Hyponatremia and Hypotonic Intravenous Fluids Are Associated With Unfavorable Outcomes of Bronchiolitis Admissions

Shein, Steven L.; Slain, Katherine; Schlurmann, Natalia Martinez; Speicher, Richard; Rotta, Alexandre T.

doi:10.1542/hpeds.2016-0205

Cited by 18 publications

(14 citation statements)

References 41 publications

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“…One study of cases of moderatesevere bronchiolitis aged less than 6 months presenting to the emergency department measured sodium levels using direct potentiometry and determined a prevalence of hyponatremia of 57% [5]. It has been proposed that hyponatremia may develop as a result of the syndrome of inappropriate antidiuretic hormone secretion (SIADH), hypotonic fluid use, or iatrogenic fluid loading [6]. Hyponatremia may be life-threatening since the passage of fluid into brain cells and alveoli is increased.…”

Section: Introductionmentioning

confidence: 99%

The relation between hyponatremia at presentation, severity of disease and length of stay in patients with bronchiolitis

Isleyen,

Tekin,

Konca

2021

Ann Clin Anal Med

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Aim: In this study, we aimed to investigate the relationship between hyponatremia at presentation and severity of disease and length of stay in children admitted to hospital with acute bronchiolitis. Material and Methods: This cross-sectional study was performed at a tertiary care hospital between May 2017 and April 2018. One hundred seventy children aged 1-24 months admitted with a diagnosis of acute bronchiolitis were included in the study. Demographic and biochemical data were recorded together with data associated with clinical course and length of stay. Results: Hyponatremia was present in 62 (36.4%) of the 170 patients. Thirteen patients (20.9%) in the hyponatremic group were diagnosed with moderate bronchiolitis and 17 (27.5%) with severe bronchiolitis, while in the normonatremic group, 14 (12.9%) with moderate bronchiolitis and 9 (8.4%) with severe bronchiolitis (p<0.001). High-flow nasal cannula (FNC) requirement was present in 17 patients in the hyponatremic group and 17 in the normonatremic group (p=0.001). The risk of development of severe bronchiolitis increased 0.085-fold in patients with hyponatremia. The median length of hospitalization was 5 (2-21) days in the hyponatremic group and 4 (2-11) days in the normonatremic group (p=0.001). Hyponatremia increased length of stay approximately 4.7-fold. Discussion: The risk of developing severe bronchiolitis and non-invasive mechanical ventilation requirements was significantly higher in the hyponatremic group. The length of hospital stay was greater in cases of bronchiolitis with hyponatremia. We think that measuring sodium levels during hospitalization in cases of bronchiolitis will be useful in predicting the risk of development of severe bronchiolitis and extended length of stay.

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Section: Introductionmentioning

confidence: 99%

The relation between hyponatremia at presentation, severity of disease and length of stay in patients with bronchiolitis

Isleyen,

Tekin,

Konca

2021

Ann Clin Anal Med

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“…21 In this issue of Hospital Pediatrics, Shein et al evaluated how the sodium composition of IVF may affect the development of hyponatremia and outcome in children with bronchiolitis. 22 They evaluated a large retrospective cohort of .1500 children, comparing those who received maintenance IVF with a sodium concentration ,70 mEq/L with those .70 mEq/L. They found that children with hyponatremia had an increased length of stay and higher need for mechanical ventilation.…”

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confidence: 99%

“…[26][27][28] The study by Shein et al suggests that 0.45% saline is superior to 0.2% saline, but neither is appropriate. 22 Large prospective studies have already demonstrated that both 0.2% and 0.45% saline result in a high incidence of hyponatremia, whereas 0.9% saline does not. 13,15,16 Neither 0.2% or 0.45% saline is appropriate maintenance IVF for the acutely ill child and certainly not a child needing mechanical ventilation.…”

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confidence: 99%

How to Improve Maintenance Intravenous Fluid Prescribing Practices in Bronchiolitis

