The incidence, hospitalisations and deaths in acutely ill children with dysnatraemias

Updates in hyponatremia and hypernatremia

PURPOSE OF REVIEW

Hyponatremia and hypernatremia are commonly encountered electrolyte abnormalities that require timely and careful intervention, as they can be associated with significant morbidity and mortality.

RECENT FINDINGS

This review article addresses the etiology, presentation, diagnosis, and management of both hyponatremia and hypernatremia, emphasizing the latest advancements and emerging trends in pediatric care.

SUMMARY

A methodical approach is needed to accurately assess and treat hyponatremia and hypernatremia. Both conditions continue to rely on serum and urine testing, however newer tests such as copeptin and stimulated testing may hold promise to further refine testing in the future.

Blood analysis for screening of electrolyte and kidney function alterations in patients with febrile urinary tract infection

AIM

To describe the prevalence, severity, risk factors, and clinical relevance of electrolyte disturbances and acute kidney injury (AKI) during febrile urinary tract infection (fUTI).

METHODS

Retrospective observational study of well/fair-appearing patients between 2 months and 16 years, with no previous relevant medical history, diagnosed with fUTI in the paediatric emergency department (PED) with subsequent microbiological confirmation. Analytical alteration (AA) data were considered: AKI (creatinine elevation × 1.5 the median for age), plasma sodium alteration (≤130 or ≥150 mEq/L), and potassium alteration (≤3 or ≥6 mEq/L).

RESULTS

We included 590 patients, 17.8% presented AA (13 hyponatremia, 7 hyperkalaemia, and 87 AKI). No patient presented severe analytic alterations or a higher frequency of symptoms potentially attributable to these alterations (seizures, irritability, or lethargy). Risk factors associated with these AA were clinical dehydration (OR = 3.5 95% CI: 1.04-11.7; p = 0.044) and presenting a temperature >39°C (OR = 1.9 95% CI: 1.14-3.1; p = 0.013).

CONCLUSIONS

Electrolyte and renal function disturbances are infrequent in the previously healthy paediatric population with a fUTI. If present, they are asymptomatic and not severe. Based on our results, performing systematic blood analysis to rule out AA appears no longer justified, especially in the absence of risk factors.

Hyponatremia and its associated factors in children admitted to the pediatric intensive care unit in eastern Ethiopia: a cross-sectional study

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.

Correcting Hypernatremia in Children

BACKGROUND

In children with hypernatremia, current clinical guidelines recommend a reduction in serum sodium of 0.5 mmol/L per hour or less to avoid complications of cerebral edema. However, no large-scale studies have been conducted in the pediatric setting to inform this recommendation. Therefore, this study aimed to report the association between the rate of correction of hypernatremia, neurological outcomes, and all-cause mortality in children.

METHODS

A retrospective cohort study was conducted from 2016 to 2019 at a quaternary pediatric center in Melbourne, Victoria, Australia. All children with at least one serum sodium level ≥150 mmol/L were identified through interrogation of the hospital's electronic medical record. Medical notes, neuroimaging reports, and electroencephalogram results were reviewed for evidence of seizures and/or cerebral edema. The peak serum sodium level was identified and correction rates over the first 24 hours and overall were calculated. Unadjusted and multivariable analyses were used to examine the association between the rate of sodium correction and neurological complications, the requirement for neurological investigation, and death.

RESULTS

There were 402 episodes of hypernatremia among 358 children over the 3-year study period. Of these, 179 were community-acquired and 223 developed during admission. A total of 28 patients (7%) died during admission. Mortality was higher in children with hospital-acquired hypernatremia, as was the frequency of intensive care unit admission and hospital length of stay. Rapid correction (>0.5 mmol/L per hour) occurred in 200 children and was not associated with greater neurological investigation or mortality. Length of stay was longer in children who received slow correction (<0.5 mmol/L per hour).

CONCLUSIONS

Our study did not find any evidence that rapid sodium correction was associated with greater neurological investigation, cerebral edema, seizures, or mortality; however, slow correction was associated with a longer hospital length of stay.

Post-operative dysnatremia is associated with adverse early outcomes after surgery for congenital heart disease

BACKGROUND

Dysnatremia is a common disorder in critically ill surgical children. The study's aim is to determine the prevalence of dysnatremia and its association with outcomes after surgery for congenital heart disease (CHD).

METHODS

This is a single-center retrospective cohort study of children <18 years of age undergoing surgery for CHD between January 2012 and December 2014. Multivariable logistic regression analysis was used to evaluate the relationship between dysnatremia and outcomes during the perioperative period. A total of 1345 encounters met the inclusion criteria.

RESULTS

The prevalence of pre- and post-operative dysnatremia were 10.2% and 47.1%, respectively. Hyponatremia occurred in 19.1%, hypernatremia in 25.6%. Hypernatremia at 24, 48, and 72 h post-operative was associated with increased hospital mortality (odds ratios (OR) [95% confidence intervals (CI)] 3.08 [1.16-8.17], p = 0.024; 4.35 [1.58-12], p = 0.0045; 4.14 [1.32-12.97], p = 0.0148, respectively. Hypernatremia was associated with adverse neurological events 3.39 [1.12-10.23], p = 0.0302 at 48 h post-operative. Hyponatremia was not associated with any adverse outcome in our secondary analysis.

CONCLUSIONS

Post-operative dysnatremia is a common finding in this heterogeneous cohort of pediatric cardiac-surgical patients. Hypernatremia was more prevalent than hyponatremia and was associated with adverse early post-operative outcomes.

IMPACT

Our study has shown that dysnatremia was highly prevalent in children after congenital heart surgery with hypernatremia associated with adverse outcomes including mortality. It is important to understand fluid and sodium regulation in the post-operative period in children with congenital heart disease to better address fluid overload and associated electrolyte imbalances and acute kidney injury. While clinicians are generally very aware of the importance of hyponatremia in critically ill children, similar attention should be given to hypernatremia in this population.