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Smith CR, Chua P, Papaioannou C, Warrier R, Nolan GJG, Hsiao YFF, Duke T. Fluid and electrolyte pathophysiology in common febrile illness in children and the implications for clinical management. Arch Dis Child 2024:archdischild-2024-327407. [PMID: 39097402 DOI: 10.1136/archdischild-2024-327407] [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: 05/15/2024] [Accepted: 07/22/2024] [Indexed: 08/05/2024]
Abstract
Achieving fluid homeostasis and the management of fluid and electrolyte complications are constants in the treatment of seriously ill children worldwide. Consensus on the most appropriate fluid strategy for unwell children has been difficult to achieve and has evolved over the last two decades, most notably in high-income countries where adverse events relating to poor fluid management were identified more readily, and official robust inquiries were possible. However, this has not been the situation in many low-income settings where fluids that are prohibited from use in high-income countries may be all that are available, local guidelines and processes to recognise adverse events are not developed, and there has been limited training on safe fluid management for front-line healthcare workers. This narrative review outlines the fluid and electrolyte pathophysiology of common febrile illnesses in children, describes the evolution of this field and concludes with implications and principles of a fluid management strategy for seriously ill children. This review was prepared as a physiological background paper to support evidence presented to the WHO Guideline Development Group for Fluid Guidelines in Children, Geneva, March 2024.
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Affiliation(s)
- Clare Ruth Smith
- Paediatric Intensive Care Unit, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Poh Chua
- Library, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Catherine Papaioannou
- Paediatric Intensive Care Unit, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Ranjana Warrier
- Paediatric Intensive Care Unit, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Gregory J G Nolan
- Paediatric Intensive Care Unit, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
| | | | - Trevor Duke
- Paediatric Intensive Care Unit, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
- Child health, School of Medicine and Health Sciences, University of Papua New Guinea, Port Moresby, Papua New Guinea
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2
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Saba L, Hanna C, Creo AL. Updates in hyponatremia and hypernatremia. Curr Opin Pediatr 2024; 36:219-227. [PMID: 38174733 DOI: 10.1097/mop.0000000000001324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
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.
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Affiliation(s)
- Leslie Saba
- Department of Pediatric and Adolescent Medicine, Mayo Clinic
| | - Christian Hanna
- Division of Pediatric Nephrology and Hypertension, Department of Pediatric and Adolescent Medicine, Mayo Clinic
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic
| | - Ana L Creo
- Division of Pediatric Endocrinology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Hayes WN, Laing E, Brown R, Silsby L, Smith L, Thomas H, Kaloyirou F, Sharma R, Griffiths J, Hume-Smith H, Marks SD, Kessaris N, Christian M, Dudley J, Shenoy M, Malina M, Muorah M, Ware N, Yadav P, Reynolds B, Bryant W, Spiridou A, Wray J, Peters MJ. A pragmatic, open-label, randomized controlled trial of Plasma-Lyte-148 versus standard intravenous fluids in children receiving kidney transplants (PLUTO). Kidney Int 2024; 105:364-375. [PMID: 37914088 PMCID: PMC10804931 DOI: 10.1016/j.kint.2023.09.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 09/07/2023] [Accepted: 09/24/2023] [Indexed: 11/03/2023]
Abstract
Acute electrolyte and acid-base imbalance is experienced by many children following kidney transplant. This is partly because doctors give very large volumes of artificial fluids to keep the new kidney working. When severe, fluid imbalance can lead to seizures, cerebral edema and death. In this pragmatic, open-label, randomized controlled trial, we randomly assigned (1:1) pediatric kidney transplant recipients to Plasma-Lyte-148 or standard of care perioperative intravenous fluids (predominantly 0.45% sodium chloride and 0.9% sodium chloride solutions). We then compared clinically significant electrolyte and acid-base abnormalities in the first 72 hours post-transplant. The primary outcome, acute hyponatremia, was experienced by 53% of 68 participants in the Plasma-Lyte-148 group and 58% of 69 participants in the standard fluids group (odds ratio 0·77 (0·34 - 1·75)). Five of 16 secondary outcomes differed with Plasma-Lyte-148: hypernatremia was significantly more frequent (odds ratio 3·5 (1·1 - 10·8)), significantly fewer changes to fluid prescriptions were made (rate ratio 0·52 (0·40-0·67)), and significantly fewer participants experienced hyperchloremia (odds ratio 0·17 (0·07 - 0·40)), acidosis (odds ratio 0·09 (0·04 - 0·22)) and hypomagnesemia (odds ratio 0·21 (0·08 - 0·50)). No other secondary outcomes differed between groups. Serious adverse events were reported in 9% of participants randomized to Plasma-Lyte-148 and 7% of participants randomized to standard fluids. Thus, perioperative Plasma-Lyte-148 did not change the proportion of children who experienced acute hyponatremia compared to standard fluids. However fewer fluid prescription changes were made with Plasma-Lyte-148, while hyperchloremia and acidosis were less common.
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Affiliation(s)
- Wesley N Hayes
- Department of Pediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK; University College London Great Ormond Street Institute of Child Health, London, UK.
| | - Emma Laing
- National Health Service Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Rosemary Brown
- National Health Service Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Laura Silsby
- National Health Service Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Laura Smith
- National Health Service Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Helen Thomas
- National Health Service Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Fotini Kaloyirou
- National Health Service Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Rupa Sharma
- National Health Service Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - James Griffiths
- National Health Service Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Helen Hume-Smith
- Department of Anesthetics, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Stephen D Marks
- Department of Pediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK; University College London Great Ormond Street Institute of Child Health, London, UK
| | - Nicos Kessaris
- Department of Transplant Surgery, Guys and St Thomas NHS Foundation Trust, London, UK
| | - Martin Christian
- Department of Pediatric Nephrology, Nottingham Children's Hospital, Nottingham, UK
| | - Jan Dudley
- Department of Pediatric Nephrology, Bristol Children's Hospital, Bristol, UK
| | - Mohan Shenoy
- Department of Pediatric Nephrology, Manchester Children's Hospital, Manchester, UK
| | - Michal Malina
- Department of Pediatric Nephrology, Great North Children's Hospital, Newcastle, UK
| | - Mordi Muorah
- Department of Pediatric Nephrology, Birmingham Children's Hospital, Birmingham, UK
| | - Nicholas Ware
- Department of Pediatric Nephrology, Evelina Childrens Hospital, London, UK
| | - Pallavi Yadav
- Department of Pediatric Nephrology, Leeds Teaching Hospitals NHS Foundation Trust, Leeds, UK
| | - Ben Reynolds
- Department of Pediatric Nephrology, Glasgow Hospital for Sick Children, Glasgow, UK
| | - William Bryant
- Department of Data Research Innovation and Virtual Environments, Great Ormond Street Hospital for Children, London, UK
| | - Anastassia Spiridou
- Department of Data Research Innovation and Virtual Environments, Great Ormond Street Hospital for Children, London, UK
| | - Jo Wray
- Department of Psychology, Great Ormond Street Hospital for Children, London, UK
| | - Mark J Peters
- University College London Great Ormond Street Institute of Child Health, London, UK; Pediatric Intensive Care Unit, Great Ormond Street Hospital for Children, London, UK
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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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Miura K, Dall'Amico R. Isotonic versus hypotonic intravenous maintenance fluid therapy: what's new? Pediatr Nephrol 2024; 39:11-13. [PMID: 37605075 DOI: 10.1007/s00467-023-06126-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 08/07/2023] [Accepted: 08/08/2023] [Indexed: 08/23/2023]
Affiliation(s)
- Kenichiro Miura
- Department of Pediatric Nephrology, Tokyo Women's Medical University, 8-1, Kawada-Cho, Shinjuku-Ku, Tokyo, Japan.
| | - Roberto Dall'Amico
- Department of Pediatrics, S. Maria Degli Angeli Hospital, Pordenone, Italy
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Lee H, Kim JT. Pediatric perioperative fluid management. Korean J Anesthesiol 2023; 76:519-530. [PMID: 37073521 PMCID: PMC10718623 DOI: 10.4097/kja.23128] [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: 02/19/2023] [Revised: 04/14/2023] [Accepted: 04/18/2023] [Indexed: 04/20/2023] Open
Abstract
The purpose of perioperative fluid management in children is to maintain adequate volume status, electrolyte level, and endocrine system homeostasis during the perioperative period. Although hypotonic solutions containing glucose have traditionally been used as pediatric maintenance fluids, recent studies have shown that isotonic balanced crystalloid solutions lower the risk of hyponatremia and metabolic acidosis perioperatively. Isotonic balanced solutions have been found to exhibit safer and more physiologically appropriate characteristics for perioperative fluid maintenance and replacement. Additionally, adding 1-2.5% glucose to the maintenance fluid can help prevent children from developing hypoglycemia as well as lipid mobilization, ketosis, and hyperglycemia. The fasting time should be as short as possible without compromising safety; recent guidelines have recommended that the duration of clear fluid fasting be reduced to 1 h. The ongoing loss of fluid and blood as well as the free water retention induced by antidiuretic hormone secretion are unique characteristics of postoperative fluid management that must be considered. Reducing the infusion rate of the isotonic balanced solution may be necessary to avoid dilutional hyponatremia during the postoperative period. In summary, perioperative fluid management in pediatric patients requires careful attention because of the limited reserve capacity in this population. Isotonic balanced solutions appear to be the safest and most beneficial choice for most pediatric patients, considering their physiology and safety concerns.
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Affiliation(s)
- Hyungmook Lee
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jin Tae Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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7
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Palmer ES, Agus MSD. Running Wide Open: Strong Evidence for Bolus Fluids Selection in Pediatric Sepsis. Crit Care Med 2023; 51:1587-1589. [PMID: 37902341 DOI: 10.1097/ccm.0000000000006010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2023]
Affiliation(s)
- Edwin S Palmer
- Division of Medical Critical Care, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA
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8
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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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Eaddy N, Watene C. Perioperative management of fluids and electrolytes in children. BJA Educ 2023; 23:273-278. [PMID: 37389277 PMCID: PMC10300462 DOI: 10.1016/j.bjae.2023.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 03/28/2023] [Indexed: 07/01/2023] Open
Affiliation(s)
- N. Eaddy
- Waikato Hospital, Hamilton, New Zealand
| | - C. Watene
- Waikato Hospital, Hamilton, New Zealand
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Soulages Arrese N, Green ML. Fluid management of the critically Ill child. Curr Opin Pediatr 2023; 35:239-244. [PMID: 36472133 DOI: 10.1097/mop.0000000000001210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW This review summarizes current literature pertaining to fluid management for critically ill children. It includes an overview on crystalloid fluid used throughout the critical illness course, management of fluid output and complications with fluid overload. RECENT FINDINGS Observational paediatric studies and adult randomized trials show mixed results regarding risk of mortality and kidney injury with 0.9% saline and crystalloid fluid. A recent adult randomized trial suggests that a fluid restrictive strategy may be well tolerated in critically ill adults with septic shock, but further randomized trials are needed in paediatrics. Fluid overload has been associated with increased morbidity and mortality. Trials exploring ways to decrease fluid accumulation must be done in paediatrics. SUMMARY Additional high-quality studies are needed to precisely define the type, timing and rate of intravenous fluid critically ill children should receive throughout their clinical illness course.
