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Mittal S, Knerr S, Prasto J, Hunt J, Mattern C, Chang T, Marchese R, Jessee M, Marlowe L, Haupt J. Closing the Fluid Gap: Improving Isotonic Maintenance Intravenous Fluid Use in a Community Hospital Network. Pediatr Qual Saf 2023; 8:e696. [PMID: 37818202 PMCID: PMC10561811 DOI: 10.1097/pq9.0000000000000696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 08/19/2023] [Indexed: 10/12/2023] Open
Abstract
Introduction The American Academy of Pediatrics recommends using isotonic intravenous fluids (IVF) for maintenance needs to decrease the risk of hyponatremia. We conducted a quality improvement project to increase the use of isotonic maintenance IVF in pediatric patients admitted to three sites in a community hospital network to >85% within 12 months. Methods We used improvement methodology to identify causes of continued hypotonic fluid use, which involved provider behavior and systems factors. We implemented interventions to address these factors including: (1) education; (2) clinical decision support; and (3) stocking automated medication dispensing systems with isotonic IVF. We compared isotonic IVF use before and after interventions in all admitted patients aged 28 days to 18 years who received maintenance IVFs at the rate of at least 10 mL/hour. We excluded admissions of patients with active chronic medical conditions like diabetic ketoacidosis. Balancing measures were the occurrence of adverse events from hypo- or hypernatremia. Data were analyzed using Laney P' statistical process control charts. Results Isotonic IVF use among patients requiring maintenance fluids at all three sites surpassed the goal of >85% within 12 months. There were no reports of hypo- or hypernatremia or other adverse outcomes related to the use of isotonic IVF. Conclusion A combination of interventions aimed at provider behavior and systems factors was critical to successfully adopting the American Academy of Pediatrics guideline regarding the use of maintenance isotonic IVF in hospitalized children.
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Affiliation(s)
- Shraddha Mittal
- From the Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pa
- Department of Pharmacy, Virtua Voorhees, Voorhees, N.J
| | - Sheila Knerr
- From the Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pa
- Department of Pharmacy, Grand View Health, Sellersville, Pa
| | - Julianne Prasto
- From the Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pa
- Department of Pharmacy, Penn Medicine Princeton Medical Center, Plainsboro, N.J
| | - Jessica Hunt
- Department of Pharmacy, Virtua Voorhees, Voorhees, N.J
| | | | - Tsae Chang
- Department of Pharmacy, Penn Medicine Princeton Medical Center, Plainsboro, N.J
| | - Ronald Marchese
- From the Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pa
- Department of Pharmacy, Virtua Voorhees, Voorhees, N.J
| | - Morgan Jessee
- From the Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pa
- Department of Pharmacy, Virtua Voorhees, Voorhees, N.J
| | - Lauren Marlowe
- From the Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pa
- Department of Pharmacy, Virtua Voorhees, Voorhees, N.J
| | - Josh Haupt
- Center for Healthcare Quality & Analytics (CHQA), Children’s Hospital of Philadelphia, Philadelphia, Pa
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2
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Soulages Arrese N, Green ML. Fluid management of the critically Ill child. Curr Opin Pediatr 2023; 35:239-244. [PMID: 36472133 DOI: 10.1097/mop.0000000000001210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW This review summarizes current literature pertaining to fluid management for critically ill children. It includes an overview on crystalloid fluid used throughout the critical illness course, management of fluid output and complications with fluid overload. RECENT FINDINGS Observational paediatric studies and adult randomized trials show mixed results regarding risk of mortality and kidney injury with 0.9% saline and crystalloid fluid. A recent adult randomized trial suggests that a fluid restrictive strategy may be well tolerated in critically ill adults with septic shock, but further randomized trials are needed in paediatrics. Fluid overload has been associated with increased morbidity and mortality. Trials exploring ways to decrease fluid accumulation must be done in paediatrics. SUMMARY Additional high-quality studies are needed to precisely define the type, timing and rate of intravenous fluid critically ill children should receive throughout their clinical illness course.
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Affiliation(s)
- Natalia Soulages Arrese
- University of Texas Southwestern Medical Center, Department of Pediatrics, Division of Critical Care Medicine, Dallas, Texas, USA
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3
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Gorga SM, Sliwicki AL, Sturza J, Carlton EF, Barbaro RP, Basu RK. Variability in Clinician Awareness of Intravenous Fluid Administration in Critical Illness: A Prospective Cohort Study. J Pediatr Intensive Care 2022. [DOI: 10.1055/s-0042-1758476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
AbstractIntravenous (IV) fluids are commonly administered to critically ill children, but clinicians lack effective guidance for the correct dose and duration of therapy resulting in variation of prescribing habits which harm children. It is unknown if clinicians recognize the amount of IV fluid that patients receive. We aimed to determine clinician's accuracy in the identification of the volume of IV fluids patients will receive over the next 24 hours. Prospective cohort study enrolled all patients admitted to the pediatric intensive care unit (PICU) from May to August 2021 at the University of Michigan's C.S. Mott Children's Hospital PICU. For each patient, clinicians estimated the volume of IV fluid that patients will receive in the next 24 hours. The primary outcome was accuracy of the estimation defined as predicted volume of IV fluids versus actual volume administered within 10 mL/kg or 500 mL depending on patient's weight. We tested for differences in accuracy by clinician type using chi-square tests. There were 259 patients for whom 2,295 surveys were completed by 177 clinicians. Clinicians' estimates were accurate 48.8% of the time with a median difference of 10 (1–26) mL/kg. We found that accuracy varied between clinician type: bedside nurses were most accurate at 64.3%, and attendings were least accurate at 30.5%. PICU clinicians have poor recognition of the amount of IV fluids their patients will receive in the subsequent 24-hour period. Estimate accuracy varied by clinician's role and improved over time, which may suggest opportunities for improvement.
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Affiliation(s)
- Stephen M. Gorga
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan, United States
| | - Alexander L. Sliwicki
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan, United States
| | - Julie Sturza
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan, United States
| | - Erin F. Carlton
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan, United States
- Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, United States
| | - Ryan P. Barbaro
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan, United States
- Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, United States
| | - Rajit K. Basu
- Ann & Robert Lurie Children's Hospital of Chicago, Department of Pediatrics, Northwestern University, Chicago, Illinois, United States
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4
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Ratnjeet K, Pallavi P, Jhamb U, Saxena R. 0.45% Versus 0.9% Saline in 5% Dextrose as Maintenance Fluids in Children Admitted With Acute Illness: A Randomized Control Trial. Pediatr Emerg Care 2022; 38:436-441. [PMID: 36040464 DOI: 10.1097/pec.0000000000002621] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The safety of giving intravenous (IV) maintenance fluids according to Holliday and Segar's recommendations of 1957 has recently been questioned after reports of complications caused by iatrogenic hyponatremia in children receiving hypotonic fluids. However, the current practice of choice of maintenance IV fluids for hospitalized children varies worldwide. This study was planned to compare 0.45% and 0.9% saline in 5% dextrose at standard maintenance rates in hospitalized children aged 3 months to 12 years. OBJECTIVE Primary objective was to study change in serum sodium level at 24 hours in children receiving total IV fluid maintenance therapy as 0.45% or 0.9% normal saline in 5% dextrose. Secondary objectives of this study were to estimate change in serum sodium levels from the baseline to 48 or 72 hours, if IV fluids were continued, and to find incidence of hyponatremia and hypernatremia after administering these 2 types of maintenance fluids. METHODS This study was an open-label, randomized control trial conducted at the Department of Pediatrics of a tertiary care hospital from July 22, 2019, to October 28, 2019. Two hundred children aged 3 months to 12 years admitted in pediatric emergency and requiring IV maintenance fluid were randomized into 2 groups (group A received 0.45% saline in 5% dextrose, group B received 0.9% normal saline in 5% dextrose) with 100 in each group. RESULTS Both groups were comparable for baseline characteristics. Fall in mean serum sodium from baseline was more with increasing duration of IV fluids until 24 hours in 0.45% saline group as compared with 0.9% saline group, which was statistically significant (P < 0.001). The incidence of mild and moderate hyponatremia was significantly more in hypotonic group at 12 hours (P < 0.001) and 24 hours (P < 0.001). However, there was no significant difference at 48 hours. CONCLUSIONS The fall in serum sodium values was significant, and there was significant risk of hyponatremia with the use of hypotonic fluids at 12 and 24 hours. Hence, the use of isotonic fluids seems to be more appropriate among the hospitalized children.Trial Registration: CTRI/2019/10/021791.
