Hypotonic versus isotonic maintenance fluids in critically ill children: a multicenter prospective randomized study

Rey, Corsino; Los-Arcos, Marta; Hernández, Arturo; Sánchez, Amelia; Díaz, Juan-José; López‐Herce, Jesús

doi:10.1111/j.1651-2227.2011.02209.x

Cited by 57 publications

(61 citation statements)

References 29 publications

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“…We identified 10 studies comparing isotonic and hypotonic maintenance IV fluid therapy in hospitalized children according to our criteria. [10][11][12][13][14][15][16]20,29,30 Two were unpublished studies, and we failed to access their data by contacting the authors. 29,30 Two studies were considered as 4 RCTs because they compared hypotonic and isotonic fluids at 2 maintenance rates.…”

Section: Discussionmentioning

confidence: 99%

“…10,13 Therefore, 10 RCTs were included in this review. [10][11][12] The shortest follow-up ranged from 8 to 72 hours. Table 2 shows the risk of bias for each study.…”

Section: Discussionmentioning

confidence: 99%

“…[10][11][12][13][14][15][16][17][18][19][20] Clinical evidence suggests that the routine use of hypotonic fluids contributes to the development of iatrogenic hyponatremia, whereas isotonic fluids offer effective prophylaxis against it. [10][11][12][13][14][15][16][17][18][19][20] However, traditional guidelines and textbooks continue recommending hypotonic maintenance fluids for pediatric patients. 21 Early systematic reviews have evaluated isotonic versus hypotonic maintenance IV fluids in hospitalized children, 6,[22][23][24] but only included limited randomized controlled trials (RCTs).…”

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confidence: 99%

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Isotonic Versus Hypotonic Maintenance IV Fluids in Hospitalized Children: A Meta-Analysis

2014

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OBJECTIVE: To assess evidence from randomized controlled trials (RCTs) on the safety of isotonic versus hypotonic intravenous (IV) maintenance fluids in hospitalized children. METHODS:We searched PubMed, Embase, Cochrane Library, and clinicaltrials.gov (up to April 11, 2013) for RCTs that compared isotonic to hypotonic maintenance IV fluid therapy in hospitalized children. Relative risk (RR), weighted mean differences, and 95% confidence intervals (CIs) were calculated based on the effects on plasma sodium (pNa). The risk of developing hyponatremia (pNa ,136 mmol/L), severe hyponatremia (pNa ,130 mmol/L), and hypernatremia (pNa .145 mmol/L) was evaluated. We adopted a random-effects model in all meta-analyses. Sensitivity analyses by missing data were also performed.RESULTS: Ten RCTs were included in this review. The meta-analysis showed significantly higher risk of hypotonic IV fluids for developing hyponatremia (RR 2.24, 95% CI 1.52 to 3.31) and severe hyponatremia (RR 5.29, 95% CI 1.74 to 16.06). There was a significantly greater fall in pNa in children who received hypotonic IV fluids (-3.49 mmol/L versus isotonic IV fluids, 95% CI -5.63 to -1.35). No significant difference was found between the 2 interventions in the risk of hypernatremia (RR 0.73, 95% CI 0.22 to 2.48). None of the findings was sensitive to imputation of missing data.CONCLUSIONS: Isotonic fluids are safer than hypotonic fluids in hospitalized children requiring maintenance IV fluid therapy in terms of pNa. Pediatrics 2014;133:105-113

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Section: Discussionmentioning

confidence: 99%

“…10,13 Therefore, 10 RCTs were included in this review. [10][11][12] The shortest follow-up ranged from 8 to 72 hours. Table 2 shows the risk of bias for each study.…”

Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

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Isotonic Versus Hypotonic Maintenance IV Fluids in Hospitalized Children: A Meta-Analysis