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Affiliation(s)
- Natalia Soulages Arrese
- University of Texas Southwestern Medical Center, Department of Pediatrics, Division of Critical Care Medicine, Dallas, Texas, USA
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Dyer C. Paediatrician who tried to hide cause of child's death from hyponatraemia 26 years ago is struck off. BMJ 2022; 379:o2746. [PMID: 36375831 DOI: 10.1136/bmj.o2746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Formeck CL, Siripong N, Joyce EL, Ayus JC, Kellum JA, Moritz ML. Association of early hyponatremia and the development of acute kidney injury in critically ill children. Pediatr Nephrol 2022; 37:2755-2763. [PMID: 35211792 PMCID: PMC9399308 DOI: 10.1007/s00467-022-05478-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 01/21/2022] [Accepted: 01/24/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND Hyponatremia is an independent prognostic factor for mortality; however, the reason for this remains unclear. An observed relationship between hyponatremia and the development of acute kidney injury (AKI) has been reported in certain disease states, but hyponatremia has not been evaluated as a predictor of AKI in critically ill patients or children. METHODS This is a single-center retrospective cohort study of critically ill children admitted to a tertiary care center. We performed regression analysis to assess the association between hyponatremia at ICU admission and the development of new or worsening stage 2 or 3 (severe) AKI on days 2-3 following ICU admission. RESULTS Among the 5057 children included in the study, early hyponatremia was present in 13.3% of children. Severe AKI occurred in 9.2% of children with hyponatremia compared to 4.5% of children with normonatremia. Following covariate adjustment, hyponatremia at ICU admission was associated with a 75% increase in the odds of developing severe AKI when compared to critically ill children with normonatremia (aOR 1.75, 95% CI 1.28-2.39). Evaluating sodium levels continuously, for every 1 mEq/L decrease in serum sodium level, there was a 0.05% increase in the odds of developing severe AKI (aOR 1.05, 95% CI 1.02-1.08). Hyponatremic children who developed severe AKI had a higher frequency of kidney replacement therapy, AKI or acute kidney disease at hospital discharge, and hospital mortality when compared to those without. CONCLUSIONS Hyponatremia at ICU admission is associated with the development of new or worsening AKI in critically ill children. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Cassandra L Formeck
- Division of Nephrology, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA.
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, USA.
| | - Nalyn Siripong
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Emily L Joyce
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, USA
- Division of Nephrology, Department of Pediatrics, University Hospitals Rainbow Babies & Children's Hospital, Cleveland, OH, USA
| | - Juan C Ayus
- School of Medicine, University of California, Irvine, CA, USA
| | - John A Kellum
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15261, USA
| | - Michael L Moritz
- Division of Nephrology, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
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Pérez-Moreno J, Gutiérrez-Vélez A, Torres Soblechero L, González Martínez F, Toledo Del Castillo B, Vierge Hernán E, Rodríguez-Fernández R. Do we overestimate intravenous fluid therapy needs? Adverse effects related to isotonic solutions during pediatric hospital admissions. Nefrologia 2022; 42:688-695. [PMID: 36907718 DOI: 10.1016/j.nefroe.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 06/21/2021] [Indexed: 06/18/2023] Open
Abstract
INTRODUCTION Maintenance intravenous fluids are frequently used in hospitalised pediatric patients. The aim of the study was to describe the adverse effects of isotonic fluid therapy in hospitalised patients, and its prevalence based on the rate of infusion. MATERIALS AND METHODS A prospective clinical observational study was designed. We included hospitalised patients between 3 months-old and 15-years-old were included with 0,9% isotonic solutions with 5% glucose within the first 24 h of administration. They were divided into two groups, depending on the quantity of liquid they received (restricted <100% vs 100% maintenance needs). Clinical data and laboratory findings were recorded in two different times (T0 when they were admitted to hospital and T1 within the first 24 h of administration). RESULTS The study included 84 patients, 33 received <100% maintenance needs and 51 patients received around 100%. The main adverse effects notified in the first 24 h of administration were hyperchloremia >110 mEq/L (16.6%) and oedema (19%). Oedema was more frequent in patients with lower age (p < 0,01). The hyperchloremia at 24 h of intravenous fluids was an independent risk factor of developing oedema (OR 1,73 (1,0-3,8), p = 0,06). CONCLUSION The use of isotonic fluids is not free from adverse effects, probably related to the rate of infusion and more likely to appear in infants. It`s necessary more studies that review the correct estimation of intravenous fluid needs in hospitalized children.
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Affiliation(s)
- Jimena Pérez-Moreno
- Hospitalización de Pediatría, Servicio de Pediatría y sus Áreas Específicas, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
| | - Ana Gutiérrez-Vélez
- Hospitalización de Pediatría, Servicio de Pediatría y sus Áreas Específicas, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Laura Torres Soblechero
- Hospitalización de Pediatría, Servicio de Pediatría y sus Áreas Específicas, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Felipe González Martínez
- Hospitalización de Pediatría, Servicio de Pediatría y sus Áreas Específicas, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Blanca Toledo Del Castillo
- Hospitalización de Pediatría, Servicio de Pediatría y sus Áreas Específicas, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Eva Vierge Hernán
- Hospitalización de Pediatría, Servicio de Pediatría y sus Áreas Específicas, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Rosa Rodríguez-Fernández
- Hospitalización de Pediatría, Servicio de Pediatría y sus Áreas Específicas, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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Dogra S, Malik MA, Peters NJ, Samujh R. Postoperative hyponatremia in neonates with esophageal atresia and tracheoesophageal fistula receiving restricted hypotonic fluids. ANNALS OF PEDIATRIC SURGERY 2022; 18:72. [PMID: 36158253 PMCID: PMC9489262 DOI: 10.1186/s43159-022-00197-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 06/30/2022] [Indexed: 11/22/2022] Open
Abstract
Background During the postoperative course following neonatal surgery, several stimuli like respiratory distress, pain, and stress cause the release of the antidiuretic hormone which can induce hyponatremia. This hyponatremia due to syndrome of inappropriate antidiuretic hormone secretion (SIADH) in neonates can lead to neurologic impairment and in severe cases can cause significant morbidity and mortality. Lung involvement in neonates undergoing TEF makes this subset of patients vulnerable to this entity because most of them are sick and require ventilation in the postoperative period. The incidence of postoperative hyponatremia following neonatal surgery has not been studied vastly. To the best of our knowledge, this is the first prospective study that has analyzed the incidence of postoperative hyponatremia in this vulnerable population. Methods Prospective observational study to assess the incidence of postoperative hyponatremia in neonates with esophageal atresia and tracheoesophageal fistula (EA and TEF) receiving restricted hypotonic fluids. As per the unit policy N/4 5% D is given in the postoperative period. Most neonatal units follow a protocol in which fluid is hiked daily to reach 150 ml/kg/day in 5–7 days. However, in our neonatal surgical unit a protocol to restrict the maintenance fluid at 100 ml/kg/day irrespective of day of life is followed. Results Out of a total of 90 neonates (270 sodium measurements), we identified 16 with hyponatremia (11%). Most of the neonates had mild hyponatremia(130–135 meq/l). The incidence of moderate and severe hyponatremia was low. Conclusion Postoperative restriction of fluids especially in neonates who are at a high risk for developing SIADH can lead to decreased incidence of severe hyponatremia.
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15
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Morice C, Alsohime F, Mayberry H, Tume LN, Brossier D, Valla FV. Intravenous maintenance fluid therapy practice in the pediatric acute and critical care settings: a European and Middle Eastern survey. Eur J Pediatr 2022; 181:3163-3172. [PMID: 35503578 DOI: 10.1007/s00431-022-04467-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 03/21/2022] [Accepted: 04/05/2022] [Indexed: 11/25/2022]
Abstract
The ideal fluid for intravenous maintenance fluid therapy (IV-MFT) in acutely and critically ill children is controversial, and evidence-based clinical practice guidelines are lacking and current prescribing practices remain unknown. We aimed to describe the current practices in prescribing IV-MFT in the context of acute and critically ill children with regard to the amount, tonicity, composition, use of balanced fluids, and prescribing strategies in various clinical contexts. A cross-sectional electronic 27-item survey was emailed in April-May 2021 to pediatric critical care physicians across European and Middle East countries. The survey instrument was developed by an expert multi-professional panel within the European Society of Pediatric and Neonatal Intensive Care (ESPNIC). A total of 154 respondents from 35 European and Middle East countries participated (response rate 64%). Respondents were physicians in charge of acute or critically ill children. All respondents indicated they routinely use a predefined formula to prescribe the amount of IV-MFT and considered fluid balance monitoring very important in the management of acute and critically ill children. The use of balanced solution was preferred if there were altered serum sodium and chloride levels or metabolic acidosis. Just under half (42%, 65/153) of respondents believed balanced solutions should always be used. Respondents considered the use of isotonic IV solutions as important for acute and critically ill children. In terms of the indication and the composition of IV-MFT prescribed, responses were heterogeneous among centers. Almost 70% (107/154) respondents believed there was a gap between current practice and what they considered ideal IV-MFT due to a lack of guidelines and inadequate training of healthcare professionals. Conclusions: Our study showed considerable variability in clinical prescribing practice of IV-MFT in acute pediatric settings across Europe and the Middle East. There is an urgent need to develop evidence-based guidelines for IV-MFT prescription in acute and critically ill children. What is Known: • The administration of maintenance intravenous fluid therapy is a standard of care for a lot of hospitalized children • Maintenance intravenous fluid therapy prescriptions are often based on Holliday and Segar's historical guidelines even if this practice has been associated with several complications. What is New: • This study provided information on the prescribing practice regarding fluid restriction, fluid tonicity, and balance. • This study showed considerable variability in clinical prescribing practice of intravenous maintenance fluid therapy across Europe and the Middle East.
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Affiliation(s)
- Claire Morice
- Pediatric and Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital of Geneva, Geneva, Switzerland
| | - Fahad Alsohime
- Pediatric Department, College of Medicine, King Saud University, Riyadh, Saudi Arabia.,Pediatric Critical Care Unit, Pediatric Department, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Huw Mayberry
- Pediatric Intensive Care Unit, Alder Hey Children's Hospital, Liverpool, UK
| | - Lyvonne N Tume
- Pediatric Intensive Care Unit, Alder Hey Children's Hospital, Liverpool, UK.,School of Health & Society, University of Salford, Manchester, UK
| | - David Brossier
- Pediatric Intensive Care Unit, CHU de Caen, 14000, Caen, France. .,Medical School, Université Caen Normandie, 14000, Caen, France.
