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Van Regenmortel N, Moers L, Langer T, Roelant E, De Weerdt T, Caironi P, Malbrain MLNG, Elbers P, Van den Wyngaert T, Jorens PG. Fluid-induced harm in the hospital: look beyond volume and start considering sodium. From physiology towards recommendations for daily practice in hospitalized adults. Ann Intensive Care 2021; 11:79. [PMID: 33999276 PMCID: PMC8128950 DOI: 10.1186/s13613-021-00851-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 04/03/2021] [Indexed: 12/21/2022] Open
Abstract
PURPOSE Iatrogenic fluid overload is a potential side effect of intravenous fluid therapy in the hospital. Little attention has been paid to sodium administration as a separate cause of harm. With this narrative review, we aim to substantiate the hypothesis that a considerable amount of fluid-induced harm is caused not only by fluid volume, but also by the sodium that is administered to hospitalized patients. METHODS We show how a regular dietary sodium intake is easily surpassed by the substantial amounts of sodium that are administered during typical hospital stays. The most significant sodium burdens are caused by isotonic maintenance fluid therapy and by fluid creep, defined as the large volume unintentionally administered to patients in the form of dissolved medication. In a section on physiology, we elaborate on the limited renal handling of an acute sodium load. We demonstrate how the subsequent retention of water is an energy-demanding, catabolic process and how free water is needed to excrete large burdens of sodium. We quantify the effect size of sodium-induced fluid retention and discuss its potential clinical impact. Finally, we propose preventive measures, discuss the benefits and risks of low-sodium maintenance fluid therapy, and explore options for reducing the amount of sodium caused by fluid creep. CONCLUSION The sodium burdens caused by isotonic maintenance fluids and fluid creep are responsible for an additional and avoidable derailment of fluid balance, with presumed clinical consequences. Moreover, the handling of sodium overload is characterized by increased catabolism. Easy and effective measures for reducing sodium load and fluid retention include choosing a hypotonic rather than isotonic maintenance fluid strategy (or avoiding these fluids when enough free water is provided through other sources) and dissolving as many medications as possible in glucose 5%.
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Affiliation(s)
- Niels Van Regenmortel
- Department of Intensive Care Medicine, Antwerp University Hospital, Wilrijkstraat 10 Edegem, B-2650, Antwerp, Belgium. .,Department of Intensive Care Medicine, Ziekenhuis Netwerk Antwerpen Campus Stuivenberg, Lange Beeldekensstraat 267, B-2060, Antwerp, Belgium.
| | - Lynn Moers
- Department of Pharmacy, Ziekenhuis Netwerk Antwerpen Campus Stuivenberg, Lange Beeldekensstraat 267, B-2060, Antwerp, Belgium
| | - Thomas Langer
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy.,Department of Anaesthesia and Intensive Care Medicine, Niguarda Ca' Granda, Milan, Italy
| | - Ella Roelant
- StatUa, Center for Statistics, University of Antwerp, Prinsstraat 13, B-2000, Antwerp, Belgium.,Clinical Trial Center (CTC), CRC Antwerp, Antwerp University Hospital, University of Antwerp, Wilrijkstraat 10, B-2650, Edegem, Belgium
| | - Tim De Weerdt
- Department of Nephrology, Kliniek Sint-Jan, Kruidtuinlaan 32, B-1000, Brussels, Belgium
| | - Pietro Caironi
- Department of Anesthesia and Critical Care, AOU S. Luigi Gonzaga, Department of Oncology, University of Turin, Turin, Italy
| | - Manu L N G Malbrain
- Faculty of Engineering, Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, 1090, Jette, Belgium
| | - Paul Elbers
- Department of Intensive Care Medicine, Research VUmc Intensive Care (REVIVE), Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Sciences (ACS), Amsterdam Infection and Immunity Institute (AI&II), Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Tim Van den Wyngaert
- Department of Nuclear Medicine, Antwerp University Hospital, Wilrijkstraat 10 Edegem, B-2650, Antwerp, Belgium.,Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1 Wilrijk, B-2610, Antwerp, Belgium
| | - Philippe G Jorens
- Department of Intensive Care Medicine, Antwerp University Hospital, Wilrijkstraat 10 Edegem, B-2650, Antwerp, Belgium.,Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1 Wilrijk, B-2610, Antwerp, Belgium