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Affiliation(s)
- Kumar Ratnjeet
- From the Department of Pediatrics, Maulana Azad Medical College, New Delhi, India
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5
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Gao ZZ, Wang F, Hua L, Cui XH, Xu J, Fu WY, Chen HZ. Effectiveness of a novel 1% glucose isotonic electrolyte solution for intraoperative fluid therapy in children: a randomized controlled trial. J Int Med Res 2021; 49:3000605211055624. [PMID: 34775865 PMCID: PMC8593312 DOI: 10.1177/03000605211055624] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background An appropriate electrolyte solution is important for safe intraoperative anesthesia management in children. This trial assessed the effectiveness of a novel 1% glucose isotonic electrolyte solution in intraoperative fluid therapy in children. Methods This trial analyzed data from 100 patients aged older than 1 month with an ASA score of I to II who received general anesthesia. Patients were randomly assigned to receive either the novel electrolyte solution (containing glucose, sodium, potassium, chloride, and bicarbonate) or lactated Ringer’s solution intraoperatively as a maintenance fluid. Patient demographics and the results of blood gas analysis at 1, 2, and 3 hours were documented, and changes in glucose and electrolyte concentrations and the acid–base status were analyzed. Results During infusion of the novel solution, the glucose and potassium concentrations were stable. Conversely, the solution was linked to increased sodium levels but decreased bicarbonate levels, although both changes were within the physiological ranges. In addition, pH remained stable during the intraoperative period. Hypoglycemia, hyperglycemia, hyponatremia, or hypernatremia was not detected. Conclusions The novel 1% glucose isotonic electrolyte solution helped to maintain glucose and electrolyte concentrations and acid–base stability, and it may therefore improve children’s safety during the intraoperative period.
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Affiliation(s)
- Zheng-Zheng Gao
- Department of Anesthesiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Fang Wang
- Department of Anesthesiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Lei Hua
- Department of Anesthesiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Xiao-Huan Cui
- Department of Anesthesiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Jie Xu
- Department of Anesthesiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Wen-Ya Fu
- Department of Anesthesiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Hui-Zi Chen
- Department of Anesthesiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
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6
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Hasim N, Bakar MAA, Islam MA. Efficacy and Safety of Isotonic and Hypotonic Intravenous Maintenance Fluids in Hospitalised Children: A Systematic Review and Meta-Analysis of Randomised Controlled Trials. CHILDREN-BASEL 2021; 8:children8090785. [PMID: 34572217 PMCID: PMC8471545 DOI: 10.3390/children8090785] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 09/03/2021] [Accepted: 09/07/2021] [Indexed: 01/21/2023]
Abstract
Hyponatraemia is a known complication in hospitalised children receiving maintenance intravenous fluid. Several studies have been published to investigate the efficacy and safety of intravenous fluids in children. However, there is still an ongoing debate regarding the ideal solution to be used in the paediatric population. Therefore, the aim of this meta-analysis was to investigate the safety and efficacy of administering isotonic versus hypotonic intravenous maintenance fluid in hospitalised children. An extensive search was undertaken on PubMed, Web of Science, Scopus, ScienceDirect, Google Scholar and Cochrane Library on 28 December 2020. Only randomised controlled trials (RCTs) were included. We used the random-effects model for all analyses. Risk ratio (RR) and mean difference with 95% confidence intervals (CIs) were used for dichotomous and continuous outcomes, respectively. The quality of each study was assessed using the Joanna Briggs Institute critical appraisal tool for RCTs. This study is registered with PROSPERO (CRD42021229067). Twenty-two RCTs with a total of 3795 participants were included. The studies encompassed surgical and medical patients admitted to intensive care unit as well as to general wards. We found that hypotonic fluid significantly increases the risk of hyponatremia at both ≤24 h (RR 0.34; 95% CI: 0.26–0.43, p < 0.00001) and >24 h (RR 0.48; 95% CI: 0.36–0.64, p < 0.00001). Isotonic fluid increases the risk of hypernatraemia at ≤24 h (RR 2.15; 95% CI: 1.24–3.73, p = 0.006). The prevalence of hyponatraemia was also higher in the hypotonic group at both ≤24 h (5.7% vs. 23.3%) and >24 h (6.0% vs. 26.3%). There was no statistically significant difference in the risk of developing adverse outcomes between the two groups. Mean serum and urine sodium as well as serum osmolality/osmolarity was lower in the hypotonic group. Isotonic solution is protective against the development of hyponatraemia while hypotonic solution increases the risk of hyponatraemia.
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Affiliation(s)
- Norfarahin Hasim
- Department of Emergency Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia;
- Hospital Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia
| | - Mimi Azliha Abu Bakar
- Department of Emergency Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia;
- Hospital Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia
- Correspondence: (M.A.A.B.); or (M.A.I.)
| | - Md Asiful Islam
- Department of Haematology, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia
- Correspondence: (M.A.A.B.); or (M.A.I.)
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7
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Akinsola B, Cheng J, Iyer SB, Jain S. Improving Isotonic Maintenance Intravenous Fluid Use in the Emergency Department. Pediatrics 2021; 148:peds.2020-022947. [PMID: 34158314 DOI: 10.1542/peds.2020-022947] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/07/2020] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Bolanle Akinsola
- Division of Pediatric Emergency Medicine, School of Medicine, Emory University, Atlanta, Georgia .,Children's Healthcare of Atlanta, Atlanta, Georgia
| | - John Cheng
- Children's Healthcare of Atlanta, Atlanta, Georgia.,Pediatric Emergency Medicine Associates, Atlanta, Georgia
| | - Srikant B Iyer
- Division of Pediatric Emergency Medicine, School of Medicine, Emory University, Atlanta, Georgia.,Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Shabnam Jain
- Division of Pediatric Emergency Medicine, School of Medicine, Emory University, Atlanta, Georgia.,Children's Healthcare of Atlanta, Atlanta, Georgia
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8
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Denis M, Di Giacomo A, Lacotte E, Porcheret F, Letouzé N, Lauzier B, Goyer I, Brossier D. From hypotonic maintenance fluid to severe hyponatremia: a case report. J Med Case Rep 2021; 15:315. [PMID: 34099019 PMCID: PMC8183082 DOI: 10.1186/s13256-021-02889-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 05/03/2021] [Indexed: 11/16/2022] Open
Abstract
Background The principles for maintenance intravenous fluid prescription in children were developed in the 1950s. These guidelines based on the use of hypotonic solutions have been challenged regularly for they seem to be associated with an increased risk of hospital-acquired hyponatremia. Case presentation We report the case of a 4-week-old Caucasian child admitted for acute bronchiolitis who received hypotonic maintenance fluids and developed severe hyponatremia (94 mmol/L) with hyponatremic encephalopathy. Conclusion This clinical situation can serve as a reminder of the latest recommendations from the American Academy of Pediatrics regarding the use of intravenous fluids that promote the use of isotonic fluids in children.
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Affiliation(s)
- M Denis
- Pediatric Intensive Care Unit, CHU de Caen, 14000, Caen, France. .,Pediatric Intensive Care Unit, CHU de Nantes, 44000, Nantes, France. .,CNRS, INSERM, l'institut du thorax, Université de Nantes, CHU Nantes, 44000, Nantes, France. .,Service de reanimation pédiatrique, CHU de Nantes, 4ème étage bâtiment HME, 38 boulevard Jean-Monnet, 44093, Nantes Cedex 1, France.
| | - A Di Giacomo
- Pediatric Intensive Care Unit, CHU de Caen, 14000, Caen, France
| | - E Lacotte
- Pediatric Intensive Care Unit, CHU de Caen, 14000, Caen, France.,Pediatric Department, CHU de Rouen, 76000, Rouen, France.,Medical School, Université de Rouen, 76000, Rouen, France
| | - F Porcheret
- Pediatric Intensive Care Unit, CHU de Caen, 14000, Caen, France.,Pediatric Nephrology, CHU de Nantes, 44000, Nantes, France
| | - N Letouzé
- Pediatric Intensive Care Unit, CHU de Caen, 14000, Caen, France
| | - B Lauzier
- Institut du thorax, INSERM, CNRS, UNIV Nantes, 44000, Nantes, France
| | - I Goyer
- Department of Pharmacy, CHU de Caen, 14000, Caen, France
| | - D Brossier
- Pediatric Intensive Care Unit, CHU de Caen, 14000, Caen, France.,Medical School, Université Caen Normandie, 14000, Caen, France
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9
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Keskin H, Keskin F, Keskin Yildirim Z, Guler MA, Ozturk N, Ozturk Karagoz B, Halici Z. Fluid Rate Is Important As Much As Fluid Tonicity: An Experimental Study. Eurasian J Med 2021; 53:118-122. [PMID: 34177294 DOI: 10.5152/eurasianjmed.2021.20276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective There is no study evaluating the effect on plasma osmolality of both fluid tonicity and high fluid rate at the same time. The aim of this experimental study was to determine the change in the plasma osmolality by different fluid tonicity and rate, and to suggest the safest and the most appropriate fluids based on the plasma osmolality for medical situations requiring fluid therapy with high or maintenance rates. Materials and methods The rats were randomly divided into seven groups (six rats in each group): [D5] D5 administered at 100 ml/kg/24h; [D5150] D5 administered at 150 ml/kg/24h; [D5(½)100] D5 0.45% NaCl administered at 100 ml/kg/24h; [D5(½)150] D5 0.45% NaCl administered at 150 ml/kg/24h; [D5(1)100] D5 0.9% NaCl administered at 100 ml/kg/24h; [D5(1)150] D5 0.9% NaCl administered at 150 ml/kg/24h; [Control group] non-treated control rats. Intracardiac blood samples were collected from all the groups at the end of 24 h. Results [D5(1)150] and [D5(½)100] were the group closest to the control group in terms of both sodium (P = .937; P = .699, respectively) and effective osmolality (P = 1, P = .818, respectively). Conclusion Our results showed that 0.9% NaCl and 0.45% NaCl solutions might be the safest and the most appropriate fluids to maintain normal plasma osmolality in medical situations requiring fluid therapy with high or maintenance rates, respectively.