| | - Frederic V Valla
- School of Health & Society, University of Salford, Manchester, UK.,Pediatric Intensive Care Unit, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, 69500, Lyon, France
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16
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Hayes W, Marshall A, Sutcliffe A, Peters M, Cathie K. Brief Report: Intravenous fluid prescribing and complications in children in the UK and Ireland. Acta Paediatr 2022; 111:1450-1451. [PMID: 35170788 DOI: 10.1111/apa.16295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 02/11/2022] [Accepted: 02/14/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Wesley Hayes
- Great Ormond Street Hospital London UK
- University College London Great Ormond Street Institute of Child Health London UK
| | - Andrew Marshall
- Oxford Children’s Hospital Oxford University Hospitals NHS Foundation Trust Oxford UK
| | - Alastair Sutcliffe
- Great Ormond Street Hospital London UK
- University College London Great Ormond Street Institute of Child Health London UK
| | - Mark Peters
- Great Ormond Street Hospital London UK
- University College London Great Ormond Street Institute of Child Health London UK
| | - Katrina Cathie
- University Hospital Southampton NHS Foundation Trust Southampton UK
- University of Southampton Southampton UK
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17
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Dyer C. Doctor is struck off for dishonesty over child's death in 1995. BMJ 2022; 377:o1558. [PMID: 35738578 DOI: 10.1136/bmj.o1558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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18
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Arshad MF, Iqbal A, Weeks J, Fonseca I, Munir A, Bennet W. Hypertonic saline for severe symptomatic hyponatraemia: real-world findings from the UK. Endocr Connect 2022; 11:e220007. [PMID: 35521799 PMCID: PMC9175607 DOI: 10.1530/ec-22-0007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 04/22/2022] [Indexed: 11/08/2022]
Abstract
Objective To evaluate 'real-world' safety and efficacy of the European Society of Endocrinology guidelines for the treatment of severe symptomatic hyponatraemia using hypertonic saline (HTS). Design Retrospective, observational, cohort study, examining the use of HTS for severe symptomatic hyponatraemia at Sheffield Teaching Hospitals between 2017 and 2020. Methods Patients were identified from pharmacy records and demographic, clinical, and treatment data extracted. Results Out of 112 patients (females:males = 61:51), the mean age ± s.d. was 66.3± 16.0 years and mean pre-treatment serum sodium ± s.d. was 113.8 ± 6.4 mmol/L. Overall, overcorrection rates at 24 and 48 h (>10 and >18 mmol/L) were 44.9 and 19.6%, respectively, while 19.6% of patients were treated for overcorrection. Above-target rise in sodium (>5 mmol/L) after first and second boluses was noted in 22.6 and 34.6% of patients, respectively. In-hospital and 12-month mortality was 7.1 and 18.7%, respectively, with no cases of osmotic demyelination. The mean venous blood gas (VBG) sodium was 1.9 mmol/L lower than paired serum sodium (n = 36) (113.6 ± 6.6 vs 115.7 ± 7.8 mmol/L). Conclusion We report real-world data demonstrating that a significant number of patients overcorrected using current guidelines. Also, several patients had above-target rise in sodium after one bolus of HTS, and sodium measurement should be considered before the second bolus unless ongoing severe symptoms persist. A point of care VBG sodium concentration was useful for this purpose. In addition to careful monitoring, a cautious but anticipatory overcorrection prevention strategy should be considered in the first 24 h.
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Affiliation(s)
- Muhammad Fahad Arshad
- Department of Diabetes and Endocrinology, Sheffield Teaching Hospitals, Sheffield, UK
- Department of Oncology and Metabolism, The Medical School, The University of Sheffield, Sheffield, UK
| | - Ahmed Iqbal
- Department of Diabetes and Endocrinology, Sheffield Teaching Hospitals, Sheffield, UK
- Department of Oncology and Metabolism, The Medical School, The University of Sheffield, Sheffield, UK
| | - James Weeks
- Department of Diabetes and Endocrinology, Sheffield Teaching Hospitals, Sheffield, UK
| | - Ines Fonseca
- Department of Diabetes and Endocrinology, Sheffield Teaching Hospitals, Sheffield, UK
| | - Alia Munir
- Department of Diabetes and Endocrinology, Sheffield Teaching Hospitals, Sheffield, UK
| | - William Bennet
- Department of Diabetes and Endocrinology, Sheffield Teaching Hospitals, Sheffield, UK
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Heinz AT, Eichholz T, Queudeville M, Hartmann U, Ott A, Heinzel O, Handgretinger R, Ebinger M. Introducing isotonic fluids into pediatric oncology. Pediatr Hematol Oncol 2022; 39:357-364. [PMID: 34752206 DOI: 10.1080/08880018.2021.1996494] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Objective: Hypotonic fluids are commonly used in pediatric oncology despite evidence that these fluids can lead to hospital-acquired hyponatremia. This practice is most likely due to lack of data evaluating risks and benefits of isotonic fluids in pediatric oncology. To address this issue, our study investigates the effects of exchanging hypotonic fluids with isotonic fluids in a large pediatric oncology unit. Study Design: Prevalence of laboratory disorders before and after the change to balanced, isotonic fluids for all patients are compared in this retrospective analysis. Disturbances in electrolyte levels, fluid-, acid-base balance and kidney function were examined. Results: The rate of hyponatremia was reduced using isotonic fluids. There were no hypernatremic events. Volume overload might increase the use of furosemide when using isotonic fluids. Potassium and bivalent cation levels increased. The risk of acidosis is greatly reduced, whereas alkalosis was more frequent due to furosemide use. The rate of acute kidney injury did not increase. Conclusion: Using isotonic fluids for hyper-hydration in pediatric oncology lead to a modest reduction of hospital-acquired hyponatremia without causing hypernatremia, but the effects on fluid balance need further investigation. The additional intake of bivalent cations and buffering anions in balanced fluids has measurable effects.
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Affiliation(s)
- Amadeus T Heinz
- Department of Hematology and Oncology, University Children's Hospital Tübingen, Tübingen, Germany
| | - Thomas Eichholz
- Department of Hematology and Oncology, University Children's Hospital Tübingen, Tübingen, Germany
| | - Manon Queudeville
- Department of Hematology and Oncology, University Children's Hospital Tübingen, Tübingen, Germany
| | - Ulrike Hartmann
- University Pharmacy, University Children's Hospital Tübingen, Tübingen, Germany
| | - Alexandra Ott
- Department of Hematology and Oncology, University Children's Hospital Tübingen, Tübingen, Germany
| | - Oliver Heinzel
- Department of Hematology and Oncology, University Children's Hospital Tübingen, Tübingen, Germany
| | - Rupert Handgretinger
- Department of Hematology and Oncology, University Children's Hospital Tübingen, Tübingen, Germany
| | - Martin Ebinger
- Department of Hematology and Oncology, University Children's Hospital Tübingen, Tübingen, Germany
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Hayes W, Laing E, Foley C, Pankhurst L, Thomas H, Hume-Smith H, Marks S, Kessaris N, Bryant WA, Spiridou A, Wray J, Peters MJ. Multicentre randomised controlled trial: protocol for Plasma-Lyte Usage and Assessment of Kidney Transplant Outcomes in Children (PLUTO). BMJ Open 2022; 12:e055595. [PMID: 35288387 PMCID: PMC8921856 DOI: 10.1136/bmjopen-2021-055595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Acute electrolyte and acid-base imbalance is experienced by many children following kidney transplantation. When severe, this can lead to complications including seizures, cerebral oedema and death. Relatively large volumes of intravenous fluid are administered to children perioperatively in order to establish perfusion to the donor kidney, the majority of which are from living and deceased adult donors. Hypotonic intravenous fluid is commonly used in the post-transplant period due to clinicians' concerns about the sodium, chloride and potassium content of isotonic alternatives when administered in large volumes.Plasma-Lyte 148 is an isotonic, balanced intravenous fluid that contains sodium, chloride, potassium and magnesium with concentrations equivalent to those of plasma. There is a physiological basis to expect that Plasma-Lyte 148 will reduce the incidence of clinically significant electrolyte and acid-base abnormalities in children following kidney transplantation compared with current practice.The aim of the Plasma-Lyte Usage and Assessment of Kidney Transplant Outcomes in Children (PLUTO) trial was to determine whether the incidence of clinically significantly abnormal plasma electrolyte levels in paediatric kidney transplant recipients will be different with the use of Plasma-Lyte 148 compared with intravenous fluid currently administered. METHODS AND ANALYSIS PLUTO is a pragmatic, open-label, randomised controlled trial comparing Plasma-Lyte 148 to current care in paediatric kidney transplant recipients, conducted in nine UK paediatric kidney transplant centres.A total of 144 children receiving kidney transplants will be randomised to receive either Plasma-Lyte 148 (the intervention) intraoperatively and postoperatively, or current fluid. Apart from intravenous fluid composition, all participants will receive standard clinical transplant care.The primary outcome measure is acute hyponatraemia in the first 72 hours post-transplant, defined as laboratory plasma sodium concentration of <135 mmol/L. Secondary outcomes include symptoms of acute hyponatraemia, other electrolyte and acid-base imbalances and transplant kidney function.The primary outcome will be analysed using a logistic regression model adjusting for donor type (living vs deceased donor), patient weight (<20 kg vs ≥20 kg pretransplant) and transplant centre as a random effect. ETHICS AND DISSEMINATION The trial received Health Research Authority approval on 20 January 2020. Findings will be presented to academic groups via national and international conferences and peer-reviewed journals. The patient and public involvement group will play an important part in disseminating the study findings to the public domain. TRIAL REGISTRATION NUMBERS 2019-003025-22 and 16586164.
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Affiliation(s)
- Wesley Hayes
- Department of Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- Institute of Child Health, University College London, London, UK
| | - Emma Laing
- Clinical Trials Unit, NHS Blood and Transplant, Cambridge, UK
| | - Claire Foley
- Clinical Trials Unit, NHS Blood and Transplant, Cambridge, UK
| | - Laura Pankhurst
- Clinical Trials Unit, NHS Blood and Transplant, Cambridge, UK
| | - Helen Thomas
- Clinical Trials Unit, NHS Blood and Transplant, Cambridge, UK
| | - Helen Hume-Smith
- Institute of Child Health, University College London, London, UK
| | - Stephen Marks
- Department of Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- Institute of Child Health, University College London, London, UK
| | - Nicos Kessaris
- Department of Nephrology and Transplantation, Guy's Hospital, London, UK
| | - William A Bryant
- Digital Research, Informatics and Virtual Environments Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Anastassia Spiridou
- Digital Research, Informatics and Virtual Environments Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Jo Wray
- Department of Health Psychology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Mark J Peters
- Institute of Child Health, University College London, London, UK
- Paediatric Intensive Care Unit, Great Ormond Street Hospital For Children NHS Trust, London, UK
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21
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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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22
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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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23
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Influence of Hyponatremia on Spinal Bone Quality and Fractures Due to Low-Energy Trauma. Medicina (B Aires) 2021; 57:medicina57111224. [PMID: 34833442 PMCID: PMC8619985 DOI: 10.3390/medicina57111224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 11/04/2021] [Accepted: 11/08/2021] [Indexed: 11/16/2022] Open
Abstract
Background and Objectives: Hyponatremia is the most common electrolyte disorder in elderly and associated with increased risk of falls. Clinical studies as well as small animal experiments suggested an association between chronic hyponatremia and osteoporosis. Furthermore, it has been assumed that subtle hyponatremia may be an independent fracture risk in the elderly. Therefore, this study was designed to evaluate the possible influence of chronic hyponatremia on osteoporosis and low-energy fractures of the spine. Materials and Methods: 144 patients with a vertebral body fracture (mean age: 69.15 ± 16.08; 73 females and 71 males) due to low-energy trauma were treated in a level one trauma center within one year and were included in the study. Chronic hyponatremia was defined as serum sodium < 135 mmol/L at admission. Bone mineral density (BMD) of the spine was measured using quantitative computed tomography in each patient. Results: Overall, 19.44% (n = 28) of patients in the low-energy trauma group had hyponatremia. In the group with fractures caused by low-energy trauma, the proportion of hyponatremia of patients older than 65 years was significantly increased as compared to younger patients (p** = 0.0016). Furthermore, there was no significant gender difference in the hyponatremia group. Of 28 patients with chronic hyponatremia, all patients had decreased bone quality. Four patients showed osteopenia and the other 24 patients even showed osteoporosis. In the low-energy trauma group, the BMD correlated significantly with serum sodium (r = 0.396; p*** < 0.001). Conclusions: The results suggest that chronic hyponatremia affects bone quality. Patients with chronic hyponatremia have an increased prevalence of fractures after low-energy trauma due to a decreased bone quality. Therefore, physicians from different specialties should focus on the treatment of chronic hyponatremia to reduce the fracture rate after low-energy trauma, particularly with elderly patients.
