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Hawkins C, Hemmann B, Hemmelgarn T. Evaluation of Hyponatremia in Infants on Vasopressin Therapy. J Pediatr Pharmacol Ther 2024; 29:385-390. [PMID: 39144386 PMCID: PMC11321805 DOI: 10.5863/1551-6776-29.4.385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 01/07/2024] [Indexed: 08/16/2024]
Abstract
OBJECTIVE Vasopressin has systemic vasoconstrictive yet pulmonary vasodilatory effects, making it an ideal agent for hypotension management in infants with congenital diaphragmatic hernia (CDH)-associated pulmonary hypertension. The side effects of vasopressin in this population, such as hyponatremia, are understudied. This study aims to characterize the effect of vasopressin on sodium concentrations in infants with and without CDH. METHODS This was a retrospective review of patients who received vasopressin while admitted to a level IV neonatal intensive care unit. The primary outcome was the incidence of hyponatremia (blood sodium <135 mmol/L) during vasopressin therapy. Secondary outcomes included time to hyponatremia, dose and duration of vasopressin, incidence of severe hyponatremia (blood sodium <125 mmol/L), and hypertonic saline use. Both blood serum and blood gas sample sodium concentrations were used to compare CDH vs non-CDH patients. RESULTS The average difference between baseline and lowest blood sodium was significant for both CDH and non-CDH patients for all samples (p < 0.001). There was no significant difference in the primary outcome, nor in the secondary outcomes of time to hyponatremia or duration of vasopressin infusion. The average dose of vasopressin was higher in the CDH vs non-CDH group (p = 0.018). The incidences of severe hyponatremia and hypertonic saline use were greater in the CDH vs non-CDH group for patients who had blood serum sodium samples collected (p = 0.049 and p = 0.033, respectively). CONCLUSIONS This study showed that severe hyponatremia occurred more frequently in CDH vs non-CDH patients. Extreme caution is necessary when managing total body sodium in patients with CDH.
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Affiliation(s)
- Caitlin Hawkins
- Department of Pharmacy (CH*), Nationwide Children’s Hospital, Columbus, OH; *CH was a student at the time of this study
| | - Brianna Hemmann
- Division of Pharmacy (BH, TH), Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Trina Hemmelgarn
- Division of Pharmacy (BH, TH), Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
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Breuler C, Lynn JV, Buchman L, Matusko N, Makar K, Ranganathan K, Mouch C, Muraszko K, Buchman SR. Low Prevalence of Clinically Significant Hyponatremia following Cranial Vault Reconstruction for Single-Suture Craniosynostosis. Plast Reconstr Surg 2024; 153:1379-1386. [PMID: 38810163 DOI: 10.1097/prs.0000000000010852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
BACKGROUND Patients are commonly monitored for hyponatremia after intracranial procedures, yet the prevalence of hyponatremia after cranial vault reconstruction (CVR) remains unclear. The purpose of this study is to define the prevalence, risk factors, and complications of hyponatremia after CVR to optimize postoperative sodium surveillance protocols. METHODS Patients with nonsyndromic, single-suture craniosynostosis who underwent primary CVR between 2009 and 2020 at Michigan Medicine were included (n = 231). Demographic, intraoperative, and postoperative characteristics were compared by postoperative hyponatremia status at P < 0.05 significance. Hyponatremia was defined as mild (<135 mEq/L), moderate (<130 mEq/L), or severe (<125 mEq/L) based on the lowest postoperative laboratory draw. RESULTS Twenty-three patients (10.0%) developed mild postoperative hyponatremia. No patient developed moderate or severe postoperative hyponatremia. On multivariable regression, decreased preoperative sodium level (P = 0.03) and decreased preoperative weight (P = 0.02) were significantly associated with mild postoperative hyponatremia. No patient developed complications or required hospital readmission because of hyponatremia. CONCLUSIONS This large retrospective cohort study of patients with nonsyndromic single-suture craniosynostosis demonstrated a 10% prevalence of mild, clinically inconsequential hyponatremia and 0% prevalence of moderate or severe, clinically significant hyponatremia after primary CVR. Patients with low preoperative sodium level or weight were at increased risk for developing mild postoperative hyponatremia. The results suggest that patients with preoperative sodium greater than 140 mEq/L or preoperative weight greater than 10 kg may be candidates for limited postoperative sodium surveillance; however, future prospective studies are warranted before implementation. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.
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Zieg J, Narla D, Gonsorcikova L, Raina R. Fluid management in children with volume depletion. Pediatr Nephrol 2024; 39:423-434. [PMID: 37452205 DOI: 10.1007/s00467-023-06080-z] [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: 12/09/2022] [Revised: 06/06/2023] [Accepted: 06/26/2023] [Indexed: 07/18/2023]
Abstract
Volume depletion is a common condition and a frequent cause of hospitalization in children. Proper assessment of the patient includes a detailed history and a thorough physical examination. Biochemical tests may be useful in selected cases. Understanding the pathophysiology of fluid balance is necessary for appropriate management. A clinical dehydration scale assessing more physical findings may help to determine dehydration severity. Most dehydrated children can be treated orally; however, intravenous therapy may be indicated in patients with severe volume depletion, in those who have failed oral therapy, or in children with altered consciousness or significant metabolic abnormalities. Proper management consists of restoring circulatory volume and electrolyte balance. In this paper, we review clinical aspects, diagnosis, and management of children with volume depletion.
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Affiliation(s)
- Jakub Zieg
- Department of Pediatrics, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Deepti Narla
- Department of Pediatric Nephrology, Akron Children's Hospital, Cleveland, OH, USA
| | - Lucie Gonsorcikova
- Department of Pediatrics, First Faculty of Medicine, Charles University in Prague and Thomayer University Hospital, Prague, Czech Republic
| | - Rupesh Raina
- Department of Pediatric Nephrology, Akron Children's Hospital, Cleveland, OH, USA.
- Cleveland Clinic Akron General Medical Center, Akron, OH, USA.
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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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Lonfat E, La Scala GC. Postoperative Dysnatremia in Pediatric Patients Undergoing Palatoplasty. J Craniofac Surg 2023; 34:1942-1947. [PMID: 37226304 PMCID: PMC10521787 DOI: 10.1097/scs.0000000000009345] [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: 12/15/2022] [Accepted: 03/30/2023] [Indexed: 05/26/2023] Open
Abstract
OBJECTIVE Identifying predisposing factors to dysnatremia to improve perioperative care after cleft surgery. DESIGN Retrospective case series. Patient data were obtained through the electronic medical records of the hospital. SETTING Tertiary care university hospital. PATIENTS The inclusion criterion was the measurement of an abnormal natremia value, defined as Na >150 or <130 mmol/l after a cleft lip or cleft palate repair procedure. The exclusion criterion was natremia between 131 and 149 mmol/l. RESULTS Natremia measurements were available for 215 patients born between 1995 and 2018. Five patients presented with postoperative dysnatremia. Several predisposing factors to dysnatremia have been identified: drugs, infection, administration of intravenous fluids, and postoperative syndrome of inappropriate antidiuretic hormone secretion. Although the hospital environment contributes to dysnatremia development, the fact that only patients undergoing cleft palate repair develop natremia anomalies suggests that this surgery may be itself a risk factor. CONCLUSION Children undergoing palatoplasty may be at higher risk to develop postoperative dysnatremia. Early recognition of symptoms and risk factors, postoperative monitoring, and prompt treatment of dysnatremia diminish the risk of neurological complications.
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Allouzi S, Rihawi B, Allouzi J, Allouzi MI, Abdulrahman N, Abdullah M. A unique presentation of hyponatremia and seizures in a 2-month-old child with cystic fibrosis: a case report. Ann Med Surg (Lond) 2023; 85:4150-4152. [PMID: 37554905 PMCID: PMC10406084 DOI: 10.1097/ms9.0000000000001048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 07/01/2023] [Indexed: 08/10/2023] Open
Abstract
UNLABELLED Cystic fibrosis is an autosomal recessive disorder that causes a broad range of clinical findings and can present unusually as electrolyte disturbance, such as hyponatremia that causes seizures in children. CASE PRESENTATION We report a case of a 2-month-old infant who presented with an episode of grand mal seizure induced by hyponatremia and moderate episodes of milky vomiting after breastfeeding. CLINICAL DISCUSSION Proper investigations showed normal cardiac and renal functions. Ultrasonography showed no pathological changes. Laboratory tests performed showed hyponatremia, mild hypokalemia, and hypochloremia. Urinary electrolyte results were normal. While broadening the scope of differential diagnosis in order to reach a final diagnosis, the sweat chloride level was elevated, which confirmed the diagnosis of cystic fibroses. CONCLUSION We aim to share our case to keep cystic fibroses in mind as a differential diagnosis when dealing with hyponatremic seizures in children.
