Hypotonic Fluids Research Articles

Case Report : Severe Hypernatremia following treatment for Hyperosmolar Hyperglycaemic State : A pragmatic approach used to manage hypernatremia

The Hyperosmolar Hyperglycaemia State (HHS) is an endocrine emergency with a mortality rate between 10 and 50%. The mainstay for the treatment of this condition is vigorous IV fluid replacement with close monitoring of blood glucose, serum osmolality, and electrolytes. However, after initial resuscitation, patients can develop hypernatremia and raised serum osmolality, which have deleterious consequences. While hypernatremia in HHS can be treated with infusions of 0.45% saline or 5% dextrose, alternate measures such as intravenous (IV) hypotonic fluid infusion [e.g. 0.18% sodium chloride (NaCl) containing 4% dextrose and 0.15% potassium chloride (KCl)], or free water administration through a nasogastric (NG) tube can be used. We report the case of a 70-year-old man, who was initially admitted to a medical high care ward (MHC) with HHS, and was transferred to the ICU 72 hours later with an altered level of consciousness and severe hypernatremia. His treatment consisted in an IV hypotonic 0.18% NaCl infusion containing 4% dextrose and 0.15% KCl. He also received free water through a NG tube at a rate that was calculated to correct natremia at an average rate of 0.55 meq L-1 hr-1 over 72 hours. A multipronged approach was instituted to manage this patient, including, in addition to natremia correction, blood glucose control with insulin, appropriate IV antibiotics to treat infected foot ulcers, adequate analgesic medications, low-molecular-weight- heparin (LMWH) for thromboprophylaxis, proton- pump inhibitors, and continuation of patient’s ongoing antidepressant drugs at the time of his Glasgow Coma Score improvement. This case report demonstrates the feasibility and success of IV hypotonic fluid (0.18% NaCl - 4% dextrose - 0.15% KCl), alongside NG free water for correcting sodium levels with lower fluid volumes than would have been otherwise required if corrected with 0.45% saline. This treatment seems to be a reasonable choice for correcting sodium levels and osmolality in HHS patients who present with hypernatremia after an initial resuscitation, insofar as it avoids fluid overload and provides dextrose as an energy substrate, in addition to potassium ions. However, while correcting natremia with hypotonic fluid, other aspects of management should not be ignored.

Effect of Isotonic and Hypotonic Fluid Therapy on Serum Sodium: A Randomized Controlled Trial

There is little consensus about the type of maintenance fluid therapy and it’s the effect on serum sodium in adults. Thus, this study was conducted to assess the effect of maintenance fluid therapy on serum sodium of hospitalized patients in the intensive care unit. This randomized clinical trial was carried out on 64 patients aged 18-90 years hospitalized in the intensive care unit (ICU) of Imam Sadjad and Shahid Beheshti hospitals, Yasuj, Iran, in 2017. These patients were randomly allocated to take 2500-3000 milliliters of intravenous maintenance isotonic (0.9% saline) or hypotonic (0.45% saline) fluids daily. Blood and urine samples were taken to measure biochemical parameters before and 48 hours after the intervention. Data analyses were done by using SPSS 16 software via descriptive and analytic statistics. Twenty-eight patients in the 0.9% saline group (19 male and 9 female) and 32 patients in 0.45% saline (20 male and 12 female) completed the study. There was no significant difference between two groups in sodium (P=0.94), potassium (P=0.21), sugar (P=0.91), creatinine (P=0.21), Blood Urea Nitrogen (P=0.99), systolic (P=0.81) and diastolic (P=0.73) blood pressure, PH (P=0.27), bicarbonate (P=0.8), and urine specific gravity (P=0.73). Based on the results of this study, it was shown that the administration of maintenance hypotonic fluids has been appropriate for the patients and will not face them with the risk of hyponatremia.

Hyponatraemia despite isotonic maintenance fluid therapy: a time series intervention study

ObjectiveTo examine the prevalence of dysnatraemias among children admitted for paediatric surgery before and after a change from hypotonic to isotonic intravenous maintenance fluid therapy.DesignRetrospective consecutive time series intervention study.SettingPaediatric...