Moritz

Ayus

2017

Hospital Pediatrics

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Bronchiolitis is the most common reason for hospitalization in infants in the first year of life. 1 There are no proven therapies to treat this common condition, with the mainstay of therapy being supportive care with intravenous fluid (IVF) and supplemental oxygen when needed. Hyponatremia is often encountered in children with bronchiolitis and has been associated with more severe disease and worse outcomes, and neurologic complications have been reported. 2-6 Explicit recommendations for IVF therapy in children with bronchiolitis are lacking in both consensus guidelines and authoritative reviews. [7][8][9] The historical approach to providing maintenance fluids in children has been to administer hypotonic IVF with a sodium concentration similar to that found in breast and cow milk (30 mEq/L). 10 In 2003, we began recommending 0.9% saline in 5% dextrose for the prevention of hospital-acquired hyponatremia, based on numerous reports of iatrogenic deaths related to hypotonic fluids and the incidence of syndrome of inappropriate secretion of antidiuretic hormone (SIADH)-like states in acutely ill children. 11 A 0.9% saline solution has a sodium concentration (154 mEq/L), which is isotonic to the aqueous phase of plasma water. 12 Since our initial recommendation, there have been .15 randomized, prospective trials involving .2000 children confirming that hypotonic maintenance fluids result in hospital-acquired hyponatremia and that isotonic fluids decrease the incidence of hyponatremia without associated complications. 13-16 It would be reasonable to conclude that hypotonic fluids should be avoided in infants with bronchiolitis in favor of 0.9% saline, because bronchiolitis is associated with SIADH. 2,17-20 However, surprisingly few studies have examined IVF prescribing practices in bronchiolitis or the impact of the sodium composition on the development of hyponatremia and how these fluids may affect outcome. 21In this issue of Hospital Pediatrics, Shein et al evaluated how the sodium composition of IVF may affect the development of hyponatremia and outcome in children with bronchiolitis. 22 They evaluated a large retrospective cohort of .1500 children, comparing those who received maintenance IVF with a sodium concentration ,70 mEq/L with those .70 mEq/L. They found that children with hyponatremia had an increased length of stay and higher need for mechanical ventilation. Those who received a more hypotonic fluid, ,70 mEq/L, had both an increased length of stay and a significantly increased incidence of hyponatremia. These data demonstrated the deleterious effects that both hyponatremia and the administration of hypotonic IVF have on children with bronchiolitis. One area of this study that we would like to draw particular attention to is the ongoing pervasive practice of administering hypotonic maintenance IVF, even to the sickest children who are in the ICU on mechanical ventilation.

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“…[9][10][11] Although the decision of whether to use 0.45% saline versus 0.9% saline for the IV maintenance fluid requirement is still being debated and may continue to be for years, 1,2 there are certain clinical circumstances of anticipated increased ADH secretion, for example, in ICU and postoperative patients as well as those with acute pulmonary or central nervous system disease, 4 in which one would expect that practice would have changed to reflect the current evidence supporting the recommendation to use isotonic 0.9% saline. Yet in a recent article published earlier this year in this journal, Shein et al 12 reported that 96% of the almost 2000 orders for maintenance IVF in children with bronchiolitis were for hypotonic 0.2% or 0.45% saline, including 65% of those on mechanical ventilation receiving 0.2% saline. The practice of choosing hypotonic maintenance IVF in conditions associated with increased ADH secretion was also shown to be prevalent among 78% of surveyed pediatric residents in the United States.…”

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confidence: 99%

At What Point Is the Accumulated Evidence Sufficient to Change Maintenance Intravenous Fluid Prescribing Practice in Children? How About Yesterday?

Friedman

2017

Hospital Pediatrics

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It is intriguing and somewhat disturbing that despite intravenous fluids (IVFs) being the most commonly prescribed therapy in hospitalized children, there still seems to be such a wide variation in the approach to choosing what type of intravenous (IV) maintenance fluid to use 1,2 and the required monitoring that goes along with it. In this issue of Hospital Pediatrics, Rooholamini et al 3 have attempted to address the discrepancy between evidence and practice through a quality improvement project using a standardized pathway to guide the choice of maintenance IVF. Their multidisciplinary approach included creating an evidence-based clinical pathway synthesizing the current consensus with regards to indications of when to start and discontinue IVFs and especially with regards to the optimal tonicity of the IVFs prescribed. They also included standardized monitoring for dysnatremia and signs of fluid overload. I would recommend readers electronically access the clinical pathway described by Romero et al 4 because it is well designed with many good principles prominently highlighted (eg, "do not use 1/4 NS for maintenance fluids," and "pay attention to weight fluctuations 63%") and presents the latest evidence in a pragmatic, algorithmic fashion. Those with increased antidiuretic hormone (ADH) secretion risk factors are recommended to receive 0.9% saline, whereas the rest are given 0.45% saline. Some guidance on total IVF maintenance calculation is also given. In the section on monitoring, they have recommended that all children receiving .75% of their maintenance by IVF have their sodium (Na) checked within 24 hours of initiation, but only those on hypotonic fluids require routine daily checks if getting .75% maintenance IVF. Their approach has tried to accommodate perceived gaps and areas of continuing controversy in the evidence (eg, potential adverse effects of isotonic fluids and frequency of Na monitoring). The most relevant and generalizable of their objectives were the following: Did the pathway implementation change the frequency of hypotonic fluid prescription, and were there any associated changes in the rate of severe dysnatremia? Did the pathway implantation improve appropriate clinical and laboratory monitoring for patients on maintenance IVF? For almost 50 years, the standard practice was prescription of hypotonic IVF (0.2% saline) for maintenance requirements based on seminal work published by Holliday and Segar 5 in 1957. At the turn of this century,

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Hyponatremia and Hypotonic Intravenous Fluids Are Associated With Unfavorable Outcomes of Bronchiolitis Admissions

Abstract: In children hospitalized with bronchiolitis, hyponatremia may be a modifiable risk factor for severe disease that may be mitigated by avoiding use of severely hypotonic IVF.

Cited by 18 publications

References 41 publications

The relation between hyponatremia at presentation, severity of disease and length of stay in patients with bronchiolitis

The relation between hyponatremia at presentation, severity of disease and length of stay in patients with bronchiolitis

How to Improve Maintenance Intravenous Fluid Prescribing Practices in Bronchiolitis

At What Point Is the Accumulated Evidence Sufficient to Change Maintenance Intravenous Fluid Prescribing Practice in Children? How About Yesterday?

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