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Affiliation(s)
- Halil Keskin
- Division of Pediatric Intensive Care Unit, Department of Pediatrics, Atatürk University Faculty of Medicine, Erzurum, Turkey.,Clinical Research, Development and Design Application and Research Center, Atatürk University, Erzurum, Turkey
| | - Filiz Keskin
- Division of Pediatric Neurology, Department of Pediatrics, Atatürk University Faculty of Medicine, Erzurum, Turkey
| | - Zuhal Keskin Yildirim
- Division of Pediatric Oncology, Department of Pediatrics, Atatürk University Faculty of Medicine, Erzurum, Turkey
| | - Muhammet Akif Guler
- Department of Pediatrics, Atatürk University Faculty of Medicine, Erzurum, Turkey
| | - Nurinnisa Ozturk
- Department of Biochemistry, Atatürk University Faculty of Medicine, Erzurum, Turkey
| | - Berna Ozturk Karagoz
- Department of Pharmacology, Atatürk University Faculty of Medicine, Erzurum, Turkey
| | - Zekai Halici
- Clinical Research, Development and Design Application and Research Center, Atatürk University, Erzurum, Turkey.,Department of Pharmacology, Atatürk University Faculty of Medicine, Erzurum, Turkey
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10
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Dathan K, Sundaram M. Comparison of isotonic versus hypotonic intravenous fluid for maintenance fluid therapy in neonates more than or equal to 34 weeks of gestational age - a randomized clinical trial. J Matern Fetal Neonatal Med 2021; 35:6338-6345. [PMID: 33879015 DOI: 10.1080/14767058.2021.1911998] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND AND OBJECTIVES The use of hypotonic fluids as maintenance therapy in the neonatal population has been in practice for a long time, but there is a lack of evidence for the choice of this fluid in neonates. This study compared isotonic (sodium chloride, 0.9%, and dextrose, 5%) versus hypotonic (sodium chloride, 0.15%, and dextrose, 5%) intravenous fluid for maintenance fluid therapy in neonates more than or equal to 34 weeks of gestational age. METHODS In this triple-blind randomized clinical trial, we recruited 60 neonates admitted to a neonatal intensive care unit of a tertiary care children's hospital from June 2017 through May 2018 with normal baseline serum sodium levels, anticipated to require intravenous maintenance fluids for 24 hours or longer (intention-to-treat analyses). Patients were randomized to receive isotonic or hypotonic intravenous fluid at maintenance rates for 72 hours. The primary outcome was the incidence of hyponatremia (defined as serum sodium <135mEq/L) at 24 hours in both groups. The secondary outcomes were incidence of hypernatremia at 24 hours (defined as serum sodium >145 mEq/L), the incidence of hypo and hypernatremia at 48 and 72 hours, mean serum sodium at 24, 48, and 72 hours, rate of change of serum sodium during the study period, mean serum osmolality at the end of the study period, the absolute difference in osmolality during the study period, the absolute difference in weight during the study period and edema during the study period. RESULTS Of 60 enrolled neonates, 31 received isotonic fluids and 29 received hypotonic fluids. Three patients in the hypotonic group developed hyponatremia and none in isotonic group at 24 h (RR = 0.13; 95% CI = 0.007 - 2.485; p = .106). Fourteen neonates developed hypernatremia in the isotonic group and one in hypotonic group at 24 h (RR = 13.09; 95% CI = 1.83 - 93.4; p = .0001). CONCLUSIONS Our study results do not support the hypothesis that isotonic fluid is superior to hypotonic fluid in reducing the proportion of neonates developing hyponatremia after 24 hours of intravenous fluid therapy. The proportion of neonates developing hypernatremia is significantly higher after using isotonic fluid for maintenance therapy. TRIAL REGISTRATION CTRI/2017/05/008585.
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Affiliation(s)
- Krishna Dathan
- Department of Neonatology, Royal Oldham Hospital, Oldham, Greater Manchester, UK
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11
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Nordstrom M, Landman G, Pfaff N, Kaiser SV. Improving Isotonic Maintenance Intravenous Fluid Use at a Tertiary Children's Hospital. Hosp Pediatr 2021; 11:374-379. [PMID: 33785518 DOI: 10.1542/hpeds.2020-003673] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Maintenance intravenous fluids (IVFs) are routinely used in the care of hospitalized children. The American Academy of Pediatrics (AAP) published clinical practice guidelines in November 2018 that recommended the use of isotonic maintenance IVF. Our primary aim was to increase the proportion of hospital days pediatric inpatients were exclusively administered isotonic maintenance IVF to ≥80% by May 2020 at our institution. METHODS We conducted a single-center quality improvement (QI) study as part of an AAP collaborative. An interdisciplinary team led QI interventions including providing targeted education to clinicians, integrating guideline recommendations into the electronic medical record, engaging hospital leaders, and providing performance data to clinicians. Our study population included children ages 28 days to 18 years admitted to inpatient wards. Our primary outcome was the proportion of hospital days with exclusive isotonic maintenance IVF use. Balancing measures included transfers to the ICU, ordering of serum sodium laboratory tests, and adverse events. Data were analyzed by using statistical process control. RESULTS We analyzed 500 hospital admissions and found a significant increase in exclusive isotonic IVF use (63% to 95%) within 9 months of starting our QI intervention. We found no significant changes in balancing measures (serum sodium laboratory tests [24% to 25%], ICU transfer [0.3% to 1%], adverse events [0.3% to 1%]). CONCLUSIONS Our interdisciplinary QI team led interventions that were associated with significant improvements in isotonic IVF use, in accordance with AAP clinical practice guidelines. With our study, we provide detailed guidance on successful interventions for implementing this evidence-based guideline.
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Affiliation(s)
| | - Geri Landman
- Sutter East Bay Medical Group, Berkeley, California
| | | | - Sunitha V Kaiser
- Departments of Pediatrics and.,Epidemiology and Biostatistics and.,Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, California; and
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12
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Fernández-Sarmiento J, Pérez A, Echeverri MA, Jimenez P, Joachim MA, Andrés-Jagua. Association Between Hyponatremia and Maintenance Intravenous Solutions in Critically Ill Children: A Retrospective Observational Study. Front Pediatr 2021; 9:691721. [PMID: 34295861 PMCID: PMC8290911 DOI: 10.3389/fped.2021.691721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 06/03/2021] [Indexed: 11/13/2022] Open
Abstract
Objetive: We sought to determine the association between maintenance intravenous solutions and the presence of hyponatremia in children in pediatric intensive care (PICU). Materials and Methods: An analytical observational study in children hospitalized in the PICU between January 2015 and December 2018. Patients who received maintenance fluids within the first 48 h after admission and who had at least two serum sodium levels drawn during this time were included. Measurements and Main Results: A total of 1,668 patients were admitted to the PICU during the study period, 503 of whom met the inclusion criteria. The median age was 24 months (IQR 8-96) and 50.9% were female. Altogether, 24.1% of the children developed hyponatremia; it was more frequent in those who received hypotonic solutions (63 vs. 37%; OR 1.41 95% CI 0.92, 2.15 p = 0.106), who also had a longer hospital stay (20 vs. 14 days, difference in means 8 days, 95% CI 2.67, 13.3, p = 0.001). Children who received loop diuretics and those who were post-operative had a greater risk of developing hyponatremia if they received hypotonic solutions (aOR 2.1 95% CI 1.41, 3.0, p = 0.000). Those with balanced isotonic solutions had a lower risk of developing hyponatremia (aOR 0.59 95% CI 0.35, 0.99, p = 0.004) and hyperchloremia (aOR 0.51 95% CI 0.34, 0.77, p = 0.000), adjusted for disease severity. A greater risk of death was found in the group with severe hyponatremia <130 mEq/L (aOR 9.75 95% CI 1.64-58.15; p = 0.01). Conclusions: Hyponatremia associated with the use of hypotonic maintenance solutions occurs in one out of four children in intensive care. The use of these solutions is associated with a longer hospital stay, and the main risk groups are post-operative patients and those who receive loop diuretics. Clinical studies are needed to determine which maintenance solutions have the greatest efficacy and safety in critically ill children.
