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Year : 2020  |  Volume : 7  |  Issue : 2  |  Page : 95-96

Chloride in intensive care

Department of Pediatrics, Pt. B. D. Sharma PGIMS, Rohtak, Haryana, India

Date of Submission15-Feb-2020
Date of Decision22-Feb-2020
Date of Acceptance29-Feb-2020
Date of Web Publication10-Apr-2020

Correspondence Address:
Dr. Kundan Mittal
Department of Pediatrics, Pt. B. D. Sharma PGIMS, Rohtak - 124 001, Haryana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JPCC.JPCC_33_20

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Chloride has significant role in the body fluid management and action potential. It also helps in the regulation of acid–base status and facilitates oxygen unloading. Hyper- and hypo-chloremia associated with certain conditions are associated with poor outcome.

Keywords: Hyperchloremia, hypochloremia, metabolic acidosis

How to cite this article:
Mittal K. Chloride in intensive care. J Pediatr Crit Care 2020;7:95-6

How to cite this URL:
Mittal K. Chloride in intensive care. J Pediatr Crit Care [serial online] 2020 [cited 2020 May 31];7:95-6. Available from: http://www.jpcc.org.in/text.asp?2020/7/2/95/282225

  Introduction Top

Chloride is the most common anion present in the extracellular fluid (ECF). It combines with sodium and potassium inside the human body. Chloride concentration is high in the cerebrospinal fluid, gastric, and bile secretion in comparison to ECF. Being negatively charged, it moves with sodium and helps in maintaining resting action potential, osmolality, and water balance. It also helps in maintaining acid–base balance (chloride and bicarbonate have inverse relationship), plasma oncotic pressure, and carbon dioxide transported in red cells.

Normal serum chloride level (related to RBC and free in the blood) is 96–107 mEq/L and intracellular chloride level is 4 mEq/L. It remains stable with age. Chloride balance is associated with sodium and bicarbonate, and its regulation depends on intake, excretion, and reabsorption from kidney. Chloride is mainly excreted through gastrointestinal tract (GIT), kidney, and skin.[1],[2],[3],[4],[5]

  Functions of Chloride Top

  • Acid–base homeostasis
  • Regulation of sodium, potassium, and chloride reabsorption
  • Chloride increases blood pressure
  • It is inversely related to renin secretion and glomerular filtration rate
  • Facilitates oxygen unloading
  • Contributes to gastric acidity
  • Maintains intestinal osmotic gradient and fluid secretion
  • Protein digestion, microorganism homeostasis, nutrients' absorption
  • Increased level decreases gastric-pyloric motility.

  Hyperchloremia Top

Serum level >108 mEq/L may be associated with rise in the sodium level or alone and decrease in the bicarbonate level. High level is seen in 25%–45% of intensive care unit patients. Increased level may be due to increased intake of saline, water loss, absorption, acidosis, retention by kidneys, salicylate toxicity, respiratory alkalosis, hyperparathyroidism, hypernatremia, saline infusion, and drug-related retention. Various drugs associated with raised chloride level are aspirin, acetazolamide, kayexalate, phenylbutazone, and ammonium chloride. Hyperchloremia does not produce signs and symptoms directly, but indirect features related to metabolic acidosis appear. Other features include altered sensorium, fluid retention, dyspnea, tachypnea, tachycardia, hypertension, and weakness. High chloride level is also associated with increased sodium level and features suggestive of fluid retention. While assessing the chloride level, it is must to measure serum sodium, bicarbonate, and anion gap.

Hyperchloremic metabolic acidosis is associated with acute kidney injury, vasodilatation, altered neurotransmission, increased inflammatory markers, decreased cardiac activity, hemodynamic instability (both hypo and hyper are detrimental), decreased endogenous catecholamine release, and decreased cellular function. Rise more than 5 mEq/l is associated with increased mortality.


  • Prevention
  • Treatment of underlying cause
  • Fluid resuscitation
  • Correction of other electrolytes
  • Acid–base status
  • In severe case, intravenous sodium bicarbonate is indicated and rarely diuretic therapy
  • Monitor intake and output, vital signs including cardiac rhythm, and neurological and respiratory status
  • Further, monitor serum electrolytes including bicarbonate level.

  Hypochloremia Top

It is defined as serum chloride level <96 mEq/L. Besides, chloride also measures serum sodium, potassium, and calcium levels. Level decreases if intake is less; loss from skin, GIT, kidney; or changes in the sodium and acid–base level. Certain drugs are also associated with low chloride level (diuretics, mannitol, corticosteroids, bicarbonate, and theophylline). Other causes include low level of sodium and potassium, metabolic alkalosis, cystic fibrosis, gastric surgery, diabetic ketoacidosis, and heart failure. If chloride loss is more than sodium, hypochloremic alkalosis develops. Signs and symptoms of the electrolytes imbalance and metabolic alkalosis appear. Other features are irritability, agitation, seizure, coma, tetany, and muscle hypertonicity. Low chloride level in congestive cardiac failure is associated with increased mortality.


  • Prevention
  • Correct underlying etiology
  • Correction of other electrolyte abnormalities
  • Fluid therapy and intravenous or oral sodium chloride
  • Monitor vitals and other electrolytes.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Agrò FE. Body Fluid Management: From Physiology to Therapy. Italy: Springer; 2013.  Back to cited text no. 1
Waikar SS, Murray PT, Singh AK. Core Concepts in Acute Kidney Injury. USA: Springer; 2018.  Back to cited text no. 2
Kellum JA, Elbers PW. Stewart's Textbook of Acid-Base. USA: Lulu.com; 2009.  Back to cited text no. 3
Mount DB, Sayegh MH, Singh AK. Core Concepts in the Disorders of Fluid, Electrolytes and Acid-Base Balance. London: Springer; 2013.  Back to cited text no. 4
Reddi AS. Fluid, Electrolyte and Acid-Base Disorders. 2nd ed. USA: Springer; 2018.  Back to cited text no. 5


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