Diuretic Use and Subsequent Electrolyte Supplementation in a Level IV Neonatal Intensive Care Unit

Dartois, Lauren L.; Levek, Claire; Grover, Theresa R.; Murphy, Michael E.; Ross, Emma L.

doi:10.5863/1551-6776-25.2.124

Cited by 4 publications

(7 citation statements)

References 17 publications

(21 reference statements)

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“…Interestingly, a recent study observed that neonates born between 36 and 41 weeks had a greater incidence of adverse events with furosemide compared to other diuretics. 14 In a recent survey amongst the Italian neonatologists, nearly half of the centers (28 out of the total 57) were observed to administer furosemide at higher doses than those recommended by neonatal guidelines. 7 There is an urgent need to standardize the furosemide doses according to gestational age categories.…”

Section: Discussionmentioning

confidence: 99%

Cumulative Doses Predict the Risk of Furosemide-Induced Electrolyte Abnormalities in Critically Ill Neonates

Sridharan¹,

Madhoob²,

Jufairi³

2022

TCRM

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Background Furosemide has limited indications in the term neonates. Its use in preterm neonates is off-label. Considering the dearth of data, we carried out a retrospective study evaluating the furosemide use and its effects on the electrolyte abnormalities in critically ill neonates. Methods Critically ill neonates receiving at least one dose of furosemide during their stay in the NICU were recruited. The following details were obtained: demographic characteristics and furosemide details (dose, frequency, route, and duration). Urine output, body weight, serum creatinine, electrolytes (sodium, potassium, calcium, bicarbonate, chloride, and magnesium) during furosemide therapy were extracted. Results Ninety neonates were recruited. Elevated serum creatinine was observed in 21.1% of the patients, and electrolyte disturbances were observed in 52.2%. Those with electrolyte disturbances had significantly greater cumulative doses compared to those without [5.5 (1–34) vs 3.9 (0.9–30.2) mg/kg; p = 0.01]. Cumulative doses adjusted to body-weight were significantly lower in very preterm and extremely preterm neonates compared to late preterm category. A significant area-under-the-curve was observed for the cumulative dose (0.66; 95% CI: 0.54–0.78; p = 0.01) in predicting the risk of electrolyte abnormalities with a cut-off value of 4 mg/kg. Eight neonates received more than 10 mg/kg cumulative dose of furosemide of which one died. No significant differences were observed between the proportion of neonates with electrolyte disturbances with cumulative furosemide dose above 10 mg/kg ( p = 0.3) and with mortality ( p = 0.3). Conclusion We observed that our critically ill neonates received relatively higher cumulative doses of furosemide and electrolyte disturbances were observed in nearly half of the population. A cumulative dose of 4 mg/kg increases the risk of electrolyte abnormalities, particularly in preterm neonates. More diligence in the dose titration coupled with deprescribing and intense monitoring of all the potential adverse effects in this vulnerable population is needed.

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Section: Discussionmentioning

confidence: 99%

Cumulative Doses Predict the Risk of Furosemide-Induced Electrolyte Abnormalities in Critically Ill Neonates

Sridharan¹,

Madhoob²,

Jufairi³

2022

TCRM

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“…These authors also suggested that the intravenous formulation can be given via the enteral route as well. 51 For correction of chloride deficit, Martin and Matzke 91 proposed that the dose of hydrochloric acid be calculated as follows: dose (mEq) = [0.2 liters/kg × body weight (kg) × (103 − observed sodium chloride)]. The authors also suggested a formula for the correction of metabolic alkalosis.…”

Section: Hypochloremiamentioning

confidence: 99%

“…(ii) Hypochloremia and metabolic alkalosis: Normal serum chloride concentrations in preterm infants are 110.5 ± 5.0 mmol/L. 50 Hypochloremia is a significant clinical finding in patients receiving chronic diuretic therapy, 51 and it often stays under-corrected. Chloride and bicarbonate levels are inversely related to each other to maintain anion balance.…”

Section: Hypochloremiamentioning

confidence: 99%

Hypochloremia Secondary to Diuretics in Preterm Infants: Should Clinicians Pay Close Attention?

