1
|
Cobo Marcos M, de la Espriella R, Comín-Colet J, Zegrí-Reiriz I, Rubio Gracia J, Morales-Rull JL, Llàcer P, Díez-Villanueva P, Jiménez-Marrero S, de Juan Bagudá J, Ortiz Cortés C, Restrepo-Córdoba MA, Goirigolzarri-Artaza J, García-Pinilla JM, Barrios E, Del Prado Díaz S, Montero Hernández E, Sanchez-Marteles M, Núñez J. Efficacy and safety of hypertonic saline therapy in ambulatory patients with heart failure: The SALT-HF trial. Eur J Heart Fail 2024. [PMID: 39056478 DOI: 10.1002/ejhf.3390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Revised: 06/13/2024] [Accepted: 07/05/2024] [Indexed: 07/28/2024] Open
Abstract
AIMS Combination of hypertonic saline solution (HSS) with intravenous loop diuretics has been suggested to improve diuretic response in patients hospitalized for heart failure (HF). The efficacy and safety of this approach in the ambulatory setting remain unexplored. METHODS AND RESULTS In this multicentre, double-blind, randomized study, we allocated ambulatory patients with worsening heart failure (WHF) to a 1-h infusion of intravenous furosemide (ivFurosemide)-HSS versus ivFurosemide. The primary endpoint was the volume of diuresis at 3 h. Secondary endpoints included 3-h natriuresis and weight variation, 7-day congestion data, kidney function and electrolytes, and 30-day clinical events. Overall, 167 participants (median age: 81 years, 30.5% female) were randomized across 13 sites between December 2020 and March 2023. There were no differences in 3-h diuresis between treatments (ivFurosemide-HSS: 1099 ml vs. ivFurosemide: 1103 ml, p = 0.963), 3-h natriuresis (∆ +2.642 mEq/L, p = 0.559), or 3-h weight (∆ +0.012 kg, p = 0.920). Patients in the ivFurosemide-HSS arm experienced significant weight decrease at 7 days (Δ -0.586 kg, p = 0.048). There were no between-treatment differences in clinical congestion score, biomarkers, inferior vena cava diameter, or the presence of lung ultrasound B-lines. At 30 days, 26.5% of the patients in the ivFurosemide-HSS group versus 33.3% in the ivFurosemide group experienced WHF (hazard ratio 0.76, p = 0.330). The incidence of death from any cause or HF hospitalization was 6% of patients in the ivFurosemide-HSS group and 8.3% of patients in the ivFurosemide group (hazard ratio 0.69, p = 0.521). The incidence of worsening kidney function or metabolic derangements was not significantly different in the two arms. CONCLUSIONS A single infusion of ivFurosemide-HSS did not improve 3-h diuresis or congestion parameters in patients with ambulatory WHF. This therapy showed an appropriate safety profile.
Collapse
Affiliation(s)
- Marta Cobo Marcos
- Department of Cardiology, Hospital Universitario Puerta de Hierro, Madrid, Spain
- Centro de Investigación Biomédica en Red (CIBER Cardiovascular), Madrid, Spain
| | - Rafael de la Espriella
- Department of Cardiology, Hospital Clínico Universitario de Valencia (INCLIVA), University of Valencia, Valencia, Spain
| | - Josep Comín-Colet
- Centro de Investigación Biomédica en Red (CIBER Cardiovascular), Madrid, Spain
- Department of Cardiology, Hospital Universitario de Bellvitge, IDIBELL, Barcelona, Spain
| | - Isabel Zegrí-Reiriz
- Department of Cardiology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Jorge Rubio Gracia
- Department of Internal Medicine, Hospital Universitario Lozano Blesa, University of Zaragoza, Aragon Health Research Institute (IIS Aragon), Zaragoza, Spain
| | - Jose Luis Morales-Rull
- Department of Internal Medicine, Hospital Universitario Arnau de Vilanova. Heart Failure Unit, Lleida Health Region. Institut de Recerca Biomèdica de Lleida (IRBLleida), Lleida, Spain
| | - Pau Llàcer
- Department of Internal Medicine, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
- Department of Medicine and Medical Specialties, Facultad de Medicina y Ciencias de la Salud, Universidad de Alcalá, Madrid, Spain
| | | | - Santiago Jiménez-Marrero
- Centro de Investigación Biomédica en Red (CIBER Cardiovascular), Madrid, Spain
- Department of Cardiology, Hospital Universitario de Bellvitge, IDIBELL, Barcelona, Spain
| | - Javier de Juan Bagudá
- Centro de Investigación Biomédica en Red (CIBER Cardiovascular), Madrid, Spain
- Department of Cardiology, University Hospital 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (Imas12), Madrid, Spain
- Department of Medicine, Faculty of Biomedical and Health Science, Universidad Europea de Madrid, Madrid, Spain
| | - Carolina Ortiz Cortés
- Department of Cardiology, Hospital Universitario San Pedro de Alcántara, Cáceres, Spain
| | | | | | - Jose Manuel García-Pinilla
- Department of Cardiology, Hospital Universitario Virgen de la Victoria, Málaga, Spain, Instituto de Investigación Biomédica-Plataforma BIONAND, Málaga Ciber-Cardiovascular, Insitituto de Salud Carlos III, Departamento de Medicina y Dermatología, Universidad de Málaga, Málaga, Spain
| | - Elvira Barrios
- Department of Cardiology, Hospital Universitario Rey Juan Carlos Móstoles, Madrid, Spain
| | - Susana Del Prado Díaz
- Centro de Investigación Biomédica en Red (CIBER Cardiovascular), Madrid, Spain
- Department of Cardiology, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Esther Montero Hernández
- Department of Internal Medicine, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | - Marta Sanchez-Marteles
- Department of Internal Medicine, Hospital Universitario Lozano Blesa, University of Zaragoza, Aragon Health Research Institute (IIS Aragon), Zaragoza, Spain
| | - Julio Núñez
- Centro de Investigación Biomédica en Red (CIBER Cardiovascular), Madrid, Spain
- Department of Cardiology, Hospital Clínico Universitario de Valencia (INCLIVA), University of Valencia, Valencia, Spain
| |
Collapse
|
2
|
Sohal S, Uppal D, Mathai SV, Wats K, Uppal NN. Acute Cardiorenal Syndrome: An Update. Cardiol Rev 2023; Publish Ahead of Print:00045415-990000000-00074. [PMID: 36883827 DOI: 10.1097/crd.0000000000000532] [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] [Indexed: 03/09/2023]
Abstract
The complex dynamic pathophysiological interplay between the heart and kidney causes a vicious cycle of worsening renal and/or cardiovascular function. Acute decompensated heart failure causing worsening renal function defines Type 1 cardiorenal syndrome (CRS). Altered hemodynamics coupled with a multitude of nonhemodynamic factors namely pathological activation of the renin angiotensin aldosterone system and systemic inflammatory pathways mechanistically incite CRS type 1. A multipronged diagnostic approach utilizing laboratory markers, noninvasive and/or invasive modalities must be implemented to enable timely initiation of effective treatment strategies. In this review, we discuss the pathophysiology, diagnosis, and emerging treatment options for CRS type 1.
