Isotonic Fluid Administration Research Articles

Korean Society of Nephrology 2022 recommendations on controversial issues in diagnosis and management of hyponatremia.

The Korean Society for Electrolyte and Blood Pressure Research, in collaboration with the Korean Society of Nephrology, has published a clinical practice guideline (CPG) document for hyponatremia treatment. The document is based on an extensive evidence-based review of the diagnosis, evaluation, and treatment of hyponatremia with the multidisciplinary participation of representative experts in hyponatremia with methodologist support for guideline development. This CPG consists of 12 recommendations (two for diagnosis, eight for treatment, and two for special situations) based on eight detailed topics and nine key questions. Each recommendation begins with statements graded by the strength of the recommendations and the quality of the evidence. Each statement is followed by rationale supporting the recommendations. The committee issued conditional recommendations in favor of rapid intermittent bolus administration of hypertonic saline in severe hyponatremia, the use of vasopressin receptor antagonists in heart failure with hypervolemic hyponatremia, and syndrome of inappropriate antidiuresis with moderate to severe hyponatremia, the individualization of desmopressin use, and strong recommendation on the administration of isotonic fluids as maintenance fluid therapy in hospitalized pediatric patients. We hope that this CPG will provide useful recommendations in practice, with the aim of providing clinical support for shared decision-making to improve patient outcomes.

Perioperative fluid management in children: an updated review

Background: Perioperative fluid management in children has been a major topic for debate. Objectives: Our aim is to review the current evidence on perioperative fluid management in children including: type of fluid, administration rates, preoperative fluid intake and monitoring techniques. Design: Narrative review. Method: Following the PRISMA-S guidelines we performed a search (2010-March 2022) in databases Medline (through PubMed) and Cochrane Library. 4297 citations were found and screened by two independent researchers. After screening, 64 articles were withheld for our review. Results: The perioperative administration of isotonic fluids is safer than hypotonic solutions, concerning the development of hyponatremia. A balanced isotonic solution with 1-2,5% glucose should be used as perioperative maintenance IV fluid in children (1 month to 18 years). Colloids can be used in children when inadequate effect in volume correction is achieved with crystalloids. The preferred synthetic colloid for children is a third generation HES in a balanced solution. To date, most clinicians use the “4-2-1 rule” for calculating fluid rate. This may not be the optimal fluid rate, as little research has been done. Preoperative fasting for clear fluids should be limited to 1 hour, children should even be encouraged to drink up until 1 hour before induction. Respiratory variation of aortic blood flow peak velocity (ΔVpeak) with echocardiography is currently the most reliable technique for evaluating fluid responsiveness in children.

Korean Society of Nephrology 2022 Recommendations on controversial issues in diagnosis and management of hyponatremia.

The Korean Society for Electrolyte and Blood Pressure Research, in collaboration with the Korean Society of Nephrology, has published a clinical practice guideline (CPG) document for hyponatremia treatment. The document is based on an extensive evidence-based review of the diagnosis, evaluation, and treatment of hyponatremia with the multidisciplinary participation of representative experts in hyponatremia with methodologist support for guideline development. This CPG consists of 12 recommendations (two for diagnosis, eight for treatment, and two for special situations) based on eight detailed topics and nine key questions. Each recommendation begins with statements graded by the strength of the recommendations and the quality of the evidence. Each statement is followed by rationale supporting the recommendations. The committee issued conditional recommendations in favor of rapid intermittent bolus administration of hypertonic saline in severe hyponatremia, the use of vasopressin receptor antagonists in heart failure with hypervolemic hyponatremia, and syndrome of inappropriate antidiuresis with moderate to severe hyponatremia, the individualization of desmopressin use, and strong recommendation on the administration of isotonic fluids as maintenance fluid therapy in hospitalized pediatric patients. We hope that this CPG will provide useful recommendations in practice, with the aim of providing clinical support for shared decision-making to improve patient outcomes.