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Pérez-Moreno J, Gutiérrez-Vélez A, Torres Soblechero L, González Martínez F, Toledo del Castillo B, Vierge Hernán E, Rodríguez-Fernández R. ¿Sobreestimamos las necesidades de líquidos? Complicaciones del uso de sueros isotónicos de mantenimiento en plantas de hospitalización pediátrica. Nefrologia 2021. [DOI: 10.1016/j.nefro.2021.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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25
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Hasim N, Bakar MAA, Islam MA. Efficacy and Safety of Isotonic and Hypotonic Intravenous Maintenance Fluids in Hospitalised Children: A Systematic Review and Meta-Analysis of Randomised Controlled Trials. CHILDREN-BASEL 2021; 8:children8090785. [PMID: 34572217 PMCID: PMC8471545 DOI: 10.3390/children8090785] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 09/03/2021] [Accepted: 09/07/2021] [Indexed: 01/21/2023]
Abstract
Hyponatraemia is a known complication in hospitalised children receiving maintenance intravenous fluid. Several studies have been published to investigate the efficacy and safety of intravenous fluids in children. However, there is still an ongoing debate regarding the ideal solution to be used in the paediatric population. Therefore, the aim of this meta-analysis was to investigate the safety and efficacy of administering isotonic versus hypotonic intravenous maintenance fluid in hospitalised children. An extensive search was undertaken on PubMed, Web of Science, Scopus, ScienceDirect, Google Scholar and Cochrane Library on 28 December 2020. Only randomised controlled trials (RCTs) were included. We used the random-effects model for all analyses. Risk ratio (RR) and mean difference with 95% confidence intervals (CIs) were used for dichotomous and continuous outcomes, respectively. The quality of each study was assessed using the Joanna Briggs Institute critical appraisal tool for RCTs. This study is registered with PROSPERO (CRD42021229067). Twenty-two RCTs with a total of 3795 participants were included. The studies encompassed surgical and medical patients admitted to intensive care unit as well as to general wards. We found that hypotonic fluid significantly increases the risk of hyponatremia at both ≤24 h (RR 0.34; 95% CI: 0.26–0.43, p < 0.00001) and >24 h (RR 0.48; 95% CI: 0.36–0.64, p < 0.00001). Isotonic fluid increases the risk of hypernatraemia at ≤24 h (RR 2.15; 95% CI: 1.24–3.73, p = 0.006). The prevalence of hyponatraemia was also higher in the hypotonic group at both ≤24 h (5.7% vs. 23.3%) and >24 h (6.0% vs. 26.3%). There was no statistically significant difference in the risk of developing adverse outcomes between the two groups. Mean serum and urine sodium as well as serum osmolality/osmolarity was lower in the hypotonic group. Isotonic solution is protective against the development of hyponatraemia while hypotonic solution increases the risk of hyponatraemia.
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Affiliation(s)
- Norfarahin Hasim
- Department of Emergency Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia;
- Hospital Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia
| | - Mimi Azliha Abu Bakar
- Department of Emergency Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia;
- Hospital Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia
- Correspondence: (M.A.A.B.); or (M.A.I.)
| | - Md Asiful Islam
- Department of Haematology, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia
- Correspondence: (M.A.A.B.); or (M.A.I.)
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Al-Lawati TT, Al Jamie A. Maintenance Intravenous Fluids in Children, Should We Change? Oman Med J 2021; 36:e278. [PMID: 34267951 PMCID: PMC8254869 DOI: 10.5001/omj.2021.126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 02/17/2021] [Indexed: 11/30/2022] Open
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Denis M, Di Giacomo A, Lacotte E, Porcheret F, Letouzé N, Lauzier B, Goyer I, Brossier D. From hypotonic maintenance fluid to severe hyponatremia: a case report. J Med Case Rep 2021; 15:315. [PMID: 34099019 PMCID: PMC8183082 DOI: 10.1186/s13256-021-02889-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 05/03/2021] [Indexed: 11/16/2022] Open
Abstract
Background The principles for maintenance intravenous fluid prescription in children were developed in the 1950s. These guidelines based on the use of hypotonic solutions have been challenged regularly for they seem to be associated with an increased risk of hospital-acquired hyponatremia. Case presentation We report the case of a 4-week-old Caucasian child admitted for acute bronchiolitis who received hypotonic maintenance fluids and developed severe hyponatremia (94 mmol/L) with hyponatremic encephalopathy. Conclusion This clinical situation can serve as a reminder of the latest recommendations from the American Academy of Pediatrics regarding the use of intravenous fluids that promote the use of isotonic fluids in children.
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Affiliation(s)
- M Denis
- Pediatric Intensive Care Unit, CHU de Caen, 14000, Caen, France. .,Pediatric Intensive Care Unit, CHU de Nantes, 44000, Nantes, France. .,CNRS, INSERM, l'institut du thorax, Université de Nantes, CHU Nantes, 44000, Nantes, France. .,Service de reanimation pédiatrique, CHU de Nantes, 4ème étage bâtiment HME, 38 boulevard Jean-Monnet, 44093, Nantes Cedex 1, France.
| | - A Di Giacomo
- Pediatric Intensive Care Unit, CHU de Caen, 14000, Caen, France
| | - E Lacotte
- Pediatric Intensive Care Unit, CHU de Caen, 14000, Caen, France.,Pediatric Department, CHU de Rouen, 76000, Rouen, France.,Medical School, Université de Rouen, 76000, Rouen, France
| | - F Porcheret
- Pediatric Intensive Care Unit, CHU de Caen, 14000, Caen, France.,Pediatric Nephrology, CHU de Nantes, 44000, Nantes, France
| | - N Letouzé
- Pediatric Intensive Care Unit, CHU de Caen, 14000, Caen, France
| | - B Lauzier
- Institut du thorax, INSERM, CNRS, UNIV Nantes, 44000, Nantes, France
| | - I Goyer
- Department of Pharmacy, CHU de Caen, 14000, Caen, France
| | - D Brossier
- Pediatric Intensive Care Unit, CHU de Caen, 14000, Caen, France.,Medical School, Université Caen Normandie, 14000, Caen, France
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Chromek M, Jungner Å, Rudolfson N, Ley D, Bockenhauer D, Hagander L. Hyponatraemia despite isotonic maintenance fluid therapy: a time series intervention study. Arch Dis Child 2021; 106:491-495. [PMID: 33115710 PMCID: PMC8070620 DOI: 10.1136/archdischild-2019-318555] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 09/16/2020] [Accepted: 09/19/2020] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To examine the prevalence of dysnatraemias among children admitted for paediatric surgery before and after a change from hypotonic to isotonic intravenous maintenance fluid therapy. DESIGN Retrospective consecutive time series intervention study. SETTING Paediatric surgery ward at the Children's Hospital in Lund, during a 7-year period, 2010-2017. PATIENTS All children with a blood sodium concentration measurement during the study period were included. Hypotonic maintenance fluid (40 mmol/L NaCl and 20 mmol/L KCl) was used during the first 3 years of the study (646 patients), and isotonic solution (140 mmol/L NaCl and 20 mmol/L KCl) was used during the following period (807 patients). MAIN OUTCOME MEASURES Primary outcomes were sodium concentration and occurrence of hyponatraemia (<135 mmol/L) or hypernatraemia (>145 mmol/L). RESULTS Overall, the change from hypotonic to isotonic intravenous maintenance fluid therapy was associated with a decreased prevalence of hyponatraemia from 29% to 22% (adjusted OR 0.65 (0.51-0.82)) without a significantly increased odds for hypernatraemia (from 3.4% to 4.3%, adjusted OR 1.2 (0.71-2.1)). Hyponatraemia <130 mmol/L decreased from 6.2% to 2.6%, and hyponatraemia <125 mmol/L decreased from 2.0% to 0.5%. CONCLUSIONS Routine use of intravenous isotonic maintenance fluids was associated with lower prevalence of hyponatraemia, although hyponatraemia still occurred in over 20% of patients. We propose that the composition and the volume of administered fluid need to be addressed.
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Affiliation(s)
- Milan Chromek
- Paediatric Nephrology, Paediatric Surgery, Paediatric Intensive Care, and Neonatal Care, Lund University, Skane University Hospital, Lund, Sweden
- Paediatric Nephrology, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - Åsa Jungner
- Paediatric Nephrology, Paediatric Surgery, Paediatric Intensive Care, and Neonatal Care, Lund University, Skane University Hospital, Lund, Sweden
| | - Niclas Rudolfson
- Paediatric Nephrology, Paediatric Surgery, Paediatric Intensive Care, and Neonatal Care, Lund University, Skane University Hospital, Lund, Sweden
| | - David Ley
- Paediatric Nephrology, Paediatric Surgery, Paediatric Intensive Care, and Neonatal Care, Lund University, Skane University Hospital, Lund, Sweden
| | - Detlef Bockenhauer
- University College London, Department of Renal Medicine and Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Lars Hagander
- Paediatric Nephrology, Paediatric Surgery, Paediatric Intensive Care, and Neonatal Care, Lund University, Skane University Hospital, Lund, Sweden
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Evaluation of Desmopressin in Critically Ill Patients with Hyponatremia Requiring 3% Hypertonic Saline. Am J Med Sci 2021; 361:711-717. [PMID: 33812910 DOI: 10.1016/j.amjms.2021.03.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 11/20/2020] [Accepted: 03/29/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Desmopressin (DDAVP) is often used for hyponatremia management but has been associated with increases in hospital length of stay and duration of hypertonic saline use. The purpose of this study was to evaluate hyponatremia management strategies and their effect on sodium correction in critically ill patients requiring 3% hypertonic saline (3HS). METHODS This retrospective, single-center study included critically ill patients with hyponatremia (serum sodium ≤ 125 mEq/L) receiving 3HS from May 31 2015, to May 31 2019. Patients were divided into those who received 3HS for hyponatremia management (HTS) and those who received proactive or reactive DDAVP in addition to 3HS (D-HTS). Patients in either group could receive rescue DDAVP. The primary outcome was the percentage of patients achieving goal sodium correction of 5-10 mEq/L 24 h after 3HS initiation. RESULTS Goal sodium correction was achieved in 52.5% of patients in HTS compared to 65.6% of patients in D-HTS (p = 0.21). Patients in HTS had a shorter duration of 3HS infusion (p = 0.0022) with no difference in ICU length of stay, free water intake, urine output, or serum sodium increases 12 and 24 h after receiving 3HS. Overcorrection during any 24- or 48 h period was not statistically different between groups. CONCLUSION Patients in HTS and D-HTS had similar rates of achieving goal sodium correction at 24 h. A proactive or reactive DDAVP strategy led to an increase in 3HS duration and total amount with no significant difference in rates of overcorrection. Prospective, randomized studies assessing standardized strategies for hyponatremia management and DDAVP administration are warranted.
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Nalin D. Issues and Controversies in the Evolution of Oral Rehydration Therapy (ORT). Trop Med Infect Dis 2021; 6:tropicalmed6010034. [PMID: 33809275 PMCID: PMC8005945 DOI: 10.3390/tropicalmed6010034] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 02/23/2021] [Accepted: 02/24/2021] [Indexed: 11/16/2022] Open
Abstract
The original studies demonstrating the efficacy of oral glucose-electrolytes solutions in reducing or eliminating the need for intravenous therapy to correct dehydration caused by acute watery diarrheas (AWD) were focused chiefly on cholera patients. Later research adapted the oral therapy (ORT) methodology for treatment of non-cholera AWDs including for pediatric patients. These adaptations included the 2:1 regimen using 2 parts of the original WHO oral rehydration solution (ORS) formulation followed by 1 part additional plain water, and a “low sodium” packet formulation with similar average electrolyte and glucose concentrations when dissolved in the recommended volume of water. The programmatic desire for a single ORS packet formulation has led to controversy over use of the “low sodium” formulations to treat cholera patients. This is the subject of the current review, with the conclusion that use of the low-sodium ORS to treat cholera patients leads to negative sodium balance, leading to hyponatremia and, in severe cases, particularly in pediatric cholera, to seizures and other complications of sodium depletion. Therefore it is recommended that two separate ORS packet formulations be used, one for cholera therapy and the other for non-cholera pediatric AWD.
