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Milani H, Tajalli S, Behrouzi K, Homan N, Zamaniashtiani F, Vafaee A, Vahedi Z, Khalesi N. Maintenance intravenous fluid therapy in infants with sepsis and hyponatremia: a clinical trial. BMC Pediatr 2024; 24:497. [PMID: 39095791 PMCID: PMC11295352 DOI: 10.1186/s12887-024-04901-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 06/20/2024] [Indexed: 08/04/2024] Open
Abstract
BACKGROUND This study aimed to compare the effect of two methods of maintenance intravenous fluid therapy on hyponatremia in hospitalized infants with sepsis. METHODS In a double-blinded randomized clinical trial, 60 term infants with sepsis were enrolled. Blood samples were taken to determine sodium, potassium, Creatinine, and BUN levels before the initiation of treatment. Urine samples were taken to assess specific gravity and urinary output. Infants in the intervention group received half saline in 10% dextrose and infants in the control group were assigned to receive the conventional solution as maintenance. The above indicators were re-evaluated 24 and 48 h after the initiation of treatment. Two groups were compared concerning the incidence of hyponatremia, and other criteria such as urinary output and urinary specific gravity, blood urea nitrogen (BUN), and creatinine levels. RESULTS Hyponatremia was more common in the control group. Sodium levels were significantly higher in half saline recipients 24 h (137.83 ± 2.86 vs. 134.37 ± 1.91 mmol/L), and 48 h (138.10 ± 2.41 vs. 133.66 ± 1.98 mmol/L) after treatment (P < 0.001). Although BUN in the intervention group was significantly higher in comparison to the control group, the difference in urinary output, urine specific gravity, potassium, and Creatinine levels were not significant in the two groups. CONCLUSIONS The use of a half-saline solution as maintenance fluid reduces the risk of hyponatremia after 48 h when compared to 0.18%NaCl. TRIAL REGISTRATION This has been registered at Iranian Registry of Clinical Trials (Retrospectively registered, Registration date: 2017-10-12, identifier: IRCT2017053034223N1, https://irct.behdasht.gov.ir/trial/26204 ).
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Affiliation(s)
- Hani Milani
- Department of Neonatology, Kamali Hospital, Alborz University of Medical Sciences, Alborz, Iran
| | - Saleheh Tajalli
- School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
| | - Kamran Behrouzi
- Department of Neonatology, Kamali Hospital, Alborz University of Medical Sciences, Alborz, Iran
| | - Nakisa Homan
- Department of Pediatrics, Iran University of Medical Sciences, Tehran, Iran
| | - Fateme Zamaniashtiani
- School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Vafaee
- Department of Nursing, Faculty of Nursing and Midwifery, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
| | - Zahra Vahedi
- Department of Pediatrics, Iran University of Medical Sciences, Tehran, Iran
| | - Nasrin Khalesi
- Department of Pediatrics, Iran University of Medical Sciences, Tehran, Iran.
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Amer BE, Abdelwahab OA, Abdelaziz A, Soliman Y, Amin AM, Mohamed MA, Albakri K, Zedan EM, Hamouda N. Efficacy and safety of isotonic versus hypotonic intravenous maintenance fluids in hospitalized children: an updated systematic review and meta-analysis of randomized controlled trials. Pediatr Nephrol 2024; 39:57-84. [PMID: 37365423 PMCID: PMC10673968 DOI: 10.1007/s00467-023-06032-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/11/2023] [Accepted: 05/15/2023] [Indexed: 06/28/2023]
Abstract
BACKGROUND Iatrogenic hyponatremia is a common complication following intravenous maintenance fluid therapy (IV-MFT) in hospitalized children. Despite the American Academy of Pediatrics' 2018 recommendations, IV-MFT prescribing practices still vary considerably. OBJECTIVES This meta-analysis aimed to compare the safety and efficacy of isotonic versus hypotonic IV-MFT in hospitalized children. DATA SOURCES We searched PubMed, Scopus, Web of Science, and Cochrane Central from inception to October 1, 2022. STUDY ELIGIBILITY CRITERIA We included randomized controlled trials (RCTs) comparing isotonic versus hypotonic IV-MFT in hospitalized children, either with medical or surgical conditions. Our primary outcome was hyponatremia following IV-MFT. Secondary outcomes included hypernatremia, serum sodium, serum potassium, serum osmolarity, blood pH, blood sugar, serum creatinine, serum chloride, urinary sodium, length of hospital stay, and adverse outcomes. STUDY APPRAISAL AND SYNTHESIS METHODS Random-effects models were used to pool the extracted data. We performed our analysis based on the duration of fluid administration (i.e., ≤ 24 and > 24 h). The Grades of Recommendations Assessment Development and Evaluation (GRADE) scale was used to evaluate the strength and level of evidence for recommendations. RESULTS A total of 33 RCTs, comprising 5049 patients were included. Isotonic IV-MFT significantly reduced the risk of mild hyponatremia at both ≤ 24 h (RR = 0.38, 95% CI [0.30, 0.48], P < 0.00001; high quality of evidence) and > 24 h (RR = 0.47, 95% CI [0.37, 0.62], P < 0.00001; high quality of evidence). This protective effect of isotonic fluid was maintained in most examined subgroups. Isotonic IV-MFT significantly increased the risk of hypernatremia in neonates (RR = 3.74, 95% CI [1.42, 9.85], P = 0.008). In addition, it significantly increased serum creatinine at ≤ 24 h (MD = 0.89, 95% CI [0.84, 0.94], P < 0.00001) and decreased blood pH (MD = -0.05, 95% CI [-0.08 to -0.02], P = 0.0006). Mean serum sodium, serum osmolarity, and serum chloride were lower in the hypotonic group at ≤ 24 h. The two fluids were comparable in terms of serum potassium, length of hospital stay, blood sugar, and the risk of adverse outcomes. LIMITATIONS The main limitation of our study was the heterogeneity of the included studies. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS Isotonic IV-MFT was superior to the hypotonic one in reducing the risk of iatrogenic hyponatremia in hospitalized children. However, it increases the risk of hypernatremia in neonates and may lead to renal dysfunction. Given that the risk of hypernatremia is not important even in the neonates, we propose to use balanced isotonic IV-MFT in hospitalized children as it is better tolerated by the kidneys than 0.9% saline. SYSTEMATIC REVIEW REGISTRATION NUMBER CRD42022372359. Graphical abstract A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Basma Ehab Amer
- Medical Research Group of Egypt, Cairo, Egypt.
- Faculty of Medicine, Benha University, Benha, Egypt.
| | - Omar Ahmed Abdelwahab
- Medical Research Group of Egypt, Cairo, Egypt
- Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Ahmed Abdelaziz
- Medical Research Group of Egypt, Cairo, Egypt
- Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Youssef Soliman
- Medical Research Group of Egypt, Cairo, Egypt
- Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ahmed Mostafa Amin
- Medical Research Group of Egypt, Cairo, Egypt
- Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Maged Ahmed Mohamed
- Medical Research Group of Egypt, Cairo, Egypt
- Faculty of Medicine, The Hashemite University, Zarqa, Jordan
| | - Khaled Albakri
- Medical Research Group of Egypt, Cairo, Egypt
- Faculty of Dentistry, Al-Azhar University, Cairo, Egypt
| | - Esraa Mohamed Zedan
- Medical Research Group of Egypt, Cairo, Egypt
- Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Naema Hamouda
- Medical Research Group of Egypt, Cairo, Egypt
- General Organization of Teaching Hospitals and Institutes, Cairo, Egypt
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3
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Brossier DW, Tume LN, Briant AR, Jotterand Chaparro C, Moullet C, Rooze S, Verbruggen SCAT, Marino LV, Alsohime F, Beldjilali S, Chiusolo F, Costa L, Didier C, Ilia S, Joram NL, Kneyber MCJ, Kühlwein E, Lopez J, López-Herce J, Mayberry HF, Mehmeti F, Mierzewska-Schmidt M, Miñambres Rodríguez M, Morice C, Pappachan JV, Porcheret F, Reis Boto L, Schlapbach LJ, Tekguc H, Tziouvas K, Parienti JJ, Goyer I, Valla FV. ESPNIC clinical practice guidelines: intravenous maintenance fluid therapy in acute and critically ill children- a systematic review and meta-analysis. Intensive Care Med 2022; 48:1691-1708. [PMID: 36289081 PMCID: PMC9705511 DOI: 10.1007/s00134-022-06882-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 09/01/2022] [Indexed: 01/20/2023]
Abstract
PURPOSE Intravenous maintenance fluid therapy (IV-MFT) prescribing in acute and critically ill children is very variable among pediatric health care professionals. In order to provide up to date IV-MFT guidelines, the European Society of Pediatric and Neonatal Intensive Care (ESPNIC) undertook a systematic review to answer the following five main questions about IV-MFT: (i) the indications for use (ii) the role of isotonic fluid (iii) the role of balanced solutions (iv) IV fluid composition (calcium, magnesium, potassium, glucose and micronutrients) and v) and the optimal amount of fluid. METHODS A multidisciplinary expert group within ESPNIC conducted this systematic review using the Scottish Intercollegiate Guidelines Network (SIGN) grading method. Five databases were searched for studies that answered these questions, in acute and critically children (from 37 weeks gestational age to 18 years), published until November 2020. The quality of evidence and risk of bias were assessed, and meta-analyses were undertaken when appropriate. A series of recommendations was derived and voted on by the expert group to achieve consensus through two voting rounds. RESULTS 56 papers met the inclusion criteria, and 16 recommendations were produced. Outcome reporting was inconsistent among studies. Recommendations generated were based on a heterogeneous level of evidence, but consensus within the expert group was high. "Strong consensus" was reached for 11/16 (69%) and "consensus" for 5/16 (31%) of the recommendations. CONCLUSIONS Key recommendations are to use isotonic balanced solutions providing glucose to restrict IV-MFT infusion volumes in most hospitalized children and to regularly monitor plasma electrolyte levels, serum glucose and fluid balance.