Risk of Electrolyte Disorders in Acutely Ill Children Receiving Commercially Available Plasmalike Isotonic Fluids

The use of isotonic fluid therapy is currently recommended in children, but there is limited evidence of optimal fluid therapy in acutely ill children. 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. 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. 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). 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. 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). 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. ClinicalTrials.gov identifier: NCT02926989.

Risks of severe hyponatremia in children receiving hypotonic fluids

Intravenous fluids are frequently used in hospitalized children. Hypotonic fluids have been the standard of care in pediatrics for many years. This might be explained by the empiricism of early recommendations favoring fluids with dextrose, but an insufficient amount of sodium. The risk of hyponatremia (<135mmol/L) might be increased by the occurrence of the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) in the course of common acute diseases (e.g., bronchiolitis, acute gastroenteritis, encephalitis, meningitis) in children. Severe hyponatremia (<130mmol/L) is often associated with neurologic complications leading to sequelae or even death. Over the last few years, hyponatremia induced by hypotonic fluids has been increasingly reported, and significant progress has been made in the understanding of cerebral edema and osmotic demyelination. Several randomized clinical trials have shown weak but significant evidence that isotonic fluids were superior to hypotonic solutions in preventing hyponatremia. However, clinical practices have not changed much in France, as suggested by the analysis of intravenous fluids ordered from the Assistance Publique–Hôpitaux de Paris (AP–HP) central pharmacy (PCH) in 2017. Therefore, it would be advisable that national guidelines be released under the French Health Authorities regarding the safe infusion of infants and children.

Current ESPEN Guideline Clinical Nutrition and Hydration inGeriatrics

Malnutrition, dehydration and obesity are relevant health problems with far-reaching consequences for older people. Routine screening for malnutrition and dehydration should be carried out in order to identify vulnerable and affected persons at an early stage and to be able to take timely countermeasures. In many cases, adequate nutrition and hydration can be supported by simple nursing measures and optimisation of the food and drink supply. Nutritional advice, sip feed, enteral and parenteral nutrition are further effective measures for the prevention and therapy of malnutrition. An ingestion deficiency dehydration should be diagnosed on the basis of serum osmolality and requires a rapid compensation of the deficit by hypotonic fluids - depending on the severity, in the form of drinks, subcutaneously or intravenously. Weight loss in old age should only be considered in cases of obesity with associated health problems and should be achieved by moderate energy reduction in combination with physical exercise.

Are Further Interventions Needed to Prevent and Manage Hospital-Acquired Hyponatraemia? A Nationwide Cross-Sectional Survey of IV Fluid Prescribing Practices.

Background: Hyponatraemia is associated with increased morbidity, increased mortality and is frequently hospital-acquired due to inappropriate administration of hypotonic fluids. Despite several attempts to minimise the risk, knowledge is lacking as to whether inappropriate prescribing practice continues to be a concern. Methods: A cross-sectional survey was performed in Danish emergency department physicians in spring 2019. Prescribing practices were assessed by means of four clinical scenarios commonly encountered in the emergency department. Thirteen multiple-choice questions were used to measure knowledge. Results: 201 physicians responded corresponding to 55.4% of the total population of physicians working at emergency departments in Denmark. About a quarter reported that they would use hypotonic fluids in patients with increased intracranial pressure and 29.4% would use hypotonic maintenance fluids in children, both of which are against guideline recommendations. Also, 29.4% selected the correct fluid, a 3% hypertonic saline solution, for a patient with hyponatraemia and severe neurological symptoms, which is a medical emergency. Most physicians were unaware of the impact of hypotonic fluids on plasma sodium in acutely ill patients. Conclusion: Inappropriate prescribing practices and limited knowledge of a large number of physicians calls for further interventions to minimise the risk of hospital-acquired hyponatraemia.

The Corrected Serum Sodium Concentration in Hyperglycemic Crises: Computation and Clinical Applications.