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Affiliation(s)
- David Nalin
- Albany Medical College, Albany, NY 12208-3478, USA
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31
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Lehtiranta S, Honkila M, Kallio M, Paalanne N, Peltoniemi O, Pokka T, Renko M, Tapiainen T. Risk of Electrolyte Disorders in Acutely Ill Children Receiving Commercially Available Plasmalike Isotonic Fluids: A Randomized Clinical Trial. JAMA Pediatr 2021; 175:28-35. [PMID: 33104176 PMCID: PMC7589076 DOI: 10.1001/jamapediatrics.2020.3383] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
IMPORTANCE The use of isotonic fluid therapy is currently recommended in children, but there is limited evidence of optimal fluid therapy in acutely ill children. OBJECTIVE To evaluate the risk for electrolyte disorders, including hyponatremia, hypernatremia, and hypokalemia, and the risk of fluid retention in acutely ill children receiving commercially available plasmalike isotonic fluid therapy. DESIGN, SETTING, AND PARTICIPANTS This unblinded, randomized clinical pragmatic trial was conducted at the pediatric emergency department of Oulu University Hospital, Finland, from October 3, 2016, through April 15, 2019. Eligible study subjects (N = 614) were between 6 months and 12 years of age, required hospitalization due to an acute illness, and needed intravenous fluid therapy. Exclusion criteria included a plasma sodium concentration of less than 130 mmol/L or greater than 150 mmol/L on admission; a plasma potassium concentration of less than 3.0 mmol/L on admission; clinical need of fluid therapy with 10% glucose solution; a history of diabetes, diabetic ketoacidosis, or diabetes insipidus; a need for renal replacement therapy; severe liver disease; pediatric cancer requiring protocol-determined chemotherapy hydration; and inborn errors of metabolism. All outcomes and samples size were prespecified except those clearly marked as exploratory post hoc analyses. All analyses were intention to treat. INTERVENTIONS Acutely ill children were randomized to receive commercially available plasmalike isotonic fluid therapy (140 mmol/L of sodium and 5 mmol/L potassium in 5% dextrose) or moderately hypotonic fluid therapy (80 mmol/L sodium and 20 mmol/L potassium in 5% dextrose). MAIN OUTCOMES AND MEASURES The primary outcome was the proportion of children with any clinically significant electrolyte disorder, defined as hypokalemia less than 3.5 mmol/L, hypernatremia greater than 148 mmol/L, or hyponatremia less than 132 mmol/L during hospitalization due to acute illness. The main secondary outcomes were the proportion of children with severe hypokalemia and weight change. RESULTS There were 614 total study subjects (mean [SD] age, 4.0 [3.1] years; 315 children were boys [51%] and all 614 were Finnish speaking [100%]). Clinically significant electrolyte disorder was more common in children receiving plasmalike isotonic fluid therapy (61 of 308 patients [20%]) compared with those receiving moderately hypotonic fluid therapy (9 of 306 patients [2.9%]; 95% CI of the difference, 12%-22%; P < .001). The risk of developing electrolyte disorder was 6.7-fold greater in children receiving isotonic fluid therapy. Hypokalemia developed in 57 patients (19%) and hypernatremia developed in 4 patients (1.3%) receiving plasmalike isotonic fluid therapy. Weight change was greater in children receiving isotonic, plasmalike fluid therapy compared with those receiving mildly hypotonic fluids (mean weight gain, 279 vs 195 g; 95% CI, 16-154 g; P = .02). CONCLUSIONS AND RELEVANCE In this randomized clinical trial, commercially available plasmalike isotonic fluid therapy markedly increased the risk for clinically significant electrolyte disorders, mostly due to hypokalemia, in acutely ill children compared with previously widely used moderately hypotonic fluid therapy containing 20 mmol/L of potassium. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02926989.
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Affiliation(s)
- Saara Lehtiranta
- Department of Pediatrics and Adolescent Medicine, Oulu University Hospital, Oulu, Finland,Research Unit of Pediatrics, Dermatology, Gynecology, and Obstetrics, Medical Research Center Oulu, University of Oulu, Oulu, Finland
| | - Minna Honkila
- Department of Pediatrics and Adolescent Medicine, Oulu University Hospital, Oulu, Finland,Research Unit of Pediatrics, Dermatology, Gynecology, and Obstetrics, Medical Research Center Oulu, University of Oulu, Oulu, Finland
| | - Merja Kallio
- Department of Pediatrics and Adolescent Medicine, Oulu University Hospital, Oulu, Finland,Research Unit of Pediatrics, Dermatology, Gynecology, and Obstetrics, Medical Research Center Oulu, University of Oulu, Oulu, Finland
| | - Niko Paalanne
- Department of Pediatrics and Adolescent Medicine, Oulu University Hospital, Oulu, Finland,Research Unit of Pediatrics, Dermatology, Gynecology, and Obstetrics, Medical Research Center Oulu, University of Oulu, Oulu, Finland
| | - Outi Peltoniemi
- Department of Pediatrics and Adolescent Medicine, Oulu University Hospital, Oulu, Finland,Research Unit of Pediatrics, Dermatology, Gynecology, and Obstetrics, Medical Research Center Oulu, University of Oulu, Oulu, Finland
| | - Tytti Pokka
- Department of Pediatrics and Adolescent Medicine, Oulu University Hospital, Oulu, Finland,Research Unit of Pediatrics, Dermatology, Gynecology, and Obstetrics, Medical Research Center Oulu, University of Oulu, Oulu, Finland
| | - Marjo Renko
- Research Unit of Pediatrics, Dermatology, Gynecology, and Obstetrics, Medical Research Center Oulu, University of Oulu, Oulu, Finland,Department of Pediatrics, University of Eastern Finland, Kuopio University Hospital, Kuopio, Finland
| | - Terhi Tapiainen
- Department of Pediatrics and Adolescent Medicine, Oulu University Hospital, Oulu, Finland,Research Unit of Pediatrics, Dermatology, Gynecology, and Obstetrics, Medical Research Center Oulu, University of Oulu, Oulu, Finland,Biocenter Oulu, University of Oulu, Oulu, Finland
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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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van den Bunder FAIM, Hall NJ, van Heurn LWE, Derikx JPM. A Delphi Analysis to Reach Consensus on Preoperative Care in Infants with Hypertrophic Pyloric Stenosis. Eur J Pediatr Surg 2020; 30:497-504. [PMID: 31958865 DOI: 10.1055/s-0039-3401987] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Infantile hypertrophic pyloric stenosis (IHPS) is a common gastrointestinal condition that can lead to metabolic alkalosis and, if uncorrected, to respiratory complications. A standardized approach to correct metabolic derangements and dehydration may reduce time until pyloromyotomy while preventing potential respiratory complications. Such an evidence-based policy regarding preoperative care is absent. We aim to formulate a recommendation about preoperative care for infants with IHPS using the Delphi technique. MATERIALS AND METHODS The RAND/UCLA appropriateness method was used to reach international consensus in a panel of pediatric surgeons, pediatric anesthetists, and pediatricians. Statements on type and frequency of blood sampling, required serum concentrations before pyloromyotomy and intravenous fluid therapy, were rated online using a 9-point Likert scale. Consensus was present if the panel rated the statement appropriate/obligatory (panel median: 7-9) or inappropriate/unnecessary (panel median: 1-3) without disagreement according to the interpercentile range adjusted for symmetry formula. RESULTS Thirty-three and twenty-nine panel members completed the first and second round, respectively. Consensus was reached in 54/74 statements (73%). The panel recommended the following laboratory tests and corresponding cutoff values prior to pyloromyotomy: pH ≤7.45, base excess ≤3.5, bicarbonate <26 mmol/L, sodium ≥132 mmol/L, potassium ≥3.5 mmol/L, chloride ≥100 mmol/L, and glucose ≥4.0 mmol/L. Isotonic crystalloid with 5% dextrose and 10 to 20 mEq/L potassium should be used for fluid resuscitation. CONCLUSION Consensus is reached in an expert panel about assessment of metabolic derangements at admission, cutoff serum concentrations to be achieved prior to pyloromyotomy, and appropriate intravenous fluid regime for the correction of dehydration and metabolic derangements in infants with IHPS.
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Affiliation(s)
- Fenne A I M van den Bunder
- Department of Pediatric Surgery, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam & Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Nigel J Hall
- Department of Pediatric Surgery, University Surgery Unit, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - L W Ernest van Heurn
- Department of Pediatric Surgery, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam & Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Joep P M Derikx
- Department of Pediatric Surgery, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam & Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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Langer T, D'Oria V, Spolidoro GCI, Chidini G, Scalia Catenacci S, Marchesi T, Guerrini M, Cislaghi A, Agostoni C, Pesenti A, Calderini E. Fluid therapy in mechanically ventilated critically ill children: the sodium, chloride and water burden of fluid creep. BMC Pediatr 2020; 20:424. [PMID: 32891127 PMCID: PMC7487923 DOI: 10.1186/s12887-020-02322-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 08/25/2020] [Indexed: 12/15/2022] Open
Abstract
Background Fluid therapy is a cornerstone of pediatric intensive care medicine. We aimed at quantifying the load of water, sodium and chloride due to different fluid indications in our pediatric intensive care unit (PICU). We were particularly interested in the role of fluid creep, i.e. fluid administered mainly as the vehicle for drugs, and the association between sodium load and water balance. Methods Critically ill children aged ≤3 years and invasively ventilated for ≥48 h between 2016 and 2019 in a single tertiary center PICU were retrospectively enrolled. Need for renal replacement therapy, plasmapheresis or parenteral nutrition constituted exclusion criteria. Quantity, quality and indication of fluids administered intravenously or enterally, urinary output and fluid balance were recorded for the first 48 h following intubation. Concentrations of sodium and chloride provided by the manufacturers were used to compute the electrolyte load. Results Forty-three patients (median 7 months (IQR 3–15)) were enrolled. Patients received 1004 ± 284 ml of water daily (153 ± 36 ml/kg/day), mainly due to enteral (39%), creep (34%) and maintenance (24%) fluids. Patients received 14.4 ± 4.8 mEq/kg/day of sodium and 13.6 ± 4.7 mEq/kg/day of chloride, respectively. The majority of sodium and chloride derived from fluid creep (56 and 58%). Daily fluid balance was 417 ± 221 ml (64 ± 30 ml/kg/day) and was associated with total sodium intake (r2 = 0.49, p < 0.001). Conclusions Critically ill children are exposed, especially in the acute phase, to extremely high loads of water, sodium and chloride, possibly contributing to edema development. Fluid creep is quantitatively the most relevant fluid in the PICU and future research efforts should address this topic in order to reduce the inadvertent water and electrolyte burden and improve the quality of care of critically ill children.