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Affiliation(s)
- David W Brossier
- Pediatric Intensive Care, Medical School, Université Caen Normandie, CHU de Caen, Caen, France
| | - Lyvonne N Tume
- Pediatric Intensive Care Unit Alder Hey Children's Hospital, Faculty of Health, Social Care and Medicine, Edge Hill University, Liverpool, Ormskirk, UK
| | - Anais R Briant
- Department of Biostatistics, CHU de Caen, 14000, Caen, France
| | - Corinne Jotterand Chaparro
- Department of Nutrition and Dietetics, Geneva School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Geneva, Switzerland.,Bureau d'Echange des Savoirs pour des praTiques Exemplaires de Soins (BEST): A JBI Centre of Excellence, Lausanne, Switzerland
| | - Clémence Moullet
- Department of Nutrition and Dietetics, Geneva School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Geneva, Switzerland
| | - Shancy Rooze
- Pediatric Intensive Care, HUDERF, Brussels, Belgium
| | | | - Luise V Marino
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Fahad Alsohime
- Pediatric Intensive Care, Pediatric Department, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Sophie Beldjilali
- Pediatric Intensive Care, Assistance Publique Hopitaux de Marseille, Marseille, France
| | - Fabrizio Chiusolo
- Pediatric Intensive Care, Bambino Gesù Children's Hospital, Rome, Italy
| | - Leonardo Costa
- Pediatric Intensive Care, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Capucine Didier
- Pediatric Intensive Care, Hospices Civils de Lyon, Lyon, France
| | - Stavroula Ilia
- Pediatric Intensive Care, Medical School, University Hospital, University of Crete, Heraklion, Greece
| | | | - Martin C J Kneyber
- Department of Paediatrics, Division of Paediatric Critical Care Medicine, Beatrix Children's Hospital, Critical Care, Anaesthesiology, Peri-Operative and Emergency Medicine (CAPE), University of Groningen, Groningen, the Netherlands
| | - Eva Kühlwein
- Department of Intensive Care and Neonatology, and Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Jorge Lopez
- Pediatric Intensive Care, Gregorio Marañón General University Hospital, Madrid, Spain
| | - Jesus López-Herce
- Pediatric Intensive Care, Gregorio Marañón General University Hospital, Madrid, Spain
| | - Huw F Mayberry
- Pediatric Intensive Care, Alder Hey Childrens Hospital, Liverpool, UK
| | - Fortesa Mehmeti
- Pediatric Intensive Care, University Hospital of Geneva, Geneva, Switzerland
| | | | | | - Claire Morice
- Pediatric Intensive Care, University Hospital of Geneva, Geneva, Switzerland
| | - John V Pappachan
- Pediatric Intensive Care, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | - Leonor Reis Boto
- Pediatric Intensive Care, Departament of Pediatrics, Faculdade de Medicina, Hospital de Santa Maria, Centro Hospitalar Universitário de Lisboa Norte, Universidade de Lisboa, Lisbon, Portugal
| | - Luregn J Schlapbach
- Department of Intensive Care and Neonatology, and Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Hakan Tekguc
- Pediatric Intensive Care, Dr. Burhan Nalbantoglu State Hospital, Nicosia, North Cyprus, Cyprus
| | | | - Jean-Jacques Parienti
- Department of Biostatistics, CHU de Caen, Université Caen Normandie, INSERM U1311 DYNAMICURE, 14000, Caen, France
| | | | - Frederic V Valla
- Pediatric Intensive Care, Hospices Civils de Lyon, Lyon, France. .,Service de Réanimation Pédiatrique, Hôpital Femme Mère Enfant, 59 Boulevard Pinel, 69500, Bron, France.
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Pérez-Moreno J, Gutiérrez-Vélez A, Torres Soblechero L, González Martínez F, Toledo Del Castillo B, Vierge Hernán E, Rodríguez-Fernández R. Do we overestimate intravenous fluid therapy needs? Adverse effects related to isotonic solutions during pediatric hospital admissions. Nefrologia 2022; 42:688-695. [PMID: 36907718 DOI: 10.1016/j.nefroe.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 06/21/2021] [Indexed: 06/18/2023] Open
Abstract
INTRODUCTION Maintenance intravenous fluids are frequently used in hospitalised pediatric patients. The aim of the study was to describe the adverse effects of isotonic fluid therapy in hospitalised patients, and its prevalence based on the rate of infusion. MATERIALS AND METHODS A prospective clinical observational study was designed. We included hospitalised patients between 3 months-old and 15-years-old were included with 0,9% isotonic solutions with 5% glucose within the first 24 h of administration. They were divided into two groups, depending on the quantity of liquid they received (restricted <100% vs 100% maintenance needs). Clinical data and laboratory findings were recorded in two different times (T0 when they were admitted to hospital and T1 within the first 24 h of administration). RESULTS The study included 84 patients, 33 received <100% maintenance needs and 51 patients received around 100%. The main adverse effects notified in the first 24 h of administration were hyperchloremia >110 mEq/L (16.6%) and oedema (19%). Oedema was more frequent in patients with lower age (p < 0,01). The hyperchloremia at 24 h of intravenous fluids was an independent risk factor of developing oedema (OR 1,73 (1,0-3,8), p = 0,06). CONCLUSION The use of isotonic fluids is not free from adverse effects, probably related to the rate of infusion and more likely to appear in infants. It`s necessary more studies that review the correct estimation of intravenous fluid needs in hospitalized children.
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Affiliation(s)
- Jimena Pérez-Moreno
- Hospitalización de Pediatría, Servicio de Pediatría y sus Áreas Específicas, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
| | - Ana Gutiérrez-Vélez
- Hospitalización de Pediatría, Servicio de Pediatría y sus Áreas Específicas, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Laura Torres Soblechero
- Hospitalización de Pediatría, Servicio de Pediatría y sus Áreas Específicas, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Felipe González Martínez
- Hospitalización de Pediatría, Servicio de Pediatría y sus Áreas Específicas, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Blanca Toledo Del Castillo
- Hospitalización de Pediatría, Servicio de Pediatría y sus Áreas Específicas, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Eva Vierge Hernán
- Hospitalización de Pediatría, Servicio de Pediatría y sus Áreas Específicas, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Rosa Rodríguez-Fernández
- Hospitalización de Pediatría, Servicio de Pediatría y sus Áreas Específicas, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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Williamson SJ, Plant ND, Shenoy M. Use of normal saline and incidence of dyselectrolytaemia in children following kidney transplantation. Pediatr Nephrol 2022; 37:2127-2130. [PMID: 35048163 DOI: 10.1007/s00467-021-05373-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 11/02/2021] [Accepted: 11/02/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND The use of hypotonic fluid, such as 0.45% saline, following kidney transplantation (KT) in children is associated with a high incidence of electrolyte imbalance, especially hyponatraemia. This can result in serious adverse events, such as cerebral oedema and seizures. The aim of this study was to investigate the incidence of electrolyte disturbance in children when 0.9% saline was the intravenous fluid used in the first 72 h following KT. METHODS This is a retrospective, observational study of 50 consecutive KT undertaken between January 2017 and January 2019 at a single centre. RESULTS The median age at KT was 9.2 years (IQR 4-14) and 16 (32%) were females. Thirty-two (64%) were living related donor (LRD) KT and 22 (44%) were carried out in children < 20 kg. The mean volume of fluid administered intra-operatively, and on Day 1, Day 2 and Day 3, were 73 ml/kg, 124 ml/kg, 97 ml/kg and 86 ml/kg, respectively. Hyponatraemia was noted in 4%, hypernatraemia in 18%, hyperkalaemia in 18%, hyperchloraemia in 68% and low bicarbonate was seen in 88%. Fifteen percent of the children had an episode of hyperglycaemia. None of the children developed symptomatic dyselectrolytaemia. There was delayed graft function (DGF) in 4 (8%) recipients - all deceased donor (DD) KT, including 2 who received donations after circulatory death. CONCLUSIONS While the use of 0.9% saline is associated with a high incidence of electrolyte disturbances, including hyperkalaemia, it reduces the risk of hyponatraemia. None of the children developed a symptomatic electrolyte abnormality. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Samantha J Williamson
- Department of Paediatric Nephrology, Royal Manchester Children's Hospital, Oxford Road, Manchester, M13 9WL, UK
| | - Nicholas D Plant
- Department of Paediatric Nephrology, Royal Manchester Children's Hospital, Oxford Road, Manchester, M13 9WL, UK
| | - Mohan Shenoy
- Department of Paediatric Nephrology, Royal Manchester Children's Hospital, Oxford Road, Manchester, M13 9WL, UK.
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Morice C, Alsohime F, Mayberry H, Tume LN, Brossier D, Valla FV. Intravenous maintenance fluid therapy practice in the pediatric acute and critical care settings: a European and Middle Eastern survey. Eur J Pediatr 2022; 181:3163-3172. [PMID: 35503578 DOI: 10.1007/s00431-022-04467-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 03/21/2022] [Accepted: 04/05/2022] [Indexed: 11/25/2022]
Abstract
The ideal fluid for intravenous maintenance fluid therapy (IV-MFT) in acutely and critically ill children is controversial, and evidence-based clinical practice guidelines are lacking and current prescribing practices remain unknown. We aimed to describe the current practices in prescribing IV-MFT in the context of acute and critically ill children with regard to the amount, tonicity, composition, use of balanced fluids, and prescribing strategies in various clinical contexts. A cross-sectional electronic 27-item survey was emailed in April-May 2021 to pediatric critical care physicians across European and Middle East countries. The survey instrument was developed by an expert multi-professional panel within the European Society of Pediatric and Neonatal Intensive Care (ESPNIC). A total of 154 respondents from 35 European and Middle East countries participated (response rate 64%). Respondents were physicians in charge of acute or critically ill children. All respondents indicated they routinely use a predefined formula to prescribe the amount of IV-MFT and considered fluid balance monitoring very important in the management of acute and critically ill children. The use of balanced solution was preferred if there were altered serum sodium and chloride levels or metabolic acidosis. Just under half (42%, 65/153) of respondents believed balanced solutions should always be used. Respondents considered the use of isotonic IV solutions as important for acute and critically ill children. In terms of the indication and the composition of IV-MFT prescribed, responses were heterogeneous among centers. Almost 70% (107/154) respondents believed there was a gap between current practice and what they considered ideal IV-MFT due to a lack of guidelines and inadequate training of healthcare professionals. Conclusions: Our study showed considerable variability in clinical prescribing practice of IV-MFT in acute pediatric settings across Europe and the Middle East. There is an urgent need to develop evidence-based guidelines for IV-MFT prescription in acute and critically ill children. What is Known: • The administration of maintenance intravenous fluid therapy is a standard of care for a lot of hospitalized children • Maintenance intravenous fluid therapy prescriptions are often based on Holliday and Segar's historical guidelines even if this practice has been associated with several complications. What is New: • This study provided information on the prescribing practice regarding fluid restriction, fluid tonicity, and balance. • This study showed considerable variability in clinical prescribing practice of intravenous maintenance fluid therapy across Europe and the Middle East.