Collapse
Affiliation(s)
- Sumit Sohal
- From the Division of Cardiovascular Diseases, Department of Medicine, RWJ-BH Newark Beth Israel Medical Center, Newark, NJ
| | - Dipan Uppal
- Department of Cardiovascular Diseases, Cleveland Clinic Florida, Weston, FL
| | | | - Karan Wats
- Division of Cardiovascular Diseases, Department of Medicine, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | - Nupur N Uppal
- Division of Kidney Diseases and Hypertension, Department of Medicine, Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY
| |
Collapse
|
3
|
Xu A, Xue Y, Zeng Y, Li J, Zhou H, Wang Z, Chen Y, Chen H, Jin J, Zhuang T. Isolation and Characterization of an Unknown Process-Related Impurity in Furosemide and Validation of a New HPLC Method. Molecules 2023; 28:molecules28052415. [PMID: 36903659 PMCID: PMC10005432 DOI: 10.3390/molecules28052415] [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: 02/14/2023] [Revised: 03/02/2023] [Accepted: 03/04/2023] [Indexed: 03/09/2023] Open
Abstract
Furosemide is a widely used loop diuretic in the treatment of congestive heart failure and edema. During the preparation of furosemide, a new process-related impurity G in the levels ranging from 0.08% to 0.13% was detected in pilot batches by a new high performance liquid chromatography (HPLC) method. The new impurity was isolated and characterized by comprehensive analysis of FT-IR, Q-TOF/LC-MS, 1D-NMR (1H, 13C, and DEPT), and 2D-NMR (1H-1H-COSY, HSQC, and HMBC) spectroscopy data. The possible formation pathway of impurity G was also discussed in detail. Moreover, a novel HPLC method was developed and validated for the determination of impurity G and the other six known impurities registered in the European Pharmacopoeia as per ICH guidelines. The HPLC method was validated with respect to system suitability, linearity, the limit of quantitation, the limit of detection, precision, accuracy, and robustness. The characterization of impurity G and the validation of its quantitative HPLC method were reported for the first time in this paper. Finally, the toxicological properties of impurity G were predicted by the in silico webserver ProTox-II.
Collapse
Affiliation(s)
- Ao Xu
- Jiangsu Key Laboratory of Marine Biological Resources and Environment, Jiangsu Key Laboratory of Marine Pharmaceutical Compound Screening, School of Pharmacy, Jiangsu Ocean University, Lianyungang 222005, China
- Co-Innovation Center of Jiangsu Marine Bio-Industry Technology, Jiangsu Ocean University, Lianyungang 222005, China
| | - Yunlin Xue
- Jiangsu Key Laboratory of Marine Biological Resources and Environment, Jiangsu Key Laboratory of Marine Pharmaceutical Compound Screening, School of Pharmacy, Jiangsu Ocean University, Lianyungang 222005, China
- Co-Innovation Center of Jiangsu Marine Bio-Industry Technology, Jiangsu Ocean University, Lianyungang 222005, China
| | - Yuyu Zeng
- Jiangsu Key Laboratory of Marine Biological Resources and Environment, Jiangsu Key Laboratory of Marine Pharmaceutical Compound Screening, School of Pharmacy, Jiangsu Ocean University, Lianyungang 222005, China
- Co-Innovation Center of Jiangsu Marine Bio-Industry Technology, Jiangsu Ocean University, Lianyungang 222005, China
| | - Jing Li
- Jiangsu Key Laboratory of Marine Biological Resources and Environment, Jiangsu Key Laboratory of Marine Pharmaceutical Compound Screening, School of Pharmacy, Jiangsu Ocean University, Lianyungang 222005, China
- Co-Innovation Center of Jiangsu Marine Bio-Industry Technology, Jiangsu Ocean University, Lianyungang 222005, China
| | - Huiling Zhou
- Jiangsu Key Laboratory of Marine Biological Resources and Environment, Jiangsu Key Laboratory of Marine Pharmaceutical Compound Screening, School of Pharmacy, Jiangsu Ocean University, Lianyungang 222005, China
- Co-Innovation Center of Jiangsu Marine Bio-Industry Technology, Jiangsu Ocean University, Lianyungang 222005, China
| | - Zhen Wang
- Jiangsu Key Laboratory of Marine Biological Resources and Environment, Jiangsu Key Laboratory of Marine Pharmaceutical Compound Screening, School of Pharmacy, Jiangsu Ocean University, Lianyungang 222005, China
- Co-Innovation Center of Jiangsu Marine Bio-Industry Technology, Jiangsu Ocean University, Lianyungang 222005, China
| | - Yin Chen
- Jiangsu Key Laboratory of Marine Biological Resources and Environment, Jiangsu Key Laboratory of Marine Pharmaceutical Compound Screening, School of Pharmacy, Jiangsu Ocean University, Lianyungang 222005, China
- Co-Innovation Center of Jiangsu Marine Bio-Industry Technology, Jiangsu Ocean University, Lianyungang 222005, China
| | - Hui Chen
- Xuzhou Institute for Food and Drug Control, Xuzhou 221000, China
| | - Jian Jin
- Jiangsu Key Laboratory of Marine Biological Resources and Environment, Jiangsu Key Laboratory of Marine Pharmaceutical Compound Screening, School of Pharmacy, Jiangsu Ocean University, Lianyungang 222005, China
- Co-Innovation Center of Jiangsu Marine Bio-Industry Technology, Jiangsu Ocean University, Lianyungang 222005, China
- Correspondence: (J.J.); (T.Z.); Tel.: +86-0518-85895786 (T.Z.)