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Affiliation(s)
- Jaime Fernández-Sarmiento
- Departament of Pediatrics and Intensive Care, Fundación Cardioinfantil-Instituto de Cardiología, Universidad de La Sabana, Bogotá, Colombia
| | - Andrea Pérez
- Departament of Pediatrics, Fundación Cardioinfantil-Instituto de Cardiología, Universidad El Rosario, Bogotá, Colombia
| | - Maria Alejandra Echeverri
- Departament of Pediatrics, Fundación Cardioinfantil-Instituto de Cardiología, Universidad El Rosario, Bogotá, Colombia
| | - Paola Jimenez
- Department of Pediatrics and Intensive Care, Universidad de La Sabana, Bogotá, Colombia
| | | | - Andrés-Jagua
- Departament of Research, Universidad Nacional de Colombia, Bogotá, Colombia
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Sindahl P, Overgaard-Steensen C, Wallach-Kildemoes H, De Bruin ML, Leufkens HGM, Kemp K, Gardarsdottir H. Are Further Interventions Needed to Prevent and Manage Hospital-Acquired Hyponatraemia? A Nationwide Cross-Sectional Survey of IV Fluid Prescribing Practices. J Clin Med 2020; 9:jcm9092790. [PMID: 32872460 PMCID: PMC7565867 DOI: 10.3390/jcm9092790] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 08/16/2020] [Accepted: 08/27/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Hyponatraemia is associated with increased morbidity, increased mortality and is frequently hospital-acquired due to inappropriate administration of hypotonic fluids. Despite several attempts to minimise the risk, knowledge is lacking as to whether inappropriate prescribing practice continues to be a concern. METHODS A cross-sectional survey was performed in Danish emergency department physicians in spring 2019. Prescribing practices were assessed by means of four clinical scenarios commonly encountered in the emergency department. Thirteen multiple-choice questions were used to measure knowledge. RESULTS 201 physicians responded corresponding to 55.4% of the total population of physicians working at emergency departments in Denmark. About a quarter reported that they would use hypotonic fluids in patients with increased intracranial pressure and 29.4% would use hypotonic maintenance fluids in children, both of which are against guideline recommendations. Also, 29.4% selected the correct fluid, a 3% hypertonic saline solution, for a patient with hyponatraemia and severe neurological symptoms, which is a medical emergency. Most physicians were unaware of the impact of hypotonic fluids on plasma sodium in acutely ill patients. CONCLUSION Inappropriate prescribing practices and limited knowledge of a large number of physicians calls for further interventions to minimise the risk of hospital-acquired hyponatraemia.
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Affiliation(s)
- Per Sindahl
- Danish Medicines Agency, Division of Pharmacovigilance and Medical Devices, 2300 Copenhagen, Denmark;
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, 3584CG Utrecht, The Netherlands; (H.G.L.); (H.G.)
- Copenhagen Centre for Regulatory Science, Department of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen, 2100 Copenhagen, Denmark;
- Correspondence:
| | | | - Helle Wallach-Kildemoes
- Section for Social and Clinical Pharmacy, Department of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen, 2100 Copenhagen, Denmark;
| | - Marie Louise De Bruin
- Copenhagen Centre for Regulatory Science, Department of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen, 2100 Copenhagen, Denmark;
| | - Hubert GM Leufkens
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, 3584CG Utrecht, The Netherlands; (H.G.L.); (H.G.)
| | - Kaare Kemp
- Danish Medicines Agency, Division of Pharmacovigilance and Medical Devices, 2300 Copenhagen, Denmark;
| | - Helga Gardarsdottir
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, 3584CG Utrecht, The Netherlands; (H.G.L.); (H.G.)
- Department of Clinical Pharmacy, Division Laboratories, Pharmacy and Biomedical Genetics, University Medical Center Utrecht, 3584CX Utrecht, The Netherlands
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14
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Kim M, Lee J, Yang S, Lee M, Chae MS, Lee H. Effect of intraoperative Hartmann's versus hypotonic solution administration on FLACC pain scale scores in children: A prospective randomized controlled trial. PLoS One 2020; 15:e0230556. [PMID: 32191766 PMCID: PMC7082008 DOI: 10.1371/journal.pone.0230556] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 03/02/2020] [Indexed: 12/04/2022] Open
Abstract
Background In healthy children, an isotonic solution containing no glucose or a small amount of glucose (1–2%) has been recommended as an intraoperative maintenance fluid due to the potential risk of hyponatremia associated with hypotonic solutions. However, a hypotonic solution with glucose is still widely used as a maintenance fluid for pediatric anesthesia. We speculated that the hypotonic solution may worsen postoperative discomfort and irritability in pediatric patients due to hyponatremia. Patients and methods In the current study, we compared the post-operative Face, Legs, Activity, Cry, Consolability(FLACC) scale scores of pediatric patients aged 3–10 years who received either a 1:2 dextrose solution or Hartmann's solution during Nuss Bar removal. Results The FLACC scale score in the post-anesthesia care unit was higher in the 1:2 dextrose solution group(HYPO) (n = 20) than in the Hartmann’s solution group(ISO) (n = 20) (6.30 vs 4.70, p = 0.044, mean difference and 95% Confidence Interval(CI) was 1.6 (0.04 to 3.16)). We also compared opioid consumption at the post-anesthesia care unit. Total dose of fentanyl per body weight in the post-anesthesia care unit was also higher in the HYPO (0.59 vs 0.37 mcg/kg, p = 0.042, mean difference and 95% CI was 0.22 mcg/kg (0.030 to 0.402)). Conclusions Intraoperative use of the hypotonic solution in children causes increased FLACC scale scores, leading to higher opioid consumption in post-anesthesia care unit.
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Affiliation(s)
- Mihyun Kim
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jiyoung Lee
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sungwon Yang
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Minsoo Lee
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Min Suk Chae
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hyungmook Lee
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- * E-mail:
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15
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Kinlin LM, Helmers AJ, Friedman JN, Beck CE. Choice of maintenance intravenous fluids among paediatric residents in Canada. Paediatr Child Health 2019; 25:518-524. [PMID: 33354261 DOI: 10.1093/pch/pxz093] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 06/06/2019] [Indexed: 11/12/2022] Open
Abstract
Background Recent literature and guidelines support routine use of isotonic intravenous (IV) fluids for maintenance therapy in hospitalized infants and children. Current prescribing practices are unknown. Objective To elicit paediatric residents' choice of maintenance IV fluids, particularly with regard to tonicity, in a variety of clinical scenarios and patient ages. We hypothesized that residents would choose isotonic fluids in most cases, but there would be substantially more variability in fluid choice in the neonatal age group. Methods An Internet-based survey was e-mailed to trainees in the 17 paediatric residency programs across Canada, via the Canadian Paediatric Program Directors. The survey instrument included questions related to training, followed by a series of questions eliciting choice of IV fluid in a variety of clinical situations. Results A total of 147 survey responses were submitted (22% response rate). Isotonic solutions were selected by >75% across all clinical scenarios involving infants and children. Very hypotonic fluids were seldom chosen. There was more variability in fluid choice in neonates, with evidence of significant differences in fluid tonicity based on senior versus junior resident status and geographical location. Conclusions Results imply a predominance of isotonic fluid use in infants and children, suggesting that clinical practice has changed in response to risk of hyponatremia with hypotonic IV fluids. As hypothesized, there was more variability with respect to choice of maintenance fluids in neonates. This likely reflects a paucity of guidance in an age group with unique physiologic factors affecting fluid and electrolyte status.
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Affiliation(s)
- Laura M Kinlin
- Department of Paediatrics, University of Toronto, Toronto, Ontario.,Division of Paediatric Medicine and the Paediatric Outcomes Research Team (PORT), The Hospital for Sick Children, Toronto, Ontario
| | - Andrew J Helmers
- Department of Critical Care Medicine, University of Toronto, Toronto, Ontario
| | - Jeremy N Friedman
- Department of Paediatrics, University of Toronto, Toronto, Ontario.,Division of Paediatric Medicine and the Paediatric Outcomes Research Team (PORT), The Hospital for Sick Children, Toronto, Ontario
| | - Carolyn E Beck
- Department of Paediatrics, University of Toronto, Toronto, Ontario.,Division of Paediatric Medicine and the Paediatric Outcomes Research Team (PORT), The Hospital for Sick Children, Toronto, Ontario
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16
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Rius Peris JM, Rivas-Juesas C, Maraña Pérez AI, Piñeiro Pérez R, Modesto i Alapont V, Miranda Mallea J, Cuellar de León A. Use of hypotonic fluids in the prescription of maintenance intravenous fluid therapy. An Pediatr (Barc) 2019. [DOI: 10.1016/j.anpede.2018.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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17
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Rius Peris JM, Rivas-Juesas C, Maraña Pérez AI, Piñeiro Pérez R, Modesto i Alapont V, Miranda Mallea J, Cuellar de León A. Uso de sueros hipotónicos en la prescripción de la fluidoterapia intravenosa de mantenimiento. An Pediatr (Barc) 2019; 91:158-165. [DOI: 10.1016/j.anpedi.2018.10.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 10/09/2018] [Accepted: 10/17/2018] [Indexed: 02/08/2023] Open
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18
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Sakornyutthadej N, Poomthavorn P, Mahachoklertwattana P. Effect of Environmental Temperature on Serum Sodium Level in Hospitalized Non-critically Ill Children. J Trop Pediatr 2019; 65:336-341. [PMID: 30203059 DOI: 10.1093/tropej/fmy056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Intravenous hypotonic fluid administered in children is associated with an increased risk of developing hyponatremia. This finding has been reported from temperate countries where climate is relatively cold. But whether this risk also occurs in tropical countries has not been elucidated. OBJECTIVE The objective of this study was to determine the relationship between environmental temperature and serum sodium in non-critically ill children. METHODS A retrospective study. RESULTS A total of 1061 hospitalized children were enrolled. Incidences of hyponatremia were not different between patients who received isotonic and hypotonic fluids (29% vs. 31%). Subgroup analysis showed a trend of higher incidence of hyponatremia in patients who received hypotonic fluid than isotonic fluid only in patients admitted to the air-conditioned wards (29% vs. 21%, p = 0.08). CONCLUSION Children admitted to the air-conditioned wards who received hypotonic fluid seemed to carry a higher risk of developing hyponatremia than those admitted to the non-air-conditioned ward.
