Severe hyponatremia and bilateral sequential facial palsy: A case report

Facial palsy (FP) is a known consequence of head trauma, manifesting either immediately at the time of injury or with delayed onset, typically occurring 2 days or more post-trauma. Unilateral FP is the more common presentation and is often attributed to partial or complete transection of facial nerves or delayed onset edema. Conversely, bilateral facial palsy is a rare occurrence, reported in only a small number of cases, accounting for approximately 3% of patients presenting with bilateral weakness. In this report, we present the case of a previously healthy 28-year-old female who suffered a closed head injury during the Beirut Port Blast. Four days following the incident, the patient exhibited right-sided peripheral FP, which was consistent with a right temporal bone fracture. Subsequently, on the fifth day, the right-sided FP worsened, accompanied by the development of new FP on the left side, characterized by sparing of the frontal region, indicating a central origin for the left-sided FP. Laboratory investigations revealed severe hypovolemic hyponatremia with a sodium level of 105 mmol/L. As isotonic saline fluid replacement was initiated, there was progressive improvement in the left-sided FP. The right-sided palsy also resolved gradually with the implementation of facial rehabilitation therapy. It is important to note that severe head trauma, particularly with a concussive injury, can lead to facial paralysis through various mechanisms. Furthermore, severe hyponatremia should be considered a potential cause of central facial palsy, particularly in the presence of bilateral facial involvement. A thorough evaluation is encompassing assessment of palsy patterns, comprehensive imaging studies, and metabolic investigations is crucial for accurate diagnosis and timely intervention, resulting in successful treatment.

Comparison of Hypertonic Saline with Normal Saline in Nasal Irrigation Post Endoscopic Sinus Surgery

Functional endoscopic sinus surgery (FESS) is indicated for the treatment of chronic rhinosinusitis that is refractory to medical treatment. Nasal irrigation is a classic and powerful adjunctive method for the management of chronic rhinosinusitis after FESS [5]. This study aimed to compare the effects of hypertonic saline and isotonic saline nasal irrigation following endoscopic sinus surgery. The study was conducted in the Department of Otorhinolaryngology at Mahatma Gandhi Medical College and Hospital, Jaipur, India, on 156 patients, who had chronic rhinosinusitis with or without nasal polyposis, and were resistant to conservative management. All patients underwent functional endoscopic sinus surgery. Patients were advised to perform nasal douching post-surgery, and were randomly divided into two groups based on the douching solution they used. Group 1 was given hypertonic saline (3%) while Group 2 was given isotonic saline (0.9%). Patients were examined at weeks 1, 3 and 6 post-operatively. Outcomes of irrigation using both solutions were assessed by- 20-item Sino-Nasal Outcome Test (SNOT20) scores [13], Visual analogue scale (VAS) scores [1, 2], mucociliary clearance (MCC) assessment [14] and endoscopic examination. The group receiving hypertonic saline showed significant improvement in 20-item Sino-Nasal Outcome Test scores, Visual analogue scale scores and improvement of sino-nasal mucosa from polypoidal to cobblestone, in the follow up period. However improvement in mucociliary clearance and resolution of postoperative crustings was consistent in both groups. Hypertonic saline nasal irrigation post FESS brings greater benefits on symptom improvement and normalization of the sino-nasal mucosa over isotonic saline.

Balanced electrolyte solutions versus isotonic saline in adult patients with diabetic ketoacidosis: A systematic review and meta-analysis

BACKGROUND

Current guidelines suggest the use of isotonic saline (IS) infusion as the preferred resuscitation fluid in the management of diabetic ketoacidosis (DKA). However, balanced electrolyte solutions (BES) have been proposed as an alternative due to a lower propensity to cause hyperchloremic metabolic acidosis. Evidence regarding the use of BES in DKA remains limited.

OBJECTIVES

To determine if the use of BES in fluid resuscitation leads to faster resolution of DKA compared to IS.