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Van Regenmortel N, De Weerdt T, Van Craenenbroeck AH, Roelant E, Verbrugghe W, Dams K, Malbrain MLNG, Van den Wyngaert T, Jorens PG. Effect of isotonic versus hypotonic maintenance fluid therapy on urine output, fluid balance, and electrolyte homeostasis: a crossover study in fasting adult volunteers. Br J Anaesth 2018; 118:892-900. [PMID: 28520883 PMCID: PMC5455256 DOI: 10.1093/bja/aex118] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2017] [Indexed: 02/03/2023] Open
Abstract
Background. Daily and globally, millions of adult hospitalized patients are exposed to maintenance i.v. fluid solutions supported by limited scientific evidence. In particular, it remains unclear whether fluid tonicity contributes to the recently established detrimental effects of fluid, sodium, and chloride overload. Methods. This crossover study consisted of two 48 h study periods, during which 12 fasting healthy adults were treated with a frequently prescribed solution (NaCl 0.9% in glucose 5% supplemented by 40 mmol litre−1 of potassium chloride) and a premixed hypotonic fluid (NaCl 0.32% in glucose 5% containing 26 mmol litre−1 of potassium) at a daily rate of 25 ml kg−1 of body weight. The primary end point was cumulative urine volume; fluid balance was thus calculated. We also explored the physiological mechanisms behind our findings and assessed electrolyte concentrations. Results. After 48 h, 595 ml (95% CI: 454–735) less urine was voided with isotonic fluids than hypotonic fluids (P<0.001), or 803 ml (95% CI: 692–915) after excluding an outlier with ‘exaggerated natriuresis of hypertension’. The isotonic treatment was characterized by a significant decrease in aldosterone (P<0.001). Sodium concentrations were higher in the isotonic arm (P<0.001), but all measurements remained within the normal range. Potassium concentrations did not differ between the two solutions (P=0.45). Chloride concentrations were higher with the isotonic treatment (P<0.001), even causing hyperchloraemia. Conclusions. Even at maintenance rate, isotonic solutions caused lower urine output, characterized by decreased aldosterone concentrations indicating (unintentional) volume expansion, than hypotonic solutions and were associated with hyperchloraemia. Despite their lower sodium and potassium content, hypotonic fluids were not associated with hyponatraemia or hypokalaemia. Clinical trial registration. ClinicalTrials.gov (NCT02822898) and EudraCT (2016-001846-24).
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Affiliation(s)
- N Van Regenmortel
- Department of Intensive Care Medicine, Antwerp University Hospital, Wilrijkstraat 10, B-2650 Edegem (Antwerp), Belgium.,Department of Intensive Care Medicine, Ziekenhuis Netwerk Antwerpen Campus Stuivenberg, Lange Beeldekensstraat 267, B-2060 Antwerp, Belgium
| | - T De Weerdt
- Department of Nephrology, Antwerp University Hospital, Wilrijkstraat 10, B-2650 Edegem (Antwerp), Belgium
| | - A H Van Craenenbroeck
- Department of Nephrology, Antwerp University Hospital, Wilrijkstraat 10, B-2650 Edegem (Antwerp), Belgium
| | - E Roelant
- Department of Scientific Coordination and Biostatistics, Clinical Research Center Antwerp, Antwerp University Hospital, Wilrijkstraat 10, B-2650 Edegem (Antwerp), Belgium.,StatUa, Center for Statistics, University of Antwerp, Prinsstraat 13, B-2000 Antwerp, Belgium
| | - W Verbrugghe
- Department of Intensive Care Medicine, Antwerp University Hospital, Wilrijkstraat 10, B-2650 Edegem (Antwerp), Belgium
| | - K Dams
- Department of Intensive Care Medicine, Antwerp University Hospital, Wilrijkstraat 10, B-2650 Edegem (Antwerp), Belgium
| | - M L N G Malbrain
- Department of Intensive Care Medicine, Ziekenhuis Netwerk Antwerpen Campus Stuivenberg, Lange Beeldekensstraat 267, B-2060 Antwerp, Belgium
| | - T Van den Wyngaert
- Department of Nuclear Medicine, Antwerp University Hospital, Wilrijkstraat 10, B-2650 Edegem (Antwerp), Belgium.,Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, B-2610 Wilrijk (Antwerp), Belgium
| | - P G Jorens
- Department of Intensive Care Medicine, Antwerp University Hospital, Wilrijkstraat 10, B-2650 Edegem (Antwerp), Belgium.,Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, B-2610 Wilrijk (Antwerp), Belgium
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