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Hyperchloremia After Noncardiac Surgery Is Independently Associated with Increased Morbidity and Mortality: A Propensity-Matched Cohort Study

McCluskey, Stuart A. PhD, MD*; Karkouti, Keyvan MSc, MD*†; Wijeysundera, Duminda PhD, MD*; Minkovich, Leonid PhD, MD*; Tait, Gordon PhD*; Beattie, W. Scott PhD, MD*

doi: 10.1213/ANE.0b013e318293d81e
Patient Safety: Research Report

BACKGROUND: The use of normal saline is associated with hyperchloremic metabolic acidosis. In this study, we sought to determine the incidence of acute postoperative hyperchloremia (serum chloride >110 mEq/L) and whether this electrolyte disturbance is associated with an increase in length of hospital stay, morbidity, or 30-day postoperative mortality.

METHODS: Data were retrospectively collected on consecutive adult patients (>18 years of age) who underwent inpatient, noncardiac, nontransplant surgery between January 1, 2003 and December 31, 2008. The impact of postoperative hyperchloremia on patient morbidity and length of hospital stay was examined using propensity-matched and logistic multivariable analysis.

RESULTS: The dataset consisted of 22,851 surgical patients with normal preoperative serum chloride concentration and renal function. Acute postoperative hyperchloremia (serum chloride >110 mmol/L) is quite common, with an incidence of 22%. Patients were propensity-matched based on their likelihood to develop acute postoperative hyperchloremia. Of the 4955 patients with hyperchloremia after surgery, 4266 (85%) patients were matched to patients who had normal serum chloride levels after surgery. These 2 groups were well balanced with respect to all variables collected. The hyperchloremic group was at increased risk of mortality at 30 days postoperatively (3.0% vs 1.9%; odds ratio = 1.58; 95% confidence interval, 1.25–1.98) (relative risk 1.6 or risk increase of 1.1%) and had a longer hospital stay (7.0 days [interquartile range 4.1–12.3] compared with 6.3 [interquartile range 4.0–11.3]) than patients with normal postoperative serum chloride levels. Patients with postoperative hyperchloremia were more likely to have postoperative renal dysfunction. Using all preoperative variables and measured outcome variables in a logistic regression analysis, hyperchloremia remained an independent predictor of 30-day mortality with an odds ratio of 2.05 (95% confidence interval, 1.62–2.59).

CONCLUSION: This retrospective cohort trial demonstrates an association between hyperchloremia and poor postoperative outcome. Additional studies are required to demonstrate a causal relationship between these variables.

Published ahead of print June 11, 2013.

From the *Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network; and Department of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.

Accepted for publication March 6, 2013.

Published ahead of print June 11, 2013.

Funding: This work was support by the Department of Anesthesia and Pain Management Research and Innovative Funds. This fund has received donations from Abbott Canada (Saint Laurent, Quebec, Canada), Bristol-Myers Squibb Canada (Toronto, Ontario), Bayer Inc. (Toronto, Ontario, Canada), Fresenius Kabi (Richmond Hill, Ontario, Canada), and General Electric Healthcare (Mississauga, Ontario, Canada). None of these companies have participated in any aspect of the report. Dr. Beattie is supported by the R. Fraser Elliot Chair in Cardiac research and a Merit Award from the Department of Anesthesia, University of Toronto. Dr. Karkouti and Wijeysundera also received funding from the Merit Awards from the Department of Anesthesia, University of Toronto.

The authors declare no conflict of interest.

This report was previously presented, in part, at the Canadian Anesthesiologist Society Meeting, June 2010.

Reprints will not be available from the authors.

Address correspondence to Stuart A. McCluskey, PhD, MD, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, 200 Elizabeth St., EN 3-405, Toronto, Ontario M5G 2C4, Canada. Address e-mail to

© 2013 International Anesthesia Research Society