Clinical Associations of Early Dysnatremias in Critically Ill Neonates and Infants Undergoing Cardiac Surgery

Abstract

subjects that demonstrated DN before surgery. Serum sodium levels were recorded for the first 72 h post-operatively. DN was present in 54% of the subjects (98/183): hypernatremia in 60 (33%), hyponatremia in 38 (21%). Multivariate analysis revealed that mild hypernatremia (146-150 mmol/dl) and moderate hypernatremia (151-155 mmol/dl) were associated with longer hospital length of stay (LOS, p < 0.05) and ventilation times (p < 0.05). No association was shown between mild/moderate hyponatremia (125-134 mmol/dl) with either outcome. Hours to DN were significantly lower in hypernatremic (median = 5.8 h) than hyponatremic (median = 43.8 h) patients (p < 0.001). Children younger than 30 days presented DN at an earlier stage than those 31 days-1 year old (median +2.2 vs. 17.3 h). No associations present between DN and the class of diuretic (loop vs. thiazide) administered, or the route of administration (intravenous bolus vs. constant infusion). Total median sodium bicarbonate administration was associated with hypernatremia, as was exposure to vasopressin within the first 72 h post-operatively. Dysnatremias are common in the early post-operative period in neonates and infants undergoing cardiac surgery. Mild to moderate hypernatremia, but not hyponatremia, is associated with longer LOS and longer ventilation time in infants undergoing cardiovascular surgery. Hypernatremia is also associated with younger infants, a higher surgical complexity, administration of bicarbonate and exposure to vasopressin. Diuretic type or interval timing of intravenous delivery did not demonstrate any effect. Prospective studies are needed in this population, in order to determine how DN, particularly hypernatremia, contributes to adverse outcomes, whether this association is independent of illness severity, and what may be safe treatments and interventions for these disorders.

Postoperative dysnatremia in infants after open‐heart surgery occurs frequently and is associated with prolonged intensive care length of stay

“…Fluctuations in sodium concentrations have been described in several studies, including children and adults admitted to intensive care, 5,14 although with variable outcomes. Previous studies have demonstrated prolonged LOS in association with hypernatremia, 9,10 whereas others have demonstrated more complications and prolonged LOS in association with hyponatremia 5,15 . The reason for these discrepancies may relate to time points for blood sampling and patient populations.…”

“…Several studies have focused on outcomes in relation to sodium disturbances in critically ill patients, 5,14,15 including postcardiac surgery in children 9,10,16 . In the majority of these studies, changes in sodium have been trichotomized into either normo‐, hypo‐, or hypernatremia, but as can be seen from Figure , several children crossed more than one boundary within the first 48 h. This led us to explore the various pathways with either decreasing or increasing sodium levels.…”

“…Hyponatremia is the most common dysnatremia during critical care, and its occurrence has been associated with prolonged length of stay 3–8 . However, in a recent study with infants undergoing surgery for congenital heart disease (CHD), postoperative hypernatremia was more common and associated with longer pediatric intensive care unit length of stay (PICU‐LOS) 9 . It has previously been shown that plasma sodium levels often fluctuate in infants undergoing surgery for CHD using cardiopulmonary bypass (CPB) due to an initial hemodilution followed by a subsequent rise in plasma sodium after weaning off CPB 10 .…”

Hiponatremia em uma Unidade de Terapia Intensiva Pediátrica

“…Poucos estudos tratam da incidência e evolução das disnatremias em pós-operatório de cirurgia cardíaca. Kaufman et al 49 No presente estudo, a hiponatremia leve foi mais frequente e relacionada a maior tempo de internação em relação à isonatremia. Reconhece-se que a hiponatremia leve está associada a fator de risco independente de mortalidade e não deve ser negligenciada e, portanto, ser tratada prontamente 51,52 .…”

“…Pacientes com hiponatremia tiveram tempo médio mais prolongado de internação (14,1 dias; DP=43,1 versus 5,1 dias; DP=6,1; p<0,000) e de ventilação mecânica (7,3 dias; DP=39,9 versus 1,7 dias; DP=3,5; p<0,000), maior gravidade (PRISM=9,1; DP=7,1 versus 6,6; DP=6,2; p< 0,000) e mortalidade (n=90; 8,5% versus n=24; 3%; p<0,000). ( 12,4) 126 (15,9) 257 (13,9) Procedência; n (%) 0,099* Domiciliar 482 (45,7) 392 (49,6) 874 (47,3) Hospitalar 573 (54,3) 399 (50,4) 972 (52,7) Doenças; n (%) 0,541* Aguda 301 (28,5) 236 (29,8) 537 (29,1) Crônica 754 (71,5) 555 (70,2) 1309 (70,9) Doenças crônicas; n (%) 0,000* Não Complexa 112 (14,9) 124 (22,3) 236 (18,2) Complexa 642 (85,1) 431 (77,7) 1073 (82,2) Diagnóstico Clínico; n (%) Falência Respiratória 211 (35,2) 152 (39,6) 363 (37,0) Sepse / Choque séptico 137 (22,9) 49 (12,8) 186 (18,9) Disfunções Neurológicas 95 (15,9) 81 (21,1) 176 (17,9) ICC / Choque cardiogênico 39 (6,5) 29 (7,6) 68 (6,9) Distúrbio HE-AB 31 …”