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Affiliation(s)
- Natee Sakornyutthadej
- Division of Endocrinology and Metabolism, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, 270 Rama 6 Road, Bangkok, Thailand
| | - Preamrudee Poomthavorn
- Division of Endocrinology and Metabolism, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, 270 Rama 6 Road, Bangkok, Thailand
| | - Pat Mahachoklertwattana
- Division of Endocrinology and Metabolism, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, 270 Rama 6 Road, Bangkok, Thailand
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19
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Elliman MG, Vongxay O, Soumphonphakdy B, Gray A. Hyponatraemia in a Lao paediatric intensive care unit: Prevalence, associations and intravenous fluid use. J Paediatr Child Health 2019; 55:695-700. [PMID: 30315614 DOI: 10.1111/jpc.14278] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 08/25/2018] [Accepted: 09/23/2018] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Mark G Elliman
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Oulaivanh Vongxay
- University of Health Sciences, Mahosot Hospital, Vientiane, Lao People's Democratic Republic
| | | | - Amy Gray
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia
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20
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Zheng F, Ye X, Shi X, Lin Z, Yang Z, Jiang L. Hyponatremia in Children With Bacterial Meningitis. Front Neurol 2019; 10:421. [PMID: 31114536 PMCID: PMC6503034 DOI: 10.3389/fneur.2019.00421] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 04/05/2019] [Indexed: 11/13/2022] Open
Abstract
Background: Hyponatremia has frequently been described as a common complication associated with bacterial meningitis, though its frequency and clinical course in children with bacterial meningitis are unclear. The present study aimed to investigate the frequency, clinical characteristics, and prognosis associated with pediatric hyponatremia due to bacterial meningitis. Methods: We performed a retrospective review of children with bacterial meningitis provided with standard care. One hundred seventy-five children were included. We documented all participants' symptoms and signs, laboratory and microbiological data, radiological findings, and complications that occurred during their hospital admission. Disease severity was determined using the maximum Pediatric Cerebral Performance Category (PCPC) and minimum Glasgow Coma Scale (GCS). Residual deficits were assessed using PCPC at discharge. Results: Hyponatremia (<135 mmol/L) was seen in 116 (66.4%) of the patients assessed and was classified as mild (130-135 mmol/L) in 77, moderate (125-129 mmol/L) in 26, and severe (<125 mmol/L) in 13. Hyponatremia was associated with a shorter duration of symptoms before admission, higher CSF white cell counts, and a longer duration of hospitalization. Moderate and severe hyponatremia were associated with an increase in convulsions, impaired consciousness, altered CSF protein levels, higher maximum PCPC scores, and lower minimum GCS scores. Severe hyponatremia was further associated with the development of systemic complications including shock, multiple organ dysfunction syndrome, respiratory failure requiring mechanical ventilation, and an increase in poor outcome (PCPC ≥ 2). Hyponatremia was not associated with the development of neurologic complications. Logistic regression analyses revealed that convulsions (OR 12.09, 95% CI 2.63-56.84) and blood glucose levels > 6.1 mmol/L (OR 8.28, 95% CI 1.65-41.60) predicted severe hyponatremia. Conclusion: Hyponatremia occurred in 66.4% of the assessed pediatric bacterial meningitis patients. Moderate and severe hyponatremia affected the severity of pediatric bacterial meningitis. Only severe hyponatremia affected the short-term prognosis of patients with pediatric bacterial meningitis. We recommend that patients with pediatric bacterial meningitis who exhibit convulsions and increased blood glucose levels should be checked for severe hyponatremia. Further studies are needed to evaluate the effectiveness of treatment of hyponatremia.
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Affiliation(s)
- Feixia Zheng
- Department of Pediatrics, The Second Affiliated Hospital & Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xiuyun Ye
- Department of Pediatrics, The Second Affiliated Hospital & Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xulai Shi
- Department of Pediatrics, The Second Affiliated Hospital & Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zhongdong Lin
- Department of Pediatrics, The Second Affiliated Hospital & Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zuqin Yang
- Department of Pediatrics, The Second Affiliated Hospital & Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Longxiang Jiang
- Department of Respiratory Medicine, Wenzhou Hospital of Integrated Traditional Chinese and Western Medicine, Wenzhou, China
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21
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Abstract
The syndrome of inappropriate antidiuresis (SIAD) is a common cause of hyponatremia in hospitalized children. SIAD refers to euvolemic hyponatremia due to nonphysiologic stimuli for arginine vasopressin production in the absence of renal or endocrine dysfunction. SIAD can be broadly classified as a result of tumors, pulmonary or central nervous system disorders, medications, or other causes such as infection, inflammation, and the postoperative state. The presence of hypouricemia with an elevated fractional excretion of urate can aid in the diagnosis. Treatment options include fluid restriction, intravenous saline solutions, oral sodium supplements, loop diuretics, oral urea, and vasopressin receptor antagonists (vaptans).
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Affiliation(s)
- Michael L Moritz
- Pediatric Nephrology, Pediatric Dialysis, Division of Nephrology, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, The University of Pittsburgh School of Medicine, 4401 Penn Avenue, Pittsburgh, PA 15224, USA.
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22
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Hopper K, Garcia Rojas A, Barter L. An online survey of small animal veterinarians regarding current fluid therapy practices in dogs and cats. J Am Vet Med Assoc 2019; 252:553-559. [PMID: 29461162 DOI: 10.2460/javma.252.5.553] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To determine common fluid therapy practices of small animal practitioners and identify fluid therapy-related knowledge gaps that may benefit from improved educational efforts, targeted research, or both. DESIGN Online survey. SAMPLE 1,496 small animal veterinarians PROCEDURES An online survey was provided to members of the Veterinary Information Network between December 23, 2013, and January 30, 2014. The survey consisted of 24 questions investigating the administration of crystalloid and synthetic colloid solutions, but not blood products, and focused primarily on the choice of fluid type, frequency of administration, type of patient treated with fluids, treatment with fluids subcutaneously versus IV, and potassium supplementation of fluids. Only responses from practicing small animal veterinarians were included. Not all respondents answered every question, and some questions allowed > 1 answer. RESULTS Balanced crystalloid solutions were the most common fluid type in all clinical scenarios described. The most common maintenance IV fluid rate reported by respondents (762/1,333 [57%]) was 60 mL/kg/d (27 mL/lb/d); calculation of fluid administration rate by means of body surface area was infrequent. Challenges of fluid therapy included determining the appropriate rate (572/1,496 [38%]) and fluid type (497/1,496 [33%]) and determining the need for potassium supplementation (229/1,496 [15%]). CONCLUSIONS AND CLINICAL RELEVANCE Small animal veterinarians tended to favor isotonic balanced crystalloid solutions for IV fluid therapy, compared with other common choices such as isotonic saline (0.9% NaCl) solution. Despite its ubiquity, respondents found many aspects of fluid therapy to be challenging, suggesting the need for easy to use, evidence-based guidelines.
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23
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Hall AM, Ayus JC, Moritz ML. How Salty Are Your Fluids? Pediatric Maintenance IV Fluid Prescribing Practices Among Hospitalists. Front Pediatr 2019; 7:549. [PMID: 32010650 PMCID: PMC6974532 DOI: 10.3389/fped.2019.00549] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 12/17/2019] [Indexed: 11/13/2022] Open
Abstract
Objective: The primary goal of this study was to assess current maintenance intravenous fluid (mIVF) prescribing practices of pediatric hospitalists after the release of the American Academy of Pediatrics Clinical Practice Guideline (AAP CPG), specifically assessing the rates of various isotonic vs. hypotonic solutions used in discrete age groups and in common clinical scenarios associated with anti-diuretic hormone (ADH) excess and hyponatremia. We hypothesized that isotonic fluids would be selected in most cases outside of the neonatal period. Methods: A voluntary and anonymous survey was distributed to the LISTSERV® for the AAP Section on Hospital Medicine. Results: There were 402 total responses (10.1% response rate) with the majority of respondents being pediatric hospitalists. Isotonic solutions were preferred by respondents in older children compared to younger age groups, at 87.8% for the 1-18 years age group compared to 66.3% for the 28 days to 1 year age group and 10.6% for the younger than 28 days age group (all p values <0.0001). When presented with disease states associated with ADH excess, isotonic fluids were preferred in higher percentages in all age groups except in children younger than 28 days when 0.45% sodium chloride was preferred; 0.2% sodium chloride was rarely chosen. Conclusions: Overall, based on survey responses, pediatric hospitalists are following the 2018 AAP CPG on mIVF and are more likely to choose isotonic fluids as their primary mIVF in pediatric patients outside of the neonatal period, including in scenarios of excess ADH. Isotonic fluids use seems to be higher with increasing age and hypotonic fluids are more commonly chosen in the neonatal period.