METHODS

The study involves a comprehensive search of literature from PubMed, Cochrane CENTRAL, Google Scholar, and Science Direct of clinical trials addressing the use of BES vs IS in fluid resuscitation in DKA. The time to resolution of DKA was examined as the primary endpoint. Pooled hazard ratios (HR) and Mean Difference (MD) in hours with their 95% confidence intervals (CI) were calculated using a random-effects model.

RESULTS

The literature search included 464 studies that were screened individually. A total of 9 studies were identified but 6 studies were excluded due to irrelevance in the outcome of interest and target population. The pooled hazard ratio HR significantly revealed 1.46 [1.10 to 1.94] (p = 0.009) with 12% heterogeneity while MD was -3.02 (95% CI -6.78-0.74; p = 0.12) with heterogeneity of 85%.

CONCLUSION

Considering the evidence from pooled small randomized trials with moderate overall certainty of evidence, the use of BES in DKA was associated with faster rates of DKA resolution compared to IS.

Effect of 0.9% NaCl compared to plasma-lyte on biomarkers of kidney injury, sodium excretion and tubular transport proteins in patients undergoing primary uncemented hip replacement - a randomized trial

Background

Isotonic saline (IS) is widely used to secure perioperative cardiovascular stability. However, the high amount of chloride in IS can induce hyperchloremic acidosis. Therefore, IS is suspected to increase the risk of acute kidney injury (AKI). Biomarkers may have potential as indicators.

Methods

In a double-blinded, placebo-controlled study, 38 patients undergoing primary uncemented hip replacement were randomized to IS or PlasmaLyte (PL). Infusion was given during surgery as 15 ml/kg the first hour and 5 ml/kg the following two hours. Urinary samples were collected upon admission and the day after surgery. As surgery was initiated, urine was collected over the course of 4 h. Hereafter, another urine collection proceeded until the morning. Urine was analyzed for markers of AKI neutrophil gelatinase-associated lipocalin (NGAL) and kidney injury molecule-1 (KIM-1). Arterious and venous blood samples for measurements of pH and plasma electrolytes including chloride (p-Cl) were collected as surgery was initiated, at the end of surgery and the following morning.

Results

IS induced an increase in p-Cl (111 ± 2 mmol/L after IS and 108 ± 3 after PL, p = 0.004) and a decrease in pH (7.39 ± 0.02 after IS and 7.43 ± 0.03 after PL, p = 0.001). Urinary NGAL excretion increased in both groups (ΔNGAL: 5.5 [4.1; 11.7] μg/mmol creatinine p = 0.004 after IS vs. 5.5 [2.1;9.4] μg/mmol creatinine after PL, p < 0.001). No difference was found between the groups (p = 0.839). Similarly, urinary KIM-1 excretion increased in both groups (ΔKIM-1: IS 115.8 [74.1; 156.2] ng/mmol creatinine, p < 0.001 vs. PL 152.4 [120.1; 307.9] ng/mmol creatinine, p < 0.001). No difference between the groups (p = 0.064).

FE_Na increased (1.08 ± 0.52% after IS and 1.66 ± 1.15% after PL, p = 0.032). ENaC excretion was different within groups (p = 0.019).

Conclusion

A significantly higher plasma chloride and a lower pH was present in the group receiving isotonic saline. However, u-NGAL and u-KIM-1 increased significantly in both groups after surgery despite absence of changes in creatinine. These results indicate that surgery induced subclinical kidney injury. Also, the IS group had a delayed sodium excretion as compared to the PL group which may indicate that IS affects renal sodium excretion differently from PL.

Trial registration

ClinicalTrials.gov Identifier: NCT02528448, 19/08/2015

The efficacy of inhaled hypertonic saline for bronchiectasis: a meta-analysis of randomized controlled studies

INTRODUCTION

The efficacy of inhaled hypertonic saline for bronchiectasis remains controversial. We conduct a systematic review and meta-analysis to explore the influence of inhaled hypertonic saline versus 0.9% isotonic saline for the treatment of bronchiectasis.