In hyperglycemia, hypertonicity results from solute (glucose) gain and loss of water in excess of sodium plus potassium through osmotic diuresis. Patients with stage 5 chronic kidney disease (CKD) and hyperglycemia have minimal or no osmotic diuresis; patients with preserved renal function and diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS) have often large osmotic diuresis. Hypertonicity from glucose gain is reversed with normalization of serum glucose ([Glu]); hypertonicity due to osmotic diuresis requires infusion of hypotonic solutions. Prediction of the serum sodium after [Glu] normalization (the corrected [Na]) estimates the part of hypertonicity caused by osmotic diuresis. Theoretical methods calculating the corrected [Na] and clinical reports allowing its calculation were reviewed. Corrected [Na] was computed separately in reports of DKA, HHS and hyperglycemia in CKD stage 5. The theoretical prediction of [Na] increase by 1.6 mmol/L per 5.6 mmol/L decrease in [Glu] in most clinical settings, except in extreme hyperglycemia or profound hypervolemia, was supported by studies of hyperglycemia in CKD stage 5 treated only with insulin. Mean corrected [Na] was 139.0 mmol/L in 772 hyperglycemic episodes in CKD stage 5 patients. In patients with preserved renal function, mean corrected [Na] was within the eunatremic range (141.1 mmol/L) in 7,812 DKA cases, and in the range of severe hypernatremia (160.8 mmol/L) in 755 cases of HHS. However, in DKA corrected [Na] was in the hypernatremic range in several reports and rose during treatment with adverse neurological consequences in other reports. The corrected [Na], computed as [Na] increase by 1.6 mmol/L per 5.6 mmol/L decrease in [Glu], provides a reasonable estimate of the degree of hypertonicity due to losses of hypotonic fluids through osmotic diuresis at presentation of DKH or HHS and should guide the tonicity of replacement solutions. However, the corrected [Na] may change during treatment because of ongoing fluid losses and should be monitored during treatment.

FRECUENCIA DE HIPONATREMIA EN PACIENTES CON GASTROENTERITIS AGUDA TRATADA CON LÍQUIDOS INTRAVENOSOS EN EL HOSPITAL DEL NIÑO DR. JOSÉ RENÁN ESQUIVEL ENERO A DICIEMBRE 2016

Introducción: La gastroenteritis aguda es una de las principales causas de morbilidad y mortalidad en la infancia. Numerosos estudios han confirmado la seguridad y eficacia de la terapia de rehidratación oral, sin embargo, la rehidratación intravenosa se continúa utilizando en escenarios donde no es posible hidratar al paciente por vía enteral. Durante la última década, se han acumulado pruebas que sugieren que la administración de un líquido de mantenimiento intravenoso hipotónico en niños hospitalizados aumenta el riesgo de hiponatremia. Objetivo general: Determinar la frecuencia de hiponatremia en pacientes con gastroenteritis que reciben soluciones salina hipotónicas en la salas Pediatría del Hospital del Niño Doctor José Renán Esquivel entre enero a diciembre del 2016. Materiales y Métodos: Realizaremos un estudio de cohorte retrospectivo, descriptivo. Examinaremos los expedientes clínicos de niños sin antecedentes patológicos previos de 1 mes a 15 años que habían ingresado a sala de pediatría del Hospital del Niño Doctor José Renán Esquivel de enero a diciembre de 2016, con diagnóstico de gastroenteritis aguda. Para la obtención de la muestra utilizamos un 95% de Confianza, la muestra obtenida fue de 190 pacientes y fue calculada utilizando el programa Epi Info versión 7.0 Resultados: No hubo diferencias significativas en el desarrollo de hiponatremia secundario al uso de soluciones salinas hipotónicas Conclusión: No se registró hiponatremia en pacientes con gastroenteritis aguda que reciben soluciones salinas hipotónicas en la salas de Pediatría del Hospital del Niño Doctor José Renán Esquivel.