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Affiliation(s)
- Alan M Hall
- Division of Hospital Medicine and Pediatrics, University of Kentucky College of Medicine, Lexington, KY, United States
| | - Juan C Ayus
- Renal Consultants of Houston, Houston, TX, United States.,School of Medicine, University of California, Irvine, Irvine, CA, United States
| | - Michael L Moritz
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
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24
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Feld LG, Neuspiel DR, Foster BA, Leu MG, Garber MD, Austin K, Basu RK, Conway EE, Fehr JJ, Hawkins C, Kaplan RL, Rowe EV, Waseem M, Moritz ML. Clinical Practice Guideline: Maintenance Intravenous Fluids in Children. Pediatrics 2018; 142:peds.2018-3083. [PMID: 30478247 DOI: 10.1542/peds.2018-3083] [Citation(s) in RCA: 112] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Maintenance intravenous fluids (IVFs) are used to provide critical supportive care for children who are acutely ill. IVFs are required if sufficient fluids cannot be provided by using enteral administration for reasons such as gastrointestinal illness, respiratory compromise, neurologic impairment, a perioperative state, or being moribund from an acute or chronic illness. Despite the common use of maintenance IVFs, there is high variability in fluid prescribing practices and a lack of guidelines for fluid composition administration and electrolyte monitoring. The administration of hypotonic IVFs has been the standard in pediatrics. Concerns have been raised that this approach results in a high incidence of hyponatremia and that isotonic IVFs could prevent the development of hyponatremia. Our goal in this guideline is to provide an evidence-based approach for choosing the tonicity of maintenance IVFs in most patients from 28 days to 18 years of age who require maintenance IVFs. This guideline applies to children in surgical (postoperative) and medical acute-care settings, including critical care and the general inpatient ward. Patients with neurosurgical disorders, congenital or acquired cardiac disease, hepatic disease, cancer, renal dysfunction, diabetes insipidus, voluminous watery diarrhea, or severe burns; neonates who are younger than 28 days old or in the NICU; and adolescents older than 18 years old are excluded. We specifically address the tonicity of maintenance IVFs in children.The Key Action Statement of the subcommittee is as follows:1A: The American Academy of Pediatrics recommends that patients 28 days to 18 years of age requiring maintenance IVFs should receive isotonic solutions with appropriate potassium chloride and dextrose because they significantly decrease the risk of developing hyponatremia (evidence quality: A; recommendation strength: strong).
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Affiliation(s)
- Leonard G Feld
- Retired, Nicklaus Children's Health System, Miami, Florida;
| | | | | | - Michael G Leu
- School of Medicine, University of Washington and Seattle Children's Hospital, Seattle, Washington
| | - Matthew D Garber
- Department of Pediatrics, College of Medicine - Jacksonville, University of Florida, Jacksonville, Florida
| | | | - Rajit K Basu
- Division of Critical Care Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia.,Department of Pediatrics, School of Medicine, Emory University, Atlanta, Georgia
| | - Edward E Conway
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Jacobi Medical Center, Bronx, New York
| | - James J Fehr
- Departments of Anesthesiology and Pediatrics, Washington University in St Louis, St Louis, Missouri
| | - Clare Hawkins
- Department of Family Medicine, Houston Methodist Hospital, Houston, Texas
| | | | - Echo V Rowe
- Department of Anesthesia, Stanford University School of Medicine, Stanford, California; and
| | | | - Michael L Moritz
- Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
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Friedman JN. At What Point Is the Accumulated Evidence Sufficient to Change Maintenance Intravenous Fluid Prescribing Practice in Children? How About Yesterday? Hosp Pediatr 2017; 7:760-762. [PMID: 29162639 DOI: 10.1542/hpeds.2017-0134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Jeremy N Friedman
- Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada and Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
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Conn RL, McVea S, Carrington A, Dornan T. Intravenous fluid prescribing errors in children: Mixed methods analysis of critical incidents. PLoS One 2017; 12:e0186210. [PMID: 29023584 PMCID: PMC5638410 DOI: 10.1371/journal.pone.0186210] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 09/27/2017] [Indexed: 11/30/2022] Open
Abstract
Introduction Recent National Institute for Health and Care Excellence (NICE) guidelines aim to improve intravenous (IV) fluid prescribing for children, but existing evidence about how and why fluid prescribing errors occur is limited. Studying this can lead to more effective implementation, through education and systems design. Aims Methods Mixed methods observational study which analysed critical incident reports relating to IV fluid prescribing errors in children aged 0–16, occurring between 2011 and 2015 in UK secondary care. We quantified characteristics and types of errors, then qualitatively analysed narrative descriptions, identifying underlying contributing factors. Results In the 40 incidents analysed, principal types of errors were incorrect rate of fluids, inappropriate choice of solution, and incorrect completion of prescription charts. Prescribers had to negotiate complex patients, interactions with other practitioners and teams, and challenging work environments; errors resulted from these inter-related contributing factors. Conclusions This study highlights the diverse range and complex nature of IV fluid prescribing errors reported in practice. While these findings have the inherent limitations of critical incident reports, they point to areas of potential improvement in education and systems design. Practising prescribing in context, inducting doctors within the many specialties who contribute to care of children, and educating them in joint working with nurses and pharmacists could help reduce errors.
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Affiliation(s)
- Richard L. Conn
- Centre for Medical Education, Queen’s University Belfast, Belfast, United Kingdom
- * E-mail:
| | - Steven McVea
- Neonatal Intensive Care Unit, Royal Jubilee Maternity Hospital, Belfast, United Kingdom
| | - Angela Carrington
- Medicines Governance Team, Belfast Health and Social Care Trust, Belfast, United Kingdom
| | - Tim Dornan
- Centre for Medical Education, Queen’s University Belfast, Belfast, United Kingdom
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Moritz ML, Ayus JC. How to Improve Maintenance Intravenous Fluid Prescribing Practices in Bronchiolitis. Hosp Pediatr 2017; 7:300-302. [PMID: 28408387 DOI: 10.1542/hpeds.2017-0050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2017] [Indexed: 06/07/2023]
Affiliation(s)
- Michael L Moritz
- Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, The University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania;
| | - Juan C Ayus
- Renal Consultants of Houston, Houston, Texas
- Hospital Italiano, Universidad Austral, Buenos Aires, Argentina; and
- University of California Irvine School of Medicine, Irvine, California
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Shein SL, Slain K, Martinez Schlurmann N, Speicher R, Rotta AT. Hyponatremia and Hypotonic Intravenous Fluids Are Associated With Unfavorable Outcomes of Bronchiolitis Admissions. Hosp Pediatr 2017; 7:263-270. [PMID: 28408388 DOI: 10.1542/hpeds.2016-0205] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Hyponatremia has been associated with unfavorable outcomes when present at admission in children with bronchiolitis. Delayed hyponatremia may be a modifiable risk factor for severe disease that is influenced by intravenous fluid (IVF) tonicity. We hypothesized that both hyponatremia and prescription of severely hypotonic IVF are associated with unfavorable outcomes, and that prescription of severely hypotonic IVF is associated with subsequent hyponatremia. METHODS Data were retrospectively extracted for 1557 pediatric inpatients with bronchiolitis. Any day on which a subject was prescribed IVF with sodium <70 mEq/L was termed "IVF <70." All other days on which IVF was prescribed were termed "IVF ≥70." Any blood sodium ≤135 mEq/L defined hyponatremia for that day. All other days with sodium available were labeled normonatremia. Variables were compared with Spearman correlation, Wilcoxon rank test, or χ2. Significant results had P < .05. RESULTS Blood sodium levels correlated negatively with hospital length of stay (r = -0.477, P < .0001). On each of the first 4 days of hospitalization, significantly increased hospital length of stay was observed in patients with hyponatremia (n = 134 [25.7% of subjects with available sodium data]) versus patients with normonatremia (n = 387 [74.3%]), and in patients prescribed IVF <70 (n = 348 [46.3% of subjects prescribed IVF]) versus patients prescribed IVF ≥70 (n = 403 [53.7%]). Patients prescribed IVF <70 had increased rates of hyponatremia on the subsequent day versus patients prescribed IVF ≥70 (50.0% vs 26.9%, P < .001). CONCLUSIONS 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.
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Affiliation(s)
- Steven L Shein
- Division of Pediatric Critical Care, Rainbow Babies & Children's Hospital, Cleveland, Ohio
| | - Katherine Slain
- Division of Pediatric Critical Care, Rainbow Babies & Children's Hospital, Cleveland, Ohio
| | | | - Richard Speicher
- Division of Pediatric Critical Care, Rainbow Babies & Children's Hospital, Cleveland, Ohio
| | - Alexandre T Rotta
- Division of Pediatric Critical Care, Rainbow Babies & Children's Hospital, Cleveland, Ohio
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Flores Robles CM, Cuello García CA. A prospective trial comparing isotonic with hypotonic maintenance fluids for prevention of hospital-acquired hyponatraemia. Paediatr Int Child Health 2016. [PMID: 26212672 DOI: 10.1179/2046905515y.0000000047] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND Recent literature suggests that hypotonic fluids increase the risk of hospital-acquired hyponatraemia; despite this, hypotonic fluids are widely used. OBJECTIVES To compare the change in serum sodium following the use of hypotonic (0.3% saline, 0.45% saline) or isotonic (0.9% saline) intravenous (IV) maintenance solutions in hospitalised children. STUDY DESIGN This was a randomised controlled trial. Children aged 3 months to 15 years with medical or surgical disorders were randomised to receive one of three maintenance IV fluids: two hypotonic solutions (3.3% dextrose in 0.3% saline or 5% dextrose in 0.45% saline) and one isotonic solution (5% dextrose in 0.9% saline). The primary outcome was serum sodium levels at 8 hours. Secondary outcomes included the incidence of hospital-acquired hyponatraemia, adverse events attributable to IV solutions and length of hospital stay. RESULTS 151 children were assigned randomly to receive 0.3% saline (n = 49), 0.45% saline (n = 50) or 0.9% saline (n = 52). Baseline characteristics were similar for the three groups. At 8 hours, mean (SD) serum sodium was lower in the hypotonic solutions groups [0.3% saline 134.65 (1.9) mmol/L, 0.45% saline 134.90 (2.3) mmol/L than 0.9% saline 137.98 (2.8) mmol/L] (P < 0.0001). The incidence of hospital-acquired hyponatraemia was higher in the hypotonic groups [0.3% saline 10/49 (20.4%), 0.45% saline 11/50 (22%) than 0.9% saline 1/52 (1.9%), P = 0.006). There were no differences in other adverse effects or length of hospital stay between the groups. CONCLUSION Hypotonic IV solutions increase the incidence of hospital-acquired hyponatraemia. Isotonic solutions are a safer alternative.