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Affiliation(s)
- Sana Allouzi
- Internal Medicine Department, Endocrinology Division
| | | | - Joud Allouzi
- Dermatology Department, Aleppo University Hospital
| | | | - Najwa Abdulrahman
- Pediatrics Department, Faculty of Medicine, University of Aleppo, Aleppo, Syria
| | - Manar Abdullah
- Pediatrics Department, Faculty of Medicine, University of Aleppo, Aleppo, Syria
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Berhanu Y, Yusuf T, Mohammed A, Meseret F, Demeke Habteyohans B, Alemu A, Tolosa G, Keneni M, Weldegebreal F, Desalew A. Hyponatremia and its associated factors in children admitted to the pediatric intensive care unit in eastern Ethiopia: a cross-sectional study. BMC Pediatr 2023; 23:310. [PMID: 37340344 DOI: 10.1186/s12887-023-04118-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 06/08/2023] [Indexed: 06/22/2023] Open
Abstract
BACKGROUND Hyponatremia is a serious problem that leads to substantial increases morbidity and mortality in critically ill children. The identification of risk factors, implementation of preventive measures, and timely diagnosis and management are crucial to reduce adverse events related to hyponatremia. Despite the higher burden of the problem in Ethiopia, evidence related to the risk factors for hyponatremia among children in Ethiopia is limited; in particular, no study has been identified in eastern Ethiopia. Therefore, we aimed to determine the magnitude of hyponatremia and its associated factors in children admitted to the pediatric intensive care unit at the Hiwot Fana Comprehensive Specialized University Hospital. METHODS A facility-based cross-sectional study was conducted using 422 medical records of pediatric patients admitted to the pediatric intensive care unit at Hiwot Fana Comprehensive Specialized University Hospital from January 2019 to December 2022. Medical records were reviewed to collect data. Data were analyzed using a statistical package for social sciences (SPSS) version 26. A binary logistic regression model with an adjusted odds ratio (aOR) and a 95% confidence interval (CI) was used to identify factors associated with the outcome variable. Statistical significance was set at p < 0.05. RESULTS The magnitude of hyponatremia was 39.1% (95% CL: 34.4-43.8%). The age of the child (aOR = 2.37;95% CL:1.31-4.31), diagnosis of sepsis (aOR = 2.33; 95% CL:1.41-3.84), surgical procedures (aOR = 2.39; 95% CL:1.26-4.56), nutritional status (aOR = 2.60; 95% CL:1.51-4.49), and length of hospital stay (aOR = 3.04; 95% CL: 1.73-5.33) were factors significantly associated with hyponatremia. CONCLUSIONS Four out of ten children admitted to pediatric intensive care units had hyponatremia. Hyponatremia was significantly associated with the age of the child, malnutrition, sepsis, surgical procedures, and length of hospital stay. To reduce the burden of hyponatremia and associated mortality, attention should be focused on improving the care of malnourished children, and those with sepsis, and the quality of postoperative monitoring services. Moreover, intervention strategies aimed at reducing the burden of hyponatremia should target the identified factors.
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Affiliation(s)
- Yeshi Berhanu
- Department of Pediatrics and Child Health, School of Medicine, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Turina Yusuf
- Department of Pediatrics and Child Health, School of Medicine, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Ahmed Mohammed
- Department of Pediatrics and Child Health, School of Medicine, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Fentahun Meseret
- Department of Pediatrics and Child Health Nursing, School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Betelhem Demeke Habteyohans
- Department of Pediatrics and Child Health, School of Medicine, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Ayichew Alemu
- Department of Pediatrics and Child Health Nursing, School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia.
| | - Gadissa Tolosa
- Department of Pediatrics and Child Health Nursing, School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Mulualem Keneni
- Department of Pediatrics and Child Health Nursing, School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Fitsum Weldegebreal
- School of Medical Laboratory Sciences, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Assefa Desalew
- Department of Pediatrics and Child Health Nursing, School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
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An adolescent with adnexal torsion presenting with severe hyponatremia. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2023. [DOI: 10.1016/j.epsc.2023.102613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
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Keating O, Hale AT, Smith AA, Jimenez V, Ashraf AP, Rocque BG. Hyponatremia after craniotomy in children: a single-institution review. Childs Nerv Syst 2023; 39:617-623. [PMID: 36308540 DOI: 10.1007/s00381-022-05729-8] [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: 06/03/2022] [Accepted: 10/25/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Hyponatremia after craniotomy can be associated with increased morbidity. However, the incidence of and factors associated with post-craniotomy hyponatremia in children are not known. METHODS We performed a retrospective cohort study of patients aged 0-21 years who underwent craniotomy in 2017-2019 at a single center to determine the incidence of and to identify risk factors for hyponatremia after craniotomy. Indications for craniotomy included tumors (excluding craniopharyngioma), epilepsy, intracranial infection, trauma, craniofacial, suboccipital decompression for the treatment of Chiari malformation, and cerebrovascular disease. Hyponatremia was defined as a serum sodium level ≤ 135 mEq/L any time during the postoperative hospital stay. Statistical significance was defined a priori at p < 0.05. RESULTS Postoperative hyponatremia occurred in 61 (25%) of 240 children. On univariate analysis, hyponatremia was associated with younger age (8.5 vs 6.3 years, p = 0.01), use of preoperative anti-epileptic drugs (p = 0.02), need for blood transfusion (p = 0.02), government/private insurance (p = 0.04), and pre-existing hydrocephalus, defined as the requirement for permanent cerebrospinal fluid (CSF) diversion (p = 0.04). On multivariate analysis, only hydrocephalus (OR 2.95, 95% CI 1.03-8.40) remained statistically significant. Hyponatremia most occurred on the first postoperative day, with normonatremia achieved in a median of 14 (IQR 9.8-24.3) h. Hyponatremia was significantly associated with longer length of stay (median 8 vs 3 days, p < 0.01). CONCLUSION Hyponatremia was present in 25% of children after craniotomy. Preoperative hydrocephalus as an independent risk factor for hyponatremia after craniotomy.
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Affiliation(s)
- Olivia Keating
- Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham, AL, USA
| | - Andrew T Hale
- Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham, AL, USA.
| | - Anastasia A Smith
- Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham, AL, USA
| | - Victoria Jimenez
- Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham, AL, USA
| | - Ambika P Ashraf
- Division of Pediatric Endocrinology, University of Alabama at Birmingham, Children's of Alabama, Birmingham, AL, USA
| | - Brandon G Rocque
- Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham, AL, USA
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Paulin MV, Snead EC. Case report: Hypoadrenocorticism crisis complicated by non-cardiogenic pulmonary edema in a dog. Front Vet Sci 2022; 9:1015739. [DOI: 10.3389/fvets.2022.1015739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 10/24/2022] [Indexed: 11/11/2022] Open
Abstract
A 6-year-old castrated male Labradoodle was referred in uncompensated hypovolemic shock, with a 72-h history of lethargy, vomiting and diarrhea that had acutely worsened with subsequent development of profuse hemorrhagic diarrhea in the last 24 h after a visit to the groomer. In most respects this case was classic for a patient with a primary hypoadrenocortical crisis. After initial attempts to address hypovolemia and refractory hypotension, no clinical improvement was seen, and the respiratory rate had increased acutely to 80 bpm with crackles detected on thoracic auscultation and serosanguineous fluid began draining from the nose and mouth. An arterial blood gas sample while breathing room air revealed moderate hypoxemia (PaO2 59.9: RI 95–100 mmHg), an elevated alveolar-arterial (A-a) gradient at 54.7 (RI < 15 mmHg) and a PaO2:FiO2 ratio of 285 mmHg. Thoracic radiographs revealed severe bilateral alveolar lung pattern largely limited to the perihilar and caudodorsal lung fields. The radiographic findings, along with signs of ongoing hypovolemia, the lack of evidence of typical long-standing acquired cardiac disease, and the rapid resolution of the pulmonary edema without the need for diuretics or long-term cardiac medications supported non-cardiogenic pulmonary edema. The proposed cause of the non-cardiogenic pulmonary edema was speculated to be neurogenically mediated. Oxygen supplementation along with mineralocorticoid and glucocorticoid replacement therapy was sufficient for the management of the non-cardiogenic pulmonary edema in this case.
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Ratnjeet K, Pallavi P, Jhamb U, Saxena R. 0.45% Versus 0.9% Saline in 5% Dextrose as Maintenance Fluids in Children Admitted With Acute Illness: A Randomized Control Trial. Pediatr Emerg Care 2022; 38:436-441. [PMID: 36040464 DOI: 10.1097/pec.0000000000002621] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The safety of giving intravenous (IV) maintenance fluids according to Holliday and Segar's recommendations of 1957 has recently been questioned after reports of complications caused by iatrogenic hyponatremia in children receiving hypotonic fluids. However, the current practice of choice of maintenance IV fluids for hospitalized children varies worldwide. This study was planned to compare 0.45% and 0.9% saline in 5% dextrose at standard maintenance rates in hospitalized children aged 3 months to 12 years. OBJECTIVE Primary objective was to study change in serum sodium level at 24 hours in children receiving total IV fluid maintenance therapy as 0.45% or 0.9% normal saline in 5% dextrose. Secondary objectives of this study were to estimate change in serum sodium levels from the baseline to 48 or 72 hours, if IV fluids were continued, and to find incidence of hyponatremia and hypernatremia after administering these 2 types of maintenance fluids. METHODS This study was an open-label, randomized control trial conducted at the Department of Pediatrics of a tertiary care hospital from July 22, 2019, to October 28, 2019. Two hundred children aged 3 months to 12 years admitted in pediatric emergency and requiring IV maintenance fluid were randomized into 2 groups (group A received 0.45% saline in 5% dextrose, group B received 0.9% normal saline in 5% dextrose) with 100 in each group. RESULTS Both groups were comparable for baseline characteristics. Fall in mean serum sodium from baseline was more with increasing duration of IV fluids until 24 hours in 0.45% saline group as compared with 0.9% saline group, which was statistically significant (P < 0.001). The incidence of mild and moderate hyponatremia was significantly more in hypotonic group at 12 hours (P < 0.001) and 24 hours (P < 0.001). However, there was no significant difference at 48 hours. CONCLUSIONS The fall in serum sodium values was significant, and there was significant risk of hyponatremia with the use of hypotonic fluids at 12 and 24 hours. Hence, the use of isotonic fluids seems to be more appropriate among the hospitalized children.Trial Registration: CTRI/2019/10/021791.