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Affiliation(s)
- Thomas Langer
- Department of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy. .,Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Anestesia e Terapia Intensiva Donna-Bambino, Milan, Italy. .,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
| | - Veronica D'Oria
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Anestesia e Terapia Intensiva Donna-Bambino, Milan, Italy
| | - Giulia C I Spolidoro
- Department of Clinical Sciences and Community Health, University of Milan, 20122, Milan, Italy
| | - Giovanna Chidini
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Anestesia e Terapia Intensiva Donna-Bambino, Milan, Italy
| | - Stefano Scalia Catenacci
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Anestesia e Terapia Intensiva Donna-Bambino, Milan, Italy
| | - Tiziana Marchesi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Anestesia e Terapia Intensiva Donna-Bambino, Milan, Italy
| | - Marta Guerrini
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Anestesia e Terapia Intensiva Donna-Bambino, Milan, Italy
| | - Andrea Cislaghi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Anestesia e Terapia Intensiva Donna-Bambino, Milan, Italy
| | - Carlo Agostoni
- Department of Clinical Sciences and Community Health, University of Milan, 20122, Milan, Italy.,Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Pediatric Intermediate Care Unit, 20122, Milan, Italy
| | - Antonio Pesenti
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.,Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Edoardo Calderini
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Anestesia e Terapia Intensiva Donna-Bambino, Milan, Italy
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35
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Bowes DE, Gamble JJ, Bajwa JS. Using automated pump-delivery devices to reduce the incidence of excessive fluid administration during pediatric dental surgery: a randomized-controlled trial. Can J Anaesth 2020; 67:1535-1540. [PMID: 32761316 DOI: 10.1007/s12630-020-01776-4] [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: 02/02/2020] [Revised: 05/22/2020] [Accepted: 05/23/2020] [Indexed: 11/26/2022] Open
Abstract
PURPOSE The harms caused by excessive perioperative intravenous (IV) fluid administration are both well recognized and avoidable. The purpose of this study was to compare the incidence of excess intraoperative fluid administration in pediatric dental surgery patients when either an automated pump-delivery device or a manual gravity-drip device is used. METHODS We randomly assigned American Society of Anesthesiologists physical status I and II pediatric dental surgery patients to receive IV fluid via either a manual gravity-drip or automated pump-delivery device. Prior to each case, the attending anesthesiologist determined the target volume of maintenance IV fluid to be administered based on patient weight, estimated fluid deficits, and expected case length. The intraoperative IV fluid delivered was determined at the end of the case by the change in the IV bag weight. The primary outcome was the proportion of procedures that delivered ≥ 10% of the target IV fluid volume. RESULTS We recruited 105 children aged two to 12 yr (n = 49 in the automated pump-delivery device; n = 53 in the manual gravity-drip device). The proportion of excessive fluid administration was 8/49 (16%) in the automated pump-delivery device group compared with 33/53 (62%) in the gravity-drip group (relative risk of excessive fluid administration, 0.26; 95% confidence interval, 0.13 to 0.51; P < 0.001). CONCLUSION Intraoperative fluid administration using an automated pump-delivery device decreased the incidence of excessive IV fluid administration in pediatric dental surgery patients. TRIAL REGISTRATION www.clinicaltrials.gov (NCT03312452); registered 17 October 2017.
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Affiliation(s)
- Duncan E Bowes
- Department of Anesthesiology, Perioperative Medicine and Pain Management, Royal University Hospital, University of Saskatchewan, G525-103 Hospital Drive, Saskatoon, SK, S7N 0W8, Canada.
| | - Jonathan J Gamble
- Department of Anesthesiology, Perioperative Medicine and Pain Management, Royal University Hospital, University of Saskatchewan, G525-103 Hospital Drive, Saskatoon, SK, S7N 0W8, Canada
| | - Jagmeet S Bajwa
- Department of Anesthesiology, Perioperative Medicine and Pain Management, Royal University Hospital, University of Saskatchewan, G525-103 Hospital Drive, Saskatoon, SK, S7N 0W8, Canada
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Oli AN, Ibeabuchi MU, Enweani IB, Emencheta SC. Pharmaceutical Quality of Selected Metronidazole and Ciprofloxacin Infusions Marketed in South Eastern Nigeria. DRUG HEALTHCARE AND PATIENT SAFETY 2020; 12:103-112. [PMID: 32765114 PMCID: PMC7369296 DOI: 10.2147/dhps.s246050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 06/11/2020] [Indexed: 11/27/2022]
Abstract
Background Pharmaceutical products need to be of good quality and it is even more critical when it comes to life saving medicaments like infusions. Objective This research surveyed the quality fitness of some ciprofloxacin and metronidazole infusion samples marketed in South-eastern of Nigeria. Methods Using Official Compendial methods, microbiological quality, active pharmaceutical ingredients quantitation, pH and particle count tests were evaluated on eighty infusion bottles (from eight pharmaceutical companies) of each of the two drugs. Results Out of the sixteen brands tested, 2 metronidazole brands and 1 ciprofloxacin brand (representing 18.75% of the total 16 brands/makes) were contaminated while the remaining 13 brands (81.25%) were found sterile. The active pharmaceutical ingredients quantitative assay showed that all the brands of ciprofloxacin infusion were between the 95% and 105% limit of label claim while one metronidazole brand has <95–110% limit label claim. Six brands each of the two drugs evaluated fall below the acceptable pH range [ciprofloxacin (3.5–4.6) and metronidazole (4.8–5.2)], while the other two brands of both drugs passed the test. In the antibacterial study, Pseudomonas aeruginosa and Escherichia coli were susceptible to the ciprofloxacin (5 µg). However, Salmonella typhi recorded inhibition zone diameters within resistant and intermediate range. Peptostrepococcus spp was susceptible (at minimum inhibitory concentrations of 100 µg/mL) to all the brands of metronidazole, while none of the brands were effective on Lactobacillus spp. All the brands passed the test for particulate contamination. The particles size range was <10µm. Conclusion About eighty-one percent (81.25%) of the infusions have acceptable good microbiological quality. However, 18.75% that failed the tests is a concern knowing that these are lifesaving products.
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Affiliation(s)
- Angus Nnamdi Oli
- Department of Pharmaceutical Microbiology and Biotechnology, Faculty of Pharmaceutical Sciences, Nnamdi Azikiwe University, Awka, Anambra State, Nigeria
| | - MaryRose Ukamaka Ibeabuchi
- Department of Pharmaceutical Microbiology and Biotechnology, Faculty of Pharmaceutical Sciences, Nnamdi Azikiwe University, Awka, Anambra State, Nigeria
| | - Ifeoma Bessie Enweani
- Department of Medical Laboratory Science, Faculty of Health Sciences and Technology, Nnamdi Azikiwe University, Nnewi Campus, Nnewi, Anambra State, Nigeria
| | - Stephen Chijioke Emencheta
- Department of Pharmaceutical Microbiology and Biotechnology, Faculty of Pharmaceutical Sciences, Nnamdi Azikiwe University, Awka, Anambra State, Nigeria.,Department of Pharmaceutical Microbiology and Biotechnology, Faculty of Pharmaceutical Sciences, University of Nigeria, Nsukka, Enugu State 41001, Nigeria
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Lerner DP, Shepherd SA, Batra A. Hyponatremia in the Neurologically Ill Patient: A Review. Neurohospitalist 2020; 10:208-216. [PMID: 32549945 PMCID: PMC7271621 DOI: 10.1177/1941874419895124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Hyponatremia is a well-known disorder commonly faced by clinicians managing neurologically ill patients. Neurological disorders are often associated with hyponatremia during their acute presentation and can be associated with specific neurologic etiologies and symptoms. Patients may present with hyponatremia with traumatic brain injury, develop hyponatremia subacutely following aneurysmal subarachnoid hemorrhage, or may manifest with seizures due to hyponatremia itself. Clinicians caring for the neurologically ill patient should be well versed in identifying these early signs, symptoms, and etiologies of hyponatremia. Early diagnosis and treatment can potentially avoid neurologic and systemic complications in these patients and improve outcomes. This review focuses on the causes and findings of hyponatremia in the neurologically ill patient and discusses the pathophysiology, diagnoses, and treatment strategies for commonly encountered etiologies.
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Affiliation(s)
- David P. Lerner
- Department of Neurology, Lahey Hospital and Medical Center, Burlington, MA, USA
| | | | - Ayush Batra
- Ken & Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Kim M, Lee J, Yang S, Lee M, Chae MS, Lee H. Effect of intraoperative Hartmann's versus hypotonic solution administration on FLACC pain scale scores in children: A prospective randomized controlled trial. PLoS One 2020; 15:e0230556. [PMID: 32191766 PMCID: PMC7082008 DOI: 10.1371/journal.pone.0230556] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 03/02/2020] [Indexed: 12/04/2022] Open
Abstract
Background In healthy children, an isotonic solution containing no glucose or a small amount of glucose (1–2%) has been recommended as an intraoperative maintenance fluid due to the potential risk of hyponatremia associated with hypotonic solutions. However, a hypotonic solution with glucose is still widely used as a maintenance fluid for pediatric anesthesia. We speculated that the hypotonic solution may worsen postoperative discomfort and irritability in pediatric patients due to hyponatremia. Patients and methods In the current study, we compared the post-operative Face, Legs, Activity, Cry, Consolability(FLACC) scale scores of pediatric patients aged 3–10 years who received either a 1:2 dextrose solution or Hartmann's solution during Nuss Bar removal. Results The FLACC scale score in the post-anesthesia care unit was higher in the 1:2 dextrose solution group(HYPO) (n = 20) than in the Hartmann’s solution group(ISO) (n = 20) (6.30 vs 4.70, p = 0.044, mean difference and 95% Confidence Interval(CI) was 1.6 (0.04 to 3.16)). We also compared opioid consumption at the post-anesthesia care unit. Total dose of fentanyl per body weight in the post-anesthesia care unit was also higher in the HYPO (0.59 vs 0.37 mcg/kg, p = 0.042, mean difference and 95% CI was 0.22 mcg/kg (0.030 to 0.402)). Conclusions Intraoperative use of the hypotonic solution in children causes increased FLACC scale scores, leading to higher opioid consumption in post-anesthesia care unit.
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Affiliation(s)
- Mihyun Kim
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jiyoung Lee
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sungwon Yang
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Minsoo Lee
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Min Suk Chae
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hyungmook Lee
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- * E-mail:
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Sharma K, Sood N, Himral P, Sharma T, Kapoor D. Clinical profile of patients with hyponatremia in a tertiary care hospital in the sub-Himalayan region. J Family Med Prim Care 2020; 9:834-838. [PMID: 32318430 PMCID: PMC7113994 DOI: 10.4103/jfmpc.jfmpc_788_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 12/28/2019] [Accepted: 01/06/2020] [Indexed: 11/12/2022] Open
Abstract
Introduction: Hyponatremia, defined as a serum sodium concentration ([Na+]) <135 mEq/L. It is not a disease but rather a pathophysiologic process indicating disturbed water homeostasis. Hyponatremia should be further classified to provide directions for diagnosis and treatment. It is a heterogeneous disorder. The classifications of hyponatremia are commonly based on tonicity and volume status. The initial differentiation in hypotonic and non-hypotonic hyponatremia is important because management is different. Several studies have been conducted previously to measure the incidence of hyponatremia in medically ill patients. Several studies have demonstrated an increased prevalence of hyponatremia in the presence of co-morbid conditions. We conducted this study to bring out various causes of hyponatremia; their relation with sex, age and outcome and hyponatremia's classification and incidence in our hospitalised population. Materials and Methods: This study was conducted to find out etiology, classification, prevalence and outcome and its relation with age and sex in patients of hyponatremia admitted in our institution. A total number of 106 patients were studied. Results: Hospital-based incidence of hyponatremia was found to be 1.17%. Mean age of patients in study was 62.25 ± 17.7 years. Male to female ratio was 1.25:1. Altered sensorium was the most common neurological symptom. Ninety-five (90%) patients were hypo-osmolar. Out of ninety four patients, 38 (40%) were euvolemic. Chronic obstructive pulmonary disorder (COPD) with cor pulmonale with right-sided heart failure (n = 9, 31%) was the most common cause in hyper-volemic hyponatremia. Acute gastroenteritis (n = 13, 48%) was the most common cause in hypo-volemic hyponatremia. Syndrome of inappropriate anti-diuretic hormone secretion (SIADH) was the most common cause (n = 20, 53%) of euvolemic hyponatremia. Out of 106 patients, 11 (10.38%) patients expired. Conclusion: Hyponatremia acts as a poor prognostic marker of the primary disease. It is important to recognise it early because of the potential morbidity and mortality, economic impact on the patients and health care associated with it. Early management of hyponatremia, which includes determination of the rate of correction, the appropriate interventions and the presence of other underlying disorders, may help in improving the outcome and shortening the hospital stay of the patients.