| | - Tao Zhuang
- Jiangsu Key Laboratory of Marine Biological Resources and Environment, Jiangsu Key Laboratory of Marine Pharmaceutical Compound Screening, School of Pharmacy, Jiangsu Ocean University, Lianyungang 222005, China
- Co-Innovation Center of Jiangsu Marine Bio-Industry Technology, Jiangsu Ocean University, Lianyungang 222005, China
- Department of Biomedical Engineering, College of Life Science and Technology, Huazhong University of Science and Technology, Wuhan 430074, China
- Correspondence: (J.J.); (T.Z.); Tel.: +86-0518-85895786 (T.Z.)
| |
Collapse
|
4
|
Pharmacological Treatment of Chronic Congestive Heart Failure. SERBIAN JOURNAL OF EXPERIMENTAL AND CLINICAL RESEARCH 2022. [DOI: 10.2478/sjecr-2021-0011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Chronic congestive heart failure is a clinical syndrome based on the progressive deterioration of contractile (systolic) heart function due to structural or functional disorders. The incidence of the disease increases with age, so the prevalence in people older than 75 years is greater than 10%. Due to the different clinical presentation, the pharmacological approach to the patient is individual, and most patients are treated on an outpatient basis, according to the guidelines taken from the recommendations of professional associations. Hospitalization is necessary in severe forms of CHF or acute exacerbations. Patients with severe hemodynamic disturbances due to acute CHF require treatment in intensive care units, due to specific cardiovascular therapy, respiratory support and vital functions monitoring. Individualized, stepwise and rational pharmacological therapy achieves significant symptomatic and functional improvement in most patients.
Collapse
|
5
|
Kapłon-Cieślicka A, Soloveva A, Mareev Y, Cabac-Pogorevici I, Verbrugge FH, Vardas P. Hyponatraemia in heart failure: time for new solutions? Heart 2021; 108:1179-1185. [PMID: 34903584 DOI: 10.1136/heartjnl-2021-320277] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 11/18/2021] [Indexed: 11/04/2022] Open
Abstract
Hyponatraemia is very common in heart failure (HF), especially in decompensated patients. It is associated with increased mortality and morbidity and considered a marker of advanced disease. Recognition of hyponatraemia and its causes may help guide treatment strategy. Historically, therapy has primarily focused on water restriction, decongestion with loop diuretics in case of volume overload (dilutional hyponatraemia) and sodium repletion in case of depletion. In this review, we summarise the potential benefits of established and emerging HF therapies on sodium homeostasis, with a focus on dual vasopressin antagonists, angiotensin receptor-neprilysin inhibitors, sodium-glucose cotransporter 2 inhibitors and hypertonic saline, and propose a potential therapeutic approach for hyponatraemia in HF.
Collapse
Affiliation(s)
| | - Anzhela Soloveva
- Department of Cardiology, Almazov National Medical Research Centre, Saint Petersburg, Russian Federation
| | - Yura Mareev
- Department of Cardiology, National Medical Research Center for Therapy and Preventive Medicine, Moscow, Russian Federation.,Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Irina Cabac-Pogorevici
- Department of Cardiology, State University of Medicine and Pharmacy 'Nicolae Testemitanu', Chisinau, Moldova (the Republic of)
| | - Frederik Hendrik Verbrugge
- Department of Cardiology, Centre for Cardiovascular Diseases, University Hospital Brussels, Jette, Belgium.,Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Panagiotis Vardas
- Heart Sector, Hygeia Hospitals Groups, Athens, Greece.,Medical School, Cardiology Department, University of Crete, Heraclion, Greece
| |
Collapse
|
6
|
Orozco Burbano JD, Saldarriaga Giraldo CI, Echeverri Marín DA. [Hypertonic saline solution and high dose of diuretic, ¿what do we know and how can we use them in persistent congestion?]. ARCHIVOS PERUANOS DE CARDIOLOGIA Y CIRUGIA CARDIOVASCULAR 2021; 2:247-253. [PMID: 37727671 PMCID: PMC10506575 DOI: 10.47487/apcyccv.v2i4.159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 11/20/2021] [Indexed: 09/21/2023]
Abstract
The presence of decompensated heart failure continues to be a condition with high rates of hospitalization, impact on the health system, and quality of life for those who suffer it. The mainstay of treatment in these cases are diuretics. However, the resistance to this pharmacological group may occasionally occur, generating an inadequate negative fluid balance and persistence of congestion with negative clinical outcomes. Hypertonic saline solution with high doses of diuretic emerges as a therapeutic option for this group of patients with probable physiological, and clinical benefits on hospitalization and re-admission rates due to heart failure decompensation. A review of the most relevant aspects and benefits of this combination is discussed in this article.