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Affiliation(s)
- Claire Morice
- Pediatric and Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital of Geneva, Geneva, Switzerland
| | - Fahad Alsohime
- Pediatric Department, College of Medicine, King Saud University, Riyadh, Saudi Arabia.,Pediatric Critical Care Unit, Pediatric Department, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Huw Mayberry
- Pediatric Intensive Care Unit, Alder Hey Children's Hospital, Liverpool, UK
| | - Lyvonne N Tume
- Pediatric Intensive Care Unit, Alder Hey Children's Hospital, Liverpool, UK.,School of Health & Society, University of Salford, Manchester, UK
| | - David Brossier
- Pediatric Intensive Care Unit, CHU de Caen, 14000, Caen, France. .,Medical School, Université Caen Normandie, 14000, Caen, France.
| | - Frederic V Valla
- School of Health & Society, University of Salford, Manchester, UK.,Pediatric Intensive Care Unit, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, 69500, Lyon, France
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Hayes W, Laing E, Foley C, Pankhurst L, Thomas H, Hume-Smith H, Marks S, Kessaris N, Bryant WA, Spiridou A, Wray J, Peters MJ. Multicentre randomised controlled trial: protocol for Plasma-Lyte Usage and Assessment of Kidney Transplant Outcomes in Children (PLUTO). BMJ Open 2022; 12:e055595. [PMID: 35288387 PMCID: PMC8921856 DOI: 10.1136/bmjopen-2021-055595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Acute electrolyte and acid-base imbalance is experienced by many children following kidney transplantation. When severe, this can lead to complications including seizures, cerebral oedema and death. Relatively large volumes of intravenous fluid are administered to children perioperatively in order to establish perfusion to the donor kidney, the majority of which are from living and deceased adult donors. Hypotonic intravenous fluid is commonly used in the post-transplant period due to clinicians' concerns about the sodium, chloride and potassium content of isotonic alternatives when administered in large volumes.Plasma-Lyte 148 is an isotonic, balanced intravenous fluid that contains sodium, chloride, potassium and magnesium with concentrations equivalent to those of plasma. There is a physiological basis to expect that Plasma-Lyte 148 will reduce the incidence of clinically significant electrolyte and acid-base abnormalities in children following kidney transplantation compared with current practice.The aim of the Plasma-Lyte Usage and Assessment of Kidney Transplant Outcomes in Children (PLUTO) trial was to determine whether the incidence of clinically significantly abnormal plasma electrolyte levels in paediatric kidney transplant recipients will be different with the use of Plasma-Lyte 148 compared with intravenous fluid currently administered. METHODS AND ANALYSIS PLUTO is a pragmatic, open-label, randomised controlled trial comparing Plasma-Lyte 148 to current care in paediatric kidney transplant recipients, conducted in nine UK paediatric kidney transplant centres.A total of 144 children receiving kidney transplants will be randomised to receive either Plasma-Lyte 148 (the intervention) intraoperatively and postoperatively, or current fluid. Apart from intravenous fluid composition, all participants will receive standard clinical transplant care.The primary outcome measure is acute hyponatraemia in the first 72 hours post-transplant, defined as laboratory plasma sodium concentration of <135 mmol/L. Secondary outcomes include symptoms of acute hyponatraemia, other electrolyte and acid-base imbalances and transplant kidney function.The primary outcome will be analysed using a logistic regression model adjusting for donor type (living vs deceased donor), patient weight (<20 kg vs ≥20 kg pretransplant) and transplant centre as a random effect. ETHICS AND DISSEMINATION The trial received Health Research Authority approval on 20 January 2020. Findings will be presented to academic groups via national and international conferences and peer-reviewed journals. The patient and public involvement group will play an important part in disseminating the study findings to the public domain. TRIAL REGISTRATION NUMBERS 2019-003025-22 and 16586164.
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Affiliation(s)
- Wesley Hayes
- Department of Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- Institute of Child Health, University College London, London, UK
| | - Emma Laing
- Clinical Trials Unit, NHS Blood and Transplant, Cambridge, UK
| | - Claire Foley
- Clinical Trials Unit, NHS Blood and Transplant, Cambridge, UK
| | - Laura Pankhurst
- Clinical Trials Unit, NHS Blood and Transplant, Cambridge, UK
| | - Helen Thomas
- Clinical Trials Unit, NHS Blood and Transplant, Cambridge, UK
| | - Helen Hume-Smith
- Institute of Child Health, University College London, London, UK
| | - Stephen Marks
- Department of Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- Institute of Child Health, University College London, London, UK
| | - Nicos Kessaris
- Department of Nephrology and Transplantation, Guy's Hospital, London, UK
| | - William A Bryant
- Digital Research, Informatics and Virtual Environments Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Anastassia Spiridou
- Digital Research, Informatics and Virtual Environments Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Jo Wray
- Department of Health Psychology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Mark J Peters
- Institute of Child Health, University College London, London, UK
- Paediatric Intensive Care Unit, Great Ormond Street Hospital For Children NHS Trust, London, UK
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Corsello A, Malandrini S, Bianchetti MG, Agostoni C, Cantoni B, Meani F, Faré PB, Milani GP. Sodium assessment in neonates, infants, and children: a systematic review. Eur J Pediatr 2022; 181:3413-3419. [PMID: 35821131 PMCID: PMC9395449 DOI: 10.1007/s00431-022-04543-3] [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: 12/14/2021] [Revised: 06/15/2022] [Accepted: 06/23/2022] [Indexed: 11/29/2022]
Abstract
Hyponatremia is a common disorder in childhood. The indirect and the direct potentiometry are currently the most popular techniques employed for sodium assessment, although discrepancies between the two techniques may be > 10 mmol/L. It is known that < 20% of the recently published articles report information about the technique used for sodium analysis, but no data are available on pediatric studies. This study aimed at investigating the laboratory technique employed for sodium measurement in studies conducted in childhood. A systematic literature search in PubMed, Embase, and Web of Science was undertaken to identify articles containing the word "hyponatremia" in the title between 2013 and 2020. Papers with < 10 subjects were excluded. A total of 565 articles were included. Information on the laboratory technique used for sodium analysis was more commonly (p = 0.035) reported in pediatric (n = 15, 28%) than in non-pediatric (n = 81, 16%) reports. The frequency of reports with and without information on the technique for sodium assessment was not different with respect to the study characteristics, the quartile of the journal where the paper was published, the country income setting, and the inclusion of neonates among the 54 pediatric studies. Conclusion: Most pediatric papers do not report any information on the technique used for sodium analysis. Although international authorities have recommended the implementation of direct potentiometry, a low awareness on this issue is still widespread in pediatric research. What is Known: • Direct potentiometry and indirect potentiometry are currently employed for sodium analysis in blood. • Direct potentiometry is more accurate. What is New: • Less than 30% of pediatric articles provide information on the technique employed for sodium analysis in blood. • Indirect potentiometry is more frequently employed than direct potentiometry in pediatric studies.
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Affiliation(s)
- Antonio Corsello
- Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, Milan, Italy
| | - Sabrina Malandrini
- Faculty of Biomedical Sciences, Università Della Svizzera Italiana, Lugano, Switzerland
| | - Mario G. Bianchetti
- Faculty of Biomedical Sciences, Università Della Svizzera Italiana, Lugano, Switzerland
| | - Carlo Agostoni
- Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, Milan, Italy ,Pediatric Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Barbara Cantoni
- Pediatric Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesco Meani
- Department of Gynecology and Obstetrics, Centro Di Senologia Della Svizzera Italiana, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Pietro B. Faré
- Department of Internal Medicine, Ente Ospedaliero Cantonale, 6600 Locarno, Switzerland
| | - Gregorio P. Milani
- Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, Milan, Italy ,Pediatric Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
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9
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Research priorities in pediatric parenteral nutrition: a consensus and perspective from ESPGHAN/ESPEN/ESPR/CSPEN. Pediatr Res 2022; 92:61-70. [PMID: 34475525 PMCID: PMC9411056 DOI: 10.1038/s41390-021-01670-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 07/07/2021] [Accepted: 07/09/2021] [Indexed: 02/07/2023]
Abstract
Parenteral nutrition is used to treat children that cannot be fully fed by the enteral route. While the revised ESPGHAN/ESPEN/ESPR/CSPEN pediatric parenteral nutrition guidelines provide clear guidance on the use of parenteral nutrition in neonates, infants, and children based on current available evidence, they have helped to crystallize areas where research is lacking or more studies are needed in order to refine recommendations. This paper collates and discusses the research gaps identified by the authors of each section of the guidelines and considers each nutrient or group of nutrients in turn, together with aspects around delivery and organization. The 99 research priorities identified were then ranked in order of importance by clinicians and researchers working in the field using a survey methodology. The highest ranked priority was the need to understand the relationship between total energy intake, rapid catch-up growth, later metabolic function, and neurocognitive outcomes. Research into the optimal intakes of macronutrients needed in order to achieve optimal outcomes also featured prominently. Identifying research priorities in PN should enable research to be focussed on addressing key issues. Multicentre trials, better definition of exposure and outcome variables, and long-term metabolic and developmental follow-up will be key to achieving this. IMPACT: The recent ESPGHAN/ESPEN/ESPR/CSPEN guidelines for pediatric parenteral nutrition provided updated guidance for providing parenteral nutrition to infants and children, including recommendations for practice. However, in several areas there was a lack of evidence to guide practice, or research questions that remained unanswered. This paper summarizes the key priorities for research in pediatric parenteral nutrition, and ranks them in order of importance according to expert opinion.
