Hypochloremia Secondary to Diuretics in Preterm Infants: Should Clinicians Pay Close Attention?

Case report: Acute severe hyponatremia-induced seizures in a newborn: a community-acquired case and literature review

Severe neonatal hyponatremia represents a critical electrolyte imbalance with potentially severe neurological outcomes, a condition rarely documented in community-acquired, full-term newborns. This report underscores a unique case of a 23-day-old, previously healthy, full-term male neonate experiencing severe hyponatremia that precipitated seizures, underscoring the urgency of prompt recognition and intervention. The neonate presented with symptoms including vomiting, groaning, chills, fixed staring, and limb tremors. Critical findings upon admission encompassed hypothermia, hypotension, tachycardia, and tachypnea accompanied by significant weight loss. The clinical presentation was marked by dehydration, lethargy, weak crying, a fixed gaze, irregular breathing, and coarse lung sounds, yet a distended abdomen, hypertonic limb movements, and recurrent seizures were observed. Immediate interventions included establishing IV access, rewarming, mechanical ventilation, seizure management, volume expansion, dopamine for circulatory support, and initiation of empirical antibiotics. Diagnostic evaluations revealed a sodium ion concentration of 105.9 mmol/L, while amplitude-integrated electroencephalography (aEEG) detected pronounced seizure activity characterized by a lack of sleep-wake rhythmicity, noticeable elevation in both the lower and upper amplitude margins, and a sustained decrease in the lower margin voltage dropping below 5 μV, presenting as sharp or serrated waveforms. The management strategy entailed rapid electrolyte normalization using hypertonic saline and sodium bicarbonate, anticonvulsant therapy, and comprehensive supportive care, with continuous aEEG monitoring until the cessation of seizures. Remarkably, by the third day, the neonate's condition had stabilized, allowing for discharge in good health 10 days post-admission. At a 16-month follow-up, the child exhibited no adverse neurological outcomes and demonstrated favorable growth and development. Our extensive review on the etiology, clinical manifestations, aEEG monitoring, characteristics of seizures induced by severe neonatal hyponatremia, treatment approaches, and the prognosis for seizures triggered by severe hyponatremia aims to deepen the understanding and enhance clinical management of this complex condition. It stresses the importance of early detection, accurate diagnosis, and customized treatment protocols to improve outcomes for affected neonates. Additionally, this review accentuates the indispensable role of aEEG monitoring in managing neonates at elevated risk for seizures. Yet, the safety and efficacy of swiftly administering hypertonic saline for correcting severe hyponatremia-induced seizures necessitate further investigation through medical research.

Acid/base balance in fortified donor human milk: An experimental study

BACKGROUND

Our goal was to quantify the pH and total acidity of human milk fortified with human milk fortifiers (HMFs), powder infant formulas, and protein additives.

METHODS

Commercial liquid HMFs and powder infant formulas were added to pasteurized pooled donor human milk in triplicate and stirred. The pH of unfortified and fortified human milk at 22, 24, 26, 27, 28, and 30 kcal/ounce (624, 680, 737, 765, 794, and 850 kcal/g, respectively) was determined using a pH meter. Phenolphthalein acidity at 24 and 30 kcal/ounce (680 and 850 kcal/g, respectively) was determined using diluted sodium hydroxide.

RESULTS

The pH of unfortified human milk increased within the first hour (6.52 ± 0.06 vs 6.62 ± 0.05, P < 0.0001). Changes in pH largely correlated with caloric density; however, directional changes varied considerably between HMFs and powder infant formulas. Two liquid HMFs demonstrated modest reductions in pH with increasing caloric density whereas one liquid HMF alkalinized human milk with increasing caloric density (analysis of variance P < 0.0001). Phenolphthalein acidity was significantly higher for five HMFs and lower for one HMF at 30 kcal/ounce (850 kcal/g) but not 24 kcal/ounce (680 kcal/g). Powder infant formulas generally increased pH with increasing caloric density (analysis of variance P < 0.0001), but no differences in phenolphthalein acidity were noted.

CONCLUSION

Changes in acid/base balancefor fortified human milk are variable and may be a consideration when selecting a fortifying agent for human milk.

Risk factors and machine learning prediction models for bronchopulmonary dysplasia severity in the Chinese population

BACKGROUND

Bronchopulmonary dysplasia (BPD) is a common chronic lung disease in extremely preterm neonates. The outcome and clinical burden vary dramatically according to severity. Although some prediction tools for BPD exist, they seldom pay attention to disease severity and are based on populations in developed countries. This study aimed to develop machine learning prediction models for BPD severity based on selected clinical factors in a Chinese population.

METHODS

In this retrospective, single-center study, we included patients with a gestational age < 32 weeks who were diagnosed with BPD in our neonatal intensive care unit from 2016 to 2020. We collected their clinical information during the maternal, birth and early postnatal periods. Risk factors were selected through univariable and ordinal logistic regression analyses. Prediction models based on logistic regression (LR), gradient boosting decision tree, XGBoost (XGB) and random forest (RF) models were implemented and assessed by the area under the receiver operating characteristic curve (AUC).