Collapse
Affiliation(s)
- Juan D Orozco Burbano
- Departamento de Medicina Interna, Universidad del Cauca. Cauca, Colombia.Universidad del CaucaDepartamento de Medicina InternaUniversidad del CaucaCaucaColombia
- Hospital Universitario San José. Popayán, Colombia Hospital Universitario San JoséPopayánColombia
| | - Clara I Saldarriaga Giraldo
- Departamento de Cardiología, Universidad Pontificia Bolivariana. Medellín, Colombia.Universidad Pontificia BolivarianaDepartamento de CardiologíaUniversidad Pontificia BolivarianaMedellínColombia
- Clínica CardioVID. Medellín, Colombia.Clínica CardioVIDMedellínColombia
- Universidad de Antioquia. Medellín, Colombia. Universidad de AntioquiaUniversidad de AntioquiaMedellínColombia
| | - Diego A Echeverri Marín
- Departamento de Cardiología, Universidad Pontificia Bolivariana. Medellín, Colombia.Universidad Pontificia BolivarianaDepartamento de CardiologíaUniversidad Pontificia BolivarianaMedellínColombia
- Clínica CardioVID. Medellín, Colombia.Clínica CardioVIDMedellínColombia
- Universidad de Antioquia. Medellín, Colombia. Universidad de AntioquiaUniversidad de AntioquiaMedellínColombia
| |
Collapse
|
7
|
Gatzoflias S, Hao S, Ferreri NR. Induction of renal tumor necrosis factor-α and other autacoids and the beneficial effects of hypertonic saline in acute decompensated heart failure. Am J Physiol Renal Physiol 2021; 320:F1159-F1164. [PMID: 33969695 DOI: 10.1152/ajprenal.00686.2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Although administration of hypertonic saline (HSS) in combination with diuretics has yielded improved weight loss, preservation of renal function, and reduction in hospitalization time in the clinical setting of patients with acute decompensated heart failure (ADHF), the mechanisms that underlie these beneficial effects remain unclear and additional studies are needed before this approach can be adopted on a more consistent basis. As high salt conditions stimulate the production of several renal autacoids that exhibit natriuretic effects, renal physiologists can contribute to the understanding of mechanisms by which HSS leads to increased diuresis both as an individual therapy as well as in combination with loop diuretics. For instance, since HSS increases TNF-α production by proximal tubule and thick ascending limb of Henle's loop epithelial cells, this article is aimed at highlighting how the effects of TNF-α produced by these cell types may contribute to the beneficial effects of HSS in patients with ADHF. Although TNF-α produced by infiltrating macrophages and T cells exacerbates and attenuates renal damage, respectively, production of this cytokine within the tubular compartment of the kidney functions as an intrinsic regulator of blood pressure and Na+ homeostasis via mechanisms along the nephron related to inhibition of Na+-K+-2Cl- cotransporter isoform 2 activity and angiotensinogen expression. Thus, in the clinical setting of ADHF and hyponatremia, induction of TNF-α production along the nephron by administration of HSS may attenuate Na+-K+-2Cl- cotransporter isoform 2 activity and angiotensinogen expression as part of a mechanism that prevents excessive Na+ reabsorption in the thick ascending limb of Henle's loop, thereby mitigating volume overload.
Collapse
Affiliation(s)
| | - Shoujin Hao
- Department of Pharmacology, New York Medical College, Valhalla, New York
| | - Nicholas R Ferreri
- Department of Pharmacology, New York Medical College, Valhalla, New York
| |
Collapse
|
8
|
Real World Use of Hypertonic Saline in Refractory Acute Decompensated Heart Failure: A U.S. Center's Experience. JACC-HEART FAILURE 2020; 8:199-208. [PMID: 32035891 DOI: 10.1016/j.jchf.2019.10.012] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 10/20/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVES The purpose of this study was to investigate real world safety and efficacy of hypertonic saline therapy in cases of refractory acute decompensated heart failure (ADHF) at a large U.S. academic medical center. BACKGROUND Hypertonic saline therapy has been described as a potential management strategy for refractory ADHF, but experience in the United States is limited. METHODS A retrospective analysis was performed in all patients receiving hypertonic saline for diuretic therapy-resistant ADHF at the authors' institution since March 2013. The primary analytic approach was a comparison of the trajectory of clinical variables prior to and after administration of hypertonic saline, with secondary focus on predictors of treatment response. RESULTS A total of 58 hypertonic saline administration episodes were identified across 40 patients with diuretic-therapy refractory ADHF. Prior to hypertonic saline administration, serum sodium, chloride, and creatinine concentrations were worsening but improved after hypertonic saline administration (p < 0.001, all). Both total urine output and weight loss significantly improved with hypertonic saline (p = 0.01 and <0.001, respectively). Diuretic efficiency, defined as change in urine output per doubling of diuretic dose, also improved over this period (p < 0.01). There were no significant changes in respiratory status or overcorrection of serum sodium with the intervention. CONCLUSIONS In a cohort of patients who were refractory to ADHF, hypertonic saline administration was associated with increased diuretic efficiency, fluid and weight loss, and improvement of metabolic derangements, and no adverse respiratory or neurological signals were identified. Additional study of hypertonic saline as a diuretic adjuvant is warranted.
