Intravenous fluids for seriously ill children: time to reconsider

Modern approaches at the management of children with community-acquired pneumonia

Experts of The Union of Pediatricians of Russia have developed current clinical guidelines for management of children with community-acquired pneumonia, which were approved by the Scientific and Practice Council of Ministry of Public Health of the Russian Federation in January 2022. Particular attention is paid to the etiological structure, modern classification, diagnostic tests and flagship approaches to antibacterial therapy of community-acquired pneumonia in children based on the principles of evidentiary medicine. 

Transfontanellar Contrast-enhanced US for Intraoperative Imaging of Cerebral Perfusion during Neonatal Arterial Switch Operation

Background Brain injury and subsequent neurodevelopmental disorders are major determinants for later-life outcomes in neonates with transposition of the great arteries (TGA). Purpose To quantitatively assess cerebral perfusion in neonates with TGA undergoing arterial switch operation (ASO) using transfontanellar contrast-enhanced US (T-CEUS). Materials and Methods In a prospective single-center cross-sectional diagnostic study, neonates with TGA scheduled for ASO were recruited from February 2018 to February 2020. Measurements were performed at five time points before, during, and after surgery (T₁-T₅), and 11 perfusion parameters were derived per cerebral hemisphere. Neonate clinical characteristics, heart rate, mean arterial pressure, central venous pressure, near-infrared spectroscopy, blood gas analyses, ventilation time, time spent in the pediatric intensive care unit, and time in hospital were correlated with imaging parameters. Analysis of variance or a mixed-effects model were used for groupwise comparisons. Results A total of 12 neonates (mean gestational age, 39 6/7 weeks ± 1/7 [SD]) were included and underwent ASO a mean of 6.9 days ± 3.4 after birth. When compared with baseline values, T-CEUS revealed a longer mean time-to-peak (right hemisphere, 4.3 seconds ± 2.1 vs 17 seconds ± 6.4 [P < .001]; left hemisphere, 4.0 seconds ± 2.3 vs 21 seconds ± 8.7 [P < .001]) and rise time (right hemisphere, 3.5 seconds ± 1.7 vs 11 seconds ± 5.1 [P = .002]; left hemisphere, 3.4 seconds ± 2.0 vs 22 seconds ± 7.8 [P = .004]) in both cerebral hemispheres during low-flow cardiopulmonary bypass and hypothermia (T₄) for all neonates. Neonate age at surgery negatively correlated with T-CEUS parameters during ASO, as calculated with the area under the flow curve (AUC) during wash-in (R = -0.60, P = .020), washout (R = -0.82, P = .002), and both wash-in and washout (R = -0.79, P = .004). Mean AUC values were lower in neonates older than 7 days compared with younger neonates during wash-in ([87 arbitrary units {au} ± 77] × 10² vs [270 au ± 164] × 10², P = .049]), washout ([15 au ± 11] × 10³ vs [65 au ± 38] × 10³, P = .020]) and both wash-in and washout ([24 au ± 18] × 10³ vs [92 au ± 53] × 10³, P = .023). Conclusion Low-flow hypothermic conditions resulted in reduced cerebral perfusion, as measured with transfontanellar contrast-enhanced US, which inversely correlated with age at surgery. Clinical trial registration no. NCT03215628 © RSNA, 2022 Online supplemental material is available for this article.

Serum sodium level is inversely correlated with body temperature in children

BACKGROUND

Several studies have demonstrated that non-osmotic antidiuretic hormone activity contributes to the development of hyponatremia in children with common febrile diseases. However, the relationship between hyponatremia and body temperature has remained unclear. We therefore examined this relationship in children with common diseases.

METHODS

In this retrospective case study based on a chart review, 1,973 children presenting with acute illnesses at Hirakata City Hospital between November 2008 and October 2009, and for whom blood test data were available, were enrolled. The median age of this cohort was 2.7 years and the mean serum sodium concentration was 136.4 mEq/L; 454 patients showed hyponatremia (<135 mEq/L). The patients were classified into four groups on the basis of body temperature, <37 °C, 37 °C (37.0-37.9 °C), 38 °C (38.0-38.9 °C) and ≥39 °C, and their serum sodium concentration was compared.

RESULTS

The mean sodium level was significantly lower in febrile (135.9 mEq/L) than in non-febrile (138.5 mEq/L) patients. The mean serum sodium levels in the four temperature groups were, in ascending order, 138.5 mEq/L (95% CI, 138.3-138.8 mEq/L), 137.3 mEq/L (137.1-137.5 mEq/L), 136.1 mEq/L (135.8-136.3 mEq/L) and 134.6 mEq/L (134.4-134.9 mEq/L), respectively. The serum sodium level in each individual temperature range became significantly lower as body temperature increased (P < 0.001).

CONCLUSIONS

There is a clear inverse correlation between serum sodium level and body temperature in children with common febrile diseases, and fever may play an important role in this relationship.

Improving Isotonic Maintenance Intravenous Fluid Use in the Emergency Department

BACKGROUND

Maintenance intravenous fluids (IVFs) are commonly used in the hospital setting. Hypotonic IVFs are commonly used in pediatrics despite concerns about high incidence of hyponatremia. We aimed to increase isotonic maintenance IVF use in children admitted from the emergency department (ED) from a baseline of 20% in 2018 to >80% by December 2019.

METHODS

We included patients aged 28 days to 18 years receiving maintenance IVFs (rate >10 mL/hour) at the time of admission. Patients with active chronic medical problems were excluded. Interventions included institutional discussions on isotonic IVF based on literature review, education on isotonic IVF use per the American Academy of Pediatrics guideline (isotonic IVF use with appropriate potassium chloride and dextrose), electronic medical record changes to encourage isotonic IVF use, and group practice review with individual physician audit and feedback. Balancing measures were the frequency of serum electrolyte checks within 24 hours of ED admission and occurrence of hypernatremia. Data were analyzed by using statistical process control charts.

RESULTS

Isotonic maintenance IVF use improved, with special cause observed twice; the 80% goal was met and sustained. No difference was noted in serum electrolyte checks within 24 hours of admission (P > .05). There was no increase in occurrence of hypernatremia among patients who received isotonic IVF compared with those who received hypotonic IVF (P > .05).