The Effect of Isotonic Drinks on the Body's Recovery Time After Performing the Harvard Step Test

Sport is an activity that is mostly done in the world. One of the most common problems experienced when exercising is dehydration. Dehydration occurs due to the amount of mineral fluid that is lost / out of the body so that it can cause the body to experience fatigue. During exercise or high physical activity, it has the potential to increase the pulse frequency because the higher the physical activity, the higher the increase in blood flow to supply nutrients and oxygen. The body will experience fatigue as a sign that the body has reached the limit of activity so that the body must rest. When the body rests the body will undergo a recovery process. At the time of recovery, hydration is needed to replace the body's lost minerals. While isotonic drinks have a composition similar to lost body fluids than ordinary mineral water. To determine the effect of isotonic fluid on blood pressure after doing the Harvard Step Test on recovery time, knowing the effect of isotonic fluid on pulse rate after doing the Harvard Step Test on recovery time, knowing the effect of isotonic fluid on Respiration rate after doing the Harvard Step Test on recovery time. The sig-p value of the normality test of recovery time. Respiration rate, heart rate and blood pressure with Shapiro Wilk were 0.001, 0.000 and 0.021 and 0.041, respectively, all of which were smaller than 0.05. The average value of the recovery time for the Respiratory Rate pre-test was 21.93 minutes while the average value for the recovery time for the Respiratory Rate post-test was 9.07 minutes with a sig-p value = 0.000 (p<0.05). This means that there is a significant decrease in the recovery time of the respiratory rate after administration of isotonic fluids (p = 0.000 < 0.05). The mean (average) recovery time of the pre-test Heart Rate is 21.80 minutes while the average value of the post-test Heart Rate recovery time is 9.20 minutes with a sig-p value = 0.000 (p<0.05). This means that there is a significant decrease in the recovery time of the Heart Rate after administration of isotonic fluids (p = 0.000 < 0.05). The average value of recovery time for pre-test blood pressure was 21.20 minutes while the average value of recovery time for post-test blood pressure was 9.80 minutes with sig-p = 0.000 (p<0.05). This means that there is a significant decrease in blood pressure recovery time after administration of isotonic fluids (p = 0.000 < 0.05). The average value of the recovery time for the respiratory rate pre-test was 21.03 minutes while the average value for recovery time for the respiratory rate post-test was 9.97 minutes with a sig-p value = 0.000 (p<0.05). This means that there is a significant decrease in the recovery time of the Respiration Rate after giving mineral water (p = 0.000 < 0.05). The average pre-test heart rate recovery time was 21.70 minutes while the post-test heart rate recovery time average was 10.30 minutes with sig-p = 0.000 (p<0.05). This means that there is a significant decrease in the recovery time of the Heart rate after giving mineral water (p = 0.000 < 0.05). The average value of recovery time for pre-test blood pressure was 16.27 minutes while the average value of post-test BP recovery time was 14.73 minutes with sig-p value = 0.653 (p>0.05). This means that there is no significant decrease in blood pressure recovery time after administration of mineral water (p = 0.000 < 0.05). The average value of isotonic recovery time is 36.68 minutes while the average value of mineral water recovery time is 54.32 minutes with a sig-p value = 0.001 (p<0.05).

Korean Society of Nephrology 2022 Recommendations on Controversial Issues in Diagnosis and Management of Hyponatremia.