METHODS

We have searched PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through April 2020 for randomized controlled trials (RCTs) assessing the efficacy of inhaled hypertonic saline versus 0.9% isotonic saline for the treatment of bronchiectasis. This meta-analysis was performed using the random-effect model.

RESULTS

Four RCTs were included in the meta-analysis. Overall, compared with control group for bronchiectasis, inhaled hypertonic saline had no obvious influence on forced expiratory volume in 1 s (FEV1, SMD = 0.12; 95% CI = -0.06 to 0.30; P = .18), forced vital capacity (FVC, SMD = 0.10; 95% CI = -0.09 to 0.28; P = .30), sputum expectorated (SMD = -0.03; 95% CI = -2.73 to 2.68; P = .99) or Leicester Cough Questionnaire (LCQ) score (SMD = -0.15; 95% CI = -0.89 to 0.58; P = .68).

CONCLUSIONS

Inhaled hypertonic saline and 0.9% isotonic saline show similar efficacy for bronchiectasis.

Randomised trial on performance, safety and clinical benefit of hyaluronic acid, hyaluronic acid plus dexpanthenol and isotonic saline nasal sprays in patients suffering from dry nose symptoms

OBJECTIVE

Limited data exist on the clinical benefits of nasal applications for moistening the nasal mucosa. We therefore investigated the effects of hyaluronic acid, hyaluronic acid plus dexpanthenol and isotonic saline nasal sprays in patients suffering from dry nose symptoms in an otorhinolaryngological outpatient setting.

METHODS

240 patients were randomised into this prospective, three-armed clinical trial with two assessment points (baseline and 4 weeks later). Patients received either hyaluronic acid, hyaluronic acid plus dexpanthenol or isotonic saline nasal spray over a period of four weeks. Rhinitis Sicca Symptom Score (RSSS) was assessed as primary endpoint, and individual symptoms and tolerability of all treatments as secondary endpoints. Patient perceptions after first application of the allocated nasal spray were recorded using the Nasal Spray Sensory Scale. Treatment effects were analysed for each study arm first and subsequently compared against each other.

RESULTS

RSSS (hyaluronic acid: mean difference = 8.90 [98.33% CI = 7.34/10.45]; hyaluronic acid plus dexpanthenol: mean difference = 8.42 [98.33% CI = 6.91/9.94]; isotonic saline: mean difference = 8.94 [98.33% CI = 7.33/10.54]), individual symptoms and Endoscopy Score improved significantly (p < 0.001) in all treatment arms. Tolerability was assessed as "flawless" in more than 85% of all treatments, which is reflected in overall high rankings in the Nasal Spray Sensory Scale. Perception of nasal moisturisation was reported to be significantly higher in patients receiving hyaluronic acid plus dexpanthenol as compared to patients receiving hyaluronic acid or isotonic saline. No further significant differences were observed between the three treatments.

CONCLUSION

All three tested sprays (hyaluronic acid, hyaluronic acid plus dexpanthenol and isotonic saline) proved to be suitable treatments for patients suffering from dry nose symptoms. (DRKS-ID: DRKS00013357).

Balanced crystalloids versus isotonic saline in critically ill patients: systematic review and meta-analysis

Objectives

Intravenous fluids are one of the most used medical therapy for patients, especially critically ill patients. We conducted a meta-analysis comparing between balanced crystalloids and normal saline in critically ill patients and its effect on various clinical outcomes.

Design

Meta-analysis and systematic review of randomized clinical trials (RCTs).

Methods and data source

Electronic search was performed using PubMed, Cochrane library, and clinical trials.gov from inception through March 1, 2018, with inclusion of prospective studies that investigated one of the primary outcomes which were acute kidney injury (AKI) and in-hospital mortality while secondary outcomes were intensive care unit (ICU) mortality and new renal replacement therapy (RRT).