CONCLUSIONS

The application of improvement methods resulted in improved isotonic IVF use in ED patients admitted to the inpatient setting. Institutional readiness for change at the time of the American Academy of Pediatrics guideline release and hardwiring of preferred fluids via electronic medical record changes were critical to success.

Issues and Controversies in the Evolution of Oral Rehydration Therapy (ORT)

The original studies demonstrating the efficacy of oral glucose-electrolytes solutions in reducing or eliminating the need for intravenous therapy to correct dehydration caused by acute watery diarrheas (AWD) were focused chiefly on cholera patients. Later research adapted the oral therapy (ORT) methodology for treatment of non-cholera AWDs including for pediatric patients. These adaptations included the 2:1 regimen using 2 parts of the original WHO oral rehydration solution (ORS) formulation followed by 1 part additional plain water, and a “low sodium” packet formulation with similar average electrolyte and glucose concentrations when dissolved in the recommended volume of water. The programmatic desire for a single ORS packet formulation has led to controversy over use of the “low sodium” formulations to treat cholera patients. This is the subject of the current review, with the conclusion that use of the low-sodium ORS to treat cholera patients leads to negative sodium balance, leading to hyponatremia and, in severe cases, particularly in pediatric cholera, to seizures and other complications of sodium depletion. Therefore it is recommended that two separate ORS packet formulations be used, one for cholera therapy and the other for non-cholera pediatric AWD.

Consensus Guidelines for Perioperative Care in Neonatal Intestinal Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations

Background

Enhanced Recovery After Surgery (ERAS^®) Society guidelines integrate evidence-based practices into multimodal care pathways that have improved outcomes in multiple adult surgical specialties. There are currently no pediatric ERAS^® Society guidelines. We created an ERAS^® guideline designed to enhance quality of care in neonatal intestinal resection surgery.

Methods

A multidisciplinary guideline generation group defined the scope, population, and guideline topics. Systematic reviews were supplemented by targeted searching and expert identification to identify 3514 publications that were screened to develop and support recommendations. Final recommendations were determined through consensus and were assessed for evidence quality and recommendation strength. Parental input was attained throughout the process.

Results

Final recommendations ranged from communication strategies to antibiotic use. Topics with poor-quality and conflicting evidence were eliminated. Several recommendations were combined. The quality of supporting evidence was variable. Seventeen final recommendations are included in the proposed guideline.

Discussion

We have developed a comprehensive, evidence-based ERAS guideline for neonates undergoing intestinal resection surgery. This guideline, and its creation process, provides a foundation for future ERAS guideline development and can ultimately lead to improved perioperative care across a variety of pediatric surgical specialties.

Electronic supplementary material

The online version of this article (10.1007/s00268-020-05530-1) contains supplementary material, which is available to authorized users.

Risks of severe hyponatremia in children receiving hypotonic fluids

Intravenous fluids are frequently used in hospitalized children. Hypotonic fluids have been the standard of care in pediatrics for many years. This might be explained by the empiricism of early recommendations favoring fluids with dextrose, but an insufficient amount of sodium. The risk of hyponatremia (<135mmol/L) might be increased by the occurrence of the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) in the course of common acute diseases (e.g., bronchiolitis, acute gastroenteritis, encephalitis, meningitis) in children. Severe hyponatremia (<130mmol/L) is often associated with neurologic complications leading to sequelae or even death. Over the last few years, hyponatremia induced by hypotonic fluids has been increasingly reported, and significant progress has been made in the understanding of cerebral edema and osmotic demyelination. Several randomized clinical trials have shown weak but significant evidence that isotonic fluids were superior to hypotonic solutions in preventing hyponatremia. However, clinical practices have not changed much in France, as suggested by the analysis of intravenous fluids ordered from the Assistance Publique-Hôpitaux de Paris (AP-HP) central pharmacy (PCH) in 2017. Therefore, it would be advisable that national guidelines be released under the French Health Authorities regarding the safe infusion of infants and children.

Estimated basal metabolic rate and maintenance fluid volume in children: A proposal for a new equation

The basal metabolic rate (BMR) of children aged <2 years is proportional to their body weight (W; kg). However, no simple mathematical model for the estimation of BMR in children aged ≥2 years has been established. Based on Japanese studies on childhood BMR, conducted until the 1960s, we noted that childhood BMR (after infancy) is proportional to body weight to the power of 1/2 (W^1/2 ). Moreover, we confirmed that the two previously reported equations for calculating BMR (Schofield's equation and Oxford University's equations) are proportional to W^1/2 . Based on these facts, we propose a new equation for the maintenance fluid volume for hospitalized children. Our equation (300 × W^1/2  mL/day) gives values almost equal to the maintenance fluid volume calculated by the most commonly used equation of Holliday and Segar in children aged 2-18 years. Our equation will be useful for pediatricians to calculate the maintenance fluid volume for children in daily clinical settings.

Hyponatraemia in a Lao paediatric intensive care unit: Prevalence, associations and intravenous fluid use

AIM

Hyponatraemia is a common and potentially deadly complication affecting hospitalised children world-wide. Hypotonic intravenous fluids can be a significant exacerbating factor. Exclusive use of isotonic fluids, coupled with rigorous blood monitoring, has proven effective in reducing hyponatraemia in developed settings. In developing countries, where hyponatraemia is often more common and severe, different factors may contribute to its incidence and detection. We aimed to determine the prevalence and disease associations of hyponatraemia and describe the intravenous maintenance fluid prescribing practices in a Lao paediatric intensive care unit.

METHODS

We conducted a cross-sectional study of 164 children aged 1 month to 15 years admitted to intensive care at a tertiary centre in Lao People's Democratic Republic (PDR) and recorded their serum sodium and clinical data at admission and on two subsequent days.

RESULTS

Hyponatraemia was detected in 41% (67/164, confidence interval 34-48%) of children, the majority of which was mild (34%, 56/164) and present at admission (35%, 55/158). Hyponatraemia was more common in malnourished children (odds ratio (OR) 2.3, P = 0.012) and females (OR 1.9, P = 0.045). Hyponatraemia correlated with death or expected death after discharge (OR 2.2, P = 0.015); 88% received maintenance intravenous fluids, with 67% of those receiving a hypotonic solution. Electrolyte testing was only performed in 20% (9/46) of patients outside the study protocol.