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10
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Rooholamini SN, Jennings B, Zhou C, Kaiser SV, Garber MD, Tchou MJ, Ralston SL. Effect of a Quality Improvement Bundle to Standardize the Use of Intravenous Fluids for Hospitalized Pediatric Patients: A Stepped-Wedge, Cluster Randomized Clinical Trial. JAMA Pediatr 2022; 176:26-33. [PMID: 34779837 PMCID: PMC8593833 DOI: 10.1001/jamapediatrics.2021.4267] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
IMPORTANCE Given that hypotonic maintenance intravenous fluids (IVF) may cause hospital-acquired harm, in November 2018, the American Academy of Pediatrics released a clinical practice guideline recommending the use of isotonic IVF for patients aged 28 days to 18 years without contraindications. No recommendations were made regarding laboratory monitoring; however, unnecessary laboratory tests may contribute to health care waste and harm patients. OBJECTIVE To examine the effect of a quality improvement intervention bundle on (1) increasing the mean proportion of hours per hospital day with exclusive isotonic IVF use to at least 80% and (2) decreasing the mean proportion of hospital days with laboratory tests obtained. DESIGN, SETTING, AND PARTICIPANTS This stepped-wedge, cluster randomized clinical trial (Standardization of Fluids in Inpatient Settings [SOFI]) was sponsored by a national quality improvement collaborative and was conducted across 106 US pediatric hospitals. The SOFI intervention period was from September 2019 to March 2020. INTERVENTIONS Hospital sites were exposed to educational materials, a clinical algorithm and order set for IVF use, electronic medical record interventions to reduce laboratory testing, and "harms of overtesting" cards. MAIN OUTCOMES AND MEASURES Primary outcomes were mean proportion of hours per hospital day receiving exclusive isotonic IVF and mean proportion of hospital days with laboratory test values obtained. Secondary measures included total IVF duration per hospital day, daily patient weight measurement while receiving IVF, serum sodium testing, and adverse events. Baseline data were collected for 2 months; intervention period data, 7 months. Outcomes were analyzed using linear mixed-effects regression models. RESULTS A total of 106 hospitals were randomly assigned to 1 of 3 intervention start dates (wedges), and 100 hospitals (94%) completed the study. In total, 5215 hospitalizations were reviewed before the intervention, and 6724 hospitalizations were reviewed after the intervention. Prior to interventions, the mean (SD) proportion of hours per day with exclusive isotonic IVF use was 88.5% (31.7%). Interventions led to an absolute increase of 5.4% (95% CI, 3.9%-6.9%) above baseline in exclusive isotonic IVF use but did not change the proportion of hospital days during which a laboratory test value was obtained (estimated difference, 0.1%; 95% CI, -1.5% to 1.7%; P = .90), IVF use duration (estimated difference, -1.2%; 95% CI, -2.9% to 0.4%), serum sodium testing, or adverse events. There was an absolute increase of 4.4% (95% CI, 2.6%-6.2%) in the mean proportion of hospital days with a patient weight measurement while receiving IVF. CONCLUSIONS AND RELEVANCE In this stepped-wedge, cluster randomized clinical trial, an intervention bundle significantly improved the use of isotonic maintenance IVF without a concomitant increase in adverse events or electrolyte testing. Further work is required to deimplement laboratory testing. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03924674.
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Affiliation(s)
| | | | - Chuan Zhou
- Department of Pediatrics, University of Washington, Seattle,Seattle Children’s Research Institute, Seattle, Washington
| | | | | | - Michael J. Tchou
- Department of Pediatrics, University of Colorado and Children’s Hospital Colorado, Aurora
| | - Shawn L. Ralston
- Department of Pediatrics, Johns Hopkins University, Baltimore, Maryland
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11
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Salvador C, Salvador R, Willeit P, Kuntner C, Haid A, Müller T, Kropshofer G, Crazzolara R. Hyponatremia During Induction Therapy in Distinct Pediatric Oncological Cohorts: A Retrospective Study. Front Oncol 2021; 11:708875. [PMID: 34778028 PMCID: PMC8586428 DOI: 10.3389/fonc.2021.708875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 09/30/2021] [Indexed: 11/13/2022] Open
Abstract
Background Hyponatremia is a well-known adverse event of repeated therapy with vincristine in oncological patients. However, to date, data in pediatric patients with malignant diseases other than acute lymphoblastic leukemia (ALL) are sparse or lacking. Materials and Methods A retrospective study of 98 pediatric patients was conducted to analyze the incidence of hyponatremia in a Caucasian cohort of newly diagnosed ALL. For comparison, we further examined five other pediatric oncological cohorts (Hodgkin’s disease, Ewing sarcoma, Wilms tumor, benign glioma of the CNS, Langerhans cell histiocytosis) that receive alkaloids in their induction regimes. Results We found a high incidence of hyponatremia (14.7%) in our ALL cohort with a trend toward male patients of elementary school age. None of the affected patients showed neurological symptoms. By comparison, patients from other malignancy groups did not show significant hyponatremia, regardless of their comparable therapy with alkaloids. We here show a noticeable coincidence of hyponatremia and hypertriglyceridemia in ALL patients, indicating a possible role of L-asparaginase-related hypertriglyceridemia in the development of severe hyponatremia in such patients. Conclusion We report a higher incidence of hyponatremia following vincristine therapy in Caucasian children with ALL than published before. This hyponatremia could not be demonstrated in other oncologic cohorts treated with alkaloids. L-Asparaginase-induced hypertriglyceridemia may play a role in the certainly multifactorial development of hyponatremia in childhood leukemia.
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Affiliation(s)
- Christina Salvador
- Department of Pediatrics I, Division of Hematology and Oncology, Medical University Innsbruck, Innsbruck, Austria
| | | | - Peter Willeit
- Department of Neurology and Neurosurgery, Medical University Innsbruck, Innsbruck, Austria.,Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Christine Kuntner
- Information Technology Management, Medical University Innsbruck, Innsbruck, Austria
| | - Alexandra Haid
- Competence Center for Clinical Studies, Medical University Innsbruck, Innsbruck, Austria
| | - Thomas Müller
- Department of Pediatrics I, Division of Hematology and Oncology, Medical University Innsbruck, Innsbruck, Austria
| | - Gabriele Kropshofer
- Department of Pediatrics I, Division of Hematology and Oncology, Medical University Innsbruck, Innsbruck, Austria
| | - Roman Crazzolara
- Department of Pediatrics I, Division of Hematology and Oncology, Medical University Innsbruck, Innsbruck, Austria
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12
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Mathew A, Rai E. Pediatric perioperative fluid management. Saudi J Anaesth 2021; 15:435-440. [PMID: 34658733 PMCID: PMC8477784 DOI: 10.4103/sja.sja_140_21] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 03/02/2021] [Indexed: 11/12/2022] Open
Abstract
Appropriate fluid management is vital for adequate tissue perfusion and balancing the internal milieu especially in perioperative settings and critically ill children. Pediatric population is heterogeneous so one formula may not suffice and hence both the quantitative and qualitative perspective of fluid management should be based on physiology and pathology of the child along with their perioperative needs. In perioperative setup, the fluid is administered to meet fluid deficits (fasting, and other daily based losses), blood losses and third space losses. Anesthetists have always followed pediatric maintenance fluid calculations based on Holiday and Segar formula; based on studies conducted on healthy children more than 70 years ago. Recently, there has been a lot of debate about this concept, especially as there are serious concerns regarding the development of complications like hyponatremia and hyperglycemia, both of which can result in neurological damage or even mortality in a sick child. This review is an attempt to provide a historical perspective and current evidence-based approach to peri-operative pediatric fluid management. We performed a PUBMED search for articles using keywords including ‘children’, ‘intravenous fluid therapy’, ‘crystalloids’, ‘colloids’, ‘fluid homeostasis’, ‘blood loss’, ‘estimation of blood loss’, ‘blood loss management’, ‘perioperative fluid ‘ to get our source articles.
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Affiliation(s)
- Amit Mathew
- Department of Anaesthesia, Christian Medical College, Vellore, Tamil Nadu, India
| | - Ekta Rai
- Department of Anaesthesia, Christian Medical College, Vellore, Tamil Nadu, India
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13
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Pérez-Moreno J, Gutiérrez-Vélez A, Torres Soblechero L, González Martínez F, Toledo del Castillo B, Vierge Hernán E, Rodríguez-Fernández R. ¿Sobreestimamos las necesidades de líquidos? Complicaciones del uso de sueros isotónicos de mantenimiento en plantas de hospitalización pediátrica. Nefrologia 2021. [DOI: 10.1016/j.nefro.2021.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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14
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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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15
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A cross-sectional survey of knowledge pertaining to IV fluid therapy and hyponatraemia among nurses working at emergency departments in Denmark. Int Emerg Nurs 2021; 57:101010. [PMID: 34139392 DOI: 10.1016/j.ienj.2021.101010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 03/17/2021] [Accepted: 04/04/2021] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Inappropriate fluid therapy may induce or worsen existing hyponatraemia with potentially life-threatening consequences. Nurses have an important role in assisting physicians in IV fluid prescribing. However, research is lacking in Denmark about nurses' knowledge pertaining to IV fluid therapy and hyponatraemia. METHODS An explorative cross-sectional survey was performed among Danish emergency department nurses in Spring 2019. Knowledge about IV fluid therapy was assessed for three common clinical scenarios, and multiple-choice questions were used to measure knowledge about hyponatraemia. RESULTS 112 nurses responded to all scenario questions corresponding to 6.2% (112/1815) of the total population of nurses working at emergency departments in Denmark. In two of the three scenarios, a minority of nurses (8-10%) inappropriately selected hypotonic fluids. Nearly one third (31%) selected a hypotonic fluid for a patient with meningitis, which is against guideline recommendations. The study revealed limited knowledge about severe symptoms of hyponatraemia, patients at high risk, and hyperglycaemia-induced hyponatraemia. CONCLUSION In accordance with guideline recommendation, the majority of nurses did not select hypotonic fluids in three clinical scenarios commonly encountered in the emergency department. However, when setting up an educational program, further awareness is needed regarding symptoms of hyponatraemia, high-risk patients, and hyperglycaemia-induced hyponatraemia.
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16
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Chromek M, Jungner Å, Rudolfson N, Ley D, Bockenhauer D, Hagander L. Hyponatraemia despite isotonic maintenance fluid therapy: a time series intervention study. Arch Dis Child 2021; 106:491-495. [PMID: 33115710 PMCID: PMC8070620 DOI: 10.1136/archdischild-2019-318555] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 09/16/2020] [Accepted: 09/19/2020] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To examine the prevalence of dysnatraemias among children admitted for paediatric surgery before and after a change from hypotonic to isotonic intravenous maintenance fluid therapy. DESIGN Retrospective consecutive time series intervention study. SETTING Paediatric surgery ward at the Children's Hospital in Lund, during a 7-year period, 2010-2017. PATIENTS All children with a blood sodium concentration measurement during the study period were included. Hypotonic maintenance fluid (40 mmol/L NaCl and 20 mmol/L KCl) was used during the first 3 years of the study (646 patients), and isotonic solution (140 mmol/L NaCl and 20 mmol/L KCl) was used during the following period (807 patients). MAIN OUTCOME MEASURES Primary outcomes were sodium concentration and occurrence of hyponatraemia (<135 mmol/L) or hypernatraemia (>145 mmol/L). RESULTS Overall, the change from hypotonic to isotonic intravenous maintenance fluid therapy was associated with a decreased prevalence of hyponatraemia from 29% to 22% (adjusted OR 0.65 (0.51-0.82)) without a significantly increased odds for hypernatraemia (from 3.4% to 4.3%, adjusted OR 1.2 (0.71-2.1)). Hyponatraemia <130 mmol/L decreased from 6.2% to 2.6%, and hyponatraemia <125 mmol/L decreased from 2.0% to 0.5%. CONCLUSIONS Routine use of intravenous isotonic maintenance fluids was associated with lower prevalence of hyponatraemia, although hyponatraemia still occurred in over 20% of patients. We propose that the composition and the volume of administered fluid need to be addressed.