2014

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“…Likewise, Rey et al randomized 125 medical and surgical pediatric patients to receive either hypotonic (Na 30-50 mmol/L+K 20 mmol/L) or isotonic (Na 136 mmol/L+K 20 mmol/L) IV fluid and demonstrated that the risk of hyponatremia was 5.8-fold (95 % CI 2.4-10, P<0.001) greater in the hypotonic group after adjusting for age, weight, and admission plasma sodium level [27]. Neville et al randomized 124 children undergoing surgery to receive either hypotonic 0.45 % saline or isotonic 0.9% saline; 8 h after extubation, hyponatremia developed in 19/62 (31.5 %) children in the hypotonic group compared to 6/62 (9.7 %) children in the isotonic group (P<0.006) [28].…”

Section: Fluid Tonicity 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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“…Additionally, obstructive hydrocephalus and < 3.5 years of age were identified as significant independent risk factors for severe hyponatremia among those affected. The risk for hospital-acquired hyponatremia and hyponatremic encephalopathy have been related to the use of hypotonic intravenous solutions [6,[70][71][72][73][74][75][76][77] . Wang et al [78] found a significantly higher risk for hyponatremia and severe hyponatremia among pediatric patients administered hypotonic solutions compared with isotonic fluids in a systematic review of ten randomized clinical trials involving 855 subjects.…”

Section: Childrenmentioning

confidence: 99%

Impact of perioperative hyponatremia in children: A narrative review

Andersen

Afshari

2014

WJCCM

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For more than 50 years, hypotonic fluids (crystalloids) have been the standard for maintenance fluid used in children. In the last decade, several studies have evaluated the risk of hyponatremia associated with the use of hypotonic vs isotonic fluids, which has lead to an intense debate. Children undergoing surgery have several stimuli for release of antidiuretic hormone, which controls renal water handling, including pain, nausea, vomiting, narcotic use and blood loss. The body's primary defense against the development of hyponatremia is the ability of the kidneys to excrete free water and dilute urine. Increased levels of antidiuretic hormone can result in hyponatremia, defined as a plasma sodium level < 136 mmol/L, which causes cells to draw in excess water and swell. This manifests as central nervous system symptoms such as lethargy, irritability and seizures. The risk for symptomatic hyponatremia is higher in children than in adults. It represents an emergency condition, and early diagnosis, prompt treatment and close monitoring are essential to reduce morbidity and mortality. The widespread use of hypotonic fluids in children undergoing surgery is a matter of concern and more focus on this topic is urgently needed. In this paper, we review the literature and describe the impact of perioperative hyponatremia in children. Key words: Children; Fluid; Hyponatremia; Pediatric; Perioperative Core tip: Hospital-acquired hyponatremia is common, particularly among children undergoing surgery. These children tend to develop hyponatremic encephalopathy at higher serum sodium concentrations than adults and they have a poorer prognosis. As the risk is increased by the use of hypotonic fluids, intraoperative fluids for children should be isotonic. Symptomatic hyponatremia should be corrected with 3% sodium chloride and close monitoring of the patient and serum sodium level is mandatory to prevent brain herniation and neurologic damage from cerebral ischemia.Andersen C, Afshari A. Impact of perioperative hyponatremia in children: A narrative review. World J Crit Care Med 2014; 3(4): 95-101 Available from:

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Hypotonic versus isotonic maintenance fluids in critically ill children: a multicenter prospective randomized study

Abstract: Hypotonic maintenance fluids increase the incidence of hyponatraemia because they decrease blood sodium levels in normonatraemic patients. IT maintenance fluids do not increase the incidence of dysnatraemias and should be considered as the standard maintenance fluids.

Cited by 57 publications

References 29 publications

Isotonic Versus Hypotonic Maintenance IV Fluids in Hospitalized Children: A Meta-Analysis

Isotonic Versus Hypotonic Maintenance IV Fluids in Hospitalized Children: A Meta-Analysis

Perioperative fluid management and postoperative hyponatremia in children

Impact of perioperative hyponatremia in children: A narrative review

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