CONCLUSIONS

Hyponatraemia is highly prevalent in critically ill children in Lao PDR, as is the continued use of hypotonic intravenous fluids. With financial and practical barriers to safely detecting and monitoring electrolyte disorders in this setting, this local audit can help promote testing and has already encouraged changes to fluid prescribing.

Perioperative intravenous fluid therapy in children: guidelines from the Association of the Scientific Medical Societies in Germany

This consensus- based S1 Guideline for perioperative infusion therapy in children is focused on safety and efficacy. The objective is to maintain or re-establish the child's normal physiological state (normovolemia, normal tissue perfusion, normal metabolic function, normal acid- base- electrolyte status). Therefore, the perioperative fasting times should be as short as possible to prevent patient discomfort, dehydration, and ketoacidosis. A physiologically composed balanced isotonic electrolyte solution (BS) with 1-2.5% glucose is recommended for the intraoperative background infusion to maintain normal glucose concentrations and to avoid hyponatremia, hyperchloremia, and lipolysis. Additional BS without glucose can be used in patients with circulatory instability until the desired effect is achieved. The additional use of colloids (albumin, gelatin, hydroxyethyl starch) is recommended to recover normovolemia and to avoid fluid overload when crystalloids alone are not sufficient and blood products are not indicated. Monitoring should be extended in cases with major surgery, and autotransfusion maneuvers should be performed to assess fluid responsiveness.

Isotonic versus Hypotonic Parenteral Maintenance Fluids in Very Severe Pneumonia

OBJECTIVE

To compare the risk of hyponatremia between hypotonic and isotonic parenteral maintenance solutions (PMS) administered to children with very severe pneumonia, admitted in the general pediatric ward.

METHODS

A randomized controlled open label trial was conducted in the pediatrics department of a tertiary care medical college hospital including euvolemic children 2 mo to 5 y of age, fulfilling the WHO clinical definition of very severe pneumonia and requiring PMS. They were randomized to receive either isotonic PMS (0.9% saline in 5% dextrose and potassium chloride 20 meq/L) or hypotonic PMS (0.18% saline in 5% dextrose and potassium chloride 20 meq/L) at standard rates for next 24 h.

RESULTS

A total of 119 children were randomized (59: Isotonic; 60: Hypototonic PMS). Nine (15%) children in the isotonic PMS group and 29 (48%) in the hypotonic PMS group developed hyponatremia during the study period, (p <0.001) with a relative risk being 3.16 (95% CI 1.64 to 6.09). Mean serum sodium was significantly lower in the hypotonic group compared to the isotonic group (p < 0.001 each at 6, 12 and 24 h). The difference in mean change in serum sodium from baseline was also significant at 12 and 24 h (5.4 and 5.8 meq/L respectively; p < 0.001 each).

CONCLUSIONS

This study demonstrates the rationality of the use of isotonic PMS in children with respiratory infections, a condition regularly encountered by most pediatricians.

Comparison of two maintenance electrolyte solutions in children in the postoperative appendectomy period: a randomized, controlled trial

OBJECTIVE

To compare two electrolyte maintenance solutions in the postoperative period in children undergoing appendectomy, in relation to the occurrence of hyponatremia and water retention.

METHODS

A randomized clinical study involving 50 pediatric patients undergoing appendectomy, who were randomized to receive 2,000mL/m(2)/day of isotonic (Na 150 mEq/L or 0.9% NaCl) or hypotonic (Na 30 mEq/L NaCl or 0.18%) solution. Electrolytes, glucose, urea, and creatinine were measured at baseline, 24h, and 48h after surgery. Volume infused, diuresis, weight, and water balance were analyzed.

RESULTS

Twenty-four patients had initial hyponatremia; in this group, 13 received hypotonic solution. Seventeen patients remained hyponatremic 48h after surgery, of whom ten had received hypotonic solution. In both groups, sodium levels increased at 24h (137.4±2.2 and 137.0±2.7mmol/L), with no significant difference between them (p=0.593). Sodium levels 48h after surgery were 136.6±2.7 and 136.2±2.3mmol/L in isotonic and hypotonic groups, respectively, with no significant difference. The infused volume and urine output did not differ between groups during the study. The water balance was higher in the period before surgery in patients who received hypotonic solution (p=0.021).

CONCLUSIONS

In the post-appendectomy period, the use of hypotonic solution (30 mEq/L, 0.18%) did not increase the risk of hyponatremia when compared to isotonic saline. The use of isotonic solution (150 mEq/L, 0.9%) did not favor hypernatremia in these patients. Children who received hypotonic solution showed higher cumulative fluid balance in the preoperative period.

The effect of NaCl 0.9% and NaCl 0.45% on sodium, chloride, and acid-base balance in a PICU population

OBJECTIVES

To study the effect of two intravenous maintenance fluids on plasma sodium (Na), and acid-base balance in pediatric intensive care patients during the first 24h of hospitalization.

METHODS

A prospective randomized controlled study was performed, which allocated 233 patients to groups: (A) NaCl 0.9% or (B) NaCl 0.45%. Patients were aged 1 day to 18 years, had normal electrolyte concentrations, and suffered an acute insult (medical/surgical).

MAIN OUTCOME MEASURED

change in plasma sodium. Parametric tests: t-tests, ANOVA, X(2) statistical significance level was set at α=0.05.

RESULTS

Group A (n=130): serum Na increased by 2.91 (±3.9)mmol/L at 24h (p<0.01); 2% patients had Na higher than 150 mmol/L. Mean urinary Na: 106.6 (±56.8)mmol/L. No change in pH at 0 and 24h. Group B (n=103): serum Na did not display statistically significant changes. Fifteen percent of the patients had Na<135 mmol/L at 24h. The two fluids had different effects on respiratory and post-operative situations.

CONCLUSIONS

The use of saline 0.9% was associated with a lower incidence of electrolyte disturbances.

Lack of difference between continuous versus intermittent heparin infusion on maintenance of intra-arterial catheter in postoperative pediatric surgery: a randomized controlled study

OBJECTIVE:

To compare two systems of arterial catheters maintenance in postoperative pediatric surgery using intermittent or continuous infusion of heparin solution and to analyze adverse events related to the site of catheter insertion and the volume of infused heparin solution.