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Affiliation(s)
- Milan Chromek
- Paediatric Nephrology, Paediatric Surgery, Paediatric Intensive Care, and Neonatal Care, Lund University, Skane University Hospital, Lund, Sweden
- Paediatric Nephrology, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - Åsa Jungner
- Paediatric Nephrology, Paediatric Surgery, Paediatric Intensive Care, and Neonatal Care, Lund University, Skane University Hospital, Lund, Sweden
| | - Niclas Rudolfson
- Paediatric Nephrology, Paediatric Surgery, Paediatric Intensive Care, and Neonatal Care, Lund University, Skane University Hospital, Lund, Sweden
| | - David Ley
- Paediatric Nephrology, Paediatric Surgery, Paediatric Intensive Care, and Neonatal Care, Lund University, Skane University Hospital, Lund, Sweden
| | - Detlef Bockenhauer
- University College London, Department of Renal Medicine and Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Lars Hagander
- Paediatric Nephrology, Paediatric Surgery, Paediatric Intensive Care, and Neonatal Care, Lund University, Skane University Hospital, Lund, Sweden
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17
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Lehtiranta S, Honkila M, Kallio M, Paalanne N, Peltoniemi O, Pokka T, Renko M, Tapiainen T. Risk of Electrolyte Disorders in Acutely Ill Children Receiving Commercially Available Plasmalike Isotonic Fluids: A Randomized Clinical Trial. JAMA Pediatr 2021; 175:28-35. [PMID: 33104176 PMCID: PMC7589076 DOI: 10.1001/jamapediatrics.2020.3383] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
IMPORTANCE The use of isotonic fluid therapy is currently recommended in children, but there is limited evidence of optimal fluid therapy in acutely ill children. OBJECTIVE To evaluate the risk for electrolyte disorders, including hyponatremia, hypernatremia, and hypokalemia, and the risk of fluid retention in acutely ill children receiving commercially available plasmalike isotonic fluid therapy. DESIGN, SETTING, AND PARTICIPANTS This unblinded, randomized clinical pragmatic trial was conducted at the pediatric emergency department of Oulu University Hospital, Finland, from October 3, 2016, through April 15, 2019. Eligible study subjects (N = 614) were between 6 months and 12 years of age, required hospitalization due to an acute illness, and needed intravenous fluid therapy. Exclusion criteria included a plasma sodium concentration of less than 130 mmol/L or greater than 150 mmol/L on admission; a plasma potassium concentration of less than 3.0 mmol/L on admission; clinical need of fluid therapy with 10% glucose solution; a history of diabetes, diabetic ketoacidosis, or diabetes insipidus; a need for renal replacement therapy; severe liver disease; pediatric cancer requiring protocol-determined chemotherapy hydration; and inborn errors of metabolism. All outcomes and samples size were prespecified except those clearly marked as exploratory post hoc analyses. All analyses were intention to treat. INTERVENTIONS Acutely ill children were randomized to receive commercially available plasmalike isotonic fluid therapy (140 mmol/L of sodium and 5 mmol/L potassium in 5% dextrose) or moderately hypotonic fluid therapy (80 mmol/L sodium and 20 mmol/L potassium in 5% dextrose). MAIN OUTCOMES AND MEASURES The primary outcome was the proportion of children with any clinically significant electrolyte disorder, defined as hypokalemia less than 3.5 mmol/L, hypernatremia greater than 148 mmol/L, or hyponatremia less than 132 mmol/L during hospitalization due to acute illness. The main secondary outcomes were the proportion of children with severe hypokalemia and weight change. RESULTS There were 614 total study subjects (mean [SD] age, 4.0 [3.1] years; 315 children were boys [51%] and all 614 were Finnish speaking [100%]). Clinically significant electrolyte disorder was more common in children receiving plasmalike isotonic fluid therapy (61 of 308 patients [20%]) compared with those receiving moderately hypotonic fluid therapy (9 of 306 patients [2.9%]; 95% CI of the difference, 12%-22%; P < .001). The risk of developing electrolyte disorder was 6.7-fold greater in children receiving isotonic fluid therapy. Hypokalemia developed in 57 patients (19%) and hypernatremia developed in 4 patients (1.3%) receiving plasmalike isotonic fluid therapy. Weight change was greater in children receiving isotonic, plasmalike fluid therapy compared with those receiving mildly hypotonic fluids (mean weight gain, 279 vs 195 g; 95% CI, 16-154 g; P = .02). CONCLUSIONS AND RELEVANCE In this randomized clinical trial, commercially available plasmalike isotonic fluid therapy markedly increased the risk for clinically significant electrolyte disorders, mostly due to hypokalemia, in acutely ill children compared with previously widely used moderately hypotonic fluid therapy containing 20 mmol/L of potassium. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02926989.
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Affiliation(s)
- Saara Lehtiranta
- Department of Pediatrics and Adolescent Medicine, Oulu University Hospital, Oulu, Finland,Research Unit of Pediatrics, Dermatology, Gynecology, and Obstetrics, Medical Research Center Oulu, University of Oulu, Oulu, Finland
| | - Minna Honkila
- Department of Pediatrics and Adolescent Medicine, Oulu University Hospital, Oulu, Finland,Research Unit of Pediatrics, Dermatology, Gynecology, and Obstetrics, Medical Research Center Oulu, University of Oulu, Oulu, Finland
| | - Merja Kallio
- Department of Pediatrics and Adolescent Medicine, Oulu University Hospital, Oulu, Finland,Research Unit of Pediatrics, Dermatology, Gynecology, and Obstetrics, Medical Research Center Oulu, University of Oulu, Oulu, Finland
| | - Niko Paalanne
- Department of Pediatrics and Adolescent Medicine, Oulu University Hospital, Oulu, Finland,Research Unit of Pediatrics, Dermatology, Gynecology, and Obstetrics, Medical Research Center Oulu, University of Oulu, Oulu, Finland
| | - Outi Peltoniemi
- Department of Pediatrics and Adolescent Medicine, Oulu University Hospital, Oulu, Finland,Research Unit of Pediatrics, Dermatology, Gynecology, and Obstetrics, Medical Research Center Oulu, University of Oulu, Oulu, Finland
| | - Tytti Pokka
- Department of Pediatrics and Adolescent Medicine, Oulu University Hospital, Oulu, Finland,Research Unit of Pediatrics, Dermatology, Gynecology, and Obstetrics, Medical Research Center Oulu, University of Oulu, Oulu, Finland
| | - Marjo Renko
- Research Unit of Pediatrics, Dermatology, Gynecology, and Obstetrics, Medical Research Center Oulu, University of Oulu, Oulu, Finland,Department of Pediatrics, University of Eastern Finland, Kuopio University Hospital, Kuopio, Finland
| | - Terhi Tapiainen
- Department of Pediatrics and Adolescent Medicine, Oulu University Hospital, Oulu, Finland,Research Unit of Pediatrics, Dermatology, Gynecology, and Obstetrics, Medical Research Center Oulu, University of Oulu, Oulu, Finland,Biocenter Oulu, University of Oulu, Oulu, Finland
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18
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Risks of severe hyponatremia in children receiving hypotonic fluids. Arch Pediatr 2020; 27:474-479. [PMID: 33028494 DOI: 10.1016/j.arcped.2020.08.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 06/07/2020] [Accepted: 08/13/2020] [Indexed: 12/17/2022]
Abstract
Intravenous fluids are frequently used in hospitalized children. Hypotonic fluids have been the standard of care in pediatrics for many years. This might be explained by the empiricism of early recommendations favoring fluids with dextrose, but an insufficient amount of sodium. The risk of hyponatremia (<135mmol/L) might be increased by the occurrence of the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) in the course of common acute diseases (e.g., bronchiolitis, acute gastroenteritis, encephalitis, meningitis) in children. Severe hyponatremia (<130mmol/L) is often associated with neurologic complications leading to sequelae or even death. Over the last few years, hyponatremia induced by hypotonic fluids has been increasingly reported, and significant progress has been made in the understanding of cerebral edema and osmotic demyelination. Several randomized clinical trials have shown weak but significant evidence that isotonic fluids were superior to hypotonic solutions in preventing hyponatremia. However, clinical practices have not changed much in France, as suggested by the analysis of intravenous fluids ordered from the Assistance Publique-Hôpitaux de Paris (AP-HP) central pharmacy (PCH) in 2017. Therefore, it would be advisable that national guidelines be released under the French Health Authorities regarding the safe infusion of infants and children.
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19
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Langer T, D'Oria V, Spolidoro GCI, Chidini G, Scalia Catenacci S, Marchesi T, Guerrini M, Cislaghi A, Agostoni C, Pesenti A, Calderini E. Fluid therapy in mechanically ventilated critically ill children: the sodium, chloride and water burden of fluid creep. BMC Pediatr 2020; 20:424. [PMID: 32891127 PMCID: PMC7487923 DOI: 10.1186/s12887-020-02322-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 08/25/2020] [Indexed: 12/15/2022] Open
Abstract
Background Fluid therapy is a cornerstone of pediatric intensive care medicine. We aimed at quantifying the load of water, sodium and chloride due to different fluid indications in our pediatric intensive care unit (PICU). We were particularly interested in the role of fluid creep, i.e. fluid administered mainly as the vehicle for drugs, and the association between sodium load and water balance. Methods Critically ill children aged ≤3 years and invasively ventilated for ≥48 h between 2016 and 2019 in a single tertiary center PICU were retrospectively enrolled. Need for renal replacement therapy, plasmapheresis or parenteral nutrition constituted exclusion criteria. Quantity, quality and indication of fluids administered intravenously or enterally, urinary output and fluid balance were recorded for the first 48 h following intubation. Concentrations of sodium and chloride provided by the manufacturers were used to compute the electrolyte load. Results Forty-three patients (median 7 months (IQR 3–15)) were enrolled. Patients received 1004 ± 284 ml of water daily (153 ± 36 ml/kg/day), mainly due to enteral (39%), creep (34%) and maintenance (24%) fluids. Patients received 14.4 ± 4.8 mEq/kg/day of sodium and 13.6 ± 4.7 mEq/kg/day of chloride, respectively. The majority of sodium and chloride derived from fluid creep (56 and 58%). Daily fluid balance was 417 ± 221 ml (64 ± 30 ml/kg/day) and was associated with total sodium intake (r2 = 0.49, p < 0.001). Conclusions Critically ill children are exposed, especially in the acute phase, to extremely high loads of water, sodium and chloride, possibly contributing to edema development. Fluid creep is quantitatively the most relevant fluid in the PICU and future research efforts should address this topic in order to reduce the inadvertent water and electrolyte burden and improve the quality of care of critically ill children.