The Korean Society for Electrolyte and Blood Pressure Research, in collaboration with the Korean Society of Nephrology, has published a clinical practice guideline (CPG) document for hyponatremia treatment. The document is based on an extensive evidence-based review of the diagnosis, evaluation, and treatment of hyponatremia with the multidisciplinary participation of representative experts in hyponatremia with methodologist support for guideline development. This CPG consists of 12 recommendations (two for diagnosis, eight for treatment, and two for special situations) based on eight detailed topics and nine key questions. Each recommendation begins with statements graded by the strength of the recommendations and the quality of the evidence. Each statement is followed by rationale supporting the recommendations. The committee issued conditional recommendations in favor of rapid intermittent bolus administration of hypertonic saline in severe hyponatremia, the use of vasopressin receptor antagonists in heart failure with hypervolemic hyponatremia, and syndrome of inappropriate antidiuresis with moderate to severe hyponatremia, the individualization of desmopressin use, and strong recommendation on the administration of isotonic fluids as maintenance fluid therapy in hospitalized pediatric patients. We hope that this CPG will provide useful recommendations in practice, with the aim of providing clinical support for shared decision-making to improve patient outcomes.

Death of an Arabian mare due to incomplete treatment of fetal maceration: a case report

Ten-year-old Arabian mare was referred to the Veterinary Teaching Hospital of Shahid Bahonar University of Kerman, central Iran, in lateral recumbency with anorexia and severe weakness. On clinical examination, the mare was depressed, tachypneic (55 breaths/min), tachycardic (50 beats/min), and had a body temperature of 36.5 °C. Stronger heart tone than normal was detectable by stethoscope and mucous membranes were hyperemic. At necropsy, a distended uterus containing a large amount of malodorous thin sanguineous exudate, inflammatory debris, and fetal bones indicated fetal maceration that previously had been diagnosed by an inexperienced clinician but had not been cured exactly. Treatment consisting of intravenous administration of isotonic fluids, anti-inflammatory agent, and antibiotic was not successful and the mare died 3 h after the onset of the treatment. The current report is the first report of fetal maceration in Arabian mares and it seems that in the present case, incomplete treatment resulted in the retained fetal materials that caused severe toxemia and death.

Association between fluid balance and survival in critically ill patients.

Although the consequences of chronic fluid retention are well known, those of iatrogenic fluid retention that occurs during critical illness have not been fully determined. Therefore, we investigated the association between fluid balance and survival in a cohort of almost 16,000 individuals who survived an intensive care unit (ICU) stay in a large, urban, tertiary medical centre. Longitudinal analysis of fluid balance at ICU discharge and 90-day post-ICU survival. Associations between fluid balance during the ICU stay, determined from the electronic bedside record, and survival were tested using Cox proportional hazard models adjusted for severity of critical illness. There were 1827 deaths in the first 90 days after ICU discharge. Compared with the lowest quartile of discharge fluid balance [median (interquartile range) -1.5 (-3.1, -0.7) L], the highest quartile [7.6 (5.7, 10.8) L] was associated with a 35% [95% confidence interval (CI) 1.13-1.61)] higher adjusted risk of death. Fluid balance was not associated with outcome amongst individuals without congestive heart failure or renal dysfunction. Amongst patients with either comorbidity, however, fluid balance was strongly associated with outcome, with the highest quartile having a 55% (95% CI 1.24-1.95) higher adjusted risk of death than the lowest quartile. Isotonic fluid balance, defined as the difference between intravenous isotonic fluid administration and urine output, was similarly associated with 90-day outcomes. Positive fluid balance at the time of ICU discharge is associated with increased risk of death, after adjusting for markers of illness severity and chronic medical conditions, particularly in patients with underlying heart or kidney disease. Restoration of euvolaemia prior to discharge may improve survival after acute illness.

