Hospital-acquired hyponatremia in children: Epidemiology, pathophysiology, and prevention

Abstract

Recent observations have revealed that otherwise healthy children with acute illnesses are prone to hyponatremia due to increased arginine vasopressin production by non-osmotic stimuli. Concern has recently been raised about the potential for iatrogenic hyponatremia as a result of maintenance fluid therapy for those children. To minimize the risk of development of hospital-acquired hyponatremia in sick children receiving maintenance fluid therapy, the routine practice of administration of hypotonic fluids (e.g., 0.18% NaCl with 4% glucose: Na 31 mEq/L, Cl 31 mEq/L) should be abandoned. Instead, isotonic solution, such as 0.9% NaCl (Na 154 mEq/L, K 0 mEq/L, Cl 154 mEq/L) or Hartmann's solution (Na 130 mEq/L, K 4 mEq/L, Cl 110 mEq/L) should be administered. In addition, it must be noted that close monitoring of the children with daily weights, frequent vitals, strict intake and output measurement, and daily chemistries, especially during the first 72 h of parenteral fluid therapy is essential.

Prevention of hospital-acquired hypokalemia in children receiving maintenance fluid therapy

“…In the past decade, however, it has been reported that the infusion of hypotonic IVF in otherwise healthy children with acute illnesses may cause hyponatremia named as "hospital-acquired hyponatremia" [2][3][4][5]. Though the pathophysiological basis for "hospital-acquired hyponatremia" is not fully understood, it is considered to be caused by administration of hypotonic IVF such as 0.18% saline/4% dextrose to sick children, who demonstrated increased AVP production induced by non-osmotic stimuli [2][3][4][5]. As increasing evidence has shown that hypotonic maintenance IVF can lead to potentially fatal hyponatremia and hyponatremia is a rather serious condition than previously believed [13], recommendations by Holliday and Segar for prescribing hypotonic IVF solution [1] need to be reassessed.…”

“…The following patients in states of AVP excess were excluded from the analysis: children requiring water restriction because of the high risk of developing syndrome of inappropriate antidiuretic hormone secretion, such as meningitis, encephalitis, acute bronchiolitis or post-operative condition [5]; children with evident dehydration; children demanding only small amount of IVF for maintenance fluid therapy (at a rate of less than 10 ml/hour). Exclusion criteria also included renal disease, cardiac dysfunction, and known adrenal dysfunction.…”

“…Their pioneering work was performed in healthy breastfed children and was based on calorific requirements; they advised that if IVF was necessary, hypotonic fluid should be used at rates based on body weight. In the past decade, however, there have been several articles suggesting that the use of hypotonic IVF puts hospitalized children at a greater risk of developing life-threatening hyponatremia [2][3][4][5]. Hyponatremia in otherwise healthy children with acute illnesses, called hospital-acquired hyponatremia, is considered to be mainly caused by increased arginine vasopressin (AVP) production: i.e., dilution of extracellular fluid caused by an impaired free water excretion due to excess AVP seems to contribute to development of hyponatremia [3][4][5].…”

Hyponatremia in Kawasaki disease: What does it mean and how does it occur?

“…Although hyponatremia in nearly all patients with KD is mild and asymptomatic, some patients develop profound hyponatremia and CNS involvement. Moreover, hypotonic intravenous fluid infusion in patients with hyponatremia may cause more profound hyponatremia and can contribute to deterioration in the patient's condition [65]. The management of hyponatremia in KD should include the use of isotonic fluids, as well as treatment targeting etiologies of hyponatremia [27,65].…”

“…Moreover, hypotonic intravenous fluid infusion in patients with hyponatremia may cause more profound hyponatremia and can contribute to deterioration in the patient's condition [65]. The management of hyponatremia in KD should include the use of isotonic fluids, as well as treatment targeting etiologies of hyponatremia [27,65]. Recently, Kaneko and colleagues [66] compared the serum sodium levels in KD patients with hyponatremia who received intravenous immunoglobulin (IVIG) preparations containing high (0.9%) or trace concentrations of sodium, and reported the following: administration of IVIG preparations increased the serum sodium levels in patients receiving preparations with high concentrations of sodium, but not trace concentrations of sodium; the median serum sodium level in patients receiving preparations with high concentrations of sodium was significantly higher than that in patients receiving trace concentrations of sodium; and the trace IVIG products had an adverse effect on hyponatremia in KD.…”