Collapse
|
9
|
Xin X, Xin F, Chen X, Zhang Q, Li Y, Huo S, Chang C, Wang Q. Hypertonic saline for prevention of delirium in geriatric patients who underwent hip surgery. J Neuroinflammation 2017; 14:221. [PMID: 29137628 PMCID: PMC5686947 DOI: 10.1186/s12974-017-0999-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 11/08/2017] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Postoperative delirium (POD) is a common disorder in the elderly patients, and neuroinflammation is the possible underlying mechanism. This study is designed to determine whether or not hypertonic saline (HS) pre-injection can alleviate POD in aged patients. METHODS This prospective study recruited 120 geriatric patients who underwent hip surgery. The patients were randomly divided into two groups: control group (NS group) and HS group. Patients in the NS group were pre-injected with 4 mL/kg isotonic saline, and those in the HS group were pre-injected with 4 mL/kg 7.5% HS. All 120 patients were then subjected to general anesthesia. Blood samples were extracted to detect the concentration of inflammatory factors, namely, IL-1β, IL-6, IL-10, and TNF-α, and the nerve injury factor S100β. Flow cytometry was used to detect the number of monocytes in peripheral venous blood and evaluate the relationship of inflammation to delirium. The nursing delirium screening scale (Nu-DESC) was used to determine cognitive function 1 to 3 days postoperatively. RESULTS Analysis using random-effect multivariable logistic regression indicated that HS administration before anesthesia was associated with a low risk of POD (odds ratio [OR], 0.13; 95% CI, 0.04 to 0.41; P = 0.001) and few CD14 + CD16+ monocytes (β = - 0.61; 95% CI, - 0.74 to - 0.48; P = 0.000) the following day. When the association between HS and delirium was controlled for CD14 + CD16+ monocytes, the effect size became nonsignificant (odds ratio [OR], 0.86; 95% CI, 0.14 to 5.33; P = 0.874). TNF-α was significantly associated with POD (odds ratio [OR], 1.10; 95% CI, 1.05 to 1.16; P = 0.000). However, IL-1β, IL-6, IL-10, and S100β were not significantly related to POD. CONCLUSION HS can alleviate POD in geriatric patients and may inhibit the secretion of inflammatory factors by monocytes.
Collapse
Affiliation(s)
- Xi Xin
- Department of Anesthesiology, The Third Hospital of Hebei Medical University, No 139, Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Fei Xin
- Department of Respiration, Tianjin Institute of Respiratory Diseases, Tianjin Haihe Hospital, Tianjin Medical University, Tianjin, 300350, People's Republic of China
| | - Xuguang Chen
- Department of Anesthesiology, The Third Hospital of Hebei Medical University, No 139, Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Qi Zhang
- Department of Anesthesiology, The Third Hospital of Hebei Medical University, No 139, Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Yanan Li
- Department of Anesthesiology, The Third Hospital of Hebei Medical University, No 139, Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Shuping Huo
- Department of Anesthesiology, The Third Hospital of Hebei Medical University, No 139, Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Chongfu Chang
- Department of Anesthesiology, The Third Hospital of Hebei Medical University, No 139, Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Qiujun Wang
- Department of Anesthesiology, The Third Hospital of Hebei Medical University, No 139, Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China.
| |
Collapse
|
10
|
Vazir A, Cowie MR. Decongestion: Diuretics and other therapies for hospitalized heart failure. Indian Heart J 2016; 68 Suppl 1:S61-8. [PMID: 27056656 PMCID: PMC4824339 DOI: 10.1016/j.ihj.2015.10.386] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 10/30/2015] [Indexed: 01/11/2023] Open
Abstract
Acute heart failure (AHF) is a potentially life-threatening clinical syndrome, usually requiring hospital admission. Often the syndrome is characterized by congestion, and is associated with long hospital admissions and high risk of readmission and further healthcare expenditure. Despite a limited evidence-base, diuretics remain the first-line treatment for congestion. Loop diuretics are typically the first-line diuretic strategy with some evidence that initial treatment with continuous infusion or boluses of high-dose loop diuretic is superior to an initial lower dose strategy. In patients who have impaired responsiveness to diuretics, the addition of an oral thiazide or thiazide-like diuretic to induce sequential nephron blockade can be beneficial. The use of intravenous low-dose dopamine is no longer supported in heart failure patients with preserved systolic blood pressure and its use to assist diuresis in patients with low systolic blood pressures requires further study. Mechanical ultrafiltration has been used to treat patients with heart failure and fluid retention, but the evidence-base is not robust, and its place in clinical practice is yet to be established. Several novel pharmacological agents remain under investigation.
Collapse
Affiliation(s)
- Ali Vazir
- Consultant in Cardiology and Critical Care (HDU), Royal Brompton Hospital, United Kingdom; Honorary Clinical Senior Lecturer, National Heart and Lung Institute, Imperial College London, United Kingdom.
| | - Martin R Cowie
- Professor of Cardiology, Imperial College London (Royal Brompton Hospital), United Kingdom.