METHODS:

Randomized control trial with 140 patients selected for continuous infusion group (CIG) and intermittent infusion group (IIG). The variables analyzed were: type of heart disease, permanence time and size of the catheter, insertion site, technique used, volume of heparin solution and adverse events. The descriptive variables were analyzed by Student's t-test and the categorical variables, by chi-square test, being significant p<0.05.

RESULTS:

The median age was 11 (0-22) months, and 77 (55%) were females. No significant differences between studied variables were found, except for the volume used in CIG (12.0±1.2mL/24 hours) when compared to IIG (5.3±3.5mL/24 hours) with p<0.0003.

CONCLUSIONS:

The continuous infusion system and the intermittent infusion of heparin solution can be used for intra-arterial catheters maintenance in postoperative pediatric surgery, regardless of patient's clinical and demographic characteristics. Adverse events up to the third postoperative day occurred similarly in both groups. However, the intermittent infusion system usage in underweight children should be considered, due to the lower volume of infused heparin solution [ClinicalTrials.gov Identifier: NCT01097031].

140 mmol/L of sodium versus 77 mmol/L of sodium in maintenance intravenous fluid therapy for children in hospital (PIMS): a randomised controlled double-blind trial

BACKGROUND

Use of hypotonic intravenous fluid to maintain hydration in children in hospital has been associated with hyponatraemia, leading to neurological morbidity and mortality. We aimed to assess whether use of fluid solutions with a higher sodium concentration reduced the risk of hyponatraemia compared with use of hypotonic solutions.

METHODS

We did a randomised controlled double-blind trial of children admitted to The Royal Children's Hospital (Melbourne, VIC, Australia) who needed intravenous maintenance hydration for 6 h or longer. With an online randomisation system that used unequal block sizes, we randomly assigned patients (1:1) to receive either isotonic intravenous fluid containing 140 mmol/L of sodium (Na140) or hypotonic fluid containing 77 mmol/L of sodium (Na77) for 72 h or until their intravenous fluid rate decreased to lower than 50% of the standard maintenance rate. We stratified assignment by baseline sodium concentrations. Study investigators, treating clinicians, nurses, and patients were masked to treatment assignment. The primary outcome was occurrence of hyponatraemia (serum sodium concentration <135 mmol/L with a decrease of at least 3 mmol/L from baseline) during the treatment period, analysed by intention to treat. The trial was registered with the Australian New Zealand Clinical Trials Registry, number ACTRN1260900924257.

FINDINGS

Between Feb 2, 2010, and Jan 29, 2013, we randomly assigned 690 patients. Of these patients, primary outcome data were available for 319 who received Na140 and 322 who received Na77. Fewer patients given Na140 than those given Na77 developed hyponatraemia (12 patients [4%] vs 35 [11%]; odds ratio [OR] 0·31, 95% CI 0·16-0·61; p=0·001). No clinically apparent cerebral oedema occurred in either group. Eight patients in the Na140 group (two potentially related to intravenous fluid) and four in the Na77 group (none related to intravenous fluid) developed serious adverse events during the treatment period. One patient in the Na140 had seizures during the treatment period compared with seven who received Na77.

INTERPRETATION

Use of isotonic intravenous fluid with a sodium concentration of 140 mmol/L had a lower risk of hyponatraemia without an increase in adverse effects than did fluid containing 77 mmol/L of sodium. An isotonic fluid should be used as intravenous fluid for maintenance hydration in children.

FUNDING

National Health and Medical Research Council, Murdoch Childrens Research Institute, The Royal Children's Hospital, and the Australian and New Zealand College of Anaesthetists.

The efficacy of isotonic and hypotonic intravenous maintenance fluid for pediatric patients: a meta-analysis of randomized controlled trials

AIM

This study aimed to analyze the effect of isotonic versus hypotonic solution as intravenous maintenance fluid on level of plasma sodium in hospitalized children.

METHODS

A fully recursive literature search in May 2013 was conducted in PubMed and EMBASE to identify potentially relevant randomized controlled trials. Jadad score and allocation concealment were adopted to evaluate the methodological quality of each trial. RevMan5.2 was used for statistical analysis.

RESULTS

Eight randomized controlled trials with 752 patients were included. Combined analysis showed a significant lower risk of hyponatremia with isotonic solution (odds ratio, 0.36; 95% confidence interval, 0.26-0.51). The isotonic intravenous maintenance did not increase the possibility of hypernatremia (odds ratio, 0.86; 95% confidence interval, 0.36-2.06).

CONCLUSIONS

The meta-analysis revealed that there was potential risk of hyponatremia for routine infusion of hypotonic maintenance fluid. The use of isotonic solution was warranted in hospitalized pediatric patients.

Impact of reduced resuscitation fluid on outcomes of children with 10-20% body surface area scalds

'Permissive hypovolaemia' fluid regimes in adult burn care are suggested to improve outcomes. Effects in paediatric burn care are less well understood. In a retrospective audit, outcomes of children from the South West Children's Burn Centre (SWCBC) less than 16 years of age with scalds of 10-20% burn surface area (BSA) managed with a reduced volume fluid resuscitation regime (post-2007) were compared to (a) an historical local protocol (pre-2007) and (b) current regimes in burn services across England and Wales (E&W). Outcomes included length of stay per percent burn surface area (LOS/%BSA), skin graft requirement and re-admission rates. 92 SWCBC patients and 475 patients treated in 15 other E&W burn services were included. Median LOS/%BSA for patients managed with the reduced fluid regime was 0.27 days: significantly less than pre-2007 and other E&W burn services (0.54 days, 0.50 days, p<0.001). Skin grafting to achieve healing reduced post-2007 compared to pre-2007 and remains comparable with other E&W services. Re-admission rates were comparable between all groups. A reduced fluid regime has significantly shortened LOS/%BSA without compromising burn depth as measured by skin grafting to achieve healing. A prospective trial comparing permissive hypovolaemia to current regimes for moderate paediatric scald injuries would help clarify.

Stabilisation and Transport of the Critically Ill Child

Since the Department of Health Report ‘Paediatric Intensive Care: A framework for the future’ in 1997, paediatric intensive care services have been centralised and 24-hour retrieval services developed. However, all hospitals admitting critically ill children must be able to resuscitate and stabilise prior to retrieval, and occasionally undertake the ‘time-critical’ transfers themselves. This article reviews the clinical and organisational skills involved in the retrieval process, and also suggests ways in which knowledge and skills can be maintained.