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Affiliation(s)
- Claudia Montserrat Flores Robles
- a Department of Pediatrics, Hospital Regional Materno Infantil de Alta Especialidad, Tecnológico de Monterrey School of Medicine , Nuevo León , México
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Toledo JD, Morell C, Vento M. Intravenous isotonic fluids induced a positive trend in natraemia in children admitted to a general paediatric ward. Acta Paediatr 2016; 105:e263-8. [PMID: 26684406 DOI: 10.1111/apa.13316] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 12/15/2015] [Indexed: 11/29/2022]
Abstract
AIM Using hypotonic intravenous solutions for baseline fluid needs in paediatric patients on a nil by mouth diet may cause serious complications, including hyponatraemia, cerebral oedema and even death. We analysed the evolution of natraemia and explored any adverse effects on children treated with intravenous isotonic fluids. METHODS This was a prospective study of 50 patients consecutively admitted to a general paediatric ward who were treated with isotonic intravenous fluids and on a nil by mouth diet. RESULTS The most prevalent diagnosis was acute gastroenteritis (64%). Hyponatraemia, defined as sodium in plasma of <135 mEq/L, affected 22% of the subjects, but none displayed this during the first postadmission analysis at a median of eight hours. Sodium levels changed by an average of +0.64 mEq/L/hour. The subgroup analysis (0.91 versus 0.56 mEq/L/hour, p = 0.02) and multiple linear regression (R(2) = 0.756) showed a greater increase in sodium when patients had hyponatraemia on admission. Iatrogenic hyponatraemia was not detected, but two patients showed mild hypernatraemia and 35% developed clinically insignificant hyperchloraemia. CONCLUSION Using intravenous isotonic fluids induced a positive trend in natraemia on a general paediatric ward, particularly if patients were hyponatraemic when admitted, and did not induce clinically relevant adverse effects.
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Affiliation(s)
- Juan Diego Toledo
- Department of Pediatrics; General and University Hospital; Castellon Spain
| | - Carlos Morell
- Department of Pediatrics; General and University Hospital; Castellon Spain
| | - Maximo Vento
- Division of Neonatology; University and Polytechnic Hospital La Fe; Valencia Spain
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Ramanathan S, Kumar P, Mishra K, Dutta AK. Isotonic versus Hypotonic Parenteral Maintenance Fluids in Very Severe Pneumonia. Indian J Pediatr 2016; 83:27-32. [PMID: 26027555 DOI: 10.1007/s12098-015-1791-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Accepted: 05/13/2015] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- Subramaniam Ramanathan
- Department of Pediatrics, Lady Hardinge Medical College, Kalawati Saran Children's Hospital, New Delhi, 110001, India
| | - Praveen Kumar
- Department of Pediatrics, Lady Hardinge Medical College, Kalawati Saran Children's Hospital, New Delhi, 110001, India
| | - Kirtisudha Mishra
- Department of Pediatrics, Lady Hardinge Medical College, Kalawati Saran Children's Hospital, New Delhi, 110001, India.
| | - Ashok Kumar Dutta
- Department of Pediatrics, Lady Hardinge Medical College, Kalawati Saran Children's Hospital, New Delhi, 110001, India
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Shukla S, Basu S, Moritz ML. Use of Hypotonic Maintenance Intravenous Fluids and Hospital-Acquired Hyponatremia Remain Common in Children Admitted to a General Pediatric Ward. Front Pediatr 2016; 4:90. [PMID: 27610358 PMCID: PMC4996996 DOI: 10.3389/fped.2016.00090] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 08/10/2016] [Indexed: 11/18/2022] Open
Abstract
AIM To evaluate maintenance intravenous fluid-prescribing practices and the incidence of hospital-acquired hyponatremia in children admitted to a general pediatric ward. METHODS This 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. RESULTS Fifty-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. CONCLUSION Administration of hypotonic fluids was a prevalent practice in children admitted to a general pediatric ward and is associated with acute hospital-acquired hyponatremia.
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Affiliation(s)
- Shikha Shukla
- Department of Pediatrics, Kalawati Saran Children's Hospital, Lady Hardinge Medical College , New Delhi , India
| | - Srikanta Basu
- Department of Pediatrics, Kalawati Saran Children's Hospital, Lady Hardinge Medical College , New Delhi , India
| | - Michael L Moritz
- Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine , Pittsburgh, PA , USA
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Padua AP, Macaraya JRG, Dans LF, Anacleto FE. Isotonic versus hypotonic saline solution for maintenance intravenous fluid therapy in children: a systematic review. Pediatr Nephrol 2015; 30:1163-72. [PMID: 25576065 DOI: 10.1007/s00467-014-3033-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2014] [Revised: 11/28/2014] [Accepted: 12/05/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND The administration of hypotonic saline solution for maintenance intravenous fluid (IVF) therapy has been the standard of care, but recent evidence has shown this treatment to be associated with hyponatremia-related complications. The aim of this systematic review was to determine which IVF, i.e., a hypotonic or an isotonic saline solution, poses less risk for the development of hyponatremia among hospitalized children who require maintenance IVF therapy. METHODS Medline, Cochrane Library, LILACS, Current Controlled Trials, reference lists, and abstract proceedings were searched for randomized controlled trials (RCTs) comparing hypotonic and isotonic saline solutions for maintenance IVF therapy in hospitalized children. Two reviewers independently assessed all potentially relevant studies and subsequently extracted data and evaluated the methodological quality of the RCTs. Studies were then combined and analyzed using a random effects model. RESULTS Eleven RCTs met the inclusion criteria. Our analysis of these 11 RCTs showed that among hospitalized children receiving maintenance IVF therapy, isotonic solutions significantly decreased the risk of developing hyponatremia [relative risk (RR) 0.50, 95% confidence interval (CI) 0.40-0.62] without significantly increasing the risk for hypernatremia (RR 0.83, 95% CI 0.41-1.67). CONCLUSIONS Current evidence does not support the standard practice of prescribing a hypotonic saline solution as maintenance IVF therapy to hospitalized children. Although there is no single IVF composition ideal for all children, an isotonic saline solution does appear to be the safer choice when maintenance IVF therapy is used in the general pediatric population.
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Affiliation(s)
- April P Padua
- Department of Pediatrics, University of the Philippines Manila-Philippine General Hospital, Manila, Philippines,
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Jayashree M, Baalaaji AM. Choice of maintenance fluids - does it hold water? Indian Pediatr 2015; 51:963-4. [PMID: 25560152 DOI: 10.1007/s13312-014-0541-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- M Jayashree
- Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
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McNab S, Ware RS, Neville KA, Choong K, Coulthard MG, Duke T, Davidson A, Dorofaeff T. Isotonic versus hypotonic solutions for maintenance intravenous fluid administration in children. Cochrane Database Syst Rev 2014; 2014:CD009457. [PMID: 25519949 PMCID: PMC10837683 DOI: 10.1002/14651858.cd009457.pub2] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Maintenance intravenous fluids are frequently used in hospitalised children who cannot maintain adequate hydration through enteral intake. Traditionally used hypotonic fluids have been associated with hyponatraemia and subsequent morbidity and mortality. Use of isotonic fluid has been proposed to reduce complications. OBJECTIVES To establish and compare the risk of hyponatraemia by systematically reviewing studies where isotonic is compared with hypotonic intravenous fluid for maintenance purposes in children.Secondly, to compare the risk of hypernatraemia, the effect on mean serum sodium concentration and the rate of attributable adverse effects of both fluid types in children. SEARCH METHODS We ran the search on 17 June 2013. We searched the Cochrane Injuries Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), MEDLINE (OvidSP), Embase (OvidSP), and ISI Web of Science. We also searched clinical trials registers and screened reference lists. We updated this search in October 2014 but these results have not yet been incorporated. SELECTION CRITERIA We included randomised controlled trials that compared isotonic versus hypotonic intravenous fluids for maintenance hydration in children. DATA COLLECTION AND ANALYSIS At least two authors assessed and extracted data for each trial. We presented dichotomous outcomes as risk ratios (RR) with 95% confidence intervals (CIs) and continuous outcomes as mean differences with 95% CIs. MAIN RESULTS Ten studies met the inclusion criteria, with a total of 1106 patients. The majority of the studies were performed in surgical or intensive care populations (or both). There was considerable variation in the composition of intravenous fluid, particularly hypotonic fluid, used in the studies. There was a low risk of bias for most of the included studies. Ten studies provided data for our primary outcome, a total of 449 patients in the analysis received isotonic fluid, while 521 received hypotonic fluid. Those who received isotonic fluid had a substantially lower risk of hyponatraemia (17% versus 34%; RR 0.48; 95% CI 0.38 to 0.60, high quality evidence). It is unclear whether there is an increased risk of hypernatraemia when isotonic fluids are used (4% versus 3%; RR 1.24; 95% CI 0.65 to 2.38, nine studies, 937 participants, low quality evidence), although the absolute number of patients developing hypernatraemia was low. Most studies had safety restrictions included in their methodology, preventing detailed investigation of serious adverse events. AUTHORS' CONCLUSIONS Isotonic intravenous maintenance fluids with sodium concentrations similar to that of plasma reduce the risk of hyponatraemia when compared with hypotonic intravenous fluids. These results apply for the first 24 hours of administration in a wide group of primarily surgical paediatric patients with varying severities of illness.
