Episode 127: Chloride content effect on patient outcomes, treatment for severe, complicated c diff, and medication identification

In this episode I’ll:

1. Discuss an article about the effect of chloride content during fluid resuscitation.

2. Answer the drug information question “What therapy is recommended for severe, complicated C. diff. infection?”

3. Share a resource for identifying medications.

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Article

Chloride Content of Fluids Used for Large-Volume Resuscitation Is Associated With Reduced Survival

Lead author: Ayan Sen

Published in Critical Care Medicine September 2016

Background

Hyperchloremic acidosis from volume resuscitation with crystalloid IV fluids and its consequences are receiving a lot of attention. The authors of this study sought to determine if the chloride content of IV fluids used in resuscitation was associated with short or long-term outcomes.

Methods

This study was a retrospective review of 4710 patients over an eight-year period at a university medical center. Patients were included if they received at least 60 mL/kg of fluid resuscitation over a 24 hour period. The authors compared the development of hyperchloremic acidosis, acute kidney injury, and survival among those with higher and lower chloride loads.

Results

Hyperchloremic acidosis occurred in 11% of patients. There was a significant increase in the unadjusted rates of hyperchloremic acidosis, acute kidney injury, and hospital mortality as chloride load increased. These findings did not hold up after adjustment. However, each 100 mEq increase in chloride load was associated with a 5.5% increase in the hazard of death.

Conclusion

The authors concluded:

Chloride load is associated with significant adverse effects on survival out to 1 year even after controlling for total fluid load, age, and baseline severity of illness. However, the relationship between chloride load and development of hyperchloremic acidosis or acute kidney injury is less clear, and further research is needed to elucidate the mechanisms underlying the adverse effects of chloride load on survival.

 

Discussion

Chloride load is an emerging and important area of research within critical care. I will be watching this area closely for future studies!

Drug information question

Q: What therapy is recommended for severe, complicated C. diff. infection?

A: According to the IDSA guidelines: IV metronidazole, plus enteral and rectal vancomycin is recommended.

The strength of the evidence for these recommendations, however, is “C-III” which represents expert opinion based on poor quality evidence.

Resource

My hospital recently let our Micromedex subscription expire. Since then I’ve been looking for a good resource to identify medications. The Merck Manual appears to be a good replacement. You can search by imprint, size, and shape. Alternatively, if you have an idea what the medication is you can search by generic name. Prescription and over-the-counter medications appear to come up in search results according to my tests.

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If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.

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