Thekkeveedu

Ramarao

Dankhara

et al. 2021

Global Pediatric Health

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Diuretic therapy, commonly used in the newborn intensive care unit, is associated with a variety of electrolyte abnormalities such as hyponatremia, hypokalemia, and hypochloremia. Hypochloremia, often ignored, is associated with significant morbidities and increased mortality in infants and adults. Clinicians respond in a reflex manner to hyponatremia than to hypochloremia. Hypochloremia is associated with nephrocalcinosis, hypochloremic alkalosis, and poor growth. Besides, the diuretic resistance associated with hypochloremia makes maintaining chloride levels in the physiological range even more logical. Since sodium supplementation counters the renal absorption of calcium and lack of evidence for spironolactone role in diuretic therapy for bronchopulmonary dysplasia (BPD), alternate chloride supplements such as potassium or arginine chloride may need to be considered in the management of hypochloremia due to diuretic therapy. In this review, we have summarized the current literature on hypochloremia secondary to diuretics and suggested a pragmatic approach to hypochloremia in preterm infants.

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“…Thiazide diuretics are often added to complement loop diuretics and also result in sodium loss [ 4 , 5 ]. Hyponatremia is a known side effect of diuretic use [ 6 , 7 ]. Severe hyponatremia can lead to cerebral injury, and children that develop hyponatremia during hospitalization are at increased risk for seizures and death [ 8 , 9 ].…”

Section: Introductionmentioning

confidence: 99%

“…Knowing how to approach diuretic-induced hyponatremia can be difficult. Sodium chloride (NaCl) supplementation is commonly ordered for children on diuretics [ 7 ] but is controversial due to concerns that sodium use will exacerbate fluid retention. How NaCl supplements affect fluid retention and fluid balance in children is unknown.…”

Section: Introductionmentioning

confidence: 99%

Enteral Sodium Chloride Supplementation and Fluid Balance in Children Receiving Diuretics

2022

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The use of sodium chloride (NaCl) supplementation in children being prescribed diuretics is controversial due to concerns that supplementation could lead to fluid retention. This is a single-center retrospective study in which fluid balance and diuretic dosing was examined in children prescribed enteral NaCl supplements for hyponatremia while receiving loop diuretics. The aim of this study was to determine whether significant fluid retention occurred with the addition of NaCl. Fifty-five patients with 68 events were studied. The median age was 5.2 months, and 82% were hospitalized for cardiac disease. Daily fluid balance the seven days prior to NaCl supplementation was lower than the seven days after, with measurement of: median 17 mL/kg/day (7–26) vs. 22 mL/kg/day (13–35) (p = 0.0003). There was no change in patient weight after supplementation (p = 0.63). There was no difference in the median loop diuretic dose before and after supplementation, with the diuretic dose in furosemide equivalents of 3.2 mL/kg/day (2.3–4.4) vs. 3.2 mL/kg/day (2.2–4.7) (p = 0.50). There was no difference in the proportion of patients receiving thiazide diuretics after supplementation (56% before vs. 50% after (p = 0.10)). NaCl supplementation in children receiving loop diuretics increased calculated fluid balance, but weight was unchanged, and this was not associated with an increase in diuretic needs, suggesting clinicians did not consider the increase in fluid balance to be clinically significant.

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Diuretic Use and Subsequent Electrolyte Supplementation in a Level IV Neonatal Intensive Care Unit

Cited by 4 publications

References 17 publications

Cumulative Doses Predict the Risk of Furosemide-Induced Electrolyte Abnormalities in Critically Ill Neonates

Cumulative Doses Predict the Risk of Furosemide-Induced Electrolyte Abnormalities in Critically Ill Neonates

Hypochloremia Secondary to Diuretics in Preterm Infants: Should Clinicians Pay Close Attention?

Enteral Sodium Chloride Supplementation and Fluid Balance in Children Receiving Diuretics

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