The effects of hydrochloric acid (HCl) administration were studied in 15 critically ill patients whose metabolic alkalosis caused a significant alkalemia (pH 7.50 to 7.58) unresponsive to sodium and potassium chloride administration. Arterial pH and bicarbonate and chloride concentrations normalized after a 6- to 12-h mean infusion of 200 +/- 54 mmol of .25 N HCl. There were no deleterious vascular, hematologic, or metabolic side-effects. HCl administration was associated with an increase in mean PaO2 from 94 +/- 21 to 121 +/- 31 torr (p less than .001). This increase was comparable in patients breathing spontaneously and those treated with controlled mechanical ventilation, and was attributed at least in part to a decrease in pulmonary shunt. These results indicate that .25 N HCl, infused at the rate of 100 ml/h into the superior vena cava, can correct metabolic alkalosis safely and rapidly. The persistence of the beneficial effects of this treatment on arterial oxygenation remains to be confirmed.
The choice of which intravenous solution to prescribe remains a matter of considerable debate in intensive care units around the world. Trends have been moving away from using hydroxyethyl starch solutions following concerns about safety. But are the available data sufficient to clearly assess the risk-benefit balance for all patients, and is there enough evidence of harm to justify removing these drugs completely from our hospitals?
Even though patients with a history of insulin-treated diabetes are more severely ill and more likely to have renal failure, insulin-treated diabetes is not associated with increased mortality in ICU patients.
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The challenging aspect in the treatment of circulatory shock, which is a life-threatening situation, is essentially to look for medications that can improve survival. Among vasoactive agents, none of the currently used catecholamines has been shown to increase survival from circulatory shock, and especially not isoproterenol, noradrenaline or adrenaline. Even with dopamine, that we have known for more than ten years, there is no evidence that survival can be increased. Dobutamine is a younger drug but it does not show any such evidence either at the present time. Therefore, we still need to improve treatment of acute circulatory failure by finding other agents that could increase survival in these conditions.
