Use of Hypotonic Maintenance Intravenous Fluids and Hospital-Acquired Hyponatremia Remain Common in Children Admitted to a General Pediatric Ward

Abstract

AimTo evaluate maintenance intravenous fluid-prescribing practices and the incidence of hospital-acquired hyponatremia in children admitted to a general pediatric ward.MethodsThis is a prospective observational study conducted over a 2-month period in children ages 2 months to 5 years who were admitted to a general pediatric ward and who were receiving maintenance intravenous fluids. The composition, rate, and duration of intravenous fluids were chosen at the discretion of the treating physician. Serum biochemistries were obtained at baseline and 24 h following admission. Patients who were at high risk for developing hyponatremia or hypernatremia or had underlying chronic diseases or were receiving medications associated with a disorder in sodium and water homeostasis were excluded. Intravenous fluid composition and the incidence of hyponatremia (sodium <135 mEq/L) were assessed.ResultsFifty-six children were enrolled. All received hypotonic fluids; 87.5% received 0.18% sodium chloride (NaCl) and 14.3% received 0.45% NaCl. Forty percent of patients (17/42) with a serum sodium (SNa) less than 140 mEq/L experienced a fall in SNa with 12.5% of all patients (7/56) developing hospital-acquired or aggravated hyponatremia (126–134 mEq/L) with fall in SNa between 2 and 10 mEq/L.ConclusionAdministration of hypotonic fluids was a prevalent practice in children admitted to a general pediatric ward and is associated with acute hospital-acquired hyponatremia.

Crystalloid and Colloid Compositions and Their Impact

“…The major adverse events that may be associated with the administration of maintenance type fluids are ineffective intravascular volume support and hyponatremia. Acute, hospital acquired hyponatremia has been associated with the administration of hypotonic, maintenance type fluids in human patients (39,42,43). Randomized controlled trials comparing isotonic crystalloids with hypotonic crystalloids as ongoing maintenance fluid therapy in adult humans and pediatric patients have shown isotonic crystalloids to be safe and is associated with a lower incidence of hyponatremia (44)(45)(46)(47).…”

Effect of intraoperative Hartmann’s versus hypotonic solution administration on FLACC pain scale scores in children: A prospective randomized controlled trial

“…Acute hyponatremia should be avoided in children because they are more vulnerable to brain swelling due to an increased brain-to-skull size ratio and smaller intracerebral volume of cerebrospinal fluid than adults, which can lead to headache, nausea, vomiting, confusion, and even death [10]. Hypotonic solutions are still prevalently used as a pediatric maintenance fluid [1,5,[10][11][12], however, despite the fact that it can potentially induce hyponatremia.…”

Iatrogenic Dysnatremias in Children with Acute Gastroenteritis in High-Income Countries: A Systematic Review

“…Hyponatremia developing in hospitalized children receiving IVFs at appropriately calculated maintenance rates of fluid and electrolytes is well documented ( 9 , 32 , 33 ). Moreover, a higher risk for hyponatremia has been linked to use of hypotonic solutions while isotonic saline was shown to be safe and superior in avoiding hyponatremia in children requiring IVF maintenance ( 34 – 38 ). Nevertheless, many of these studies excluded children with AGE who present unique challenges related to the existence of dehydration, baseline dysnatremias, and ongoing gastrointestinal losses.…”