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Affiliation(s)
- Sarah McNab
- c/o Centre for International Child Health, Royal Children's Hospital, Flemington Rd, Parkville, VIC, 3052, Australia.
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Andersen C, Afshari A. Impact of perioperative hyponatremia in children: A narrative review. World J Crit Care Med 2014; 3:95-101. [PMID: 25374805 PMCID: PMC4220142 DOI: 10.5492/wjccm.v3.i4.95] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2014] [Revised: 09/13/2014] [Accepted: 10/27/2014] [Indexed: 02/06/2023] Open
Abstract
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.
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Hypotonic versus isotonic fluids in hospitalized children: a systematic review and meta-analysis. J Pediatr 2014; 165:163-169.e2. [PMID: 24582105 DOI: 10.1016/j.jpeds.2014.01.040] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Revised: 12/23/2013] [Accepted: 01/21/2014] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To determine whether the use of hypotonic vs isotonic maintenance fluids confers an increased risk of hyponatremia in hospitalized children. STUDY DESIGN A search of MEDLINE (1946 to January 2013), the Cochrane Central Registry (1991 to December 2012), Cumulative Index for Nursing and Allied Health Literature (1990 to December 2012), and Pediatric Academic Societies (2000-2012) abstracts was conducted using the terms "hypotonic fluids/saline/solutions" and "isotonic fluids/saline/solutions," and citations were reviewed using a predefined protocol. Data on the primary and secondary outcomes were extracted from original articles by 2 authors independently. Meta-analyses of the primary and secondary outcomes were performed when possible. RESULTS A total of 1634 citations were screened. Ten studies (n = 893) identified as independent randomized controlled trials were included. Five studies examined subjects in the intensive care unit setting, including 4 on regular wards and 1 in a mixed setting. In hospitalized children receiving maintenance intravenous fluids, hyponatremia was seen more often in those receiving hypotonic fluids than in those receiving isotonic fluids, with an overall relative risk of 2.37 (95% CI, 1.72-3.26). Receipt of hypotonic fluids was associated with a relative risk of moderate hyponatremia (<130 mmol/L) of 6.1 (95% CI, 2.2-17.3). A subgroup analysis of hypotonic fluids with half-normal saline found a relative risk of hyponatremia of 2.42 (95% CI, 1.32-4.45). CONCLUSION In hospitalized children in intensive care and postoperative settings, the administration of hypotonic maintenance fluids increases the risk of hyponatremia when compared with administration of isotonic fluids. For patients on general wards, insufficient data are available based on the reviewed studies, and individual risk factors must be assessed.
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Rodrigues RM, Schvartsman BGS, Farhat SCL, Schvartsman C. Hypotonic solution decreases serum sodium in infants with moderate bronchiolitis. Acta Paediatr 2014; 103:e111-5. [PMID: 24188330 DOI: 10.1111/apa.12493] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Revised: 10/27/2013] [Accepted: 10/30/2013] [Indexed: 01/09/2023]
Abstract
AIM To investigate the influence of hypotonic parenteral hydration on serum and urinary sodium and osmolality in infants with moderate bronchiolitis. METHODS We studied 36 infants (mean age 3.7 ± 2.3 months), with a diagnosis of moderate bronchiolitis admitted to a paediatric emergency unit in São Paulo, Brazil. Patients received a standard parenteral hypotonic solution, according to Holliday and Segar, during the first 24 h, due to respiratory distress. The disease was monitored by a respiratory severity score (RDAI-Respiratory Distress Assessment Instrument), respiratory rate and oxygen saturation. Serum and urinary sodium and osmolality were monitored at admission, 24 and 48 h after admission. RESULTS All respiratory parameters improved during hospitalisation. Serum sodium and osmolality dropped after 24 h (136.8 ± 2.8 and 135.8 ± 2.6 mEq/L, p = 0.031; 283.4 ± 4.1 and 281.6 ± 3.9 mOsm/kg, p = 0.004 respectively) as well as urinary osmolality (486.8 ± 243.4 mOsm/kg and 355.7 ± 205.0 mOsm/kg, p < 0.001) when compared to admission. CONCLUSION This study reinforces the occurrence of hyponatraemia in bronchiolitis even in patients with moderate disease and highlights the risk of serum sodium drop caused by hypotonic parenteral hydration.
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Affiliation(s)
- Regina M Rodrigues
- Emergency Department; Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo; São Paulo Brazil
| | - Benita GS Schvartsman
- Paediatric Nephrology Unit; Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo; São Paulo Brazil
| | - Sylvia CL Farhat
- Emergency Department; Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo; São Paulo Brazil
| | - Cláudio Schvartsman
- Emergency Department; Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo; São Paulo Brazil
- Hospital Israelita Albert Einstein; São Paulo Brazil
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Wang J, Xu E, Xiao Y. Isotonic versus hypotonic maintenance IV fluids in hospitalized children: a meta-analysis. Pediatrics 2014; 133:105-13. [PMID: 24379232 DOI: 10.1542/peds.2013-2041] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
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.
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Affiliation(s)
- Jingjing Wang
- Department of Pediatrics, Second Affiliated Hospital of Medical School of Xi'an Jiaotong University, 157 Xiwu Rd, Xi'an, Shaanxi 710004, China.
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Abstract
Intravenous maintenance fluid therapy aims to replace daily urinary and insensible losses for ill children in whom adequate enteric administration of fluids is contraindicated or infeasible. The traditional determination of fluid volumes and composition dates back to Holliday and Segar's seminal article from 1957, which describes the relationship between weight, energy expenditure, and physiologic losses in healthy children. Combined with estimates of daily electrolyte requirements, this information supports the use of the hypotonic maintenance fluids that were widely used in pediatric medicine. However, using hypotonic intravenous fluids in a contemporary hospitalized patient who may have complex physiologic derangements, less caloric expenditure, decreased urinary output, and elevated antidiuretic hormone levels is often not optimal; evidence over the last 2 decades shows that it may lead to an increased incidence of hyponatremia. In this review, we present the evidence for using isotonic rather than hypotonic fluids as intravenous maintenance fluid.
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Abstract
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.
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Affiliation(s)
- Endre Sulyok
- Pécsi Tudományegyetem Egészségtudományi Kar Pécs Vörösmarty u. 4. 7621
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Lee JM, Jung Y, Lee SE, Lee JH, Kim KH, Koo JW, Park YS, Cheong HI, Ha IS, Choi Y, Kang HG. Intravenous fluid prescription practices among pediatric residents in Korea. KOREAN JOURNAL OF PEDIATRICS 2013; 56:282-5. [PMID: 23908667 PMCID: PMC3728446 DOI: 10.3345/kjp.2013.56.7.282] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2012] [Revised: 10/05/2012] [Accepted: 10/24/2012] [Indexed: 02/07/2023]
Abstract
Purpose Recent studies have established the association between hypotonic fluids administration and hospital-acquired hyponatremia in children. The present paper investigated the pattern of current practice in intravenous fluid prescription among Korean pediatric residents, to underscore the need for updated education. Methods A survey-based analysis was carried out. Pediatric residents at six university hospitals in Korea completed a survey consisting of four questions. Each question proposed a unique scenario in which the respondents had to prescribe either a hypotonic or an isotonic fluid for the patient. Results Ninety-one responses were collected and analyzed. In three of the four scenarios, a significant majority prescribed the hypotonic fluids (98.9%, 85.7%, and 69.2%, respectively). Notably, 69.2% of the respondents selected the hypotonic fluids for postoperative management. Almost all (96.7%) selected the isotonic fluids for hydration therapy. Conclusion In the given scenarios, the majority of Korean pediatric residents would prescribe a hypotonic fluid, except for initial hydration. The current state of pediatric fluid management, notably, heightens the risk of hospital-acquired hyponatremia. Updated clinical practice education on intravenous fluid prescription, therefore, is urgently required.
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Affiliation(s)
- Jiwon M Lee
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
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