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Hoffmann DB, Popescu C, Komrakova M, Welte L, Saul D, Lehmann W, Hawellek T, Beil FT, Dakna M, Sehmisch S. Chronic hyponatremia in patients with proximal femoral fractures after low energy trauma: A retrospective study in a level-1 trauma center. Bone Rep 2019; 12:100234. [PMID: 31909095 PMCID: PMC6940722 DOI: 10.1016/j.bonr.2019.100234] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 11/13/2019] [Accepted: 12/05/2019] [Indexed: 01/08/2023] Open
Abstract
Introduction We evaluated the prevalence and influence of chronic hyponatremia in patients with low energy trauma. We also investigated the influence of medication and diseases on hyponatremia. Material and methods This retrospective study included 314 cases of proximal femoral fracture due to low energy trauma. Patients were treated in the University Medical Center Goettingen within 3 years. Hyponatremia was defined as serum sodium <135 mmol/L at admission. Results Overall, 15.6% of patients in the low energy trauma group had hyponatremia. Among patients older than 80 years, women showed distinctly higher rates of hyponatremia (female: 16.4%; male: 5.9%). In contrast only 4.7% of patients who underwent elective hip arthroplasty showed hyponatremia. Patients on sartanes and aldosterone antagonists showed significantly higher rates of hyponatremia. Alcoholism was significantly associated with hyponatremia. Conclusions We confirmed a high prevalence of chronic hyponatremia in patients with fractures due to low energy trauma. Our data underscore chronic hyponatremia as a contributing factor to hip fractures. Women older than 80 have a higher risk of developing hyponatremia. Sartanes, aldosterone antagonists, and alcohol disease are associated with hyponatremia. Treating hyponatremia may decrease the risk of fracture after low energy trauma. Therefore, physicians of different specialties should focus on treatment of chronic hyponatremia to reduce the fracture rate associated with low energy trauma. 15.6% of patients with prox. femur fracture after low energy trauma had hyponatremia. Hyponatremia rate in group of patients before hip arthroplasty was only 4.7%. Sartanes, aldosterone antagonists, and alcohol disease are associated with hyponatremia. Women older than 80 have a higher risk of developing hyponatremia.
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Affiliation(s)
- Daniel Bernd Hoffmann
- Department of Trauma-, Orthopaedic- and Plastic Surgery, University Medical Center Goettingen, Goettingen, Germany
| | - Christian Popescu
- Department of Trauma-, Orthopaedic- and Plastic Surgery, University Medical Center Goettingen, Goettingen, Germany
| | - Marina Komrakova
- Department of Trauma-, Orthopaedic- and Plastic Surgery, University Medical Center Goettingen, Goettingen, Germany
| | - Lena Welte
- Department of Trauma-, Orthopaedic- and Plastic Surgery, University Medical Center Goettingen, Goettingen, Germany
| | - Dominik Saul
- Department of Trauma-, Orthopaedic- and Plastic Surgery, University Medical Center Goettingen, Goettingen, Germany
| | - Wolfgang Lehmann
- Department of Trauma-, Orthopaedic- and Plastic Surgery, University Medical Center Goettingen, Goettingen, Germany
| | - Thelonius Hawellek
- Department of Trauma-, Orthopaedic- and Plastic Surgery, University Medical Center Goettingen, Goettingen, Germany
| | - Frank Timo Beil
- Department of Trauma-, Orthopaedic- and Plastic Surgery, University Medical Center Goettingen, Goettingen, Germany
| | - Mohammed Dakna
- Department of Medical Statistics, University Medical Center Goettingen, Goettingen, Germany
| | - Stephan Sehmisch
- Department of Trauma-, Orthopaedic- and Plastic Surgery, University Medical Center Goettingen, Goettingen, Germany
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Bagri NK, Saurabh VK, Basu S, Kumar A. Isotonic versus Hypotonic Intravenous Maintenance Fluids in Children: A Randomized Controlled Trial. Indian J Pediatr 2019; 86:1011-1016. [PMID: 31280410 DOI: 10.1007/s12098-019-03011-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 06/06/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To compare the incidence of hyponatremia during the first 48 h in hospitalized children receiving normal saline vs. N/2 saline as maintenance intravenous fluid. METHODS This open label, randomized controlled trial to compare the incidence of hyponatremia in hospitalized children receiving normal saline (0.9% sodium chloride in 5% dextrose) vs. N/2 saline (0.45% sodium chloride in 5% dextrose) as maintenance fluid was conducted from December 2014 through November 2015 in a tertiary care teaching hospital. Children between 1 mo and 18 y requiring maintenance intravenous fluids were randomized to receive normal saline with 5% dextrose (n = 75) or N/2 saline with 5% dextrose (n = 75). RESULTS Both groups were comparable for demographic variables and illness severity at baseline. Incidence of hyponatremia at 24 h of hospitalization was comparable between normal saline and N/2 saline group, 3(4%) vs. 6(8%) cases, respectively; p value 0.494. Mean serum sodium levels were marginally higher in normal saline group (138.3 ± 6.0 mEq/L) as compared with N/2 saline group (135.1 ± 4.4 mEq/L) (p value <0.01) at 24 h of hospitalization. Incidence of hyponatremia at 48 h and hypernatremia at 24 and 48 h was comparable in two groups. CONCLUSIONS The use of either N/2 saline or normal saline in sick children at standard maintenance fluid rates is associated with low but comparable incidence of hypo or hypernatremia in first 24 h of hospitalization. Both types of fluids appear acceptable in hospitalized sick children.
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Affiliation(s)
- Narendra K Bagri
- Department of Pediatrics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Vidya K Saurabh
- Department of Pediatrics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Sriparna Basu
- Department of Pediatrics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Ashok Kumar
- Department of Pediatrics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India.
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Tandukar S, Rondon‐Berrios H. Treatment of severe symptomatic hyponatremia. Physiol Rep 2019; 7:e14265. [PMID: 31691515 PMCID: PMC6831993 DOI: 10.14814/phy2.14265] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 09/17/2019] [Accepted: 09/19/2019] [Indexed: 12/31/2022] Open
Abstract
Hyponatremia is the most common electrolyte abnormality seen in the hospital. Severe symptomatic hyponatremia is associated with grave consequences including cerebral edema, brain herniation, seizures, obtundation, coma, and respiratory arrest. However, rapid correction of chronic severe hyponatremia may lead to osmotic demyelination syndrome (ODS) and even death. Given the serious consequences of severe hyponatremia or its inadvertent overcorrection, it is of paramount importance for the clinician to be aware of the various scenarios in which hyponatremic patients can present and tailor the management strategies accordingly. We present here a case of severe hyponatremia of unknown duration with the presenting plasma sodium level of 95 mmol/L and use it to illustrate the various treatment strategies - proactive, reactive, or rescue therapy - along with the physiological basis to support these approaches.
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Affiliation(s)
- Srijan Tandukar
- Division of Transplant NephrologyThomas E. Starzl Transplant InstituteUniversity of Pittsburgh Medical CenterPittsburghPennsylvania
- Renal‐Electrolyte DivisionUniversity of Pittsburgh Medical CenterPittsburghPennsylvania
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Benzon HA, Bobrowski A, Suresh S, Wasson NR, Cheon EC. Impact of preoperative hyponatraemia on paediatric perioperative mortality. Br J Anaesth 2019; 123:618-626. [DOI: 10.1016/j.bja.2019.07.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 06/28/2019] [Accepted: 07/22/2019] [Indexed: 10/26/2022] Open
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Bibevski S, Mendoza L, Ruzmetov M, Tayon K, Alkon J, Vandale B, Scholl F. Custodiol cardioplegia solution compared to cold blood cardioplegia in pediatric cardiac surgery: a single-institution experience. Perfusion 2019; 35:316-322. [PMID: 31581896 DOI: 10.1177/0267659119878006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Custodiol is an intracellular, crystalloid cardioplegia solution that is a single-dose alternative to multi-dose cold blood cardioplegia; however, there is scarce data regarding its use in infants and children. The objective of this study was to compare its impact on myocardial function in infants. METHODS Single-center retrospective review including 132 patients <12 months old undergoing biventricular repair. There were 106 patients who received single-dose Custodiol and 27 patients who received multi-dose blood cardioplegia. Demographic and echocardiographic data were compared between the two groups. RESULTS Patients receiving Custodiol were slightly younger (100 ± 62 days) and lower weight (4.7 ± 1.3 kg) compared to 152 ± 86 days and 5.2 ± 1.3 kg for blood cardioplegia (p < 0.05). The Society of Thoracic Surgeons/European Association for Cardio-Thoracic Surgery Congenital Heart Surgery score was similar between both groups. Average cardiopulmonary bypass time was similar between both groups (Custodiol 93 ± 54 minutes vs. blood 81 ± 44 minutes, p = 0.46) as was aortic cross-clamp time (Custodiol 58 ± 33 minutes vs. cold blood 53 ± 33 minutes, p = 0.62). Pre-operative left ventricular ejection fraction was similar for blood 73 ± 8% versus Custodiol 70 ± 9%, p = 0.21. There was also no intergroup difference in left ventricular ejection fraction 24 hours post op (blood 64 ± 9% vs. Custodiol 65 ± 12%, p = 0.53) or at discharge (blood 66 ± 10% vs. Custodiol 66 ± 11%, p = 0.95). The pre-operative right ventricle function by fractional area change was also similar in blood cardioplegia (46 ± 13%) versus Custodiol (48 ± 9%, p = 0.38) and showed similar drops in parameters in the two groups 24 hours after surgery and at discharge. CONCLUSION Single-dose Custodiol is as safe as blood cardioplegia for myocardial protection in congenital cardiac surgery for the cross-clamp times evaluated in this study. Evaluation at longer cross-clamp times would be helpful to determine if there is a greater benefit to single-dose Custodiol versus more repeated doses of blood cardioplegia for longer cross-clamp times.