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Affiliation(s)
- Thomas Langer
- Department of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy. .,Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Anestesia e Terapia Intensiva Donna-Bambino, Milan, Italy. .,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
| | - Veronica D'Oria
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Anestesia e Terapia Intensiva Donna-Bambino, Milan, Italy
| | - Giulia C I Spolidoro
- Department of Clinical Sciences and Community Health, University of Milan, 20122, Milan, Italy
| | - Giovanna Chidini
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Anestesia e Terapia Intensiva Donna-Bambino, Milan, Italy
| | - Stefano Scalia Catenacci
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Anestesia e Terapia Intensiva Donna-Bambino, Milan, Italy
| | - Tiziana Marchesi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Anestesia e Terapia Intensiva Donna-Bambino, Milan, Italy
| | - Marta Guerrini
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Anestesia e Terapia Intensiva Donna-Bambino, Milan, Italy
| | - Andrea Cislaghi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Anestesia e Terapia Intensiva Donna-Bambino, Milan, Italy
| | - Carlo Agostoni
- Department of Clinical Sciences and Community Health, University of Milan, 20122, Milan, Italy.,Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Pediatric Intermediate Care Unit, 20122, Milan, Italy
| | - Antonio Pesenti
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.,Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Edoardo Calderini
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Anestesia e Terapia Intensiva Donna-Bambino, Milan, Italy
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20
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Hypertonic saline for fluid resuscitation in ICU patients post-cardiac surgery (HERACLES): a double-blind randomized controlled clinical trial. Intensive Care Med 2020; 46:1683-1695. [PMID: 32519005 DOI: 10.1007/s00134-020-06132-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 05/22/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Recent evidence questions a liberal approach to fluid resuscitation in intensive care unit (ICU) patients. Here, we assess whether use of hypertonic saline applied as single infusion at ICU admission after cardiac surgery can reduce cumulative perioperative fluid volume. METHODS Prospective randomized double-blind single-center clinical trial investigates effects of a single infusion of hypertonic saline (HS) versus normal saline (comparator). Primary endpoint was the cumulative amount of fluid administered in patients in the hypertonic saline versus the 0.9% saline groups (during ICU stay). Upon ICU admission, patients received a single infusion of 5 ml/kg body weight of 7.3% NaCl (or 0.9% NaCl) over 60 min. Patients undergoing cardiac surgery for elective valvular and/or coronary heart disease were included. Patients with advanced organ dysfunction, infection, and/or patients on chronic steroid medication were excluded. RESULTS A total of 101 patients were randomized to receive the study intervention (HS n = 53, NS n = 48). Cumulative fluid intake on the ICU (primary endpoint) did not differ between the HS and the NS groups [median 3193 ml (IQR 2052-4333 ml) vs. 3345 ml (IQR 2332-5043 ml)]. Postoperative urinary output until ICU discharge was increased in HS-treated patients [median 2250 ml (IQR 1640-2690 ml) vs. 1545 ml (IQR 1087-1976 ml)], and ICU fluid balance was lower in the HS group when compared to the NS group [296 ml (IQR - 441 to 1412 ml) vs. 1137 ml (IQR 322-2660 ml)]. CONCLUSION In a monocentric prospective double-blind randomized clinical trial, we observed that hypertonic saline did not reduce the total fluid volume administered on the ICU in critically ill cardiac surgery patients. Hypertonic saline infusion was associated with timely increase in urinary output. Variations in electrolyte and acid-base homeostasis were transient, but substantial in all patients.
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21
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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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22
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Bagri NK, Saurabh VK, Basu S, Kumar A. Isotonic versus Hypotonic Intravenous Maintenance Fluids in Children: A Randomized Controlled Trial. Indian J Pediatr 2019; 86:1011-1016. [PMID: 31280410 DOI: 10.1007/s12098-019-03011-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 06/06/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To compare the incidence of hyponatremia during the first 48 h in hospitalized children receiving normal saline vs. N/2 saline as maintenance intravenous fluid. METHODS This open label, randomized controlled trial to compare the incidence of hyponatremia in hospitalized children receiving normal saline (0.9% sodium chloride in 5% dextrose) vs. N/2 saline (0.45% sodium chloride in 5% dextrose) as maintenance fluid was conducted from December 2014 through November 2015 in a tertiary care teaching hospital. Children between 1 mo and 18 y requiring maintenance intravenous fluids were randomized to receive normal saline with 5% dextrose (n = 75) or N/2 saline with 5% dextrose (n = 75). RESULTS Both groups were comparable for demographic variables and illness severity at baseline. Incidence of hyponatremia at 24 h of hospitalization was comparable between normal saline and N/2 saline group, 3(4%) vs. 6(8%) cases, respectively; p value 0.494. Mean serum sodium levels were marginally higher in normal saline group (138.3 ± 6.0 mEq/L) as compared with N/2 saline group (135.1 ± 4.4 mEq/L) (p value <0.01) at 24 h of hospitalization. Incidence of hyponatremia at 48 h and hypernatremia at 24 and 48 h was comparable in two groups. CONCLUSIONS The use of either N/2 saline or normal saline in sick children at standard maintenance fluid rates is associated with low but comparable incidence of hypo or hypernatremia in first 24 h of hospitalization. Both types of fluids appear acceptable in hospitalized sick children.
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Affiliation(s)
- Narendra K Bagri
- Department of Pediatrics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Vidya K Saurabh
- Department of Pediatrics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Sriparna Basu
- Department of Pediatrics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Ashok Kumar
- Department of Pediatrics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India.
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Abstract
Fluid and blood administration are required during surgery in children. The type, amount and tonicity of the intravenous fluids is an important aspect to be considered during anaesthesia management. The physiological differences between adults and children regarding the body water and blood volume needs to be understood. We performed a PUBMED search for English language articles using keywords including 'children', 'intravenous fluid therapy', 'crystalloids', 'colloids', 'fluid homeostasis', 'Starling equation', 'Donnan effect', 'blood loss', 'estimation of blood loss', 'blood management program'. This review discusses the physiological basis, historical background, risk of hyponatraemia, need of glucose in the intravenous fluids as well as the recent concepts in blood transfusion as related to children.
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Affiliation(s)
- Neerja Bhardwaj
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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24
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Cernat E, Puntis J. Paediatric parenteral nutrition: current issues. Frontline Gastroenterol 2019; 11:148-154. [PMID: 32133114 PMCID: PMC7043071 DOI: 10.1136/flgastro-2018-101127] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 06/12/2019] [Accepted: 06/13/2019] [Indexed: 02/04/2023] Open
Abstract
Parenteral nutrition transformed the prognosis for infants and children with intestinal failure. Soon after its introduction into clinical care 50 years ago, parenteral nutrition was also rapidly adopted for use in the preterm infant, where immaturity of gastrointestinal motor function precluded enteral feeding. Preterm infants subsequently became the single largest group of patients to be fed in this way. Although the development of scientific knowledge and the lessons of clinical experience have reduced the risk of complications, some of the problems and difficulties associated with this form of nutritional support remain challenging. These include central venous catheter-related sepsis, thrombosis, liver disease, bone disease and metabolic disturbance. In an initiative to promote best practice, guidelines on parenteral nutrition were first published by the European Society for Paediatric Gastroenterology, Hepatology and Nutrition and collaborating organisations in 2005. These were constructed following a thorough review of the scientific literature, allowing a series of evidence-based recommendations to be made. The exercise was repeated just over 10 years later and updated guidelines published in 2018. This review summarises key elements from the new guideline, with a focus on what has changed since 2005.
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Affiliation(s)
- Elena Cernat
- Department of Paediatric Gastroenterology and Nutrition, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - John Puntis
- Department of Paediatric Gastroenterology and Nutrition, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Abstract
Management of the pediatric organ donor necessitates understanding the physiologic changes that occur preceding and after death determination. Recognizing these changes allows application of the therapeutic strategies designed to optimize hemodynamics and metabolic state to allow for preservation of end-organ function for maximal organ recovery and minimal damage to the donor grafts. The pediatric pharmacist serves as the medication expert and may collaborate with the organ procurement organizations for provision of pharmacologic hemodynamic support, hormone replacement therapy, antimicrobials, and nutrition for the pediatric organ donor.
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Bulfon AF, Alomani HL, Anton N, Comrie BT, Rochwerg B, Stef SA, Thabane L, Vanniyasingam T, Choong K. Intravenous Fluid Prescription Practices in Critically Ill Children: A Shift in Focus from Natremia to Chloremia? J Pediatr Intensive Care 2019; 8:218-225. [PMID: 31673457 DOI: 10.1055/s-0039-1692413] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 05/04/2019] [Indexed: 12/12/2022] Open
Abstract
Our objective is to evaluate intravenous (IV) fluid prescription practice patterns in critically ill children in the first 72 hours of pediatric intensive care unit (PICU) admission and to evaluate the incidence and predictors of hyperchloremic metabolic acidemia (HCMA) and the association between HCMA and adverse outcomes. This retrospective cohort study was conducted in two tertiary-care Canadian PICUs. Children aged 0 to 18 years admitted to the PICU between January 2015 and January 2016 who received at least 50% of their calculated maintenance fluid requirements parenterally during the first 24 hours of admission were included. Children with known preexisting conditions associated with HCMA, such as renal tubular acidosis and gastrointestinal bicarbonate losses, were excluded. Of the 771 children screened, 543 met eligibility criteria and were included. The commonest prescribed maintenance fluid was 0.9% NaCl (72.9%) followed by lactated Ringer's solution (19.6%) and hypotonic solutions (4.6%). Balanced salt solutions (i.e., lactated Ringer's and Plasma-Lyte) were as commonly administered as unbalanced solutions (0.9% NaCl) for volume expansion (49.6 vs. 48.5%, respectively). Medications contributed to a significant proportion of total daily intake, in excess of bolus fluids. The incidence of hyperchloremia and HCMA was 94.9% (95% confidence interval [CI]: 93.2-96.9; 470/495) and 38.9% (95% CI: 34.6-43.2; 196/504), respectively. Predictors of HCMA were increasing combined bolus and maintenance 0.9% NaCl intake (odds ratio: 1.13; 95% CI: 1.04-1.23) and increasing severity of illness. HCMA was not associated with an increased risk of acute kidney injury, feeding intolerance, or PICU-acquired weakness. Isotonic fluids, specifically 0.9% NaCl, were the most commonly administered maintenance IV fluid in critically ill children. Sources of chloride load are not isolated to resuscitation fluids as previously suggested. Maintenance fluids and fluids administered with medications and IV flushes (fluid creep) are under-recognized significant sources of fluid and electrolyte intake in critically ill children. HCMA is common, and further prospective research is required to determine whether HCMA is indeed harmful in children. However, all significant sources of fluid should be accounted for in the design of future trials comparing balanced and unbalanced salt solutions.
