, Soriano FG, Kellum JA, Cappi SB, Biselli PJ, Libório AB, Park M. Metabolic acidosis in patients with severe sepsis and septic shock: a longitudinal quantitative study. Crit Care Med. 2009;37(10):2733-9.

9. Park M, Taniguchi LU, Noritomi DT, Libório AB, Maciel AT, Cruz-Neto LM. Clinical utility of standard base excess in the diagnosis and interpretation of metabolic acidosis in critically ill patients. Braz J Med Biol Res. 2008;41(3):241-9. Erratum in Braz J Med Biol Res. 2011;44(3):267. Braga, AL [corrected to Libório, AB] .

10. Park M, Azevedo LC, Maciel AT, Pizzo VR, Noritomi DT, da Cruz Neto LM. Evolutive standard base excess and serum lactate level in severe sepsis and septic shock patients resuscitated with early goal-directed therapy: still outcome markers? Clinics (Sao Paulo). 2006;61(1):47-52.

11. Kellum JA. Clinical review: reunification of acid-base physiology. Crit Care. 2005;9(5):500-7.

12. Stewart PA. Modern quantitative acid-base chemistry. Can J Physiol Pharmacol .1983;61(12):1444-61.

13. Bone RC, Sibbald WJ, Sprung CL. The ACCP-SCCM consensus conference on sepsis and organ failure. Chest. 1992;101(6):1481-3.

14. Siggaard-Andersen O. The van Slyke equation. Scand J Clin Lab Invest Suppl. 1977;146:15-20.

15. Kellum JA, Kramer DJ, Pinsky MR. Strong ion gap: a methodology for exploring unexplained anions. J Crit Care. 1995;10(2):51-5.

16. Park M, Maciel AT, Noritomi DT, Pontes de Azevedo LC, Taniguchi LU, da Cruz Neto LM. Effect of PaCO2 variation on standard base excess value in critically ill patients. J Crit Care. 2009;24(4):484-91.

17. Maciel AT, Park M. Differences in acid-base behavior between intensive care unit survivors and nonsurvivors using both a physicochemical and a standard base excess approach: a prospective, observational study. J Crit Care. 2009;24(4):477-83.

18. Nagaoka D, Nassar Junior AP, Maciel AT, Taniguchi LU, Noritomi DT, Azevedo LC, et al. The use of sodium-chloride difference and chloride-sodium ratio as strong ion difference surrogates in the evaluation of metabolic acidosis in critically ill patients. J Crit Care; 2010;25(3):525-31.

19. Gilfix BM, Bique M, Magder S. A physical chemical approach to the analysis of acid-base balance in the clinical setting. J Crit Care. 1993;8(4):187-97.

20. Whitley E, Ball J. Statistics review 5: Comparison of means. Crit Care. 2002;6(5):424-8.

21. Kellum JA, Bellomo R, Kramer DJ, Pinsky MR. Etiology of metabolic acidosis during saline resuscitation in endotoxemia. Shock. 1998;9(5):364-8.

22. 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(2):300-5.

23. Marques FO, Libório AB, Daher EF. Effect of chloride dialysate concentration on metabolic acidosis in maintenance hemodialysis patients. Braz J Med Biol Res. 2010;43(10):996-1000.

24. Fleck A, Raines G, Hawker F, Trotter J, Wallace PI, Ledingham IM, Calman KC. Increased vascular permeability: a major cause of hypoalbuminaemia in disease and injury. Lancet. 1985;1(8432):781-4.

25. Ruot B, Papet I, Bechereau F, Denis P, Buffiere C, Gimonet J, et al. Increased albumin plasma efflux contributes to hypoalbuminemia only during early phase of sepsis in rats. Am J Physiol Regul Integr Comp Physiol. 2003;284(3):R707-13.

26. Boniatti MM, Cardoso PR, Castilho RK, Vieira SR. Is hyperchloremia associated with mortality in critically ill patients? A prospective cohort study. J Crit Care. 2011;26(2):175-9.

27. Masevicius FD, Tuhay G, Pein MC, Ventrice E, Dubin A. Alterations in urinary strong ion difference in critically ill patients with metabolic acidosis: a prospective observational study. Crit Care Resusc. 2010;12(4):248-54.

 

 

This study was conducted at the Emergency Department - Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - USP - São Paulo (SP), Brazil.

 

 

Submission On-line

Indexed in

Scopus

SciELO

LILACS

Associação de Medicina Intensiva Brasileira - AMIB

Rua Arminda nº 93 - 7º andar - Vila Olímpia - São Paulo, SP, Brasil - Tel./Fax: (55 11) 5089-2642 | e-mail: rbti.artigos@amib.org.br

GN1 - Systems and Publications