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Affiliation(s)
- Kumar Ratnjeet
- From the Department of Pediatrics, Maulana Azad Medical College, New Delhi, India
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Kronborg JR, Lindhardt RB, Vejlstrup N, Holst LM, Juul K, Smerup MH, Gjedsted J, Ravn HB. Postoperative dysnatremia in infants after open-heart surgery occurs frequently and is associated with prolonged intensive care length of stay. Acta Anaesthesiol Scand 2022; 66:337-344. [PMID: 34870843 DOI: 10.1111/aas.14009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 11/18/2021] [Accepted: 11/24/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Dysnatremia after surgery for congenital heart disease (CHD) is well known and has been associated with prolonged pediatric intensive care unit length of stay (PICU-LOS). Fluctuations in plasma sodium levels occur perioperatively. The primary aim of the study was to evaluate the occurrence of dysnatremia during the first 48 h after surgery and whether it was associated with PICU-LOS. The secondary aim was to evaluate if the degree of sodium fluctuations was associated with PICU-LOS. METHODS A retrospective observational, single-center study including infants undergoing surgery for CHD. The highest and lowest plasma sodium value was registered for the prespecified time periods. PICU-LOS was analyzed in relation to the occurrence of dysnatremia and the degree of plasma sodium fluctuations. The occurrence of dysnatremia was evaluated in relation to surgical procedure and fluid administration. RESULTS Two hundred and thirty infants who underwent 249 surgical procedures were included. Dysnatremia developed in more than 60% within 48 h after surgery. Infants with normonatremia had a 40%-50% shorter PICU-LOS among children in RACHS-1 category 3-6, compared with infants developing either hypo- or hyper-/hyponatremia within 48 h after surgery (p = .006). Infants who had a decline of plasma sodium >11 mmol/L had almost double the PICU-LOS compared to those with a decline of <8 mmol/L. CONCLUSION Dysnatremias were common after surgery for CHD and associated with prolonged PICU-LOS. The degree of decline in plasma sodium was significantly associated with PICU-LOS. Fluid administration both in terms of volume and components (blood products and crystalloids) as well as diuresis were related to the occurrence of dysnatremias.
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Affiliation(s)
- Jonas Rønne Kronborg
- Department of Cardiothoracic Anesthesiology Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
| | - Rasmus Bo Lindhardt
- Department of Cardiothoracic Anesthesiology Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
- Faculty of Health and Medical Sciences University of Copenhagen Copenhagen Denmark
| | - Niels Vejlstrup
- Department of Cardiology Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
| | - Line Marie Holst
- Department of Pediatric Cardiology Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
| | - Klaus Juul
- Department of Pediatric Cardiology Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
| | - Morten Holdgaard Smerup
- Department of Cardiothoracic Surgery Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
| | - Jakob Gjedsted
- Department of Cardiothoracic Anesthesiology Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
| | - Hanne Berg Ravn
- Department of Cardiothoracic Anesthesiology Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
- Department of Anesthesiology and Intensive Care Odense University Hospital Odense Denmark
- Department of Clinical Research University of Southern Denmark Odense Denmark
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13
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Shah SA, Ayus JC, Moritz ML. A Survey of Hospital Pharmacy Guidelines for the Administration of 3% Sodium Chloride in Children. CHILDREN 2022; 9:children9010057. [PMID: 35053682 PMCID: PMC8774731 DOI: 10.3390/children9010057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 12/21/2021] [Accepted: 12/30/2021] [Indexed: 01/16/2023]
Abstract
Three percent sodium chloride (3% NaCl) is the treatment of choice for symptomatic hyponatremia. A barrier to the use of 3% NaCl is the perceived risk of both local infusion reactions and neurologic complications from overcorrection. We examine whether children’s hospital pharmacies have policies or practice guidelines for the administration of 3% NaCl and whether these pharmacies have restrictions on the administration of 3% NaCl in terms of rate, route, volume and setting. An Internet survey was distributed to the pharmacy directors of 43 children’s hospitals participating in the Children’s Hospital Association (CHA) network. The response rate was 65% (28/43). Ninety-three percent (26/28) of pharmacy directors reported a restriction for the administration of 3% NaCl, with 57% restricting its use through a peripheral vein or in a non-intensive care unit setting, 68% restricting the rate of administration and 54% restricting the volume of administration. Seventy-one percent (20/28) reported having written policy or practice guidelines. Only 32% of hospital pharmacies allowed 3% NaCl to be administered through a peripheral IV in a non-intensive care unit setting. The majority of children’s hospital pharmacies have restrictions on the administration of 3% NaCl. These restrictions could prevent the timely administration of 3% NaCl in children with symptomatic hyponatremia.
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Affiliation(s)
- Siddharth A. Shah
- Department of Pediatrics, Norton Children’s Hospital, University of Louisville, Louisville, KY 40202, USA;
| | - Juan C. Ayus
- Division of Nephrology and Hypertension and Kidney Transplantation, University of California Irvine, Orange, CA 92617, USA;
| | - Michael L. Moritz
- Division of Nephrology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
- Division of Nephrology, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA 15224, USA
- Correspondence:
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14
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Lehtiranta S, Honkila M, Kallio M, Halt K, Paalanne N, Pokka T, Tapiainen T. Severe hospital-acquired hyponatremia in acutely ill children receiving moderately hypotonic fluids. Pediatr Nephrol 2022; 37:443-448. [PMID: 34398305 PMCID: PMC8816776 DOI: 10.1007/s00467-021-05227-0] [Citation(s) in RCA: 2] [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: 05/05/2021] [Revised: 07/06/2021] [Accepted: 07/06/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Hypotonic fluids have been associated with hospital-acquired hyponatremia. The incidence of life-threatening severe hyponatremia associated with hypotonic fluids has not been evaluated. METHODS This was a population-based cohort study of 46,518 acutely ill children 15 years of age or under who visited the pediatric emergency department (ED) at Oulu University Hospital, Finland, between 2007 and 2017. We retrieved all electrolyte measurements from the comprehensive electronic laboratory system and reviewed medical records for all patients with severe hyponatremia. RESULTS The overall occurrence of severe hyponatremia (serum sodium < 125 mmol/L) was found in 27 out of 46,518 acutely ill children (0.06%, 95% confidence interval 0.04-0.08%). After admission, severe hyponatremia developed in seven of 6,984 children receiving moderately hypotonic fluid therapy (0.1%, 95% confidence interval 0.04-0.2%), usually within 8 h of admission. All children who developed severe hyponatremia during hospitalization were severely ill. CONCLUSION In this register-based cohort study of children presenting to the ED, severe hyponatremia developed in one of 998 acutely ill children receiving moderately hypotonic fluid therapy. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Saara Lehtiranta
- Department of Pediatrics and Adolescent Medicine, Oulu University Hospital, PO Box 23, N90029, OYS, Oulu, Finland. .,PEDEGO (Pediatrics, Dermatology, Gynecology and Obstetrics) Research Unit and Medical Research Centre Oulu, University of Oulu, Oulu, Finland.
| | - Minna Honkila
- Department of Pediatrics and Adolescent Medicine, Oulu University Hospital, PO Box 23, N90029 OYS, Oulu, Finland ,PEDEGO (Pediatrics, Dermatology, Gynecology and Obstetrics) Research Unit and Medical Research Centre Oulu, University of Oulu, Oulu, Finland
| | - Merja Kallio
- PEDEGO (Pediatrics, Dermatology, Gynecology and Obstetrics) Research Unit and Medical Research Centre Oulu, University of Oulu, Oulu, Finland ,Department of Pediatric Cardiology, New Children’s Hospital, University Hospital of Helsinki, Helsinki, Finland
| | - Kimmo Halt
- Department of Pediatrics and Adolescent Medicine, Oulu University Hospital, PO Box 23, N90029 OYS, Oulu, Finland ,PEDEGO (Pediatrics, Dermatology, Gynecology and Obstetrics) Research Unit and Medical Research Centre Oulu, University of Oulu, Oulu, Finland
| | - Niko Paalanne
- Department of Pediatrics and Adolescent Medicine, Oulu University Hospital, PO Box 23, N90029 OYS, Oulu, Finland ,PEDEGO (Pediatrics, Dermatology, Gynecology and Obstetrics) Research Unit and Medical Research Centre Oulu, University of Oulu, Oulu, Finland
| | - Tytti Pokka
- Department of Pediatrics and Adolescent Medicine, Oulu University Hospital, PO Box 23, N90029 OYS, Oulu, Finland ,PEDEGO (Pediatrics, Dermatology, Gynecology and Obstetrics) Research Unit and Medical Research Centre Oulu, University of Oulu, Oulu, Finland
| | - Terhi Tapiainen
- Department of Pediatrics and Adolescent Medicine, Oulu University Hospital, PO Box 23, N90029 OYS, Oulu, Finland ,PEDEGO (Pediatrics, Dermatology, Gynecology and Obstetrics) Research Unit and Medical Research Centre Oulu, University of Oulu, Oulu, Finland ,Biocenter Oulu, University of Oulu, Oulu, Finland
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15
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Tzoulis P. Prevalence, prognostic value, pathophysiology, and management of hyponatraemia in children and adolescents with COVID-19. ACTA BIO-MEDICA : ATENEI PARMENSIS 2021; 92:e2021474. [PMID: 34738553 PMCID: PMC8689294 DOI: 10.23750/abm.v92i5.12330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 09/30/2021] [Indexed: 11/23/2022]
Abstract
Hyponatraemia is frequently encountered in adults with coronavirus disease 2019 (COVID-19) and is associated with poor prognosis. This review aims to describe for the first time the prevalence, aetiology, prognostic value, pathophysiology, and management of hyponatraemia in children and adolescents with COVID-19, taking into account all relevant studies published in PubMed and Cochrane Library studies until 26th September 2021. Literature search did not detect any studies evaluating the prevalence and prognostic value of sodium disorders in paediatric patients with COVID-19. A broader literature review showed a high prevalence of hyponatraemia in children with bacterial pneumonia, while some studies have reported that hyponatraemia is relatively common in Multisystem Inflammatory Syndrome in Children (MIS-C). In adults with COVID-19, an inverse association between sodium and interleukin-6 levels has been found, indicating that hyponatraemia could be used as a surrogate marker for the risk of cytokine storm and may facilitate the identification of patients who could benefit from immunomodulatory agents. Studies are urgently needed to evaluate the frequency and prognostic impact of electrolyte abnormalities in children with COVID-19. In the meantime, clinicians are urged to consider hyponatraemia in children with COVID-19 as a potential red flag, investigate the cause and administer fluids and other therapies accordingly.