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Affiliation(s)
- Adrian F Bulfon
- Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Hakem L Alomani
- Department of Pediatrics (Critical Care), McMaster University, London, Ontario, Canada
| | - Natalie Anton
- Department of Pediatrics, Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Brooke T Comrie
- Department of Physiology, University of Alberta, Edmonton, Alberta, Canada
| | - Bram Rochwerg
- McMaster University, Hamilton, Ontario, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Sorina A Stef
- Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Thuva Vanniyasingam
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Karen Choong
- Department of Pediatrics (Critical Care), McMaster University, London, Ontario, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
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27
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Ab-normal saline in abnormal kidney function: risks and alternatives. Pediatr Nephrol 2019; 34:1191-1199. [PMID: 29987459 PMCID: PMC6531391 DOI: 10.1007/s00467-018-4008-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 06/19/2018] [Accepted: 06/19/2018] [Indexed: 12/27/2022]
Abstract
Intravenous 0.9% saline has saved countless lives since it was introduced over a century ago. It remains the most widespread crystalloid in both adult and pediatric practice. However, in recent years, evidence of deleterious effects is accruing. These include increased mortality, acute kidney injury (AKI), metabolic acidosis, and coagulopathy. The predominant cause for these sequelae appears to be the excess chloride concentration of 0.9% saline relative to plasma. This has led to development of balanced isotonic solutions such as PlasmaLyte. This review summarizes current evidence for adverse effects of chloride-rich intravenous fluid and considers whether 0.9% saline should still be used in 2018 or abandoned as a historical treatment in favor of balanced crystalloid solutions.
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28
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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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Park SW, Shin SM, Jeong M, Cho DH, Lee KH, Eisenhut M, Kronbichler A, Moritz M, Il Shin J. Hyponatremia in children with respiratory infections: a cross-sectional analysis of a cohort of 3938 patients. Sci Rep 2018; 8:16494. [PMID: 30405154 PMCID: PMC6220324 DOI: 10.1038/s41598-018-34703-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 10/11/2018] [Indexed: 11/30/2022] Open
Abstract
Hyponatremia can be a life-threatening illness among hospitalized children. The aims of this study were to evaluate the incidence and risk factors of hyponatremia in 3938 children who were admitted to the Cheil General Hospital and Women’s Health Care Center with respiratory infections. Clinical data were collected, and multiplex RT-PCR analyses were done for various microorganisms. Hyponatremia was observed in 531 (13.5%) patients. The incidence of hyponatremia differed according to the respiratory tract infection (P < 0.0001) and microorganism (P = 0.001). In children with hyponatremia, the age at admission was significantly older (P < 0.0001), male gender was more frequent (P = 0.019), CRP was higher (P < 0.0001), and coinfection with multiple organisms was more common (P = 0.001) than in children without hyponatremia. In multivariate analyses, an older age at admission (P = 0.006), male gender (P = 0.004), and increased CRP (P < 0.0001) were independent risk factors. Sodium levels correlated negatively with WBC (P = 0.037), CRP (P < 0.0001), and number of hospital days (P = 0.020). The AUC values of age (0.586, P < 0.0001), CRP (0.599, P < 0.0001), and blood urea nitrogen (0.559, P < 0.0001) were all significant predictors of hyponatremia. This study is the first to show that the incidence of hyponatremia differs according to infecting microorganism and radiological findings.
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Affiliation(s)
- Sung Won Park
- Department of Pediatrics, Dankook University College of Medicine, Cheil General Hospital & Woman's Health Care Center, Seoul, Korea
| | - Son Moon Shin
- Department of Pediatrics, Dankook University College of Medicine, Cheil General Hospital & Woman's Health Care Center, Seoul, Korea
| | - Moonsun Jeong
- Department of Pediatrics, Dankook University College of Medicine, Cheil General Hospital & Woman's Health Care Center, Seoul, Korea
| | - Dong-Hee Cho
- Department of Laboratory Medicine, Dankook University College of Medicine, Cheil General Hospital & Woman's Health Care Center, Seoul, Korea
| | - Keum Hwa Lee
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Michael Eisenhut
- Luton & Dunstable University Hospital NHS Foundation Trust, Luton, United Kingdom
| | - Andreas Kronbichler
- Medical University Innsbruck, Department of Internal Medicine IV (Nephrology and Hypertension), Innsbruck, Austria
| | - Michael Moritz
- Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, The University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea. .,Department of Pediatric Nephrology, Institute of Kidney Disease Research, Severance Children's Hospital, Seoul, South Korea.
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30
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Karageorgos SA, Kratimenos P, Landicho A, Haratz J, Argentine L, Jain A, McInnes AD, Fisher M, Koutroulis I. Hospital-Acquired Hyponatremia in Children Following Hypotonic versus Isotonic Intravenous Fluids Infusion. CHILDREN-BASEL 2018; 5:children5100139. [PMID: 30279348 PMCID: PMC6209932 DOI: 10.3390/children5100139] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 09/26/2018] [Accepted: 09/26/2018] [Indexed: 11/16/2022]
Abstract
Hypotonic solutions have been used in pediatrics for maintenance of intravenous (IV) hydration. However, recent randomized control trials and cohort studies have raised significant concerns for association with hospital-acquired hyponatremia (HAH). The study aimed to assess whether the use of hypotonic parenteral solutions (PS) compared with isotonic PS is associated with increased HAH risk in children with common pediatric conditions. Retrospective chart review of 472 patients aged 2 months to 18 years who received either isotonic or hypotonic PS as maintenance fluids. Administration of hypotonic PS was associated with a four-fold increase in risk of developing HAH in the univariate analysis, (unadjusted odds ratio (OR) = 3.99; 95% confidence interval (CI): 1.36–11.69, p = 0.01). Hypotonic PS were associated with HAH (p = 0.04) when adjusted for the level of admission serum CO2. There was a mean decrease of serum sodium of 0.53 mEq/L in the hypotonic group compared to the mean increase of 4.88 mEq/L in the isotonic group. These data suggest that hypotonic PS are associated with HAH in children admitted for common pediatric conditions. Isotonic PS should be considered as a safer choice for maintenance fluid hydration.
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Affiliation(s)
- Spyridon A Karageorgos
- Division of Infectious Diseases and Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA.
| | - Panagiotis Kratimenos
- Division of Neonatology, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC 20010, USA.
| | - Ashley Landicho
- Crozer-Chester Medical Center, Crozer-Keystone Health Network, Upland, PA 19013, USA.
| | - Joshua Haratz
- St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA 19134, USA.
| | - Louis Argentine
- St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA 19134, USA.
| | - Amit Jain
- Sanford Children's Hospital, Sanford School of Medicine, University of South Dakota, Sioux Falls, SD 57105; USA.
| | - Andrew D McInnes
- K. Hovnanian Children's Hospital, Jersey Shore University Medical Center, Neptune, NJ 07753, USA.
| | - Margaret Fisher
- The Unterberg Children's Hospital, Monmouth Medical Center, Drexel University College of Medicine, Long Branch, NJ 07740, USA.
| | - Ioannis Koutroulis
- Division of Emergency Medicine, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC 20010, USA.
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Hall AM, Ayus JC, Moritz ML. Things We Do For No Reason: The Default Use of Hypotonic Maintenance Intravenous Fluids in Pediatrics. J Hosp Med 2018; 13:637-640. [PMID: 30157287 DOI: 10.12788/jhm.3040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Alan M Hall
- Divisions of Hospital Medicine and Pediatrics, University of Kentucky College of Medicine, Lexington, Kentucky, USA.
| | - Juan C Ayus
- Renal Consultants of Houston, Houston, Texas, USA
- University of California Irvine School of Medicine, Irvine, California, USA
| | - Michael L Moritz
- Department of Pediatrics, Childrens Hospital of Pittsburgh of UPMC, The University of Pittsburg, School of Medicine, Pittsburgh, Pennsylvania, USA
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Jaidev MD, Maddukuri E, Castelino D, Khan H, Hegde P. Study of the serum sodium changes in children between 3 months and 5 years age receiving isotonic maintenance intravenous fluids. MULLER JOURNAL OF MEDICAL SCIENCES AND RESEARCH 2018. [DOI: 10.4103/mjmsr.mjmsr_53_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Rooholamini SN, Clifton H, Haaland W, McGrath C, Vora SB, Crowell CS, Romero H, Foti J. Outcomes of a Clinical Pathway to Standardize Use of Maintenance Intravenous Fluids. Hosp Pediatr 2017; 7:703-709. [PMID: 29162640 DOI: 10.1542/hpeds.2017-0099] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Improper use of maintenance intravenous fluids (IVFs) may cause serious hospital-acquired harm. We created an evidence-based clinical pathway to guide providers on the indications for IVF, its preferred composition, and appropriate clinical monitoring. METHODS Pathway implementation was supported by the creation of an electronic order set (PowerPlan) and hospital-wide education. Outcomes were measured among pathway-eligible patients for the years before (July 1, 2014-June 30, 2015) and after (July 1, 2015-June 30, 2016) implementation. An interrupted time series analysis was used to evaluate monthly trends related to IVF use, including the following: median duration, proportions of isotonic and hypotonic IVF, adherence to monitoring recommendations, incidence of associated severe dysnatremia, potassium-containing IVF use in the emergency department, and costs. RESULTS There were 11 602 pathway-eligible encounters (10 287 patients) across the study. Median IVF infusion hours did not change. Isotonic maintenance IVF use increased significantly from 9.3% to 50.6%, whereas the use of any hypotonic fluid decreased from 94.2% to 56.6%. There were significant increases in daily weight measurement and recommended serum sodium testing. Cases of dysnatremia increased from 2 to 4 among pathway-eligible patients and were mostly associated with hypotonic IVF use. Patients in the emergency department had a significant increase in the number of potassium-containing IVF bags (52.9% to 75.3%). Total hospitalization and laboratory test costs did not change significantly. CONCLUSIONS This is the first report of outcomes of a clinical pathway to standardize IVF use. Implementation was feasible in both medical and surgical units, with sustained improvements for 1 year. Future improvement work includes increasing PowerPlan use and developing clinical assessment tools.
