Prevention of Hyponatremia during Maintenance Intravenous Fluid Administration: A Prospective Randomized Study of Fluid Type versus Fluid Rate

Neville, Kristen A; Sandeman, David J.; Rubinstein, Alan; Henry, Guy; McGlynn, Michael; Walker, Judith S.

doi:10.1016/j.jpeds.2009.07.059

Cited by 144 publications

(141 citation statements)

References 32 publications

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“…Apesar de a tonicidade dos fluidos ser o cerne da discussão na maioria dos estudos 2,5,6,38 , o volume de líquidos infundidos pode ter papel importante no distúrbio do sódio, e essa variável foi estudada em dois trabalhos desta revisão 33,34 . Em ambos a taxa de infusão de fluidos não repercutiu de maneira estatisticamente significante no distúrbio do só-dio, sendo a variável da hipotonicidade a responsável pela hiponatremia.…”

Section: Discussionunclassified

Isotonic saline solution as maintenance intravenous fluid therapy to prevent acquired hyponatremia in hospitalized children

Alves¹,

Troster²,

Oliveira³

2011

J Pediatr (Rio J)

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Objectives: This review aims to evaluate if the use of hypotonic saline solutions as maintenance intravenous fluid therapy in hospitalized children increases the risk of hyponatremia, if the administration of isotonic fluids is able to protect against acquired hyponatremia and if the isotonic solutions increase the risks of deleterious effects such as hypernatremia or fluid overload. Sources:We researched the relevant literature on the PubMed (Jan 01 1969 to Jul 13 2011), EMBASE (1989to 2011) and Cochrane Library (1989to 2011 databases. Furthermore, references of selected studies were included. Summary of the findings:Hospitalized children are potentially at risk of developing hyponatremia and the use of hypotonic saline solutions is the main risk factor for this disease. Isotonic saline solutions have shown a protective effect against hyponatremia, and, so far, there have been no significant deleterious effects such as fluid overload, hypernatremia or phlebitis. Conclusions:The evidence found indicates that the traditional recommendation of Holliday and Segar to use maintenance fluid therapy for sick and hospitalized children deserves to be reconsidered due to the adverse effects found to arise from it, apart from the better results obtained by using isotonic solutions.J Pediatr (Rio J). 2011;87(6):478-86: Isotonic solutions, hypotonic solutions, fluid therapy, hyponatremia, child, hospitalization. ResumoObjetivos: Avaliar se o uso de soluções salinas hipotônicas como fluidoterapia de manutenção em crianças hospitalizadas aumenta o risco de hiponatremia, se a administração de fluidos isotônicos é capaz de proteger contra a hiponatremia adquirida e se as soluções isotôni-cas aumentam os riscos de efeitos deletérios como hipernatremia ou sobrecarga hídrica. Síntese dos dados:Crianças hospitalizadas têm riscos potenciais para hiponatremia, e o uso de soluções salinas hipotônicas é o principal fator de risco para esse agravo. As soluções salinas isotônicas têm mostrado efeito protetor para hiponatremia e, até o momento, sem efeitos deletérios significativos, como sobrecarga hídrica, hipernatremia ou flebites. Conclusões:As evidências indicam que a tradicional recomendação de Holliday & Segar quanto à fluidoterapia de manutenção para crianças doentes e hospitalizadas merece ser reconsiderada em virtude das evidên-cias sobre os efeitos adversos dela advindos, assim como dos melhores resultados obtidos com o emprego das soluções isotônicas. J Pediatr (Rio J) IntroduçãoA hiponatremia é definida como a concentração do sódio sérico inferior a 136 mmol/L. Quando sintomático, esse distúrbio pode manifestar-se por disfunção do sistema nervoso central (SNC), caracterizado por: cefaleia, náuseas, vômitos, letargia, desorientação, depressão de reflexos tendinosos, convulsões, disfunção neurológica permanente, morte por

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Section: Discussionunclassified

Isotonic saline solution as maintenance intravenous fluid therapy to prevent acquired hyponatremia in hospitalized children

Alves¹,

Troster²,

Oliveira³

2011

J Pediatr (Rio J)

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“…The change in plasma sodium was significantly affected by fluid type (P=0.006) but not by fluid rate (P=0.12). Likewise, Neville et al showed that the fluid type (P<0.001) but not the fluid rate (P=0.27) influenced the change in plasma sodium [28]. In this latter study, children were randomized to receive either 0.9 % saline at maintenance, 0.9 % saline at half maintenance, 0.45 % saline at maintenance, or 0.45 % saline at half maintenance.…”

Section: Bmaintenance^fluid Rate and Hyponatremiamentioning

confidence: 99%

“…Likewise, Rey et al randomized 125 medical and surgical pediatric patients to receive either hypotonic (Na 30-50 mmol/L+K 20 mmol/L) or isotonic (Na 136 mmol/L+K 20 mmol/L) IV fluid and demonstrated that the risk of hyponatremia was 5.8-fold (95 % CI 2.4-10, P<0.001) greater in the hypotonic group after adjusting for age, weight, and admission plasma sodium level [27]. Neville et al randomized 124 children undergoing surgery to receive either hypotonic 0.45 % saline or isotonic 0.9% saline; 8 h after extubation, hyponatremia developed in 19/62 (31.5 %) children in the hypotonic group compared to 6/62 (9.7 %) children in the isotonic group (P<0.006) [28]. Likewise, when Choong et al randomized 130 children to receive 0.45 % saline and 128 children to receive 0.9 % saline following elective surgery, hyponatremia (Na ≤135 mmol/L) was observed in 41 % of the hypotonic group and 23 % in the isotonic group during the 48 hours after surgery [relative risk (RR) 1.82, 95 % CI 1.21-2.74, P=0.004] [23].…”