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16
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Al Suhaibani A, Ben Bacha A, Alonazi M, Bhat RS, El‐Ansary A. Testing the combined effects of probiotics and prebiotics against neurotoxic effects of propionic acid orally administered to rat pups. Food Sci Nutr 2021; 9:4440-4451. [PMID: 34401092 PMCID: PMC8358352 DOI: 10.1002/fsn3.2418] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 05/31/2021] [Accepted: 06/01/2021] [Indexed: 11/13/2022] Open
Abstract
The present study investigated the combined effects of mixed probiotic and bee pollen on brain intoxication induced by propionic acid (PPA) in rat pups. Thirty western albino rats were divided into five groups, six animals each: (1) Control group receiving phosphate-buffered saline; (2) Probiotic and bee pollen-treated group being administered at the same dose with 200 mg/kg body weight; (c) PPA-treated group receiving a neurotoxic dose 250 mg/kg body weight of PPA for 3 days; (d) Therapeutic group being administered the neurotoxic dose of PPA followed by probiotic and bee pollen treatment 200 mg/kg body weight; (e) Protective group receiving probiotic and bee pollen mixture treatment followed by neurotoxic dose of PPA. Selected biochemical parameters linked to oxidative stress, energy metabolism, and neurotransmission were investigated in brain homogenates from all the five groups. PPA treatment showed an increase in oxidative stress markers like lipid peroxidation coupled with a significant decrease in glutathione level. Impaired energy metabolism was ascertained via the alteration of creatine kinase (CK) and lactate dehydrogenase (LDH) activities. Dramatic increase of Na+ and K+ concentrations together with a decrease of GABA and IL-6 and an elevation of glutamate levels in PPA-treated rat's pups confirmed the neurotoxicity effect of PPA. Interestingly, the mixed probiotic and bee pollen treatment were effective in restoring the levels of glutamate, GABA, and IL-6 in addition to normalizing the levels of lipid peroxidation and glutathione and the activities of CK and LDH. The present study indicates that mixed probiotic and bee pollen treatment can improve poor detoxification, oxidative stress, and neuroinflammation as mechanisms implicated in the etiology of autism.
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Affiliation(s)
- Anwar Al Suhaibani
- Biochemistry DepartmentScience CollegeKing Saud UniversityRiyadhSaudi Arabia
| | - Abir Ben Bacha
- Biochemistry DepartmentScience CollegeKing Saud UniversityRiyadhSaudi Arabia
- Laboratory of Plant Biotechnology Applied to Crop ImprovementFaculty of Science of SfaxUniversity of SfaxSfaxTunisia
| | - Mona Alonazi
- Biochemistry DepartmentScience CollegeKing Saud UniversityRiyadhSaudi Arabia
| | - Ramesa Shafi Bhat
- Biochemistry DepartmentScience CollegeKing Saud UniversityRiyadhSaudi Arabia
| | - Afaf El‐Ansary
- Central LaboratoryKing Saud UniversityRiyadhSaudi Arabia
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17
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Driano JE, Lteif AN, Creo AL. Vasopressin-Dependent Disorders: What Is New in Children? Pediatrics 2021; 147:peds.2020-022848. [PMID: 33795481 DOI: 10.1542/peds.2020-022848] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/12/2021] [Indexed: 11/24/2022] Open
Abstract
Arginine vasopressin (AVP)-mediated osmoregulatory disorders, such as diabetes insipidus (DI) and syndrome of inappropriate secretion of antidiuretic hormone (SIADH) are common in the differential diagnosis for children with hypo- and hypernatremia and require timely recognition and treatment. DI is caused by a failure to concentrate urine secondary to impaired production of or response to AVP, resulting in hypernatremia. Newer methods of diagnosing DI include measuring copeptin levels; copeptin is AVP's chaperone protein and serves as a surrogate biomarker of AVP secretion. Intraoperative copeptin levels may also help predict the risk for developing DI after neurosurgical procedures. Copeptin levels hold diagnostic promise in other pediatric conditions, too. Recently, expanded genotype and phenotype correlations in inherited DI disorders have been described and may better predict the clinical course in affected children and infants. Similarly, newer formulations of synthetic AVP may improve pediatric DI treatment. In contrast to DI, SIADH, characterized by inappropriate AVP secretion, commonly leads to severe hyponatremia. Contemporary methods aid clinicians in distinguishing SIADH from other hyponatremic conditions, particularly cerebral salt wasting. Further research on the efficacy of therapies for pediatric SIADH is needed, although some adult treatments hold promise for pediatrics. Lastly, expansion of home point-of-care sodium testing may transform management of SIADH and DI in children. In this article, we review recent developments in the understanding of pathophysiology, diagnostic workup, and treatment of better outcomes and quality of life for children with these challenging disorders.
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Affiliation(s)
- Jane E Driano
- School of Medicine, Creighton University, Omaha, Nebraska; and
| | - Aida N Lteif
- Division of Pediatric Endocrinology and Metabolism, Mayo Clinic, Rochester, Minnesota
| | - Ana L Creo
- Division of Pediatric Endocrinology and Metabolism, Mayo Clinic, Rochester, Minnesota
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18
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Mazzolai M, Apicella A, Marzuillo P, Rabach I, Taddio A, Barbi E, Cozzi G. Severe hyponatremia in children: a review of the literature through instructive cases. Minerva Pediatr (Torino) 2021; 74:61-69. [PMID: 33820399 DOI: 10.23736/s2724-5276.21.05856-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Hyponatriemia is the most common electrolyte disorder in the paediatric population. Symptoms are related to the time in which hyponatriemia has developed. The acute presentation could be dramatic, with neurological symptoms like headache, seizure, impaired mental status and even coma. It is essential for the physician to be aware of the possible causes of hyponatremia in the child in order to start a prompt treatment.
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Affiliation(s)
- Michele Mazzolai
- Department of Medicine, Surgery, and Health Sciences, University of Trieste, Trieste, Italy -
| | | | - Pierluigi Marzuillo
- Department of Woman, Child and of General and Specialized Surgery, Università degli Studi della Campania Luigi Vanvitelli, Naples, Italy
| | - Ingrid Rabach
- Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
| | - Andrea Taddio
- Department of Medicine, Surgery, and Health Sciences, University of Trieste, Trieste, Italy.,Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
| | - Egidio Barbi
- Department of Medicine, Surgery, and Health Sciences, University of Trieste, Trieste, Italy.,Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
| | - Giorgio Cozzi
- Department of Medicine, Surgery, and Health Sciences, University of Trieste, Trieste, Italy
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19
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Baek SH, Jo YH, Ahn S, Medina-Liabres K, Oh YK, Lee JB, Kim S. Risk of Overcorrection in Rapid Intermittent Bolus vs Slow Continuous Infusion Therapies of Hypertonic Saline for Patients With Symptomatic Hyponatremia: The SALSA Randomized Clinical Trial. JAMA Intern Med 2021; 181:81-92. [PMID: 33104189 PMCID: PMC7589081 DOI: 10.1001/jamainternmed.2020.5519] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
IMPORTANCE Few high-quality studies have clarified whether hypertonic saline is best administered as slow continuous infusion (SCI) therapy or rapid intermittent bolus (RIB) therapy for symptomatic severe hyponatremia. OBJECTIVE To compare the risk of overcorrection in RIB and SCI with hypertonic saline in patients with symptomatic hyponatremia. DESIGN, SETTING, AND PARTICIPANTS This prospective, investigator-initiated, multicenter, open-label, randomized clinical trial enrolled 178 patients older than 18 years with moderately severe to severe hyponatremia and glucose-corrected serum sodium (sNa) levels of 125 mmol/L or less. Recruitment took place from August 24, 2016, until August 21, 2019, across emergency departments and wards of 3 general hospitals in the Republic of Korea. INTERVENTIONS Either RIB or SCI of hypertonic saline, 3%, for 24 to 48 hours stratified by the severity of clinical symptoms. MAIN OUTCOME AND MEASURES The primary outcome was overcorrection at any given period, defined as increase in the sNa level by greater than 12 or 18 mmol/L within 24 or 48 hours, respectively. Secondary and post hoc outcomes included efficacy and safety of the treatment approaches. The sNa concentrations were measured every 6 hours for 2 days. RESULTS The 178 patients (mean [SD] age, 73.1 [12.2] years; 80 (44.9%) male; mean [SD] sNa concentrations, 118.2 [5.0] mmol/L) were randomly assigned to the RIB group (n = 87) or the SCI group (n = 91). Overcorrection occurred in 15 of 87 (17.2%) and 22 of 91 (24.2%) patients in the RIB and SCI groups, respectively (absolute risk difference, -6.9% [95% CI, -18.8% to 4.9%]; P = .26). The RIB group showed lower incidence of relowering treatment than the SCI group (36 of 87 [41.4%] vs 52 of 91 [57.1%] patients, respectively; absolute risk difference, -15.8% [95% CI, -30.3% to -1.3%]; P = .04; number needed to treat, 6.3). Groups did not differ in terms of efficacy in increasing sNa concentrations nor improving symptoms, but RIB, when compared with SCI, showed better efficacy in achieving target correction rate within 1 hour (intention-to-treat analysis: 28 of 87 (32.2%) vs 16 of 91 (17.6%) patients, respectively; absolute risk difference, 14.6% [95% CI, 2%-27.2%]; P = .02; number needed to treat, 6.8; per-protocol analysis: 21 of 72 (29.2%) vs 12 of 73 (16.4%) patients, respectively; absolute risk difference, 12.7% [95% CI, -0.8% to 26.2%]; P = .07). The statistical significance of the intention-to-treat and per-protocol analyses were similar for all outcomes except for achieving the target correction rate within 1 hour. CONCLUSIONS AND RELEVANCE This randomized clinical trial found that both RIB and SIC therapies of hypertonic saline for treating hyponatremia were effective and safe, with no difference in the overcorrection risk. However, RIB had a lower incidence of therapeutic relowering treatment and tended to have a better efficacy in achieving sNa within 1 hour than SCI. RIB could be suggested as the preferred treatment of symptomatic hyponatremia, which is consistent with the current consensus guidelines. TRIAL REGISTRATION ClinicalTrials.org Identifier: NCT02887469.
