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Balancing Chloride and Glucose in Critical Illness: A 10 Year Study on Diluent Strategies and ICU Outcomes
Payam Rahimi1, Furkan Tontu2, Batoul Khoundabi3
1Bakırköy Dr. Sadi Konuk Training and Research Hospital, 34147 Istanbul, Turkey.
Insights
Replacing saline with dextrose for medication dilution in intensive care units (ICUs) reduced patient mortality and improved acid-base balance. This chloride-sparing strategy requires careful glucose monitoring in critically ill patients.
Area of Science:
- Critical Care Medicine
- Clinical Chemistry
- Fluid and Electrolyte Management
Background:
- High-chloride intravenous fluids, like 0.9% saline, are common in ICUs and can cause hyperchloremia and metabolic acidosis.
- Excess chloride negatively impacts the strong ion difference (SID), potentially worsening patient outcomes.
- This study investigates the clinical impact of switching from saline to dextrose as a diluent in ICUs.
Purpose of the Study:
- To evaluate the effect of a chloride-sparing diluent strategy (5% dextrose) versus a saline-based strategy on ICU outcomes.
- To assess changes in acid-base balance, mortality, and other clinical parameters after the diluent strategy change.
Main Methods:
- Retrospective cohort study of 4347 adult ICU patients requiring mechanical ventilation for ≥12 hours.
- Comparison of outcomes between a saline-based diluent period (2015-2018) and a chloride-sparing dextrose-based period (2019-2025).
- Analysis included demographics, comorbidities, illness severity scores (APACHE II, SOFA), fluid exposure, SID, and laboratory values within 48 hours; multivariate logistic regression identified mortality predictors.
Main Results:
- Mortality decreased from 44.6% to 39.2% (absolute 5.4% reduction, p=0.003) after adopting chloride-sparing diluents, with similar renal function.
- The dextrose group showed higher SID (39 vs. 38 mmol/L), lower chloride, and improved acid-base profiles.
- Chloride levels were strongly associated with mortality in the saline era (12-13% increased odds/mmol/L), attenuated in the dextrose era (2%/mmol/L); SID improved as a marker of acid-base balance.
Conclusions:
- Transitioning to chloride-sparing diluents in ICUs is linked to reduced mortality and better acid-base status without compromising renal function.
- Increased glucose levels necessitate vigilant glycemic monitoring when using dextrose-based diluents.
- The findings support the adoption of chloride-sparing strategies with careful glycemic control in critical care settings.
Abstract:
Background: High-chloride solutions such as 0.9% saline are widely used for medication dilution in intensive care units (ICUs) and are an underrecognized source of hyperchloremia and acid-base disturbances. Excess chloride reduces the strong ion difference (SID), contributing to hyperchloremic metabolic acidosis and worse clinical outcomes. This study evaluated the impact of replacing isotonic saline with 5% dextrose as a diluent on ICU outcomes in mechanically ventilated patients. Methods: In this retrospective cohort study, 4347 adult ICU patients requiring ≥12 h of mechanical ventilation were analyzed across two periods with different diluent strategies (2015-2018: saline-based; 2019-2025: chloride-sparing, dextrose-based). Demographics, comorbidities, illness severity (APACHE II, SOFA), fluid exposure, SID, and laboratory values over the first 48 h were compared. Predictors of mortality were identified using multivariate logistic regression. Results: Mortality decreased from 44.6% to 39.2% after adoption of chloride-sparing diluents (absolute reduction 5.4%, p = 0.003), despite similar renal function across periods. The later cohort demonstrated significantly higher SID (median 39 vs. 38 mmol/L; p < 0.001), lower chloride levels, and more favorable acid-base profiles. In 2015-2018, chloride showed a strong association with mortality (~12-13% increased odds per mmol/L), while in 2019-2025 the association persisted but was attenuated (~2% per mmol/L). SID emerged as a significant marker of improved acid-base balance after the diluent transition. pH remained the most powerful predictor of mortality in both periods. Mean glucose levels increased by ~30-40 mg/dL after switching to dextrose diluents, although insulin requirements did not change. Conclusions: Transitioning from chloride-rich to chloride-sparing diluents was associated with reduced ICU mortality and improved acid-base balance, without changes in renal function. However, modestly increased glucose levels highlight the need for strict glycemic monitoring. These findings support chloride-sparing strategies with robust glycemic monitoring in critical care.
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