RESULTS

We ultimately included 471 patients (279 mild, 147 moderate, and 45 severe cases). On ordinal logistic regression, gestational diabetes mellitus, initial fraction of inspiration O2 value, invasive ventilation, acidosis, hypochloremia, C-reactive protein level, patent ductus arteriosus and Gram-negative respiratory culture were independent risk factors for BPD severity. All the XGB, LR and RF models (AUC = 0.85, 0.86 and 0.84, respectively) all had good performance.

CONCLUSIONS

We found risk factors for BPD severity in our population and developed machine learning models based on them. The models have good performance and can be used to aid in predicting BPD severity in the Chinese population.

Nomogram Prediction Model of Serum Chloride and Sodium Ions on the Risk of Acute Kidney Injury in Critically Ill Patients

Purpose

This study aims to investigate the effect of serum chloride and sodium ions on AKI occurrence in ICU patients, and further constructs a prediction model containing these factors to explore the predictive value of these ions in AKI.

Methods

The clinical information of patients admitted to ICU of Beijing Friendship Hospital Affiliated to Capital Medical University was collected for retrospective analysis. Logistic regression analysis was used to analyzing the influencing factors. A nomogram for predicting AKI risk was constructed with R software and validated by repeated sampling. Afterwards, the effectiveness and accuracy of the model were tested and evaluated.

Results

A total of 446 cases met the requirements of this study, of which 178 developed AKI during their stay in ICU, with an incidence rate of 39.9%. Hypernatremia, heart failure, sepsis, APACHE II score, and initial creatinine value and BE value at ICU admission before the diagnosis of AKI were identified as independent risk factors for developing AKI during ICU stay. These predictors were incorporated into the nomogram of AKI risk in critically ill patients, which was constructed by using R software. Receiver operating characteristic curve analysis was further used and showed that the area under the curve of the model was 0.7934 (95% CI 0.742–0.8447), indicating that the model had an ideal value. Finally, further evaluated its clinical effectiveness. The clinical effect curve and decision curve showed that most areas of the decision curve of this model were greater than 0, indicating that this model owned a certain clinical effectiveness.

Conclusion

The nomogram based on hypernatremia, heart failure, sepsis, APACHE II score, and initial creatinine and BE value in ICU can predict the individualized risk of AKI with satisfactory distinguishability and accuracy.

Cumulative Doses Predict the Risk of Furosemide-Induced Electrolyte Abnormalities in Critically Ill Neonates

Background

Furosemide has limited indications in the term neonates. Its use in preterm neonates is off-label. Considering the dearth of data, we carried out a retrospective study evaluating the furosemide use and its effects on the electrolyte abnormalities in critically ill neonates.

Methods

Critically ill neonates receiving at least one dose of furosemide during their stay in the NICU were recruited. The following details were obtained: demographic characteristics and furosemide details (dose, frequency, route, and duration). Urine output, body weight, serum creatinine, electrolytes (sodium, potassium, calcium, bicarbonate, chloride, and magnesium) during furosemide therapy were extracted.

Results

Ninety neonates were recruited. Elevated serum creatinine was observed in 21.1% of the patients, and electrolyte disturbances were observed in 52.2%. Those with electrolyte disturbances had significantly greater cumulative doses compared to those without [5.5 (1–34) vs 3.9 (0.9–30.2) mg/kg; p = 0.01]. Cumulative doses adjusted to body-weight were significantly lower in very preterm and extremely preterm neonates compared to late preterm category. A significant area-under-the-curve was observed for the cumulative dose (0.66; 95% CI: 0.54–0.78; p = 0.01) in predicting the risk of electrolyte abnormalities with a cut-off value of 4 mg/kg. Eight neonates received more than 10 mg/kg cumulative dose of furosemide of which one died. No significant differences were observed between the proportion of neonates with electrolyte disturbances with cumulative furosemide dose above 10 mg/kg (p = 0.3) and with mortality (p = 0.3).

Conclusion

We observed that our critically ill neonates received relatively higher cumulative doses of furosemide and electrolyte disturbances were observed in nearly half of the population. A cumulative dose of 4 mg/kg increases the risk of electrolyte abnormalities, particularly in preterm neonates. More diligence in the dose titration coupled with deprescribing and intense monitoring of all the potential adverse effects in this vulnerable population is needed.

Fluid and Electrolyte Disturbances in COVID-19 and Their Complications

The novel coronavirus disease 2019 (COVID-19) is the cause of an acute respiratory illness which has spread around the world. The virus infects the host by binding to the angiotensin-converting enzyme 2 (ACE2) receptors. Due to the presence of ACE2 receptors in the kidneys and gastrointestinal (GI) tract, kidneys and GI tract damage arising from the virus can be seen in patients and can cause acute conditions such as acute kidney injury (AKI) and digestive problems for the patient. One of the complications of kidneys and GI involvement in COVID-19 is fluid and electrolyte disturbances. The most common ones of these disorders are hyponatremia, hypernatremia, hypokalemia, hypocalcemia, hypochloremia, hypervolemia, and hypovolemia, which if left untreated, cause many problems for patients and even increase mortality. Fluid and electrolyte disturbances are more common in hospitalized and intensive care patients. Children are also at greater risk for fluid and electrolyte disturbances complications. Therefore, clinicians should pay special attention to the fluid and electrolyte status of patients. Changes in fluid and electrolyte levels can be a good indicator of disease progression.