Hypotonic versus Isotonic Fluids in Hospitalized Children: A Systematic Review and Meta-Analysis

To determine whether the use of hypotonic vs isotonic maintenance fluids confers an increased risk of hyponatremia in hospitalized children. A search of MEDLINE (1946 to January 2013), the Cochrane Central Registry (1991 to December 2012), Cumulative Index for Nursing and Allied Health Literature (1990 to December 2012), and Pediatric Academic Societies (2000-2012) abstracts was conducted using the terms "hypotonic fluids/saline/solutions" and "isotonic fluids/saline/solutions," and citations were reviewed using a predefined protocol. Data on the primary and secondary outcomes were extracted from original articles by 2 authors independently. Meta-analyses of the primary and secondary outcomes were performed when possible. A total of 1634 citations were screened. Ten studies (n = 893) identified as independent randomized controlled trials were included. Five studies examined subjects in the intensive care unit setting, including 4 on regular wards and 1 in a mixed setting. In hospitalized children receiving maintenance intravenous fluids, hyponatremia was seen more often in those receiving hypotonic fluids than in those receiving isotonic fluids, with an overall relative risk of 2.37 (95% CI, 1.72-3.26). Receipt of hypotonic fluids was associated with a relative risk of moderate hyponatremia (<130 mmol/L) of 6.1 (95% CI, 2.2-17.3). A subgroup analysis of hypotonic fluids with half-normal saline found a relative risk of hyponatremia of 2.42 (95% CI, 1.32-4.45). In hospitalized children in intensive care and postoperative settings, the administration of hypotonic maintenance fluids increases the risk of hyponatremia when compared with administration of isotonic fluids. For patients on general wards, insufficient data are available based on the reviewed studies, and individual risk factors must be assessed.

Hypercalcemia in the Intensive Care Unit

Hypercalcemia may be seen in a variety of clinical settings and often requires intensive management when serum calcium levels are dramatically elevated. All of the many etiologies of mild hypercalcemia can lead to severe hypercalcemia. Knowledge of the physiologic mechanisms involved in maintaining normocalcemia and basic pathophysiology is essential for making a timely diagnosis and hence prompt institution of etiology-specific therapy. The development of new medications and critical reviews of traditional therapies have changed the treatment paradigm for severe hypercalcemia, calling for a more limited role for aggressive isotonic fluid administration and furosemide and an expanded role for calcitonin and the bisphosphonates. Experimental therapies such as denosumab show promise.

Cost-effectiveness of recombinant human hyaluronidase-facilitated subcutaneous versus intravenous rehydration in children with mild to moderate dehydration

ObjectiveTo evaluate the cost-effectiveness of recombinant human hyaluronidase–facilitated subcutaneous (rHFSC) fluid administration compared to intravenous (IV) fluid administration in children with mild to moderate dehydration in the emergency department (ED). MethodsA decision analytic model was created based on the results of a controlled clinical trial that compared the administration of isotonic fluids via rHFSC or IV for rehydration. The costs were determined from the hospital’s perspective. The effectiveness unit was successful rehydration in the ED without the need for hospitalization for continued hydration. Mean estimates were determined for both the cost and effectiveness of each treatment. The incremental differences in costs and effectiveness were determined between treatments. Sensitivity analysis testing was also conducted. ResultsThe treatment success rate was 93% with rHFSC fluids and 76% for IV fluids. Across all ages, the mean cost of rHFSC fluids was $722, compared to $889 for IV fluids. The difference in effectiveness was due to the larger number of patients for whom IV access could not be established, necessitating a rescue route of administration to deliver parenteral fluids. The difference in the overall cost was primarily due to the shorter time in the ED for patients receiving rHFSC fluids versus those treated with IV fluids. The cost-effectiveness of rHFSC compared to IV was most apparent in younger patients (<3 years of age), where IV access was more difficult to obtain. ConclusionAnalysis of this clinical trial data revealed that rHFSC fluid administration demonstrated greater treatment effectiveness and cost-effectiveness than traditional IV fluid administration in the ED. The primary reasons for this were the ease of obtaining parenteral access via rHFSC in young patients (especially those under 3) where IV access is difficult, and a shorter ED stay with rHFSC fluid administration.