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Affiliation(s)
- Steven Bibevski
- Joe DiMaggio Children's Hospital Heart Institute, Hollywood, FL, USA
| | - Laura Mendoza
- Joe DiMaggio Children's Hospital Heart Institute, Hollywood, FL, USA
| | - Mark Ruzmetov
- Joe DiMaggio Children's Hospital Heart Institute, Hollywood, FL, USA
| | - Kevin Tayon
- Joe DiMaggio Children's Hospital Heart Institute, Hollywood, FL, USA
| | - Jaime Alkon
- Joe DiMaggio Children's Hospital Heart Institute, Hollywood, FL, USA
| | - Breanna Vandale
- Joe DiMaggio Children's Hospital Heart Institute, Hollywood, FL, USA
| | - Frank Scholl
- Joe DiMaggio Children's Hospital Heart Institute, Hollywood, FL, USA
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Kinlin LM, Helmers AJ, Friedman JN, Beck CE. Choice of maintenance intravenous fluids among paediatric residents in Canada. Paediatr Child Health 2019; 25:518-524. [PMID: 33354261 DOI: 10.1093/pch/pxz093] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 06/06/2019] [Indexed: 11/12/2022] Open
Abstract
Background Recent literature and guidelines support routine use of isotonic intravenous (IV) fluids for maintenance therapy in hospitalized infants and children. Current prescribing practices are unknown. Objective To elicit paediatric residents' choice of maintenance IV fluids, particularly with regard to tonicity, in a variety of clinical scenarios and patient ages. We hypothesized that residents would choose isotonic fluids in most cases, but there would be substantially more variability in fluid choice in the neonatal age group. Methods An Internet-based survey was e-mailed to trainees in the 17 paediatric residency programs across Canada, via the Canadian Paediatric Program Directors. The survey instrument included questions related to training, followed by a series of questions eliciting choice of IV fluid in a variety of clinical situations. Results A total of 147 survey responses were submitted (22% response rate). Isotonic solutions were selected by >75% across all clinical scenarios involving infants and children. Very hypotonic fluids were seldom chosen. There was more variability in fluid choice in neonates, with evidence of significant differences in fluid tonicity based on senior versus junior resident status and geographical location. Conclusions Results imply a predominance of isotonic fluid use in infants and children, suggesting that clinical practice has changed in response to risk of hyponatremia with hypotonic IV fluids. As hypothesized, there was more variability with respect to choice of maintenance fluids in neonates. This likely reflects a paucity of guidance in an age group with unique physiologic factors affecting fluid and electrolyte status.
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Affiliation(s)
- Laura M Kinlin
- Department of Paediatrics, University of Toronto, Toronto, Ontario.,Division of Paediatric Medicine and the Paediatric Outcomes Research Team (PORT), The Hospital for Sick Children, Toronto, Ontario
| | - Andrew J Helmers
- Department of Critical Care Medicine, University of Toronto, Toronto, Ontario
| | - Jeremy N Friedman
- Department of Paediatrics, University of Toronto, Toronto, Ontario.,Division of Paediatric Medicine and the Paediatric Outcomes Research Team (PORT), The Hospital for Sick Children, Toronto, Ontario
| | - Carolyn E Beck
- Department of Paediatrics, University of Toronto, Toronto, Ontario.,Division of Paediatric Medicine and the Paediatric Outcomes Research Team (PORT), The Hospital for Sick Children, Toronto, Ontario
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Storey C, Dauger S, Deschenes G, Heneau A, Baud O, Carel JC, Martinerie L. Hyponatremia in children under 100 days old: incidence and etiologies. Eur J Pediatr 2019; 178:1353-1361. [PMID: 31300884 DOI: 10.1007/s00431-019-03406-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 06/03/2019] [Accepted: 06/04/2019] [Indexed: 12/21/2022]
Abstract
Hyponatremia is one of the most common electrolyte disorders in hospitalized children. The underlying mechanisms are poorly understood and potentially multifactorial, making management difficult, particularly in neonates. This retrospective study aimed to determine the incidence and etiologies of hyponatremia in hospitalized children under the age of 100 days, in our pediatric tertiary care hospital over a 1-year period. The etiology of hyponatremia was determined by reviewing the data noted in each patient's medical reports. Neonatal hyponatremia had a prevalence of 4.3% (86/2012 patients) and was mostly hospital-acquired (74/86 patients). Fifty-nine patients (68.9%) were preterm neonates. The etiology was iatrogenic in 26 cases (30.2%). In other cases, hyponatremia was due to transient (23 patients, 26.7%) or genetic abnormalities of the renal mineralocorticoid pathway (3 patients, 3.4%), SIADH (12 patients, 14%), digestive disease (3 patients, 3.5%), acute renal failure (3 patients, 3.5%), or heart failure (1 patient, 1.2%).Conclusion: Our findings confirm that hyponatremia is a frequent electrolyte disorder in neonates. Various mechanisms underlie this condition, most of which could be prevented by optimized management. The prevalence of genetic hypoaldosteronism and pseudohypoaldosteronism was higher than expected. We provide a simple diagram to help physicians identify the mechanisms underlying neonatal hyponatremia. What is Known: • In neonates, hyponatremia may be multifactorial, making it difficult to treat. • Newborns display partial resistance to aldosterone, and preterms have a defect in aldosterone secretion. What is New: • Four percent of hospitalized neonates had hyponatremia, 86% hospital-acquired. Hyponatremia was due to a transient or constitutional defect of the mineralocorticoid pathway in 26/86 patients (30%) which is higher than expected. • We propose a tree diagram for improving the management of hyponatremia in neonates.
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Affiliation(s)
- Caroline Storey
- Assistance Publique-Hôpitaux de Paris (AP-HP), Department of Pediatric Endocrinology and Diabetology, and Centre de Référence des Maladies Endocriniennes Rares de la Croissance, Hôpital Universitaire Robert-Debré, F-75019, Paris, France.,Université Paris Diderot, Sorbonne Paris Cité, F-75019, Paris, France
| | - Stéphane Dauger
- Université Paris Diderot, Sorbonne Paris Cité, F-75019, Paris, France.,Assistance Publique-Hôpitaux de Paris (AP-HP), Service de Réanimation et surveillance continue pédiatriques, Hôpital Universitaire Robert-Debré, F-75019, Paris, France
| | - Georges Deschenes
- Université Paris Diderot, Sorbonne Paris Cité, F-75019, Paris, France.,Assistance Publique-Hôpitaux de Paris (AP-HP), Service de Néphrologie Hémodialyse, Hôpital Universitaire Robert-Debré, F-75019, Paris, France
| | - Alice Heneau
- Assistance Publique-Hôpitaux de Paris (AP-HP), Service de Réanimation néonatale et néonatologie, Hôpital Universitaire Robert-Debré, F-75019, Paris, France
| | - Olivier Baud
- Université Paris Diderot, Sorbonne Paris Cité, F-75019, Paris, France.,Assistance Publique-Hôpitaux de Paris (AP-HP), Service de Réanimation néonatale et néonatologie, Hôpital Universitaire Robert-Debré, F-75019, Paris, France.,Institut National de la Santé et de la Recherche Médicale U1141, F-75019, Paris, France
| | - Jean Claude Carel
- Assistance Publique-Hôpitaux de Paris (AP-HP), Department of Pediatric Endocrinology and Diabetology, and Centre de Référence des Maladies Endocriniennes Rares de la Croissance, Hôpital Universitaire Robert-Debré, F-75019, Paris, France.,Université Paris Diderot, Sorbonne Paris Cité, F-75019, Paris, France.,Institut National de la Santé et de la Recherche Médicale U1141, F-75019, Paris, France
| | - Laetitia Martinerie
- Assistance Publique-Hôpitaux de Paris (AP-HP), Department of Pediatric Endocrinology and Diabetology, and Centre de Référence des Maladies Endocriniennes Rares de la Croissance, Hôpital Universitaire Robert-Debré, F-75019, Paris, France. .,Université Paris Diderot, Sorbonne Paris Cité, F-75019, Paris, France. .,Institut National de la Santé et de la Recherche Médicale U1185, F-94276, Le Kremlin Bicêtre, France.
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47
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Al-Sofyani KA. Prevalence and Clinical Significance of Hyponatremia in Pediatric Intensive Care. J Pediatr Intensive Care 2019; 8:130-137. [PMID: 31404453 DOI: 10.1055/s-0038-1676635] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 11/11/2018] [Indexed: 12/17/2022] Open
Abstract
A retrospective chart review was conducted to estimate the prevalence and severity level of hyponatremia on admission at the pediatric intensive care unit (PICU) in a Saudi tertiary hospital. Hyponatremia was highly prevalent (67.2%) and severe hyponatremia was frequent among patients with Pediatric Risk of Mortality score > 10%. Severe hyponatremia was also associated with increased length of stay ( p = 0.04) and a trend of increased mortality ( p = 0.054). However, disease severity was not an independent risk factor of mortality in PICU, but might confound other risk factors that render the children requiring prolonged hospital stay, mechanical ventilation, and increased health costs.
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Affiliation(s)
- Khouloud A Al-Sofyani
- Division of Pediatric Intensive Care, Department of Pediatrics, King Abdul-Aziz University Hospital, Jeddah, Saudi Arabia
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48
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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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49
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Moritz ML, Ayus JC. Hypotonic maintenance i.v. fluids are not appropriate in acutely ill patients. Conclusions can't be extrapolated from healthy volunteers. Br J Anaesth 2019; 119:1064-1065. [PMID: 29077830 DOI: 10.1093/bja/aex376] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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50
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Lacey J, Corbett J, Forni L, Hooper L, Hughes F, Minto G, Moss C, Price S, Whyte G, Woodcock T, Mythen M, Montgomery H. A multidisciplinary consensus on dehydration: definitions, diagnostic methods and clinical implications. Ann Med 2019; 51:232-251. [PMID: 31204514 PMCID: PMC7877883 DOI: 10.1080/07853890.2019.1628352] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 03/28/2019] [Accepted: 05/28/2019] [Indexed: 01/02/2023] Open
Abstract
Background: Dehydration appears prevalent, costly and associated with adverse outcomes. We sought to generate consensus on such key issues and elucidate need for further scientific enquiry. Materials and methods: A modified Delphi process combined expert opinion and evidence appraisal. Twelve relevant experts addressed dehydration's definition, objective markers and impact on physiology and outcome. Results: Fifteen consensus statements and seven research recommendations were generated. Key findings, evidenced in detail, were that there is no universally accepted definition for dehydration; hydration assessment is complex and requires combining physiological and laboratory variables; "dehydration" and "hypovolaemia" are incorrectly used interchangeably; abnormal hydration status includes relative and/or absolute abnormalities in body water and serum/plasma osmolality (pOsm); raised pOsm usually indicates dehydration; direct measurement of pOsm is the gold standard for determining dehydration; pOsm >300 and ≤280 mOsm/kg classifies a person as hyper or hypo-osmolar; outside extremes, signs of adult dehydration are subtle and unreliable; dehydration is common in hospitals and care homes and associated with poorer outcomes. Discussion: Dehydration poses risk to public health. Dehydration is under-recognized and poorly managed in hospital and community-based care. Further research is required to improve assessment and management of dehydration and the authors have made recommendations to focus academic endeavours. Key messages Dehydration assessment is a major clinical challenge due to a complex, varying pathophysiology, non-specific clinical presentations and the lack of international consensus on definition and diagnosis. Plasma osmolality represents a valuable, objective surrogate marker of hypertonic dehydration which is underutilized in clinical practice. Dehydration is prevalent within the healthcare setting and in the community, and appears associated with increased morbidity and mortality.
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Affiliation(s)
- Jonathan Lacey
- Institute of Sport Exercise & Health, University College London, London, UK
| | - Jo Corbett
- Department of Sport & Exercise Science, University of Portsmouth, Portsmouth, UK
| | - Lui Forni
- Intensive Care Unit, Royal Surrey County Hospital, Guildford, UK
| | - Lee Hooper
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Fintan Hughes
- Institute of Sport Exercise & Health, University College London, London, UK
| | - Gary Minto
- Department of Anaesthesia, University Hospitals Plymouth, Plymouth, UK
- Peninsula School of Medicine, Plymouth, UK
| | - Charlotte Moss
- Division of Surgery & Interventional Science, University College London, London, UK
| | - Susanna Price
- Intensive Care Unit, Royal Brompton Hospital, London, UK
| | - Greg Whyte
- Research Institute for Sport & Exercise Science, Liverpool John Moores University, UK
| | - Tom Woodcock
- Formerly Consultant University Hospitals Southampton NHS Trust, Southampton, UK
| | - Michael Mythen
- Institute of Sport Exercise & Health, University College London, London, UK
| | - Hugh Montgomery
- Centre for Human Health and Performance, University College London, London, UK
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