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Affiliation(s)
- Seon Ha Baek
- Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Republic of Korea
| | - You Hwan Jo
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Soyeon Ahn
- Medical Research Collaborating Center, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Kristianne Medina-Liabres
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Yun Kyu Oh
- Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Jung Bok Lee
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sejoong Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
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20
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Patel S, Chiu RG, Rosinski CL, Chaker AN, Burch TG, Behbahani M, Sadeh M, Mehta AI. Risk Factors for Hyponatremia and Perioperative Complications With Malignant Intracranial Tumor Resection in Adults: An Analysis of the Nationwide Inpatient Sample from 2012 to 2015. World Neurosurg 2020; 144:e876-e882. [DOI: 10.1016/j.wneu.2020.09.097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 09/17/2020] [Indexed: 12/16/2022]
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21
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Pérez-Piaya MR, Miranda-Alcalde B, Cárdenas-Rebollo JM, Riaza-Gómez M, Carnicer H, Romera-Modamio G. Risk factors for the development of early hyponatraemia in the premature infant. A review of the practice of giving sodium in the first days of life. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2020. [DOI: 10.1016/j.anpede.2019.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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22
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Pérez-Piaya Moreno MR, Miranda Alcalde B, Cárdenas Rebollo JM, Riaza Gómez M, Carnicer H, Romera Modamio G. [Risk factors for the development of early hyponatraemia in the premature infant. A review of the practice of giving sodium in the first days of life]. An Pediatr (Barc) 2019; 92:359-364. [PMID: 31399354 DOI: 10.1016/j.anpedi.2019.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Revised: 06/04/2019] [Accepted: 06/28/2019] [Indexed: 10/26/2022] Open
Abstract
INTRODUCTION A retrospective study was conducted in the Neonatal Intensive Care Unit of a tertiary hospital to determine the incidence of early hyponatraemia (first 48hours of life) in preterm infants. Risk and protection factors in this condition were also examined as a starting point for a change in the medical action when prescribing intravenous fluids. MATERIAL AND METHODS The study included a sample of 256 premature babies (gestational age: 235-366) admitted to the Neonatal Intensive Care Unit of a tertiary hospital between January 2016 and June 2018. The number of patients receiving intravenous sodium in different intervals during the first 48hours of life was determined, as well as the number of those with hyponatraemia of any type (<135mmol / l), and moderate-severe (<130mmol / l). An analysis was made of the relationship between early hyponatraemia and weight / gestational age, antenatal steroids exposure, respiratory pathology, early sepsis, and perinatal asphyxia. RESULTS Hyponatraemia occurred in 81 patients, 31.64% of the total (up to 50% in<30 weeks of gestational age), and was moderate-severe (<130mmol / l) in 17.3% of the cases. The period of time with the most cases of hyponatraemia was in the first 12hours of life (22.64%). Weight (P=.034), gestational age (P<.001) and respiratory disease (P<.001) were found to be risk factors and, in a multivariate analysis, the latter was independently related to early hyponatremia (P<.01, OR=5.24, 95% CI: 2.79-9.84). Antenatal betamethasone exposure did not show to be a protection factor. CONCLUSION According to the results of this study, it is considered an advantage to provide sodium in the intravenous fluids prescribed during the first days of life, particularly in preterm infants of lower gestational age and with respiratory disease involvement.
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Affiliation(s)
| | | | | | - Mónica Riaza Gómez
- Servicio de Pediatría, Unidad de Neonatología, Hospital Universitario Montepríncipe, Madrid, España
| | - Hernán Carnicer
- Servicio de Pediatría, Unidad de Neonatología, Hospital Universitario Montepríncipe, Madrid, España
| | - Gerardo Romera Modamio
- Servicio de Pediatría, Unidad de Neonatología, Hospital Universitario Montepríncipe, Madrid, España
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23
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Elliman MG, Vongxay O, Soumphonphakdy B, Gray A. Hyponatraemia in a Lao paediatric intensive care unit: Prevalence, associations and intravenous fluid use. J Paediatr Child Health 2019; 55:695-700. [PMID: 30315614 DOI: 10.1111/jpc.14278] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 08/25/2018] [Accepted: 09/23/2018] [Indexed: 11/27/2022]
Abstract
AIM Hyponatraemia is a common and potentially deadly complication affecting hospitalised children world-wide. Hypotonic intravenous fluids can be a significant exacerbating factor. Exclusive use of isotonic fluids, coupled with rigorous blood monitoring, has proven effective in reducing hyponatraemia in developed settings. In developing countries, where hyponatraemia is often more common and severe, different factors may contribute to its incidence and detection. We aimed to determine the prevalence and disease associations of hyponatraemia and describe the intravenous maintenance fluid prescribing practices in a Lao paediatric intensive care unit. METHODS We conducted a cross-sectional study of 164 children aged 1 month to 15 years admitted to intensive care at a tertiary centre in Lao People's Democratic Republic (PDR) and recorded their serum sodium and clinical data at admission and on two subsequent days. RESULTS Hyponatraemia was detected in 41% (67/164, confidence interval 34-48%) of children, the majority of which was mild (34%, 56/164) and present at admission (35%, 55/158). Hyponatraemia was more common in malnourished children (odds ratio (OR) 2.3, P = 0.012) and females (OR 1.9, P = 0.045). Hyponatraemia correlated with death or expected death after discharge (OR 2.2, P = 0.015); 88% received maintenance intravenous fluids, with 67% of those receiving a hypotonic solution. Electrolyte testing was only performed in 20% (9/46) of patients outside the study protocol. CONCLUSIONS Hyponatraemia is highly prevalent in critically ill children in Lao PDR, as is the continued use of hypotonic intravenous fluids. With financial and practical barriers to safely detecting and monitoring electrolyte disorders in this setting, this local audit can help promote testing and has already encouraged changes to fluid prescribing.
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Affiliation(s)
- Mark G Elliman
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Oulaivanh Vongxay
- University of Health Sciences, Mahosot Hospital, Vientiane, Lao People's Democratic Republic
| | | | - Amy Gray
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia
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Ayus JC, Moritz ML. Misconceptions and Barriers to the Use of Hypertonic Saline to Treat Hyponatremic Encephalopathy. Front Med (Lausanne) 2019; 6:47. [PMID: 30931308 PMCID: PMC6428704 DOI: 10.3389/fmed.2019.00047] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 02/20/2019] [Indexed: 12/11/2022] Open
Abstract
Hyponatremic encephalopathy is a potentially life-threatening condition with a high associated morbidity and mortality. It can be difficult to diagnose as the presenting symptoms can be non-specific and do not always correlate with the degree of hyponatremia. It can rapidly progress leading to death from transtentorial herniation. Hypertonic saline is the recommended treatment for hyponatremic encephalopathy, whether acute or chronic, yet it is infrequently used. We believe that the main barriers to its use is the perception that hypertonic saline is associated with a significant risk for cerebral demyelination, that it can't be administered through a peripheral IV and that it requires monitoring in the ICU. Two illustrative cases are presented followed by a discussion of how intermittent bolus's of 100−150 ml of 3% NaCl in rapid succession to acutely increase the plasma sodium by 4−6 mEq/L is a safe and effective way to treat hyponatremic encephalopathy, that can be administered through a peripheral IV in a non-ICU setting.
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Affiliation(s)
- Juan Carlos Ayus
- Renal Consultants of Houston, Houston, TX, United States.,Division of Nephrology, School of Medicine Irvine, University of California, Irvine, Irvine, CA, United States
| | - Michael L Moritz
- Division of Nephrology, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
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25
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Abstract
The syndrome of inappropriate antidiuresis (SIAD) is a common cause of hyponatremia in hospitalized children. SIAD refers to euvolemic hyponatremia due to nonphysiologic stimuli for arginine vasopressin production in the absence of renal or endocrine dysfunction. SIAD can be broadly classified as a result of tumors, pulmonary or central nervous system disorders, medications, or other causes such as infection, inflammation, and the postoperative state. The presence of hypouricemia with an elevated fractional excretion of urate can aid in the diagnosis. Treatment options include fluid restriction, intravenous saline solutions, oral sodium supplements, loop diuretics, oral urea, and vasopressin receptor antagonists (vaptans).
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Affiliation(s)
- Michael L Moritz
- Pediatric Nephrology, Pediatric Dialysis, Division of Nephrology, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, The University of Pittsburgh School of Medicine, 4401 Penn Avenue, Pittsburgh, PA 15224, USA.
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27
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Sojar SH, Goldner JSV, Krishnamoorthy K, Murphy SA, Masiakos PT, Klig JE. A 17-Year-Old Boy With High-Functioning Autism, Gastrointestinal Illness, and Seizures. Pediatrics 2019; 143:peds.2017-3964. [PMID: 30545828 DOI: 10.1542/peds.2017-3964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/19/2018] [Indexed: 11/24/2022] Open
Abstract
A healthy 17-year-old boy with a high-functioning pervasive developmental disorder presented to the emergency department after having a 4-minute episode of seizure-like activity in the setting of presumed viral gastroenteritis. Within an hour of emergency department arrival, he developed a forehead-sparing facial droop, right-sided ptosis, and expressive aphasia, prompting stroke team assessment and urgent neuroimaging. Laboratory results later revealed a serum sodium of 119 mmol/L. Neurologic deficits self-resolved, and a full physical examination revealed diffuse abdominal tenderness in the lower abdomen with rebound tenderness in the right-lower quadrant. The patient was admitted to the PICU for electrolyte management and monitoring. A computed tomography (CT) scan of the abdomen obtained the following morning revealed the patient's final diagnosis.
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Affiliation(s)
- Sakina H Sojar
- Massachusetts General Hospital, Boston, Massachusetts; and
| | | | | | - Sarah A Murphy
- Massachusetts General Hospital, Boston, Massachusetts; and
| | | | - Jean E Klig
- Massachusetts General Hospital, Boston, Massachusetts; and
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28
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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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29
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Affiliation(s)
- Deborah P Jones
- Division of Nephrology and Hypertension, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
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30
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Water Intoxication and Child Abuse. J Emerg Nurs 2018; 44:13-18. [DOI: 10.1016/j.jen.2017.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 09/12/2017] [Accepted: 10/02/2017] [Indexed: 11/15/2022]
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31
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S K R, Dakshayani B, R P. Full Volume Isotonic (0.9%) vs. Two-Thirds Volume Hypotonic (0.18%) Intravenous Maintenance Fluids in Preventing Hyponatremia in Children Admitted to Pediatric Intensive Care Unit-A Randomized Controlled Study. J Trop Pediatr 2017; 63:454-460. [PMID: 28334885 DOI: 10.1093/tropej/fmx012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND We aimed to compare the effect of two different intravenous fluid regimes on the incidence of hyponatremia in children. METHODS Children 1 month to 18 years of age, admitted to pediatric intensive care unit (PICU) of a tertiary care medical college hospital were randomized to receive either isotonic fluid (0.9% saline in 5% dextrose) at the standard maintenance rate or hypotonic fluid (0.18% saline in 5% dextrose) at two-thirds of the standard maintenance rate. RESULTS A total of 240 children were randomized (120 isotonic, 120 hypotonic). In all, 16.7% children in hypotonic group developed hyponatremia compared with 7.5% in isotonic group (p = 0.029). Duration of PICU stay was significantly more in Hypotonic group. CONCLUSION We conclude that use of 0.9% saline in 5% dextrose as maintenance fluid helps in reducing the incidence of hospital-acquired hyponatremia and duration of intensive care unit stay among children admitted to PICU.