Results

Six RCTs were included. Total of 19,332 patients were included in the final analysis. There was no significant difference in in-hospital mortality (11.5% vs 12.2%; OR 0.92; 95% CI 0.85-1.01; P = 0.09; I² = 0%), incidence of AKI (12% vs 12.7%, OR 0.92; 95% CI 0.84-1.01; P = 0.1; I² = 0), overall ICU mortality (OR 0.9, 95% CI 0.81-1.01, P = 0.08, I² = 0%), or need for new RRT (OR 0.92, 95% CI 0.67-1.28, P = 0.65, I² = 38%) between balanced crystalloids and isotonic saline in critically ill patients.

Conclusion

Balanced crystalloids and isotonic saline have no difference on various clinical outcomes including in-hospital mortality, AKI, overall ICU mortality, and new RRT. Further powerful clinical trials are required to determine the relationship between crystalloid fluid type and clinical outcomes.

Effects of salso-bromo-iodine thermal water in children suffering from otitis media with effusion: a randomized controlled pilot study

BACKGROUND

Otitis media with effusion (OME) is an ear disorder defined by the presence of fluid in the middle ear without signs or symptoms of acute infection. The aim of this randomised and controlled pilot study was to evaluate whether the treatment with a watery salsobromo- iodine solution, administered by nasal douche, could induce ear healing better than isotonic saline in children with OME.

METHODS

The study was randomized, single-blind, and controlled. Study group (40 children) was treated with salso-bromo-iodine thermal water solution and Control group (40 children) was treated with isotonic saline; both compounds were administered by nasal nebulization with Rinowash nasal douche twice/day for 10 days a month for 3 consecutive months. Tympanogram and audiometry were performed at baseline and after treatment.

RESULTS

Salso-bromo-iodine therapy shows better and statistically significant trend after treatment when compared to control group both for tympanogram results with greater improvement (represented by type C tympanogram; p = 0.031) and healing (represented by type A tympanogram; p < 0.001) and audiometric results, with higher presence of patients with normal hearing (p = 0.029) and lower among patients with moderate hypoacusis (p = 0.014).

CONCLUSIONS

The current randomized-controlled pilot study demonstrated that watery salso-bromo-iodine solution was effective in the treatment of children with OME.

Nasal care in intensive care unit patients

PURPOSE

The aim of this study was to investigate nasal hygiene in intensive care patients and improve patient care using isotonic saline nasal spray.

MATERIAL AND METHODS

In the study group, over a period of tendays saline nasal spray was administered four times daily. Nasal treatment was not given to the control group. Each patient was examined with a flexible nasopharyngoscope before and after the treatment and a nasal culture was taken.

RESULTS

In the study group, the secretion score (1- absent; 2- serosal; 3- seropurulent and 4- purulent) mean value improved from 1.9 to 1.4. In the control group, the secretion score mean value had risen from 1.7 to 3.1. At the beginning of the study, there was no difference in secretion scores between the groups, but on the tenth day a statistically significant difference was found.

CONCLUSION

The use of saline nasal spray in this group of intensive care patients was found to be effective in achieving nasal hygiene.

Euvolemic hyponatremia in cancer patients. Report of the Hyponatremia Registry: an observational multicenter international study

Purpose

Hyponatremia secondary to SIADH is frequent in cancer patients and potentially deleterious. The aim of this sub-analysis of the Hyponatremia Registry database is to analyze current diagnostic and therapeutic management practices in cancer patients with SIADH.

Methods

We analyzed 358 cancer patients who had serum sodium concentration ([Na⁺]) ≤ 130 mEq/L and a clinical diagnosis of SIADH from 225 sites in the USA and EU.

Results

Precise diagnostic testing was performed in only 46%. Almost 12% of all patients did not receive any hyponatremia treatment. The most frequent therapies were fluid restriction (20%), isotonic saline (14%), fluid restriction/isotonic saline (7%), tolvaptan (8%), and salt tablets (7%). Hypertonic saline was used in less than 3%. Tolvaptan produced the greatest median rate of [Na⁺] change (IQR) (3.0 (4.7) mEq/L/day), followed by hypertonic saline (2.0(7.0) mEq/L/day), and fluid restriction/isotonic saline (1.9(3.2) mEq/L/day). Both fluid restriction and isotonic saline monotherapies were significantly less effective (0.8(2.0) mEq/L/day and 1.3(3.0) mEq/L/day, respectively) and were associated with clinically relevant rates of treatment failure. Only 46% of patients were discharged with [Na⁺] ≥ 130 mEq/L. Overly rapid correction of hyponatremia occurred in 11.7%.

