Acute Hyponatremia Related to Intravenous Fluid Administration in Hospitalized Children: An Observational Study

Hoorn, Ewout J.; Geary, Denis F.; Robb, Maryanne; Halperin, Mitchell L.; Bohn, Desmond

doi:10.1542/peds.113.5.1279

Cited by 225 publications

(207 citation statements)

References 47 publications

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“…The incidence of hyponatremia with the use of hypotonic intravenous fluids has ranged from 7.6% to 57% [9][10][11][12][13]. We observed unusually high incidence of 70% hyponatremia with the use of hypotonic 'standard volume' maintenance fluid in a selected group of nonsurgical pediatric patients.…”

Section: Discussionmentioning

confidence: 73%

Safety and efficacy of isotonic (0.9%) vs. hypotonic (0.18%) saline as maintenance intravenous fluids in children: A randomized controlled trial

2014

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Objective: To compare the safety and efficacy of isotonic versus hypotonic maintenance fluid in children. Design: Randomized controlled trial.Setting: Tertiary-level teaching hospital.Participants: 60 children (age 0.5 to 12 years) who were admitted and anticipated to receive intravenous fluid for the next 48 hours.Intervention: Hypotonic fluid (Standard maintenance volume as 0.18% NaCl in 5% dextrose) or Isotonic fluid (60% Standard maintenance volume as 0.9% NaCl solution in 5% dextrose).Outcome measures: Primary: Incidence of hyponatremia. Secondary: Serum sodium, serum osmolality, blood sugar, blood urea, serum creatinine, serum potassium, serum chloride, pH, urine output, change in weight, morbidity and death. Results: At 24 hours, hyponatremia was noted in 7 (24%) patients in the isotonic and 16 (55%) in hypotonic group (P=0.031). At 48 hours, hyponatremia was noted in 4 (14%) and 13 (45%) patients in isotonic and hypotonic group, respectively (P=0.02). There was significant change in sodium levels in both isotonic (P=0.036) and hypotonic (P<0.001) intervention groups. The peak fall in mean serum sodium level was noted at 24 hours (-6.5, 95%CI: -3.5, -9.6 mEq/L; P<0.001) in hypotonic group. In isotonic group, there was significant increase between 24 and 48 hours R R R R R E E E E E S S S S S E E E E E A A A A A R R R R R C C C C C H P H P H P H P H P A A A A A P P P P P E E E E E R R R R RR ecommendation for the use of a hypotonic saline solution (0.18% saline in 5% dextrose) in children is still a debated subject despite half a century of its practice [1]. Reports of symptomatic hyponatremia in hospitalized surgical and non-surgical pediatric patients -caused primarily by various non-osmotic release of vasopressin, but contributed by electrolyte-free water input in a proportion of cases -have fueled these debates [2][3][4][5]. Use of conventional volume maintenance isotonic saline has been shown to reduce the incidence of hyponatraemia [6]. Using indirect calorimetric measurements, energy expenditure in critically ill children may be as low as 50-60 kcal/kg/day [7]. Consequently, fluid requirement, which is directly proportional to the actual energy expenditure, is much less than previously assumed in critically ill children for a variety of reasons such as physical immobility, the use of muscle relaxants and sedatives, mechanical ventilation, and additional factors such as nonessential or facultative metabolism [8]. Therefore, we hypothesized that use of reduced volume isotonic maintenance fluid would decrease the incidence of hyponatremia in sick children, when compared to hypotonic fluid. We compared the efficacy and safety of isotonic fluid (0.9% NaCl in 5% dextrose) at the rate of 60% of daily fluid requirement versus hypotonic fluid (0.18% NaCl in 5% dextrose) at the rate of standard maintenance volume in sick children.Accompanying Editorials: Pages 963-66.

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Section: Discussionmentioning

confidence: 73%

Safety and efficacy of isotonic (0.9%) vs. hypotonic (0.18%) saline as maintenance intravenous fluids in children: A randomized controlled trial

2014

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“…The investigators observed more dehydration in the group receiving half maintenance than in that receiving full maintenance. In a retrospective case-control study, higher IV fluid rate and amount were associated with hyponatremia (Na <136 mmol/L); patients with hyponatremia received a higher rate of electrolyte-free fluid (2±2 mL/kg/h vs. 1±1 mL/kg/h; P<0.001) and more commonly received greater than the recommended maintenance rate (73 vs. 23 %; P<0.001) [38]. As mentioned previously, Saba et al reported that when maintenance fluids were delivered at the appropriate rate and pre-existing volume deficits were corrected, hypotonic fluids were not associated with an increased risk for hyponatremia [31].…”

Section: Bmaintenance^fluid Rate and Hyponatremiamentioning

confidence: 99%

Perioperative fluid management and postoperative hyponatremia in children

Sutherland

2015

Pediatr Nephrol

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Intravenous (IV) fluids are used ubiquitously when children undergo surgical procedures. Until recently, Holliday and Segar's guidelines for calculating maintenance fluids dictated fluid management strategies in postoperative pediatric patients. An increased recognition of hospitalacquired hyponatremia and its associated morbidity has led to a critical re-examination of IV fluid management in this population. Postsurgical patients are at high risk of developing hyponatremia due to the presence of non-osmotic stimuli for antidiuretic hormone release. Recent studies have established that, as they are administered in current practice, hypotonic maintenance fluids are associated with increased rates of hyponatremia. The best available data demonstrate that administration of isotonic fluid reduces hyponatremic risk. In this review, we discuss the collective data available on the subject and offer guidelines for fluid management and therapeutic monitoring.

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“…1 The rate of fall of the plasma sodium appears to be as important a factor as the magnitude of the reduction and plasma sodium is frequently normal at baseline. 4 It is recognized that children may be susceptible to developing the problems associated with hyponatraemia at higher concentrations of sodium than adults. 1 Fatal cerebral oedema was associated with a fall in sodium of as little as 6 mmol/L over 9 h (137--131mmol/L) in an 8-week-old infant, 5 and a fall of 17 mmol/L (137--120 mmol/L) over 12 h in a child aged 13 months.…”

Section: Introductionmentioning

confidence: 99%

Sodium measurement: effects of differing sampling and analytical methods

Loughrey¹,

Hanna²,

McDonnell³

et al. 2006

Ann Clin Biochem

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Acute Hyponatremia Related to Intravenous Fluid Administration in Hospitalized Children: An Observational Study

Abstract: The most important factor for hospital-acquired hyponatremia is the administration of hypotonic fluid. We suggest that hypotonic fluid not be given to children when they have a P(Na) <138 mmol/L.

Cited by 225 publications

References 47 publications

Safety and efficacy of isotonic (0.9%) vs. hypotonic (0.18%) saline as maintenance intravenous fluids in children: A randomized controlled trial

Safety and efficacy of isotonic (0.9%) vs. hypotonic (0.18%) saline as maintenance intravenous fluids in children: A randomized controlled trial

Perioperative fluid management and postoperative hyponatremia in children

Sodium measurement: effects of differing sampling and analytical methods

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