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

Abstract

Purpose: Inorganic apparent strong ion difference (SIDai) improves chloride-associated acidosis recognition in dysnatremic patients. We investigated whether the difference between sodium and chloride (Na(+)-Cl(-)) or the ratio between chloride and sodium (Cl(-)/Na(+)) could be used as SIDai surrogates in mixed and dysnatremic patients.

Patients and methods: Two arterial blood samples were collected from 128 patients. Physicochemical analytical approach was used. Correlation, agreement, accuracy, sensitivity, and specificity were measured to examine whether Na(+)-Cl(-) and Cl(-)/Na(+) could be used instead of SIDai in the diagnosis of acidosis.

Results: Na(+)-Cl(-) and Cl(-)/Na(+) were well correlated with SIDai (R = 0.987, P < 0.001 and R = 0.959, P < 0.001, respectively). Bias between Na(+)-Cl(-) and SIDai was high (6.384 with a limit of agreement of 4.463-8.305 mEq/L). Accuracy values for the identification of SIDai acidosis (<38.9 mEq/L) were 0.989 (95% confidence interval [CI], 0.980-0.998) for Na(+)-Cl(-) and 0.974 (95% CI, 0.959-0.989) for Cl(-)/Na(+). Receiver operator characteristic curve showed that values revealing SIDai acidosis were less than 32.5 mEq/L for Na(+)-Cl(-) and more than 0.764 for Cl(-)/Na(+) with sensitivities of 94.0% and 92.0% and specificities of 97.0% and 90.0%, respectively. Na(+)-Cl(-) was a reliable SIDai surrogate in dysnatremic patients.

Conclusions: Na(+)-Cl(-) and Cl(-)/Na(+) are good tools to disclose SIDai acidosis. In patients with dysnatremia, Na(+)-Cl(-) is an accurate tool to diagnose SIDai acidosis.