Effect of Intravenous Fluid on Perioperative Plasma Sodium Concentration in Paediatric Surgical Patients

Background: There have been various publications on the risk of developing iatrogenic hyponatraemia following intravenous fluid administration in the pediatric age group. The aim of this study was to determine the suitable maintenance fluid that sustains normal plasma sodium levels in children in the perioperative period by comparing 4.3% dextrose in 0.18% saline with Ringer’s lactate when either is administered as maintenance fluid. Method: This study was carried out at the paediatric surgery unit of the Obafemi Awolowo University Teaching Hospital, Ile Ife, Nigeria between 1st September 2014 and 31st October 2015. This study is a comparative prospective study. There were 25 children in each group. One group received 4.3% dextrose in 0.18% saline, while the other group received Ringer’s lactate as maintenance fluid in the perioperative period. Serial blood and urine samples were collected before, during and after the surgery up till the first 24 hours. These samples were analyzed for sodium and creatinine concentration. Fractional excretion of sodium was calculated. Results were analyzed using SPSS software version 22. Results: There was no statistical significant difference between the two groups (p0.49) in term of age. The proportion of patients that developed hyponatraemia in the group that received hypotonic fluid was 32% (8/25), while it was 8% (2/25) in the group that received isotonic fluid (p=0.034). The patients who received Ringer’s lactate as maintenance fluid also had a higher mean plasma sodium concentration during the study. Conclusion: Ringer’s lactate was found to be a better fluid in terms of preventing hyponatraemia in children who are five years and below during the perioperative period compared to 4.3% dextrose in 0.18% normal saline.

Parenteral Fluid Therapy in Children

Parenteral fluids are commonly administered in the hospital setting. For decades, clinicians have used a standardized approach for the prescription of maintenance IV fluids. Such an approach, however, has led to concerns regarding the development of hyponatremia using hypotonic fluids, especially in settings of heightened ADH release such as hypovolemia. Compared to balanced solutions for IV fluid administration, normal saline use has led to separate concerns regarding the development of hyperchloremic metabolic acidosis and acute kidney injury. A number of randomized controlled trials have shown lower rates of hyponatremia using isotonic fluids when compared to hypotonic fluids. Clinical practice guidelines from the United Kingdom and United States have both recommended isotonic IV fluids for the otherwise healthy child in need of maintenance fluid administration, while those with alterations in water or solute balance require more individualized approaches. Large studies in adults have shown lower rates of acute kidney injury with balanced solutions compared to normal saline although similar data in children is lacking. Retrospective pediatric data has not shown a consistent difference between these interventions. Isotonic fluids should be first line therapy for otherwise healthy children in need of maintenance IV fluids. Evidence for the standard use of balanced solutions in children remains more limited, until large randomized trials can be performed.

SUN-292 Life-Threatening Hypernatremia in Partial Diabetes Insipidus with Adipsia Due to Cranial Radiation: Diagnostic and Therapeutic Challenges

Background: Anterior pituitary dysfunction is a known, time and dose dependent effect of cranial radiotherapy but central diabetes insipidus (CDI) has been rarely reported. We present a patient with partial CDI (PCDI) and adipsia, months after subtotal resection and radiation therapy for a large anterior cranial fossa meningioma. Clinical Case: A 53-year-old woman with history of subtotal resection of a 7 cm meningioma ~2 years ago and radiation therapy (54 Gy, completed 15 months ago), was admitted to the ICU with obtundation, tachycardia (120/min), hypotension (87/52 mmHg, on vasopressors in the first 24 hours), severe hypernatremia (serum Na 170 mmol/L), and acute kidney injury (creatinine 2.11 mg/dL; baseline 1.0 mg/dL). Plasma osmolality (pOSM) was 385 mOsm/kg and urine osmolality (uOSM) was 982 mOsm/kg. MRI brain 3 months ago showed frontal lobe encephalomalacia, residual meningioma at the planum sphenoidale (1.8x3.5x2.8 cm) with cavitary lesion compatible with post-radiation necrosis. After receiving 4 litres (L) isotonic fluids and 5 L hypotonic fluids in the first 38 hours, serum Na was 168 mmol/L, creatinine 1.35 mg/dl and uOSM 386 mOsm/kg. Urine output was 2.6 L on day-1 and 1.9 L during first 7 hours on day-2. After an IV dose of 2 mcg DDAVP, uOSM increased to 784 mOsm/kg, and Na decreased to 164 mmol/L, supporting CDI diagnosis. ACTH stimulation test was normal. Levothyroxine 50 mcg daily was started for central hypothyroidism. By day-6, her mental status returned to baseline (alert only to person). DDAVP dose adjustment was challenging due to frequent fluctuation in her serum Na (130s to 150s), adipsia and urinary incontinence. On day-44, she was discharged on subcutaneous (subQ) DDAVP 0.25 mcg every 36 hours, with a serum Na of 145 mmol/L. She was readmitted 3 days later with serum Na of 164 mmol/L, followed by another prolonged hospitalization complicated by acute kidney injury and popliteal DVT. On day-64, she was discharged to a nursing facility on DDAVP 0.25 mcg subQ twice daily. Clinical Lesson: Delayed PCDI with adipsia is an exceedingly rare but challenging complication of cranial radiation therapy. The initial uOSM (twice as high as pOSM) in our case caused a delay in diagnosis. This could reflect enhanced antidiuretic response to low circulating ADH levels, possibly due to lower rate of solute extraction in dehydration, upregulation of ADH receptors due to chronic hormone deficiency, and to a fall in glomerular filtration rate. Decrease in uOSM after hydration could be due to ADH exhaustion.