| |
Collapse
|
11
|
Paterna S, Di Gaudio F, La Rocca V, Balistreri F, Greco M, Torres D, Lupo U, Rizzo G, di Pasquale P, Indelicato S, Cuttitta F, Butler J, Parrinello G. Hypertonic Saline in Conjunction with High-Dose Furosemide Improves Dose-Response Curves in Worsening Refractory Congestive Heart Failure. Adv Ther 2015; 32:971-82. [PMID: 26521190 PMCID: PMC4635178 DOI: 10.1007/s12325-015-0254-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Diuretic responsiveness in patients with chronic heart failure (CHF) is better assessed by urine production per unit diuretic dose than by the absolute urine output or diuretic dose. Diuretic resistance arises over time when the plateau rate of sodium and water excretion is reached prior to optimal fluid elimination and may be overcome when hypertonic saline solution (HSS) is added to high doses of furosemide. METHODS Forty-two consecutively hospitalized patients with refractory CHF were randomized in a 1:1:1 ratio to furosemide doses (125 mg, 250 mg, 500 mg) so that all patients received intravenous furosemide diluted in 150 ml of normal saline (0.9%) in the first step (0-24 h) and the same furosemide dose diluted in 150 ml of HSS (1.4%) in the next step (24-48 h) as to obtain 3 groups as follows: Fourteen patients receiving 125 mg (group 1), fourteen patients receiving 250 mg (group 2), and fourteen patients receiving 500 mg (group 3) of furosemide. Urine samples of all patients were collected at 30, 60, and 90 min, and 3, 4, 5, 6, 8, and 24 h after infusion. Diuresis, sodium excretion, osmolality, and furosemide concentration were evaluated for each urine sample. RESULTS After randomization, 40 patients completed the study. Two patients, one in group 2 and one in group 3 dropped out. Patients in group 1 (125 mg furosemide) had a mean age of 77 ± 17 years, 43% were male, 6 (43%) had heart failure with a preserved ejection fraction (HFpEF), and 64% were in New York Heart Association (NYHA) class IV; the mean age of patients in group 2 (250 mg furosemide) was 80 ± 8.1 years, 15% were male, 5 (38%) had HFpEF, and 84% were in NYHA class IV; and the mean age of patients in group 3 (500 mg furosemide) was 73 ± 12 years, 54% were male, 6 (46%) had HFpEF, and 69% were in NYHA class IV. HSS added to furosemide increased total urine output, sodium excretion, urinary osmolality, and furosemide urine delivery in all patients and at all time points. The percentage increase was 18,14, and 14% for urine output; 29, 24, and 16% for total sodium excretion; 45, 34, and 20% for urinary osmolarity; and 27, 36, and 32% for total furosemide excretion in groups 1, 2, and 3, respectively. These findings were translated in an improvement in the furosemide dose-response curves in these patients. CONCLUSION These results may serve as new pathophysiological basis for HSS use in the treatment of refractory CHF.
Collapse
Affiliation(s)
- Salvatore Paterna
- Dipartimento Biomedico di Medicina Interna e Specialistica (DIBIMIS), AOUP "Paolo Giaccone" Università degli Studi di Palermo, Palermo, Italy
| | - Francesca Di Gaudio
- Dipartimento Biopatologia e Biotecnologie Mediche e Forensi (DiBiMEF), AOUP "Paolo Giaccone" Università degli Studi di Palermo, Palermo, Italy
| | - Vincenzo La Rocca
- Dipartimento Energia, Ingegneria dell'Informazione e Modelli Matematici (DEIM), Università degli Studi di Palermo, Palermo, Italy
| | - Fabio Balistreri
- Dipartimento Biomedico di Medicina Interna e Specialistica (DIBIMIS), AOUP "Paolo Giaccone" Università degli Studi di Palermo, Palermo, Italy
| | - Massimiliano Greco
- Dipartimento Biopatologia e Biotecnologie Mediche e Forensi (DiBiMEF), AOUP "Paolo Giaccone" Università degli Studi di Palermo, Palermo, Italy
| | - Daniele Torres
- Dipartimento Biomedico di Medicina Interna e Specialistica (DIBIMIS), AOUP "Paolo Giaccone" Università degli Studi di Palermo, Palermo, Italy
| | - Umberto Lupo
- Dipartimento Biomedico di Medicina Interna e Specialistica (DIBIMIS), AOUP "Paolo Giaccone" Università degli Studi di Palermo, Palermo, Italy
| | - Giuseppina Rizzo
- UO Medicina D'Urgenza e Pronto Soccorso AOUP "Paolo Giaccone" Università degli Studi di Palermo, Palermo, Italy
| | - Pietro di Pasquale
- UO di Cardiologia "Paolo Borsellino", Ospedale GF Ingrassia Palermo, Palermo, Italy
| | - Sergio Indelicato
- Dipartimento Biopatologia e Biotecnologie Mediche e Forensi (DiBiMEF), AOUP "Paolo Giaccone" Università degli Studi di Palermo, Palermo, Italy
| | - Francesco Cuttitta
- Dipartimento Biomedico di Medicina Interna e Specialistica (DIBIMIS), AOUP "Paolo Giaccone" Università degli Studi di Palermo, Palermo, Italy
| | - Javed Butler
- Cardiology Division, Stony Brook University, Stony Brook, NY, USA
| | - Gaspare Parrinello
- Dipartimento Biomedico di Medicina Interna e Specialistica (DIBIMIS), AOUP "Paolo Giaccone" Università degli Studi di Palermo, Palermo, Italy.
| |
Collapse
|
12
|
Clemente G, Tuttolomondo A, Colomba D, Pecoraro R, Renda C, Della Corte V, Maida C, Simonetta I, Pinto A. When sepsis affects the heart: A case report and literature review. World J Clin Cases 2015; 3:743-750. [PMID: 26301236 PMCID: PMC4539415 DOI: 10.12998/wjcc.v3.i8.743] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Revised: 12/24/2014] [Accepted: 06/16/2015] [Indexed: 02/05/2023] Open
Abstract
A 59-year-old nursing home patient with Down syndrome was brought to the internal medicine department of our hospital due to fever, cough without expectorate, and dyspnea. A thoracic computed tomography revealed the presence of bilateral basal parenchymal opacities. Her condition deteriorated after admission and troponin reached a peak serum concentration of 16.9 ng/mL. The patient was in cardiogenic shock. In addition to fluid resuscitation, vaso-active amine infusion was administered to achieve hemodynamic stabilization. The differential diagnosis investigated possible pulmonary embolism, myocardial infarction, and myocarditis. Furthermore, a second transthoracic echocardiogram suggested Tako-Tsubo syndrome. This is a septic patient. The purpose of this manuscript is to review studies which formerly examined the possible association between high levels of troponin and mortality to see if it can be considered a positive predictive factor of fatal prognosis as the case of thrombocytopenia, already a positive independent predictive factor of multiple organ failure syndrome, and generally to characterize risk profile in a septic patient.