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Affiliation(s)
- Raksha S K
- Department of Pediatrics, Bangalore Medical College and Research institute, Bangalore 560079, India
| | - B Dakshayani
- Department of Pediatrics, Bangalore Medical College and Research institute, Bangalore 560079, India
| | - Premalatha R
- Department of Pediatrics, Bangalore Medical College and Research institute, Bangalore 560079, India
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32
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Palacios-Fong Y. 50 Years Ago in The Journal of Pediatrics: Acute Symptomatic Hyponatremia. J Pediatr 2017; 187:72. [PMID: 28750767 DOI: 10.1016/j.jpeds.2017.02.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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33
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Gaudreault-Tremblay MM, Faqeehi H, Langlois V, Hébert D, Parra DA, Annich G, Harvey E, Lemaire M. Management of Severe Hyponatremia With a Custom Continuous Renal Replacement Therapy in an Infant With Newly Diagnosed Chronic Kidney Disease. Kidney Int Rep 2017; 2:1254-1258. [PMID: 29270536 PMCID: PMC5733878 DOI: 10.1016/j.ekir.2017.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
| | - Hassan Faqeehi
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Valérie Langlois
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Diane Hébert
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Dimitri A Parra
- Division of Interventional Radiology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Gail Annich
- Division of Critical Care Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Elizabeth Harvey
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Mathieu Lemaire
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
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34
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Hansen R. Hyponatraemic seizure in a 6-month-old infant due to water intoxication. J Paediatr Child Health 2017; 53:717-719. [PMID: 24953638 DOI: 10.1111/jpc.12646] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/02/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Rakel Hansen
- Paediatrics, Coffs Harbour Health Campus, Coffs Harbour, New South Wales, Australia
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35
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Lavagno C, Milani GP, Uestuener P, Simonetti GD, Casaulta C, Bianchetti MG, Fare PB, Lava SAG. Hyponatremia in children with acute respiratory infections: A reappraisal. Pediatr Pulmonol 2017; 52:962-967. [PMID: 28267276 DOI: 10.1002/ppul.23671] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 12/19/2016] [Accepted: 12/29/2016] [Indexed: 12/18/2022]
Abstract
Hyponatremia (<135 mmol/L), typically associated with an elevated anti-diuretic hormone level, is common among children admitted with bronchiolitis, pneumonia, or pulmonary exacerbation of cystic fibrosis. The main consequences of acute hyponatremia include cerebral edema and Ayus-Arieff pulmonary edema. A widespread belief is that, in children with pneumonia or bronchiolitis, hyponatremia results from inappropriate anti-diuresis. By contrast, the pathogenic role of extracellular fluid volume depletion or decreased effective circulating blood volume is underscored. Considering the prevalence of hyponatremia, sodium determination is advised on admission in children diagnosed with bronchiolitis, pneumonia, or pulmonary exacerbation of cystic fibrosis. There is no necessity to do anything beyond reassessing the appropriateness of fluid therapy in cases with mild (130-134 mmol/L) hyponatremia. In children with sodium <130 mmol/L, the underlying etiology is sometimes evident from history and physical findings. Given that clinical assessment of fluid volume status is difficult in hyponatremia, further laboratory evaluation is often required in these patients. An increase in sodium level ≤6 mmol/L per day is currently considered the therapeutic goal in all cases. Emergency correction with a 2 mL/kg body weight bolus of 3.0% saline over 10-15 min intravenously is advised in cases with severe symptoms due to hyponatremia and in cases with symptoms, even if mild, due to a rapid-onset (<48 h) of hyponatremia (two additional doses are administered if the patient's condition does not improve).
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Affiliation(s)
- Camilla Lavagno
- Pediatric Department of Southern Switzerland, Bellinzona, Switzerland
| | - Gregorio P Milani
- Foundation IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Pediatric Emergency Department and Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Peter Uestuener
- Pediatric Department of Southern Switzerland, Bellinzona, Switzerland
| | | | - Carmen Casaulta
- Department of Pediatrics, University Children's Hospital of Bern, Inselspital, Bern, Switzerland
| | | | - Pietro B Fare
- Pediatric Department of Southern Switzerland, Bellinzona, Switzerland
| | - Sebastiano A G Lava
- Department of Pediatrics, University Children's Hospital of Bern, Inselspital, Bern, Switzerland.,Pediatric Pharmacology and Pharmacogenetics, Hôpital Robert Debré, Paris, France
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36
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Moritz ML, Ayus JC. How to Improve Maintenance Intravenous Fluid Prescribing Practices in Bronchiolitis. Hosp Pediatr 2017; 7:300-302. [PMID: 28408387 DOI: 10.1542/hpeds.2017-0050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2017] [Indexed: 06/07/2023]
Affiliation(s)
- Michael L Moritz
- Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, The University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania;
| | - Juan C Ayus
- Renal Consultants of Houston, Houston, Texas
- Hospital Italiano, Universidad Austral, Buenos Aires, Argentina; and
- University of California Irvine School of Medicine, Irvine, California
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37
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Afroze F, Ahmed T, Sarmin M, SMSB Shahid A, Shahunja KM, Shahrin L, Chisti MJ. Risk factors and outcome of Shigella encephalopathy in Bangladeshi children. PLoS Negl Trop Dis 2017; 11:e0005561. [PMID: 28453565 PMCID: PMC5425222 DOI: 10.1371/journal.pntd.0005561] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2016] [Revised: 05/10/2017] [Accepted: 04/08/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Although, Shigella encephalopathy, a serious extra-intestinal complication of shigellosis, significantly increases the risks of death, data are very limited on predicting factors particularly related to electrolyte profiles in children below five years of age with Shigella encephalopathy. Our objective was to determine the clinical as well as laboratory predicting factors and outcome of children with Shigella encephalopathy. METHODOLOGY/PRINCIPAL FINDINGS In this unmatched case-control design, children aged 2-59 months having a positive stool culture for Shigella and who had their serum electrolytes been done from July 2012 to June 2015 were studied. Children with Shigella encephalopathy, defined as having abnormal mentation, constituted the cases, and those without encephalopathy constituted the controls. During the study period, we identified a total of 541 children less than five years of age, who had Shigella in their stool culture. Only 139 children fulfilled the study criteria and among them 69 were cases and 70 were controls. The cases more often had fatal outcome compared to the controls (7% vs. 0%, P = 0.02). In logistic regression analysis, the cases were independently associated with shorter duration (1.2 ± 0.4 days) of diarrhea prior to admission, dehydrating diarrhea, sepsis and hyponatremia (p<0.05 for all). Among 139 Shigella isolates, S. flexneri (88/139, 63%) and S. sonnei(34/139, 24%) were the dominant species. S. dysenteriae was not isolated throughout the study period. S.sonnei was more frequently isolated from the cases (24/69, 35%) than the controls (10/70, 14%), whereas the isolation of S. flexneri was comparable between the groups (40/69, 58% vs 48/70, 69%). A total of 94 (67.6%) isolates were resistant to trimethoprim-sulphamethoxazole, 84 (60.4%) to ciprofloxacin, 66/138 (48%) to ampicillin, 5 (3.5%) to ceftriaxone, 17 (12.2%) to mecillinum and 35 (25%) to azithromycin. CONCLUSIONS/SIGNIFICANCE The case-fatality-rate was significantly higher among the children with Shigella encephalopathy compared to those without encephalopathy. Early identification and aggressive management of simple risk factors for Shigella encephalopathy may help to reduce morbidity and deaths in such children especially in resource-limited settings.
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Affiliation(s)
- Farzana Afroze
- Nutrition & Clinical Services Division (NCSD), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Tahmeed Ahmed
- Nutrition & Clinical Services Division (NCSD), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Monira Sarmin
- Nutrition & Clinical Services Division (NCSD), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Abu SMSB Shahid
- Nutrition & Clinical Services Division (NCSD), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - K. M. Shahunja
- Nutrition & Clinical Services Division (NCSD), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Lubaba Shahrin
- Nutrition & Clinical Services Division (NCSD), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Mohammod Jobayer Chisti
- Nutrition & Clinical Services Division (NCSD), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- * E-mail:
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38
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Good P. Simplifying study of fever's dramatic relief of autistic behavior. Clin Nutr ESPEN 2017; 17:1-7. [PMID: 28361738 DOI: 10.1016/j.clnesp.2016.09.002] [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: 08/17/2016] [Revised: 09/13/2016] [Accepted: 09/13/2016] [Indexed: 11/29/2022]
Abstract
Dramatic relief of autistic behavior by infectious fever continues to tantalize parents and practitioners, yet researchers still hesitate to study its physiology/biochemistry, fearing stress and heat of brain imaging, contagion, and fever's complexity. Yet what could be more revealing than a common event that virtually 'normalizes' autistic behavior for a time? This paper proposes study of three simplified scenarios: (1) improvements appearing hours before fever, (2) return of autistic behavior soon after fever, (3) improvements persisting long after fever. Each scenario limits some risk - and some explanation - inviting triangulation of decisive factor(s) in relief and recurrence. Return of autistic behavior after fever may be most revealing. The complex mechanisms that generated fever have all abated; simpler cooling mechanisms prevail - how many plausible explanations can there be? The decisive factor in fever's benefit is concluded to be water drawn/carried from brain myelin and astrocytes by osmolytes glutamine and taurine released from muscles and brain; the decisive factor in return of autistic behavior after fever is return of water.
