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Chloride Imbalance

Hypochloremia and hyperchloremia are,respectively, conditions of deficient or excessive serum levels of the anion chloride. A predominantly extra cellular anion, chloride accounts for two-thirds of all serum anions.

Secreted by stomach mucosa as hydrochloric acid, chloride provides an acid medium conducive to digestion and activation of enzymes. It also participates in maintaining acid-base and body water balances, influences the osmolality or tonicity of extracellular fluid, plays a role in the exchange of oxygen and carbon dioxide in red blood cells, and helps activate salivary amylase(which, in turn, activates the digestive process).

Causes

Chloride imbalance can stem from a variety of causes.

Hypochloremia

Insufficient serum chloride levels can result from decreased chloride intake or absorption, as in low dietary sodium intake, sodium deficiency, potassium deficiency, and metabolic alkalosis. Administration of dextrose I. V. without electrolytes can also interfere with chloride absorption.

Excessive chloride loss can result from prolonged diarrhea or diaphoresis as well as loss of hydrochloric acid in gastric secretions from vomiting, gastric suctioning, or gastric surgery.

Hyperchloremia

Excessive chloride intake or absorption - as in hyperingestion of ammonium chloride or ureterointestinal anastomosis- can lead to hyperchloremia by allowing reabsorption of chloride by the bowel.

CLINICAL TIP Excessive chloride intake can also result from administering normal saline solution I.V. or by another route, such as orally or by nasogastric tube, saline enema, or irrigation.

Hemoconcentration from dehydration can also lead to excess serum chloride.

Compensatory mechanisms for other metabolic abnormalities can also cause hyperchloremia. These abnormalities include metabolic acidosis,brain stem injury causing neurogenic hyperventilation, and hyperparathyroidism.

Signs and symptoms

Because of the natural affinity of sodium and chloride ions, chloride imbalance frequently produces signs and symptoms also associated with sodium imbalance. Symptoms include:

• weakness
• headache
• nausea
• cardiac arrest

Diagnosis

A serum chloride level that's less than 98 mEq/L confirms hypochloremia; supportive values with metabolic alkalosis include a serum pH greater than 7.45 and a serum carbon dioxide level greater than 32 mEqIL.

A serum chloride level greater than 108 mEq/L confirms hyperchloremia; with metabolic acidosis, serum pH is less than 7.35 and the serum carbon dioxide level is less than 22 mEqlL.

Treatment

In either kind of chloride imbalance, treatment must correct the underlying disorder.

Hypochloremia

In addtion to correcting the condition that caused excessive chloride loss, treatment can include giving oral replacement such as salty broth. When oral therapy isn't possible or when emergency measures are necessary, treatment may include normal saline solution LV. (if hypovolemia is present); chloride containing drugs, such as ammonium chloride, to increase serum chloride levels; and potassium chloride for metabolic alkalosis.

Hyperchloremia

For severe hyperchloremic acidosis, treatment consists of sodium bicarbonate I.V. to raise serum bicarbonate level and permit renal excretion of the chloride anion because bicarbonate and chloride compete for combination with sodium. For mild hyperchloremia, lactated Ringer's solution is administered; it converts to bicarbonate in the liver, thus increasing base bicarbonate to correct acidosis.