A Clinical Approach to the Treatment of Chronic Hypernatremia

Hypernatremia is a commonly encountered electrolyte disorder occurring in both the inpatient and outpatient settings. Community-acquired hypernatremia typically occurs at the extremes of age, whereas hospital-acquired hypernatremia affects patients of all age groups. Serum sodium concentration is linked to water homeostasis, which is dependent on the thirst mechanism, arginine vasopressin, and kidney function. Because both hypernatremia and the rate of correction of hypernatremia are associated with significant morbidity and mortality, prompt effective treatment is crucial. Chronic hypernatremia can be classified into 3 broad categories, hypovolemic, euvolemic, and hypervolemic forms, with each form having unique treatment considerations. In this teaching case, we provide a clinically based quantitative approach to the treatment of both hypervolemic and hypovolemic hypernatremia, which occurred in the same patient during the course of a prolonged illness.

Hypertonic Fluid Administration in Patients With Septic Shock

We assessed the short-term effects of hypertonic fluid versus isotonic fluid administration in patients with septic shock. This was a double-blind, prospective randomized controlled trial in a 15-bed intensive care unit. Twenty-four patients with septic shock were randomized to receive 250 mL 7.2% NaCl/6% hydroxyethyl starch (HT group) or 500 mL 6% hydroxyethyl starch (IT group). Hemodynamic measurements included mean arterial blood pressure (MAP), central venous pressure, stroke volume index, stroke volume variation, intrathoracic blood volume index, gastric tonometry, and sublingual microcirculatory flow as assessed by sidestream dark field imaging. Systolic tissue Doppler imaging velocities of the medial mitral annulus were measured using echocardiography to assess left ventricular contractility. Log transformation of the ratio MAP divided by the norepinephrine infusion rate (log MAP/NE) quantified the combined effect on both parameters. Compared with the IT group, hypertonic solution treatment resulted in an improvement in log MAP/NE (P = 0.008), as well as an increase in systolic tissue Doppler imaging velocities (P = 0.03) and stroke volume index (P = 0.017). No differences between the groups were found for preload parameters (central venous pressure, stroke volume variation, intrathoracic blood volume index) or for afterload parameters (systemic vascular resistance index, MAP). Hypertonic solution treatment decreased the need for ongoing fluid resuscitation (P = 0.046). No differences between groups were observed regarding tonometry or the sublingual microvascular variables. In patients with septic shock, hypertonic fluid administration did not promote gastrointestinal mucosal perfusion or sublingual microcirculatory blood flow in comparison to isotonic fluid. Independent of changes in preload or afterload, hypertonic fluid administration improved the cardiac contractility and vascular tone compared with isotonic fluid. The need for ongoing fluid resuscitation was also reduced.

Isotonic saline solution as maintenance intravenous fluid therapy to prevent acquired hyponatremia in hospitalized children

This review aims to evaluate if the use of hypotonic saline solutions as maintenance intravenous fluid therapy in hospitalized children increases the risk of hyponatremia, if the administration of isotonic fluids is able to protect against acquired hyponatremia and if the isotonic solutions increase the risks of deleterious effects such as hypernatremia or fluid overload. We researched the relevant literature on the PubMed (Jan 01 1969 to Jul 13 2011), EMBASE (1989 to 2011) and Cochrane Library (1989 to 2011) databases. Furthermore, references of selected studies were included. Hospitalized children are potentially at risk of developing hyponatremia and the use of hypotonic saline solutions is the main risk factor for this disease. Isotonic saline solutions have shown a protective effect against hyponatremia, and, so far, there have been no significant deleterious effects such as fluid overload, hypernatremia or phlebitis. The evidence found indicates that the traditional recommendation of Holliday and Segar to use maintenance fluid therapy for sick and hospitalized children deserves to be reconsidered due to the adverse effects found to arise from it, apart from the better results obtained by using isotonic solutions.