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Affiliation(s)
- Sahar N Rooholamini
- Department of Pediatrics, Division of General Pediatrics and Hospital Medicine, University of Washington, Seattle, Washington;
| | - Holly Clifton
- Clinical Effectiveness Program, Seattle Children's Hospital, Seattle, Washington
| | - Wren Haaland
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington; and
| | - Caitlin McGrath
- Department of Pediatrics, Division of General Pediatrics and Hospital Medicine, University of Washington, Seattle, Washington
| | - Surabhi B Vora
- Department of Pediatrics, Division of General Pediatrics and Hospital Medicine, University of Washington, Seattle, Washington.,Clinical Effectiveness Program, Seattle Children's Hospital, Seattle, Washington
| | - Claudia S Crowell
- Department of Pediatrics, Division of General Pediatrics and Hospital Medicine, University of Washington, Seattle, Washington.,Clinical Effectiveness Program, Seattle Children's Hospital, Seattle, Washington
| | - Holly Romero
- Department of Pediatrics, Hawaii Permanente Medical Group, Wailuku, Hawaii
| | - Jeffrey Foti
- Department of Pediatrics, Division of General Pediatrics and Hospital Medicine, University of Washington, Seattle, Washington.,Clinical Effectiveness Program, Seattle Children's Hospital, Seattle, Washington
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Okada M, Egi M, Yokota Y, Shirakawa N, Fujimoto D, Taguchi S, Furushima N, Mizobuchi S. Comparison of the incidences of hyponatremia in adult postoperative critically ill patients receiving intravenous maintenance fluids with 140 mmol/L or 35 mmol/L of sodium: retrospective before/after observational study. J Anesth 2017; 31:657-663. [PMID: 28455602 DOI: 10.1007/s00540-017-2370-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 04/23/2017] [Indexed: 01/10/2023]
Abstract
PURPOSE The purpose of this study was to compare the incidences of hyponatremia in adult postoperative critically ill patients receiving isotonic and hypotonic maintenance fluids. METHODS In this single-center retrospective before/after observational study, we included patients who had undergone an elective operation for esophageal cancer or for head and neck cancer and who received postoperative intensive care for >48 h from August 2014 to July 2016. In those patients, sodium-poor solution (35 mmol/L of sodium; Na35) had been administered as maintenance fluid until July 2015. From August 2015, the protocol for postoperative maintenance fluid was revised to the use of isotonic fluid (140 mmol/L of sodium; Na140). The primary outcome was the incidence of hyponatremia (<135 mmol/L) until the morning of postoperative day (POD) 2. RESULTS We included 179 patients (Na35: 87 patients, Na140: 92 patients) in the current study. The mean volume of fluid received from ICU admission to POD 2 was not significantly different between the two groups (3291 vs 3337 mL, p = 0.84). The incidence of postoperative hyponatremia was 16.3% (15/92) in the Na140 cohort, which was significantly lower than that of 52.9% (46/87) in the Na35 group (odds ratio = 0.17, 95% confidence interval 0.09-0.35, p < 0.001]. The incidences of hypernatremia, defined as serum sodium concentration >145 mmol/L, were not significantly different between the two groups. CONCLUSION In this study, the use of intravenous maintenance fluid with 35 mmol/L of sodium was significantly associated with an increased risk of hyponatremia compared to that with 140 mmol/L of sodium in adult postoperative critically ill patients.
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Affiliation(s)
- Masako Okada
- Department of Anesthesiology, Kobe University Hospital, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Moritoki Egi
- Department of Anesthesiology, Kobe University Hospital, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan.
| | - Yuri Yokota
- Department of Anesthesiology, Kobe University Hospital, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Naotaka Shirakawa
- Department of Anesthesiology, Kobe University Hospital, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Daichi Fujimoto
- Department of Anesthesiology, Kobe University Hospital, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Shinya Taguchi
- Department of Anesthesiology, Kobe University Hospital, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Nana Furushima
- Department of Anesthesiology, Kobe University Hospital, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Satoshi Mizobuchi
- Department of Anesthesiology, Kobe University Hospital, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
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Abstract
OBJECTIVE Intravenous fluids are broadly categorized into colloids and crystalloids. The aim of this review is to present under a clinical point of view the characteristics of intravenous fluids that make them more or less appropriate either for maintaining hydration when enteral intake is contraindicated or for treating hypovolemia. METHODS We considered randomized trials and meta-analyses as well as narrative reviews evaluating the effects of colloids or crystalloids in patients with hypovolemia or as maintenance fluids published in the PubMed and Cochrane databases. RESULTS Clinical studies have not shown a greater clinical benefit of albumin solutions compared with crystalloid solutions. Furthermore, albumin and colloid solutions may impair renal function, while there is no evidence that the administration of colloids reduces the risk of death compared with resuscitation with crystalloids in patients with trauma, burns or following surgery. Among crystalloids, normal saline is associated with the development of hyperchloremia-induced impairment of kidney function and metabolic acidosis. On the other hand, the other commonly used crystalloid solution, the Ringer's Lactate, has certain indications and contraindications. These matters, along with the basic principles of the administration of potassium chloride and bicarbonate, are meticulously discussed in the review. CONCLUSIONS Intravenous fluids should be dealt with as drugs, as they have specific clinical indications, contraindications and adverse effects.
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Affiliation(s)
- N El Gkotmi
- a Department of Internal Medicine, School of Medicine , University of Ioannina , Ioannina , Greece
| | - C Kosmeri
- a Department of Internal Medicine, School of Medicine , University of Ioannina , Ioannina , Greece
| | - T D Filippatos
- a Department of Internal Medicine, School of Medicine , University of Ioannina , Ioannina , Greece
| | - M S Elisaf
- a Department of Internal Medicine, School of Medicine , University of Ioannina , Ioannina , Greece
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Sodium Disturbances in Children Admitted to a Kenyan Hospital: Magnitude, Outcome and Associated Factors. PLoS One 2016; 11:e0161320. [PMID: 27603309 PMCID: PMC5014322 DOI: 10.1371/journal.pone.0161320] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 08/03/2016] [Indexed: 01/16/2023] Open
Abstract
Background Perturbations of blood sodium are the most frequently encountered electrolyte disorder in sick children, and may influence fluid therapy. We examined the frequency of blood sodium perturbations, and factors and outcomes associated with hyponatremia in children admitted to a rural Kenyan hospital and investigated the risk factors associated with deaths in hyponatremic children. Methods Plasma sodium levels and other laboratory parameters were measured in children admitted to a rural Kenyan hospital. Clinical measurements were collected using standard forms and entered into a computer database. The proportion of children admitted with hyponatremia was determined. Logistic regression models were used to investigate factors associated with hyponatremia, and death in those with hyponatremia. Results Abnormal plasma sodium occurred in 46.6% (95% confidence interval (95%CI) 43.5–49.6%) of 1026 pediatric admissions. Hyponatremia occurred in 44.4% (95%CI 41.4–47.5%) and hypernatremia in 2.1% (95%CI 1.3–3.0%). Malaria (40.8%) was the most common underlying primary diagnosis in hyponatremic children. Malaria, hyperglycemia, wasting, high creatinine levels and preserved consciousness were associated with hyponatremia. Pallor and seizures were associated with increased mortality in hyponatremic children. Conclusions Sodium disturbances are common in pediatric admissions to a County hospital in rural Kenya. Seizures and pallor were predictors of mortality in hyponatremic children.
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Rizza A, Romagnoli S, Ricci Z. Fluid Status Assessment and Management During the Perioperative Phase in Pediatric Cardiac Surgery Patients. J Cardiothorac Vasc Anesth 2016; 30:1085-93. [DOI: 10.1053/j.jvca.2015.11.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Indexed: 02/07/2023]
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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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Southerland JH, Brown LR. Conscious Intravenous Sedation in Dentistry: A Review of Current Therapy. Dent Clin North Am 2016; 60:309-346. [PMID: 27040288 DOI: 10.1016/j.cden.2015.11.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Several sedation options are used to minimize pain, anxiety, and discomfort during oral surgery procedures. Minimizing or eliminating pain and anxiety for dental care is the primary goal for conscious sedation. Intravenous conscious sedation is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate as well as cardiovascular function. Patients must retain their protective airway reflexes, and respond to and understand verbal communication. The drugs and techniques used must therefore carry a broad margin of safety.
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Affiliation(s)
- Janet H Southerland
- Department of Oral and Maxillofacial Surgery, Meharry Medical College School of Dentistry, 1005 Dr. DB Todd Jr. Boulevard, Nashville, TN 37208, USA.
| | - Lawrence R Brown
- Dadeland Oral Surgery Associates, 8950 S.W. 74th Court, Suite 1610, Miami Florida 33156; Baptist Hospital Of Miami, 8900 North Kendall Drive, Miami Florida 33176
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McNab S. Intravenous maintenance fluid therapy in children. J Paediatr Child Health 2016; 52:137-40. [PMID: 27062616 DOI: 10.1111/jpc.13076] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 11/17/2015] [Accepted: 11/25/2015] [Indexed: 01/19/2023]
Abstract
Intravenous fluids are frequently used in paediatrics but have been associated with significant adverse outcomes. Understanding the composition of fluid prescribed and administering an appropriate rate is essential for safe fluid administration, along with regular monitoring. Recent evidence has shown that using an isotonic fluid with a sodium concentration similar to plasma can decrease the risk of hyponatraemia without an increase in adverse effects. This should lead to a change in guidelines: isotonic fluid should now be used as the primary maintenance intravenous fluid given to the majority of children.
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Affiliation(s)
- Sarah McNab
- Department of General Medicine, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Childrens Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
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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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Belter CW. Citation analysis as a literature search method for systematic reviews. J Assoc Inf Sci Technol 2015. [DOI: 10.1002/asi.23605] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Abstract
The presentation of endocrine and metabolic emergencies represents one of the more challenging clinical scenarios faced by pediatricians and emergency providers. In this review, the authors attempt to describe some of the more common entities that a provider may see and provide a guide for the recognition and management of these difficult-to-assess and often very ill children.
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Affiliation(s)
- Jennifer M Barker
- Section of Endocrinology, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, Aurora, CO 80045, USA
| | - Lalit Bajaj
- Section of Emergency Medicine, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, Aurora, CO 80045, USA.
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Neville KA, Walker JL. Isotonic fluid for intravenous hydration maintenance in children. Lancet 2015; 386:135-6. [PMID: 26194392 DOI: 10.1016/s0140-6736(15)61239-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Kristen A Neville
- Department of Endocrinology, Sydney Children's Hospital, Randwick NSW 2031, Australia.
| | - Jan L Walker
- Department of Endocrinology, Sydney Children's Hospital, Randwick NSW 2031, Australia; School of Women's & Children's Health, University of New South Wales, Sydney, Australia
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Krishnan P. Late decompensation after a prolonged lucid interval in chronic posterior fossa extradural hematoma. Indian Pediatr 2015; 52:342-3. [PMID: 25929638 DOI: 10.1007/s13312-015-0636-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Prasad Krishnan
- Department of Neurosurgery, National Neurosciences Centre, Peerless Hospital Complex, Kolkata, West Bengal, India
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