Fluid management in the critically ill child

Fluid management has a major impact on the duration, severity and outcome of critical illness. The overall strategy for the acutely ill child should be biphasic. Aggressive volume expansion to support tissue oxygen delivery as part of early goal-directed resuscitation algorithms for shock--especially septic shock--has been associated with dramatic improvements in outcome. Recent data suggest that the cost-benefit of aggressive fluid resuscitation may be more complex than previously thought, and may depend on case-mix and the availability of intensive care. After the resuscitation phase, critically ill children tend to retain free water while having reduced insensible losses. Fluid regimens that limit or avoid positive fluid balance are associated with a reduced length of hospital stay and fewer complications. Identifying the point at which patients change from the 'early shock' pattern to the later 'chronic critical illness' pattern remains a major challenge. Very little data are available on the choice of fluids, and most of the information that is available arises from studies of critically ill adults. There is therefore an urgent need for high-quality trials of both resuscitation and maintenance fluid regimens in critically ill children.

A few clinical aspects of sodium homeostasis disorders

In this review three major issues of sodium homeostasis are addressed. Specifically, volume-dependent (salt-sensitive) hypertension, sodium chloride content of maintenance fluid and clinical evaluation of hyponatremia are discussed. Regarding volume-dependent hypertension the endocrine/paracrine systems mediating renal sodium retention, the relationship between salt intake, plasma sodium levels and blood pressure, as well as data on the dissociation of sodium and volume regulation are presented. The concept of perinatal programming of salt-preference is also mentioned. Some theoretical and practical aspects of fluid therapy are summarized with particular reference to using hypotonic sodium chloride solution for maintenance fluid as opposed to the currently proposed isotonic sodium chloride solution. Furthermore, the incidence, the aetiological classification and central nervous system complications of hyponatremia are presented, too. In addition, clinical and pathophysical features of hyponatremic encephalophathy and osmotic demyelinisation are given. The adaptive reactions of the brain to hypotonic stress are also described with particular emphasis on the role of brain-specific water channel proteins (aquaporin-4) and the benzamil-inhibitable sodium channels. In view of the outmost clinical significance of hyponatremia, the principles of efficient and safe therapeutic approaches are outlined. Orv. Hetil., 2013, 154, 1488–1497.

European consensus statement for intraoperative fluid therapy in children

The intraoperative infusion of isotonic solutions with 1-2.5% glucose in children is considered well established use in Europe and other countries. Unfortunately, a European marketing authorisation of such a solution is currently missing and as a consequence paediatric anaesthetists tend to use suboptimal intravenous fluid strategies that may lead to serious morbidity and even mortality because of iatrogenic hyponatraemia, hyperglycaemia or medical errors. To address this issue, the German Scientific Working Group for Paediatric Anaesthesia suggests a European consensus statement on the composition of an appropriate intraoperative solution for infusion in children, which was discussed during a working session at the 2nd Congress of the European Society for Paediatric Anaesthesiology in Berlin in September 2010. As a result, it was recommended that an intraoperative fluid should have an osmolarity close to the physiologic range in children in order to avoid hyponatraemia, an addition of 1-2.5% instead of 5% glucose in order to avoid hypoglycaemia, lipolysis or hyperglycaemia and should also include metabolic anions (i.e. acetate, lactate or malate) as bicarbonate precursors to prevent hyperchloraemic acidosis. Thus, the underlying intention of this consensus statement is to facilitate the granting of a European marketing authorisation for such a solution with the ultimate goal of improving the safety and effectiveness of intraoperative fluid therapy in children.

Hypotonic versus isotonic maintenance fluids after surgery for children: a randomized controlled trial

OBJECTIVE

The objective of this randomized controlled trial was to evaluate the risk of hyponatremia following administration of a isotonic (0.9% saline) compared to a hypotonic (0.45% saline) parenteral maintenance solution (PMS) for 48 hours to postoperative pediatric patients.

METHODS

Surgical patients 6 months to 16 years of age with an expected postoperative stay of >24 hours were eligible. Patients with an uncorrected baseline plasma sodium level abnormality, hemodynamic instability, chronic diuretic use, previous enrollment, and those for whom either hypotonic PMS or isotonic PMS was considered contraindicated or necessary, were excluded. A fully blinded randomized controlled trial was performed. The primary outcome was acute hyponatremia. Secondary outcomes included severe hyponatremia, hypernatremia, adverse events attributable to acute plasma sodium level changes, and antidiuretic hormone levels.

RESULTS

A total of 258 patients were enrolled and assigned randomly to receive hypotonic PMS (N = 130) or isotonic PMS (N = 128). Baseline characteristics were similar for the 2 groups. Hypotonic PMS significantly increased the risk of hyponatremia, compared with isotonic PMS (40.8% vs 22.7%; relative risk: 1.82 [95% confidence interval: 1.21-2.74]; P = .004). Admission to the pediatric critical care unit was not an independent risk factor for the development of hyponatremia. Isotonic PMS did not increase the risk of hypernatremia (relative risk: 1.30 [95% confidence interval: 0.30-5.59]; P = .722). Antidiuretic hormone levels and adverse events were not significantly different between the groups.

CONCLUSION

Isotonic PMS is significantly safer than hypotonic PMS in protecting against acute postoperative hyponatremia in children.

Survey of paediatric intravenous fluid prescription: are we safe in what we know and what we do?

OBJECTIVE

The administration of i.v. fluids to children is common in hospital. There are risks associated with fluid therapy, especially iatrogenic hyponatraemia. The objective of this study was to assess the workplace practices and knowledge of tertiary hospital doctors regarding paediatric i.v. fluid prescription.

METHODS

This is a prospective, questionnaire-based observational study conducted at a 570-bed teaching hospital in June 2009. A convenience sample of doctors (n= 150), representing all levels of experience and all specialties that regularly prescribe paediatric i.v. fluids, were invited to participate. The main outcome measures consisted of demographical data and the ability to correctly prescribe paediatric fluids measured as 'fluid calculation', 'fluid choice' and 'total' percentage scores based on a percentage score of correctly answered questions using eight clinical scenarios.