Collapse
|
13
|
Clinical Use of Diuretics in Heart Failure, Cirrhosis, and Nephrotic Syndrome. Int J Nephrol 2015; 2015:975934. [PMID: 26294976 PMCID: PMC4532861 DOI: 10.1155/2015/975934] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2015] [Revised: 05/22/2015] [Accepted: 07/15/2015] [Indexed: 12/03/2022] Open
Abstract
Diuretics play significant role in pharmacology and treatment options in medicine. This paper aims to review and evaluate the clinical use of diuretics in conditions that lead to fluid overload in the body such as cardiac failure, cirrhosis, and nephrotic syndrome. To know the principles of treatment it is essential to understand the underlying pathophysiological mechanisms that cause the need of diuresis in the human body. Various classes of diuretics exist, each having a unique mode of action. A systemic approach for management is recommended based on the current guidelines, starting from thiazides and proceeding to loop diuretics. The first condition for discussion in the paper is cardiac failure. Treatment of ascites in liver cirrhosis with spironolactone as the primary agent is highlighted with further therapeutic options. Lastly, management choices for nephrotic syndrome are discussed and recommended beginning from basic sodium restriction to combined diuretic therapies. Major side effects are discussed.
Collapse
|
14
|
Xu D, Michie SA, Zheng M, Takeda S, Wu M, Peltz G. Humanized thymidine kinase-NOG mice can be used to identify drugs that cause animal-specific hepatotoxicity: a case study with furosemide. J Pharmacol Exp Ther 2015; 354:73-8. [PMID: 25962391 DOI: 10.1124/jpet.115.224493] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 05/08/2015] [Indexed: 12/21/2022] Open
Abstract
Interspecies differences have limited the predictive utility of toxicology studies performed using animal species. A drug that could be a safe and effective treatment in humans could cause toxicity in animals, preventing it from being used in humans. We investigated whether the use of thymidine kinase (TK)-NOG mice with humanized livers could prevent this unfortunate outcome (i.e., "rescue" a drug for use in humans). A high dose of furosemide is known to cause severe liver toxicity in mice, but it is a safe and effective treatment in humans. We demonstrate that administration of a high dose of furosemide (200 mg/kg i.p.) causes extensive hepatotoxicity in control mice but not in humanized TK-NOG mice. This interspecies difference results from a higher rate of production of the toxicity-causing metabolite by mouse liver. Comparison of their survival curves indicated that the humanized mice were more resistant than control mice to the hepatotoxicity caused by high doses of furosemide. In this test case, humanized TK-NOG mouse studies indicate that humans could be safely treated with a high dose of furosemide.
Collapse
Affiliation(s)
- Dan Xu
- Department of Anesthesia, Stanford University School of Medicine, Stanford, California (D.X., M.Z., M.W., G.P.); Department of Pathology, Stanford University, Stanford, California (S.A.M.); and In Vivo Sciences International, Sunnyvale, California (S.T.)
| | - Sara A Michie
- Department of Anesthesia, Stanford University School of Medicine, Stanford, California (D.X., M.Z., M.W., G.P.); Department of Pathology, Stanford University, Stanford, California (S.A.M.); and In Vivo Sciences International, Sunnyvale, California (S.T.)
| | - Ming Zheng
- Department of Anesthesia, Stanford University School of Medicine, Stanford, California (D.X., M.Z., M.W., G.P.); Department of Pathology, Stanford University, Stanford, California (S.A.M.); and In Vivo Sciences International, Sunnyvale, California (S.T.)
| | - Saori Takeda
- Department of Anesthesia, Stanford University School of Medicine, Stanford, California (D.X., M.Z., M.W., G.P.); Department of Pathology, Stanford University, Stanford, California (S.A.M.); and In Vivo Sciences International, Sunnyvale, California (S.T.)
| | - Manhong Wu
- Department of Anesthesia, Stanford University School of Medicine, Stanford, California (D.X., M.Z., M.W., G.P.); Department of Pathology, Stanford University, Stanford, California (S.A.M.); and In Vivo Sciences International, Sunnyvale, California (S.T.)
| | - Gary Peltz
- Department of Anesthesia, Stanford University School of Medicine, Stanford, California (D.X., M.Z., M.W., G.P.); Department of Pathology, Stanford University, Stanford, California (S.A.M.); and In Vivo Sciences International, Sunnyvale, California (S.T.)