Conclusions

Although essential for successful hyponatremia management, appropriate diagnostic testing is not routinely performed in current practice. The most frequently employed monotherapies were often ineffective and sometimes even aggravated hyponatremia. Tolvaptan was used less often but showed significantly greater effectiveness. Despite clear evidence that hyponatremia is associated with poor outcome in oncology patients, most patients were discharged still hyponatremic. Further studies are needed to assess the beneficial impact of hyponatremia correction with effective therapies.

Electronic supplementary material

The online version of this article (doi:10.1007/s00520-017-3638-3) contains supplementary material, which is available to authorized users.

Diagnosing and Treating the Syndrome of Inappropriate Antidiuretic Hormone Secretion

BACKGROUND

The syndrome of inappropriate antidiuretic hormone secretion is the most common cause of hyponatremia in clinical practice, but current management of hyponatremia and outcomes in patients with syndrome of inappropriate antidiuretic hormone secretion are not well understood. The objective of the Hyponatremia Registry was to assess the current state of management of hyponatremia due to syndrome of inappropriate antidiuretic hormone secretion in diverse hospital settings, specifically which diagnostic and treatment modalities are currently used and how rapidly and reliably they result in an increase in serum sodium concentration ([Na(+)]). A secondary objective was to determine whether treatment choices and outcomes differ across the United States and the European Union.

METHODS

The Hyponatremia Registry recorded selected diagnostic measures and use, efficacy, and outcomes of therapy for euvolemic hyponatremia diagnosed clinically as syndrome of inappropriate antidiuretic hormone secretion in 1524 adult patients with [Na(+)] ≤130 mEq/L (1034 from 146 US sites and 490 from 79 EU sites). A subgroup of patients with more rigorously defined syndrome of inappropriate antidiuretic hormone secretion via measurement of relevant laboratory parameters was also analyzed.

RESULTS

The most common monotherapy treatments for hyponatremia in syndrome of inappropriate antidiuretic hormone secretion were fluid restriction (48%), isotonic (27%) or hypertonic (6%) saline, and tolvaptan (13%); 11% received no active agent. The mean rate of [Na(+)] change (mEq/L/d) was greater for all active therapies than no active treatment. Hypertonic saline and tolvaptan produced the greatest mean rate of [Na(+)] change (interquartile range, both 3.0 [6.0] mEq/L/d) compared with lower interquartile range rates of [Na(+)] change for isotonic saline (1.5 [3.0] mEq/L/d) and fluid restriction (1.0 [2.3] mEq/L/d). The general pattern of responses was similar in both the US and EU cohorts. At discharge, [Na(+)] was <135 mEq/L in 75% of patients and ≤130 mEq/L in 43% of patients. Overly rapid correction occurred in 10.2% of patients.

CONCLUSIONS

Current treatment of hyponatremia in syndrome of inappropriate antidiuretic hormone secretion often uses therapies with limited efficacy; the most commonly chosen monotherapy treatments, fluid restriction and isotonic saline, failed to increase the serum [Na(+)] by ≥5 mEq/L in 55% and 64% of monotherapy treatment episodes, respectively. Appropriate laboratory tests to diagnose syndrome of inappropriate antidiuretic hormone secretion were obtained in <50% of patients; success rates in correcting hyponatremia were significantly higher when such tests were obtained. Few outcome differences were found between the United States and the European Union. A notable exception was hospital length of stay; use of tolvaptan was associated with significantly shorter length of stay in the European Union but not in the United States. Despite the availability of effective therapies, most patients with syndrome of inappropriate antidiuretic hormone secretion were discharged from the hospital still hyponatremic.