RESULTS

One hundred and six (71%) doctors returned a completed questionnaire. The great majority of respondents had a method for calculating a fluid bolus and maintenance rates (91% and 97%, respectively). Scenarios involving infants, especially where an increased risk of antidiuretic hormone secretion was possible, were answered poorly. Senior doctors performed better than junior doctors. ED and paediatric doctors performed better than those in other specialities.

CONCLUSIONS

Most doctors in this Australian tertiary hospital have a correct method for prescribing bolus and maintenance fluid rates. However, the potential for adverse events from i.v. fluid prescription remains. Further education in this area for junior doctors, introduction of standardized guidelines for fluid use and restriction of available fluid choice may reduce the risk of iatrogenic hyponatraemia in children.

A randomized controlled trial of isotonic versus hypotonic maintenance intravenous fluids in hospitalized children

Background

Isotonic saline has been proposed as a safer alternative to traditional hypotonic solutions for intravenous (IV) maintenance fluids to prevent hyponatremia. However, the optimal tonicity of maintenance intravenous fluids in hospitalized children has not been determined. The objective of this study was to estimate and compare the rates of change in serum sodium ([Na]) for patients administered either hypotonic or isotonic IV fluids for maintenance needs.

Methods

This was a masked controlled trial. Randomization was stratified by admission type: medical patients and post-operative surgical patients, aged 3 months to 18 years, who required IV fluids for at least 8 hours. Patients were randomized to receive either 0.45% or 0.9% saline in 5.0% dextrose. Treating physicians used the study fluid for maintenance; infusion rate and the use of additional fluids were left to their discretion.

Results

Sixteen children were randomized to 0.9% saline and 21 to 0.45% saline. Baseline characteristics, duration (average of 12 hours) and rate of study fluid infusion, and the volume of additional isotonic fluids given were similar for the two groups. [Na] increased significantly in the 0.9% group (+0.20 mmol/L/h [IQR +0.03, +0.4]; P = 0.02) and increased, but not significantly, in the 0.45% group (+0.08 mmol/L/h [IQR -0.15, +0.16]; P = 0.07). The rate of change and absolute change in serum [Na] did not differ significantly between groups.

Conclusions

When administered at the appropriate maintenance rate and accompanied by adequate volume expansion with isotonic fluids, 0.45% saline did not result in a drop in serum sodium during the first 12 hours of fluid therapy in children without severe baseline hyponatremia. Confirmation in a larger study is strongly recommended.

Clinical Trial Registration Number

NCT00457873 (http://www.clinicaltrials.gov/)

The challenges of managing severe dehydrating diarrhoea in a resource-limited setting

Diarrhoea remains one of the most common causes of childhood deaths worldwide despite the widespread use of oral rehydration solution (ORS). The vast majority of the nearly 2 million diarrhoeal deaths occurring annually in children under five years of age are in south Asia and sub-Saharan Africa. Signs of critical illness in severely dehydrated children are poorly recognised, and although considerable efforts have gone into establishing the management of diarrhoeal disease in general, there is surprisingly little understanding of the aetiology, metabolic processes and risk factors for the very high mortality associated with severe dehydrating diarrhoea (SDD). We suggest that in many resource-poor settings, the degree of fluid requirement as well as the prevalence of electrolyte disturbances are seriously under-recognised and may be contributing significantly to mortality. The heterogeneity of children with SDD renders the generic 'one size fits all' approach to fluid and electrolyte management in these critically ill children inadequate. In this review we will highlight SDD as an important target for research in resource-limited settings, and emphasise the need to re-evaluate the efficacy of prevailing intravenous fluid protocols in well conducted multi-centre interventional trials.

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

AIM

Study the influence of hypotonic (HT) and isotonic (IT) maintenance fluids in the incidence of dysnatraemias in critically ill children.

METHODS

Prospective, randomized study conducted in three paediatric intensive care units (PICU). One hundred and twenty-five children requiring maintenance fluid therapy were included: 62 received HT fluids (50-70 mmol/L tonicity) and 63 IT fluids (156 mmol/L tonicity). Age, weight, cause of admission, sodium and fluid intake, and diuresis were collected. Blood electrolytes were measured on admission, 12 and 24 h later.

RESULTS

Blood sodium levels at 12 h were 133.7±2.7 mmol/L in HT group vs. 136.8±3.5 mmol/L in IT group (p=0.001). Adjusted for age, weight and sodium level at PICU admission, the blood sodium values of patients receiving HT fluids decrease by 3.22 mmol/L (CI: 4.29/2.15)(p=0.000). Adjusted for age, weight and hyponatraemia incidence at admission, patients receiving HT fluids increased the risk of hyponatraemia by 5.8-fold (CI: 2.4-14.0) during the study period (p=0.000).

CONCLUSIONS

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.

Iatrogenic hyponatremia in hospitalized children: Can it be avoided?

Iatrogenic hyponatremia in hospitalized children is a common problem. It is usually caused by the administration of free water, either orally or through the prescription of hypotonic intravenous fluids. It can result in cerebral edema and death, and is most commonly reported in healthy children undergoing minor surgery. The current teachings and practical guidelines for maintenance fluid infusions are based on caloric expenditure data in healthy children that were derived and published more than 50 years ago. A re-evaluation of these data and more recent recognition that hospitalized children are vulnerable to hyponatremia, with its resulting morbidity and mortality rates, suggest that changes in paediatricians' approach to fluid administration are necessary. There is no single fluid therapy that is optimal for all hospitalized children. A thorough assessment of the type of fluid, volume of fluid and electrolyte requirements based on individual patient requirements, plus rigorous monitoring, is required in any child receiving intravenous fluids. The present article reviews how hyponatremia occurs and makes recommendations for minimizing the risk of iatrogenic hyponatremia.

Neonatal fluid management

Perioperative fluid management in paediatrics has been the subject of many controversies in recent years, but fluid management in the neonatal period has not been considered in most reviews and guidelines. The literature regarding neonatal fluid management mainly appears in the paediatric textbooks and few recent data are available, except for resuscitation and fluid loading during shock and major surgery. In the context of anaesthesia, many neonates requiring surgery within the first month of life have organ malformation and/or dysfunction. This article aims at reviewing basic physiological considerations important for neonatal fluid management and mainly focusses on fluid maintenance and replacement during surgery.