| |
Collapse
|
15
|
Bebarta VS, Vargas TE, Castaneda M, Boudreau S. Evaluation of extremity tissue and bone injury after intraosseous hypertonic saline infusion in proximal tibia and proximal humerus in adult swine. PREHOSP EMERG CARE 2014; 18:505-10. [PMID: 24830735 DOI: 10.3109/10903127.2014.912704] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Hypertonic saline (HTS) has been reported as a treatment for sever traumatic brain injury and hemorrhagic shock and current clinical guidelines recommend it. Intraosseous (IO) infusion is often needed in the pre-hospital and combat settings to administer life-saving treatments. However, the safety of IO HTS infusion is not clear. The aim of our study was to evaluate the clinical and histological outcome of HTS IO infusion into the extremity of a large animal model. METHODS We conducted a randomized comparative study of adult pigs that were infused intraosseously with one of the following solutions: 7.5% HTS, 3% HTS or normal 0.9% isotonic saline. The animals were observed daily for infection, necrosis and gait (5 point Tarlov score) up to 5 days. Five days after infusion, necropsy and histological analysis was performed using a validated scale of tissue necrosis. RESULTS The mean Tarlov gait scores were similar in all arms and all animals showed a score of 4 (normal ambulation) by day 5. During the 5 day observation period, there were no signs of infection or tissue abnormalities. Histological examinations showed no indication of necrosis, or abnormal bone and muscle healing (p < 0.05). CONCLUSION We observed regular tissue morphology and normal gait scores over the 5 day observation period. There was an absence of gross tissue necrosis and microscopic ischemia post IO HTS infusion in this swine model. This data confirms the clinical safety of IO HTS infusion and highlights its use as an alternative lifesaving treatment.
Collapse
|
16
|
Gandhi S, Mosleh W, Myers RBH. Hypertonic saline with furosemide for the treatment of acute congestive heart failure: a systematic review and meta-analysis. Int J Cardiol 2014; 173:139-45. [PMID: 24679680 DOI: 10.1016/j.ijcard.2014.03.020] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Revised: 02/22/2014] [Accepted: 03/09/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND Advanced congestive heart failure (CHF) therapies include intravenous inotropic agents, change in class of diuretics, and venous ultrafiltration or hemodialysis. These modalities have not been associated with improved prognosis and are limited by availability and cost. Compared to high-dose furosemide alone, concomitant hypertonic saline solution (HSS) administration has demonstrated improved clinical outcomes with good safety profile. METHODS A literature search was conducted for randomized controlled trials that investigated the use of HSS in patients admitted to hospital with acute CHF. RESULTS 1032 patients treated with HSS and 1032 controls, demonstrated decreased all-cause mortality in patients treat with HSS with RR of 0.56 (95% CI 0.41-0.76,p=0.0003). 1012 patients treated with HSS and 1020 controls, demonstrated decreased heart failure hospital readmission with RR of 0.50 (95% CI 0.33-0.76,p=0.001). Patients treated with HSS also demonstrated decreased hospital length of stay (p=0.0002), greater weight loss (p<0.00001), and preservation of renal function (p<0.00001). CONCLUSION The results of this meta-analysis demonstrate that in patients with advanced CHF concomitant hypertonic saline administration improved weight loss, preserved renal function, and decreased length of hospitalization, mortality and heart failure rehospitalization. A future adequately powered, multi-centre, placebo controlled, randomized, double dummy, blinded trial is needed to assess the benefit of hypertonic saline in patients with renal dysfunction, in diverse patient populations, as well using a patient population on optimal current heart failure treatment. Pending further validation, there is promise for hypertonic saline as an advanced therapy for the management of acute advanced CHF.
Collapse
Affiliation(s)
- Sumeet Gandhi
- McMaster University, Division of Cardiology, Hamilton, ON, Canada; Sunnybrook Health Sciences Centre, Division of Cardiology, University of Toronto, ON, Canada.
| | | | - Robert B H Myers
- Sunnybrook Health Sciences Centre, Division of Cardiology, University of Toronto, ON, Canada
| |
Collapse
|
17
|
Overgaard-Steensen C, Ring T. Clinical review: practical approach to hyponatraemia and hypernatraemia in critically ill patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:206. [PMID: 23672688 PMCID: PMC4077167 DOI: 10.1186/cc11805] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Disturbances in sodium concentration are common in the critically ill patient and associated with increased mortality. The key principle in treatment and prevention is that plasma [Na+] (P-[Na+]) is determined by external water and cation balances. P-[Na+] determines plasma tonicity. An important exception is hyperglycaemia, where P-[Na+] may be reduced despite plasma hypertonicity. The patient is first treated to secure airway, breathing and circulation to diminish secondary organ damage. Symptoms are critical when handling a patient with hyponatraemia. Severe symptoms are treated with 2 ml/kg 3% NaCl bolus infusions irrespective of the supposed duration of hyponatraemia. The goal is to reduce cerebral symptoms. The bolus therapy ensures an immediate and controllable rise in P-[Na+]. A maximum of three boluses are given (increases P-[Na+] about 6 mmol/l). In all patients with hyponatraemia, correction above 10 mmol/l/day must be avoided to reduce the risk of osmotic demyelination. Practical measures for handling a rapid rise in P-[Na+] are discussed. The risk of overcorrection is associated with the mechanisms that cause hyponatraemia. Traditional classifications according to volume status are notoriously difficult to handle in clinical practice. Moreover, multiple combined mechanisms are common. More than one mechanism must therefore be considered for safe and lasting correction. Hypernatraemia is less common than hyponatraemia, but implies that the patient is more ill and has a worse prognosis. A practical approach includes treatment of the underlying diseases and restoration of the distorted water and salt balances. Multiple combined mechanisms are common and must be searched for. Importantly, hypernatraemia is not only a matter of water deficit, and treatment of the critically ill patient with an accumulated fluid balance of 20 litres and corresponding weight gain should not comprise more water, but measures to invoke a negative cation balance. Reduction of hypernatraemia/hypertonicity is critical, but should not exceed 12 mmol/l/day in order to reduce the risk of rebounding brain oedema.
Collapse
|