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Affiliation(s)
- Peter Good
- Autism Studies, La Pine, OR, United States.
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39
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Lee A, Jo YH, Kim K, Ahn S, Oh YK, Lee H, Shin J, Chin HJ, Na KY, Lee JB, Baek SH, Kim S. Efficacy and safety of rapid intermittent correction compared with slow continuous correction with hypertonic saline in patients with moderately severe or severe symptomatic hyponatremia: study protocol for a randomized controlled trial (SALSA trial). Trials 2017; 18:147. [PMID: 28356136 PMCID: PMC5372334 DOI: 10.1186/s13063-017-1865-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 02/24/2017] [Indexed: 12/15/2022] Open
Abstract
Background Hyponatremia is the most common electrolyte imbalance encountered in clinical practice, associated with increased mortality and length of hospital stay. However, no high-quality evidence regarding whether hypertonic saline is best administered as a continuous infusion or a bolus injection has been found to date. Therefore, in the current study, we will evaluate the efficacy and safety of rapid intermittent correction compared with slow continuous correction with hypertonic saline in patients with moderately severe or severe symptomatic hyponatremia. Methods/design This is a prospective, investigator-initiated, multicenter, open-label, randomized controlled study with two experimental therapy groups. A total of 178 patients with severe symptomatic hyponatremia will be enrolled and randomly assigned to receive either rapid intermittent bolus or slow continuous infusion management with hypertonic saline. The primary outcome is the incidence of overcorrection at any given period over 2 days. The secondary outcomes will include the efficacy and safety of two other approaches to the treatment of hyponatremia with 3% hypertonic saline. Discussion This is the first clinical trial to investigate the efficacy and safety of rapid intermittent correction compared with slow continuous correction with hypertonic saline in patients with moderately severe or severe hyponatremia. Trial registration ClinicalTrials.gov, identifier number: NCT02887469. Registered on 1 August 2016. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-1865-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Anna Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - You Hwan Jo
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Kyuseok Kim
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Soyeon Ahn
- Department of Medical Research Collaborating Center, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Yun Kyu Oh
- Department of Internal Medicine, Seoul National University Boramae Hospital, Seoul, Republic of Korea
| | - Huijai Lee
- Department of Emergency Medicine, Seoul National University Boramae Hospital, Seoul, Republic of Korea
| | - Jonghwan Shin
- Department of Emergency Medicine, Seoul National University Boramae Hospital, Seoul, Republic of Korea
| | - Ho Jun Chin
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Ki Young Na
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Jung Bok Lee
- Clinical Epidemiology and Biostatistics, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Seon Ha Baek
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea. .,Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong-si, Republic of Korea.
| | - Sejoong Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea.
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40
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García-Soler P, Amores-Torres M, Sanchiz-Cárdenas S, González-Gómez JM, Dayaldasani A, Milano-Manso G. Thiopental and false hypernatremia: Check your analyzer. Med Intensiva 2017; 41:573-574. [PMID: 28318672 DOI: 10.1016/j.medin.2017.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 01/13/2017] [Accepted: 01/21/2017] [Indexed: 11/29/2022]
Affiliation(s)
- P García-Soler
- Unidad de Cuidados Intensivos Pediátricos, Hospital Regional Universitario de Málaga, Málaga, España.
| | - M Amores-Torres
- Unidad de Cuidados Intensivos Pediátricos, Hospital Regional Universitario de Málaga, Málaga, España
| | - S Sanchiz-Cárdenas
- Unidad de Cuidados Intensivos Pediátricos, Hospital Regional Universitario de Málaga, Málaga, España
| | - J M González-Gómez
- Unidad de Cuidados Intensivos Pediátricos, Hospital Regional Universitario de Málaga, Málaga, España
| | - A Dayaldasani
- Unidad de Análisis Clínicos, Hospital Regional Universitario de Málaga, Málaga, España
| | - G Milano-Manso
- Unidad de Cuidados Intensivos Pediátricos, Hospital Regional Universitario de Málaga, Málaga, España
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41
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Abstract
Hyponatremia is a common electrolyte disorder in children. It is generally defined as plasma sodium of less than 135 mmol/l. Sodium homeostasis is essential for maintaining intravascular volume and is tightly linked to water balance. Plasma water volume is regulated mainly by the secretion of an antidiuretic hormone (ADH) and by the thirst mechanism. ADH is synthesized in the hypothalamus and stored in the posterior hypophysis. It binds to V2 receptors in the distal nephron and induces translocation of aquaporin water channels in the plasma membrane to retain water. There are two main types of receptors involved in the control of the body water balance-osmoreceptors and baroreceptors. Osmoreceptors reside in hypothalamus and respond to changes of extracellular fluid (ECF) osmolality. Baroreceptors are mechanoreceptors that sense blood pressure in the vessel wall. Response reflexes from baroreceptors influence sympathetic outflow, vessel tonus, and cardiac output. An increase of 1% of plasma osmolality may cause an increase in ADH levels, while the threshold of volume receptors for ADH secretion is higher. However, significant hypotension is a more potent stimulus for ADH secretion than increased osmolality. The main cause of pediatric hyponatremia is an abundance of free water. This may occur in hypovolemic children with low ECF volume, normovolemic patients with inappropriately increased ADH secretion, and also in hypervolemic individuals with decreased effective circulating volume and appropriately increased ADH levels. Proper understanding of the pathophysiology of hyponatremic states is essential for establishing the correct diagnosis and appropriate therapy.
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Affiliation(s)
- Jakub Zieg
- Second Faculty of Medicine, Department of Pediatrics, Motol University Hospital, Charles University in Prague, Praha, Czechia
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42
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Price JF, Kantor PF, Shaddy RE, Rossano JW, Goldberg JF, Hagan J, Humlicek TJ, Cabrera AG, Jeewa A, Denfield SW, Dreyer WJ, Akcan-Arikan A. Incidence, Severity, and Association With Adverse Outcome of Hyponatremia in Children Hospitalized With Heart Failure. Am J Cardiol 2016; 118:1006-10. [PMID: 27530824 DOI: 10.1016/j.amjcard.2016.07.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 07/05/2016] [Accepted: 07/05/2016] [Indexed: 01/11/2023]
Abstract
Hyponatremia is a common finding in adults hospitalized with heart failure (HF) and is associated with longer hospital stays and increased mortality. The significance of hyponatremia in children with HF is not known. We sought to determine the incidence of hyponatremia and association with clinical outcome in children hospitalized with HF. Admission and inpatient serum sodium concentrations were analyzed in 141 consecutive children hospitalized with acute decompensated HF. Inclusion criteria include patients (age, birth to 21 years) with biventricular hearts who were hospitalized for HF from January 2007 to December 2012. The primary composite end point was death, cardiac transplantation, or the use of mechanical circulatory support (MCS) during hospitalization. Data for 141 patients were included in the analysis. The cohort included 48 patients (34%) with preexisting HF. Mean serum sodium at admission was 136 ± 4 mmol/L (range 124 to 150 mmol/L). Hyponatremia (serum sodium <135 mmol/L) was present in 45 patients (32%) at admission. Seventy-one patients (75%) with normal serum sodium concentrations at admission subsequently developed acquired hyponatremia during their hospitalization. Hyponatremia persisted at discharge in 17 of 66 patients (26%). Fifty-eight patients (41%) reached the composite end point during hospitalization (death, n = 15; cardiac transplantation, n = 27; MCS, n = 46). Hyponatremia at admission was independently associated with death, cardiac transplantation, or the use of MCS during hospitalization (odds ratio 3.1, p = 0.02). In conclusion, hyponatremia occurs commonly in children hospitalized with acute decompensated HF and is associated with increased risk of in-hospital mortality, cardiac transplantation, and need for MCS.
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Affiliation(s)
- Jack F Price
- Department of Pediatrics, Lillie Frank Abercrombie Section of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas.
| | - Paul F Kantor
- Division of Pediatric Cardiology, Stollery Children's Hospital, University of Alberta, Edmonton, Canada
| | - Robert E Shaddy
- Division of Pediatric Cardiology, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Joseph W Rossano
- Division of Pediatric Cardiology, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Jason F Goldberg
- Department of Pediatrics, Lillie Frank Abercrombie Section of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Joseph Hagan
- Office of Research, Texas Children's Hospital, Houston, Texas
| | - Timothy J Humlicek
- Department of Pediatrics, Lillie Frank Abercrombie Section of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Antonio G Cabrera
- Department of Pediatrics, Lillie Frank Abercrombie Section of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Aamir Jeewa
- Department of Pediatrics, Lillie Frank Abercrombie Section of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Susan W Denfield
- Department of Pediatrics, Lillie Frank Abercrombie Section of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - William J Dreyer
- Department of Pediatrics, Lillie Frank Abercrombie Section of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Ayse Akcan-Arikan
- Department of Pediatrics, Section of Pediatric Nephrology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas; Department of Pediatrics, Section of Critical Care Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
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Analysis of Risk Factors for Hyponatremia During or Following Chemotherapy in Children With Cancer: A Hospital-based, Retrospective Cohort Study. J Pediatr Hematol Oncol 2016; 38:443-8. [PMID: 26583616 DOI: 10.1097/mph.0000000000000478] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Hyponatremia is the most common electrolyte abnormality in hospitalized patients. The objective of this study was to identify risk factors for hyponatremia during chemotherapy in children. A total of 111 consecutive pediatric patients (age, 0 to 18 y) with hematological malignancy (n=87) or solid tumor (n=24) who received chemotherapy in our hospital between 2010 and 2014 were enrolled. The number of chemotherapy cycles reviewed was 472, with a median of 3 (range, 1 to 8) per patient. Hyponatremia was defined as a serum sodium level of <135 mmol/L. Hyponatremia was observed in 80 of 111 (72%) patients, and 138 of 472 (29%) cycles. Neurological sequelae were seen in 2 of 111 (2%) patients, and 2 of 472 (0.4%) cycles. Multivariate logistic regression identified age 10 to 18 years (odds ratio [OR]=3.24, 95% confidence interval [CI], 2.07-5.07), total parenteral nutrition (OR=8.15, 95% CI, 2.17-30.5), first or second chemotherapy cycle (OR=1.74, 95% CI, 1.12-2.70) as independent risk factors for hyponatremia. Clinical conditions of patients and chemotherapeutic agents may have a profound impact on the development of hyponatremia. Patients with these factors should be managed carefully to prevent severe symptoms and sequelae caused by hyponatremia.