Intravenous fluid regimen and hyponatraemia among children: a randomized controlled trial

The aim of this study was to compare the effect of three different intravenous (i.v.) fluid regimes on the incidence of hyponatraemia in hospitalized children ranging in age from 3 months to 12 years. Children who required the administration of i.v. maintenance fluid for at least 24 h following hospitalization were eligible for inclusion. The children were randomized to three i.v. fluid groups: Group A, 0.9% saline in 5% dextrose at the standard maintenance rate; Group B, 0.18% saline in 5% dextrose at the standard maintenance rate; Group C, 0.18% saline in 5% dextrose at two-thirds of the standard maintenance rate. The primary outcome measure was incidence of hyponatraemia (plasma sodium < 130 mEq/L). Of the 167 patients enrolled, 58, 56 and 53 patients were randomized to Group A, B and C, respectively. We observed that 14.3% (8/56) of the children administered 0.18% saline in 5% dextrose at the standard maintenance rate (Group B) developed hyponatraemia compared with 1.72% of the children in Group A and 3.8% of those in Group C. Based on these results, we conclude that the administration of 0.9% saline in 5% dextrose as i.v. maintenance fluid helps in reducing the incidence of hospital-acquired hyponatraemia among children.

A novel isotonic-balanced electrolyte solution with 1% glucose for intraoperative fluid therapy in children: results of a prospective multicentre observational post-authorization safety study (PASS)

BACKGROUND

The recommendations for intraoperative fluid therapy in children have been adapted from hypotonic to isotonic electrolyte solutions with lower glucose concentrations (1-2.5% instead of 5%) to avoid hyponatremia and hyperglycemia.

OBJECTIVE

The objective of this prospective multicentre observational post-authorization safety study was to evaluate the intraoperative use of a novel isotonic-balanced electrolyte solution with 1% glucose (BS-G1) with a particular focus on changes in acid-base status, electrolyte and glucose concentrations.

METHODS

Following local ethics committee approval, pediatric patients aged up to 4 years with an ASA risk score of I-III undergoing intraoperative administration of BS-G1 were enrolled. Patient demographics, the performed procedure, adverse drug reactions, hemodynamic data, and the results of blood gas analysis before and after infusion were documented with a focus on changes in acid-base status, electrolyte and glucose concentrations.

RESULTS

In 107 patients (ASA I-III; age 16.2 ± 15.4, range day of birth to 47.7 months; body weight 8.8 ± 4.8, range 1.6-18.8 kg), the mean volume infused was 20 ± 12.6 (range 3.6-83.3) ml·kg(-1) BS-G1. During the infusion, hemoglobin, hematocrit, anion gap, strong ion difference, and calcium decreased and chloride and glucose increased significantly within the physiologic range. All other measured parameters including sodium, bicarbonate, base excess, and lactate remained stable. Neither hypoglycemia (glucose <2.5 mmol·l(-1) ) nor hyperglycemia (glucose >10 mmol·l(-1) ) was documented after BS-G1 infusion. No adverse drug reactions were reported.

CONCLUSION

The studied isotonic-balanced electrolyte solution with 1% glucose helps to avoid perioperative acid-base imbalance, hyponatremia, hyperglycemia, and ketoacidosis in infants and toddlers and may therefore enhance patient safety.

Hyponatremia and syndrome of inappropriate antidiuretic hormone secretion in kawasaki disease

Background and Objectives

The pathogenesis of hyponatremia (serum sodium <135 mEq/L) in Kawasaki disease (KD) remains unclear. We investigated the clinical significance of hyponatremia, and the role of interleukin (IL)-6 and IL-1β in the development of hyponatremia and syndrome of inappropriate antidiuretic hormone secretion (SIADH) in KD.

Subjects and Methods

Fifty KD patients were prospectively enrolled and analyzed for clinical and laboratory variables according to the presence of hyponatremia or SIADH.

Results

Thirteen KD patients (26%) had hyponatremia and 6 of these had SIADH. In patients with hyponatremia, the percentage of neutrophils (% neutrophils), C-reactive protein (CRP), and N-terminal pro-brain natriuretic peptide (NT-proBNP) were higher than in those without hyponatremia, while serum triiodothyronine (T3) and albumin were lower. Patients with hyponatremia had a higher incidence of intravenous immunoglobulin-resistance but this was not statistically significant. No differences existed between patients with and without SIADH with regard to clinical or laboratory variables and the incidence of IVIG-resistance. Serum sodium inversely correlated with % neutrophils, CRP, and NT-proBNP, and positively correlated with T3 and albumin. Serum IL-6 and IL-1β levels increased in KD patients and were higher in patients with hyponatremia. Plasma antidiuretic hormone increased in patients with SIADH, which tended to positively correlate with IL-6 and IL-1β levels.

Conclusion

Hyponatremia occurs in KD patients with severe inflammation, while increased IL-6 and IL-1β may activate ADH secretion, leading to SIADH and hyponatremia in KD.

Incidence of hyponatremia in children with gastroenteritis treated with hypotonic intravenous fluids