Section: Fluid Tonicity and Hyponatremiamentioning

confidence: 99%

“…It is also important to note that hyponatremia can occur in patients receiving isotonic IV fluids, likely due to the presence of high circulating ADH levels [23]. Hyponatremia was observed in 9.7-23 % of children who received 5 % dextrose-0.9 % saline following surgical procedures [23,28]. ADH leads to the reabsorption of water in the collecting duct and the creation of concentrated urine with a urine osmolality of >100 mOsm/kg.…”

Section: Fluid Tonicity and Hyponatremiamentioning

confidence: 99%

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Perioperative fluid management and postoperative hyponatremia in children

Sutherland

2015

Pediatr Nephrol

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Intravenous (IV) fluids are used ubiquitously when children undergo surgical procedures. Until recently, Holliday and Segar's guidelines for calculating maintenance fluids dictated fluid management strategies in postoperative pediatric patients. An increased recognition of hospitalacquired hyponatremia and its associated morbidity has led to a critical re-examination of IV fluid management in this population. Postsurgical patients are at high risk of developing hyponatremia due to the presence of non-osmotic stimuli for antidiuretic hormone release. Recent studies have established that, as they are administered in current practice, hypotonic maintenance fluids are associated with increased rates of hyponatremia. The best available data demonstrate that administration of isotonic fluid reduces hyponatremic risk. In this review, we discuss the collective data available on the subject and offer guidelines for fluid management and therapeutic monitoring.

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“…It is now well established that hypotonic maintenance fluids result in hospital-acquired hyponatremia in children [8][9][10]. This has been best demonstrated in the post-operative setting where the incidence of hospital-acquired hyponatremia (sodium<135 mEq/L) is 20-30% [11][12][13][14][15]. Surprisingly, there have been no studies to evaluate the safety of the deficit-plus-maintenance-fluid approach in hospitalized children with gastroenteritis.…”

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confidence: 99%

Improving intravenous fluid therapy in children with gastroenteritis

Moritz

Ayus

2010

Pediatr Nephrol

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Gastroenteritis is one of the most common medical conditions seen by pediatricians. The standard approach to intravenous fluid therapy for these children has been to administer a 0.9% sodium chloride (NaCl) bolus followed by a hypotonic solution ranging from 0.2-0.45% NaCl to replace the remaining deficit plus maintenance. We have questioned the safety of this approach as there have been reports of death or permanent neurologic impairment from hyponatremic encephalopathy. Hanna and Saberi (Pediatr Nephrol. doi:10.1007/s00467-009-1428-y) found the incidence of hospital-acquired hyponatremia (sodium<135 mEq/L) to be 18.5% for patients presenting with isonatremic dehydration from gastroenteritis. This confirms that the current approach of using hypotonic fluids results in a high incidence of hyponatremia. Hypotonic fluids are not appropriate for rehydration in patients with gastroenteritis as it is a state of arginine vasopressin (AVP) excess due to both hemodynamic stimuli from volume depletion and non-hemodynamic stimuli such as nausea and vomiting. Free water will be retained until the volume deficit is corrected and the hemodynamic stimulus for AVP production abates. A safer and more effective approach is the administration of 0.9% NaCl in a continuous infusion following bolus therapy. 0.9% NaCl not only serves as prophylaxis against hyponatremia, but it is superior to hypotonic fluids as an extracellular volume expander and corrects the volume deficit more rapidly.Keywords Encephalopathy . Fluid therapy . Gastroenteritis . Hypernatremia . Hyponatremia . Sodium Gastroenteritis is one of the most common medical conditions seen by pediatricians, accounting for over 150,000 hospitalizations per year or approximately 10% of all hospital admissions in children <5 years of age in the USA [1]. The standard approach to intravenous fluid therapy for these children has been to administer a 20-40 ml/kg bolus of 0.9% sodium chloride (NaCl) followed by a hypotonic solution with a sodium concentration ranging from 0.2-0.45% NaCl to replace the remaining deficit plus maintenance if unable to tolerate an oral rehydration solution [2]. We have questioned the safety of using a hypotonic fluid in this approach [3,4], as there have been reports of death or permanent neurologic impairment from hospital-acquired hyponatremic encephalopathy [5][6][7]. It is now well established that hypotonic maintenance fluids result in hospital-acquired hyponatremia in children [8][9][10]. This has been best demonstrated in the post-operative setting where the incidence of hospital-acquired hyponatremia (sodium<135 mEq/L) is 20-30% [11][12][13][14][15]. Surprisingly, there have been no studies to evaluate the safety of the deficit-plus-maintenance-fluid approach in hospitalized children with gastroenteritis.In this issue of Pediatric Nephrology, Hanna and Saberi evaluated the incidence of hyponatremia (sodium<135 mEq/ L) in children treated with deficit-plus-maintenance-fluid therapy for gastroenteritis [16]. They found the incidence of ho...

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Prevention of Hyponatremia during Maintenance Intravenous Fluid Administration: A Prospective Randomized Study of Fluid Type versus Fluid Rate

Cited by 144 publications

References 32 publications

Isotonic saline solution as maintenance intravenous fluid therapy to prevent acquired hyponatremia in hospitalized children

Isotonic saline solution as maintenance intravenous fluid therapy to prevent acquired hyponatremia in hospitalized children

Perioperative fluid management and postoperative hyponatremia in children

Improving intravenous fluid therapy in children with gastroenteritis

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