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Flores Robles CM, Cuello García CA. A prospective trial comparing isotonic with hypotonic maintenance fluids for prevention of hospital-acquired hyponatraemia. Paediatr Int Child Health 2016. [PMID: 26212672 DOI: 10.1179/2046905515y.0000000047] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND Recent literature suggests that hypotonic fluids increase the risk of hospital-acquired hyponatraemia; despite this, hypotonic fluids are widely used. OBJECTIVES To compare the change in serum sodium following the use of hypotonic (0.3% saline, 0.45% saline) or isotonic (0.9% saline) intravenous (IV) maintenance solutions in hospitalised children. STUDY DESIGN This was a randomised controlled trial. Children aged 3 months to 15 years with medical or surgical disorders were randomised to receive one of three maintenance IV fluids: two hypotonic solutions (3.3% dextrose in 0.3% saline or 5% dextrose in 0.45% saline) and one isotonic solution (5% dextrose in 0.9% saline). The primary outcome was serum sodium levels at 8 hours. Secondary outcomes included the incidence of hospital-acquired hyponatraemia, adverse events attributable to IV solutions and length of hospital stay. RESULTS 151 children were assigned randomly to receive 0.3% saline (n = 49), 0.45% saline (n = 50) or 0.9% saline (n = 52). Baseline characteristics were similar for the three groups. At 8 hours, mean (SD) serum sodium was lower in the hypotonic solutions groups [0.3% saline 134.65 (1.9) mmol/L, 0.45% saline 134.90 (2.3) mmol/L than 0.9% saline 137.98 (2.8) mmol/L] (P < 0.0001). The incidence of hospital-acquired hyponatraemia was higher in the hypotonic groups [0.3% saline 10/49 (20.4%), 0.45% saline 11/50 (22%) than 0.9% saline 1/52 (1.9%), P = 0.006). There were no differences in other adverse effects or length of hospital stay between the groups. CONCLUSION Hypotonic IV solutions increase the incidence of hospital-acquired hyponatraemia. Isotonic solutions are a safer alternative.
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Affiliation(s)
- Claudia Montserrat Flores Robles
- a Department of Pediatrics, Hospital Regional Materno Infantil de Alta Especialidad, Tecnológico de Monterrey School of Medicine , Nuevo León , México
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Fatal Hyponatremic Encephalopathy as a Result of Child Abuse From Forced Exercise. Am J Forensic Med Pathol 2016; 37:7-8. [PMID: 26600233 DOI: 10.1097/paf.0000000000000212] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Williams CN, Riva-Cambrin J, Bratton SL. Etiology of postoperative hyponatremia following pediatric intracranial tumor surgery. J Neurosurg Pediatr 2016; 17:303-9. [PMID: 26613271 DOI: 10.3171/2015.7.peds15277] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Cerebral salt wasting (CSW) and the syndrome of inappropriate antidiuretic hormone secretion (SIADH) cause postoperative hyponatremia in neurosurgery patients, can be difficult to distinguish clinically, and are associated with increased morbidity. The authors aimed to determine risk factors associated with CSW and SIADH among children undergoing surgery for intracranial tumors. METHODS This retrospective cohort study included children 0-19 years of age who underwent a first intracranial tumor surgery with postoperative hyponatremia (sodium ≤ 130 mEq/L). CSW was differentiated from SIADH by urine output and fluid balance, exclusive of other causes of hyponatremia. The CSW and SIADH groups were compared with basic bivariate analysis and recursive partitioning. RESULTS Of 39 hyponatremic patients, 17 (44%) had CSW and 10 (26%) had SIADH. Patients with CSW had significantly greater natriuresis compared with those with SIADH (median urine sodium 211 vs 28 mEq/L, p = 0.01). Age ≤ 7 years and female sex were significant risk factors for CSW (p = 0.03 and 0.04, respectively). Both patient groups had hyponatremia onset within the first postoperative week. Children with CSW had trends toward increased sodium variability and symptomatic hyponatremia compared with those with SIADH. Most received treatment, but inappropriate treatment was noted to worsen hyponatremia. CONCLUSIONS The authors found that CSW was more common following intracranial tumor surgery and was associated with younger age and female sex. Careful assessment of fluid balance and urine output can separate patients with CSW from those who have SIADH, and high urine sodium concentrations (> 100 mEq/L) support a CSW diagnosis. Patients with CSW and SIADH had similar clinical courses, but responded to different interventions, making appropriate diagnosis and treatment imperative to prevent morbidity.
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Affiliation(s)
- Cydni N Williams
- Department of Pediatrics, Oregon Health and Sciences University, Portland, Oregon; and
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Knepper C, Ellemunter H, Eder J, Niedermayr K, Haerter B, Hofer P, Scholl-Bürgi S, Müller T, Heinz-Erian P. Low sodium status in cystic fibrosis-as assessed by calculating fractional Na(+) excretion-is associated with decreased growth parameters. J Cyst Fibros 2016; 15:400-5. [PMID: 26777601 DOI: 10.1016/j.jcf.2015.12.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Revised: 11/03/2015] [Accepted: 12/14/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND In CF infants, normonatremic Na(+) depletion (NNaD), identified by fractional Na(+) excretion (FENa) values <0.5%, was recently linked to impaired growth. Our paper investigates the relationship between FENa and growth in CF children >2years. METHODS FENa values were calculated in 35 CF and 24 control children, and tested for correlations with z-scores for weight, height and BMI. RESULTS All CF children and controls had normal plasma Na(+) concentrations. A total of 25 of 35 (71.4%) CF patients had decreased FENa values <0.5% (group I). FENa results of 10 CF patients (group II) and 23/24 controls (group III) were normal. In Na(+)-depleted CF children, compared to normal controls, mean z-scores for weight (-0.18±0.87 vs +1.03±0.57, p<0.001), height (-0.06±0.89 vs +0.53±0.72, p=0.009) and BMI (-0.22±0.87 vs +1.00±1.06, p<0.001) were significantly reduced. Also, we found positive correlations between FENa values and z-scores for weight (r=0.521), height (r=0.292) and BMI (r=0.468), respectively. CONCLUSION NNaD may contribute to poor growth in CF.
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Affiliation(s)
- Christiane Knepper
- Department of Pediatrics I, Medical University of Innsbruck, Innsbruck, Austria
| | - Helmut Ellemunter
- Department of Pediatrics III, Cystic Fibrosis Center, Medical University of Innsbruck, Innsbruck, Austria
| | - Johannes Eder
- Department of Pediatrics III, Cystic Fibrosis Center, Medical University of Innsbruck, Innsbruck, Austria
| | - Katharina Niedermayr
- Department of Pediatrics III, Cystic Fibrosis Center, Medical University of Innsbruck, Innsbruck, Austria
| | - Bettina Haerter
- Department of General and Transplant Surgery, Division of Pediatric Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Philipp Hofer
- Division of Medical Statistics and Informatics, Medical University of Innsbruck, Innsbruck, Austria
| | - Sabine Scholl-Bürgi
- Department of Pediatrics I, Medical University of Innsbruck, Innsbruck, Austria
| | - Thomas Müller
- Department of Pediatrics I, Medical University of Innsbruck, Innsbruck, Austria
| | - Peter Heinz-Erian
- Department of Pediatrics I, Medical University of Innsbruck, Innsbruck, Austria.
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Drake K, Nehus E, Goebel J. Hyponatremia, hypo-osmolality, and seizures in children early post-kidney transplant. Pediatr Transplant 2015; 19:698-703. [PMID: 26299753 DOI: 10.1111/petr.12575] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/07/2015] [Indexed: 11/29/2022]
Abstract
Post-transplant seizures are uncommon in young kidney transplant recipients but can be harbingers of devastating outcomes such as cerebral edema and death. We reviewed all transplants performed at our institution from January 2013 to January 2014 and compared three patients who seized within 24 h post-transplant (cases) with the remaining 33 transplant recipients (controls). Records were reviewed for hyponatremia, hypocalcemia, hypomagnesemia, BUN clearance, osmolality shifts, and blood pressure control in the first 24 h post-transplant. All cases had more pronounced (p < 0.001) shifts in serum sodium and calculated serum osmolality, with their sodium decreasing by >15 mmol/L to nadir values of 124, 131, and 131 mmol/L, respectively. There were no differences in serum calcium corrected for hypoalbuminemia, serum magnesium, urine output, or blood pressure control between the groups. Our study suggests that mild hyponatremia and an acute decrease in serum osmolality are risk factors for potentially severe postoperative neurologic complications following kidney transplantation. Thus, peri-transplant management should be optimized to anticipate and prevent these abnormalities.
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Affiliation(s)
- Keri Drake
- Division of Pediatric Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Edward Nehus
- Division of Pediatric Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Jens Goebel
- Division of Pediatric Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Handa D, Barclay N, Rehrauer D, Lakshminrusimha S. Case 2: Early Neonatal Seizures. Neoreviews 2015; 16:e645. [PMID: 27004045 PMCID: PMC4798245 DOI: 10.1542/neo.16-11-e645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- Deepali Handa
- Department of Pediatrics, University at Buffalo, State University of New York and Neonatal Intensive Care Unit, Women and Children's Hospital of Buffalo, NY
| | - Nancy Barclay
- Department of Pediatrics, University at Buffalo, State University of New York and Neonatal Intensive Care Unit, Women and Children's Hospital of Buffalo, NY
| | - David Rehrauer
- Department of Pediatrics, University at Buffalo, State University of New York and Neonatal Intensive Care Unit, Women and Children's Hospital of Buffalo, NY
| | - Satyan Lakshminrusimha
- Department of Pediatrics, University at Buffalo, State University of New York and Neonatal Intensive Care Unit, Women and Children's Hospital of Buffalo, NY
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