Hypotonic saline solutions have been used for over five decades to treat children with diarrheal dehydration. However, concern has recently been raised about the potential for iatrogenic hyponatremia as a result of this therapy. We reviewed the medical records of 531 otherwise healthy children with gastroenteritis who had been admitted to the hospital for intravenous fluid therapy. We retrospectively collected data on 141 of these children who had received two serum electrolytes (one upon admission and the other 4-24 h thereafter). The remaining 390 children were excluded because their charts lacked the required data. We analyzed data in 124 of these 141 patients whose initial serum sodium (Na) level was between 130-150 mEq/l and excluded 17 patients whose admission serum sodium fell outside this range. All patients were treated with intravenous hypotonic fluids (5% dextrose in 0.2% saline, n = 4; 5% dextrose in 0.3% saline, n = 102; 5% dextrose in 0.45% saline, n = 18 patients) as maintenance fluid therapy or maintenance fluid plus deficit therapy; 100 of these children had received an initial saline bolus of 21.05 +/- 8.5 ml/kg upon admission. The serum Na level decreased by 1.7 +/- 4.3 mEq/l in the whole group. Of the 97 children with isonatremia (Na 139.5 +/- 2.7 mEq/l) on admission, 18 (18.5%) developed mild hyponatremia (Na 133.4 +/- 0.9 mEq/l, range 131-134), with a decrease in serum Na of 5.7 +/- 3.1 mEq/l, and 79 remained isonatremic (Na 138.3 +/- 2.7 mEq/l), with a decrease in serum Na of 1.8 +/- 3.4 mEq/l (p < 0.0005). There was no significant difference in type, rate, or amount of intravenous fluid or saline bolus (26.1 +/- 10.4 vs. 20.2 +/- 8.6 ml/kg, respectively) administered in these two groups. Children who became hyponatremic were older (5.8 +/- 2.7 years) than those who remained isonatremic (2.8 +/- 3.1 years) (p < 0.0005), but there was no statistical difference in gender, degree of dehydration, and severity of metabolic acidosis between the two groups. Although serum Na increased by 3.9 +/- 2.5 mEq/l in 19 patients with mild hyponatremia upon admission (Na 132.8 +/- 1.3 to 136.7 +/- 2.6 mEq/l) and 73% of these became isonatremic, hypotonic saline solutions have the potential to cause hyponatremia in children with gastroenteritis and isonatremic dehydration.

Immunoglobulin preparations affect hyponatremia in Kawasaki disease

Hyponatremia frequently occurs in Kawasaki disease (KD). The aim of this study was to investigate the effect of Na content of the intravenous immunoglobulin (IVIG) preparation on serum Na levels in KD. Seventy-eight subjects, of whom 27 had hyponatremia, were split up into two groups: group A receiving IVIG preparations containing high Na (0.9%) and group B receiving IVIG preparations containing trace Na. While the data before IVIG therapy revealed no significant differences in the median serum Na between the groups, an administration of IVIG preparations increased the serum levels of Na in group A (P < 0.01) but not in group B (P > 0.05). Furthermore, the median serum Na level was significantly higher in group A than that in group B (139.0 vs 137.0 mEq/L, respectively, P < 0.01). No significant difference was found in the prevalence of coronary artery lesions between the groups. In conclusion, we should keep it in mind that the IVIG products without Na have an adverse affect on hyponatremia in KD though their efficacy seems to be equivalent to those containing high Na.

The impact of the National Patient Safety Agency intravenous fluid alert on iatrogenic hyponatraemia in children

In March 2007, the National Patient Safety Agency (NPSA) issued an alert regarding intravenous fluid (IVF) prescription to hospitalised infants and children, to be implemented in UK hospitals by September 2007. Previously, the most commonly used IVF (0.18% saline/4% dextrose) has been associated with iatrogenic hyponatraemia, resulting in four deaths and one near miss since 2000. The alert recommended 0.45% (or 0.9%) saline/5% dextrose as maintenance IVF and banned 0.18% saline/4% dextrose. We audited practice and outcome in children receiving maintenance IVF in June 2007 (before guideline implementation) and June 2008 (after guideline implementation). In June 2007, 44 (30%) children were prescribed IVF, six received IVF not recommended by NPSA alert 22 and one became hyponatraemic. In June 2008, 56 (30%) children received IVF; one received IVF not recommended by NPSA alert 22 and became hyponatraemic. The median change in serum sodium levels for all children who received IVF not recommended by NPSA alert 22 [-5 (-15 to 0) mmol/l] was significantly greater than those who received IVF recommended by NPSA alert 22 [0 (-13 to +7) mmol/l, p = 0.002]. In addition, there was a significant (p = 0.04) reduction in the number of children who had electrolytes checked while on IVF after implementation of the guideline. Implementation of a new IVF guideline has been associated with less use of IVF not recommended by NPSA alert 22, resulting in less serum sodium level reduction. The only children who became hyponatraemic received IVF not recommended by NPSA alert 22. Despite the NPSA alert and guideline implementation, less children had electrolyte levels checked while receiving IVF.

Hospital-acquired hyponatremia in postoperative pediatric patients: prospective observational study

OBJECTIVE

To establish the incidence and factors associated with hospital-acquired hyponatremia in pediatric surgical patients who received hypotonic saline (sodium 40 mmol/L plus potassium 20 mmol/L) at the rate suggested by the Holliday and Segar's formula for calculations of maintenance fluids.

DESIGN

Prospective, observational, cohort study.

SETTING

Pediatric intensive care unit.

PATIENTS

: Eighty-one postoperative patients.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Incidence and factors associated with hyponatremia (sodium < or = 135 mmol/L). Univariate analysis was conducted post surgery at 12 hrs and at 24 hrs. Mean values were compared with independent t test samples. Receiver operating characteristics curve analysis was performed in variables with a p <.05, and relative risks were calculated. Eighty-one patients were included in the study. The incidence of hyponatremia at 12 hrs was 17 (21%) of 81 (95% confidence interval, 3.7-38.3); at 24 hrs, it was was 15 (31%) of 48 (95% confidence interval, 11.4-50.6). Univariate analysis at 12 hrs showed that hyponatremic patients had a higher sodium loss (0.62 mmol/kg/hr vs. 0.34 mmol/kg/hr, p = .0001), a more negative sodium balance (0.39 mmol/kg/hr vs. 0.13 mmol/kg/hr, p < .0001), and a higher diuresis (3.08 mL/kg/hr vs. 2.2 mL/kg/hr, p = .0026); relative risks were 11.55 (95% confidence interval, 2.99-44.63; p = .0004) for a sodium loss >0.5 mmol/kg/hr; 10 (95% confidence interval, 2.55-39.15; p = .0009) for a negative sodium balance >0.3 mmol/kg/hr; and 4.25 (95% confidence interval, 1.99-9.08; p = .0002) for a diuresis >3.4 mL/kg/hr. At 24 hrs, hyponatremic patients were in more positive fluid balance (0.65 mL/kg/hr vs. 0.10 mL/kg/hr, p = .0396); relative risk was 3.25 (95% confidence interval, 1.2-8.77; p = .0201), for a positive fluid balance >0.2 mL/kg/hr.

CONCLUSIONS

The incidence of hyponatremia in this population was high and progressive over time. Negative sodium balance in the first 12 postoperative hours and then a positive fluid balance could be associated with the development of postoperative hyponatremia.