Hyponatremia and the syndrome of inappropriate secretion of antidiuretic hormone (SIADH)

The syndrome of inappropriate ADH secretion (SIADH), also recently referred to as the "syndrome of inappropriate antidiuresis", is an often underdiagnosed cause of hypotonic hyponatremia, resulting for instance from ectopic release of ADH in lung cancer or as a side-effect of various drugs. In SIADH, hyponatremia results from a pure disorder of water handling by the kidney, whereas external Na+ balance is usually well regulated. Despite increased total body water, only minor changes of urine output and modest edema are usually seen. Renal function and acid-base balance are often preserved, while neurological impairment may range from subclinical to life-threatening. Hypouricemia is a distinguishing feature. The major causes and clinical variants of SIADH are reviewed, with particular emphasis on iatrogenic complications and hospital-acquired hyponatremia. Effective treatment of SIADH with water restriction, aquaretics, or hypertonic saline + loop diuretics, as opposed to worsening of hyponatremia during parenteral isotonic fluid administration, underscores the importance of an early accurate diagnosis and careful follow-up of these patients.

Changes in colloid osmotic pressure as a function of anesthesia and surgery in the presence and absence of isotonic fluid administration in dogs

ObjectiveTo determine how a combination of anesthetic drugs; including pre-medication, induction agents and inhalational agents; affect colloid osmotic pressure (COP) in the presence and absence of isotonic fluid administration. Secondarily, to determine if changes in total plasma protein (TPP) correlate with COP in anesthetized patients. Study designProspective, randomized clinical study. AnimalsTen female dogs, 4 months to 4 years of age and >8 kg undergoing elective ovariohysterectomy. MethodsAll dogs were anesthetized in a similar fashion. After induction, five dogs received lactated ringer's solution (LRS) at 10 mL kg−1 hour−1 and five dogs received no fluid therapy during anesthesia. Blood samples were collected prior to pre-medication, prior to induction, immediately post-induction/prior to the inhalational agent, 30 minutes post-induction, at the time of recovery and 45 minutes post-discontinuation of inhalant. TPP and COP were measured from each sample. ResultsAdministration of fluids resulted in a decrease in COP and TPP over time that did not return to baseline by 45 minutes after recovery. Anesthesia without the administration of fluids also resulted in a significant decrease in COP over time, that was rebounding by recovery (but still significantly less than baseline). TPP had variable correlation with COP at different time points with or without fluid administration. Conclusions and clinical relevanceAnesthetic drugs alter COP similarly in the presence and absence of isotonic fluids. These changes in COP did not have a simple relationship to TPP and so the latter could not be used to predict COP in this patient population.

Hypertonic saline dextran prime reduces increased intracranial pressure during cardiopulmonary bypass in pigs.

Children and adults who develop neurologic deficits after cardiac surgery may experience cerebral ischemia during cardiopulmonary bypass. Increased intracranial pressure (ICP) may contribute to cerebral ischemia during bypass. Hypertonic saline dextran (HSD), a hyperosmotic, hyperoncotic resuscitation solution, decreases ICP in trauma resuscitation. We hypothesized that HSD would decrease ICP, reduce brain water, and reduce intravascular fluid requirements during bypass. Twelve swine were divided into two bypass groups: Group 1 (ISO = isotonic) received as prime 1 L of lactated Ringer's solution and 500 mL of 6% hydroxyethyl starch. Group 2 (HSD = hypertonic saline/dextran) received as prime 1 L of lactated Ringer's solution, 500 mL of 6% hydroxyethyl starch, and 1 mL/kg of 24% hypertonic saline/25% dextran. Normothermic bypass was instituted at 100 mL.kg-1.min-1. ICP increased significantly during bypass with ISO prime but not with HSD. Brain water in the cerebrum did not differ between groups but was reduced in the cerebellum to 75.9% +/- 1.4%. We conclude that HSD prevented any significant increase in ICP during normothermic bypass, and substantially improved fluid balance during bypass. In cardiac surgery patients in whom maintaining decreased ICP and reducing isotonic fluid administration is important, HSD may be a useful addition to the bypass prime solution.