ELBW infants receive inadvertent sodium load above the recommended intake.

To determine total sodium load, including inadvertent load, during the first 2 postnatal weeks, and its influence on serum sodium, morbidity, and mortality in extremely low birth weight (ELBW, birth weight <1000 g) infants and to calculate sodium replacement models. Retrospective data analysis on ELBW infants with a gestational age <28 + 0/7 weeks. Ninety patients with a median birth weight of 718 g and a median gestational age of 24 + 6/7 weeks were included. Median sodium intake during the first 2 postnatal weeks was 10.2 mmol/kg/day, which was significantly higher than recommended (2-5 mmol/kg/day). Sodium intake did not affect the risk for hypernatremia. Each mmol of sodium intake during the first postnatal week was associated with an increased risk of bronchopulmonary dysplasia (45%) and higher-grade intraventricular hemorrhage (31%), during the second postnatal week for necrotizing enterocolitis (19%), and during both postnatal weeks of mortality (13%). Calculations of two sodium replacement models resulted in a decrease in sodium intake during the first postnatal week of 3.2 and 4.0 mmol/kg/day, respectively. Sodium load during the first 2 postnatal weeks of ELBW infants was significantly higher than recommended owing to inadvertent sodium intake and was associated with a higher risk of subsequent morbidity and mortality, although the study design does not allow conclusions on causality. Replacement of 0.9% saline with alternative carrier solutions might reduce sodium intake. Sodium intake in ELBW infants during the first 2 postnatal weeks was twofold to threefold higher than recommended; this was mainly caused by inadvertent sodium components. High sodium intake is not related to severe hypernatremia but might be associated with a higher morbidity in terms of BPD, IVH, and NEC. Inadvertent sodium load can be reduced by replacing high sodium-containing carrier solutions with high levels of sodium with alternative hypotonic and/or balanced fluids, model based.

Comparison of isotonic and hypotonic intravenous fluids in term newborns: is it time to quit hypotonic fluids

Objective Hypotonic fluids have been traditionally used in newborns. National Institute for Health and Clinical Excellence-2015 (NICE) fluid therapy guideline recommends the use of isotonic fluids as maintenance fluid therapy in term newborns. However, there is no clear evidence supporting this recommendation. This study aims to compare isotonic (5% dextrose in 0.9% sodium chloride (NaCl)) and hypotonic (5% dextrose in 0.45% NaCl) parenteral fluid therapies in hospitalized term newborns with regard to changes in plasma Na (pNa) and complications related with fluid therapy. Methods This was a retrospective cohort study performed in a tertiary university hospital NICU between January 2016 and April 2018. Term newborns who were initially isonatremic or mildly dysnatremic (pNa <130 or >155 meq/L) and receiving fluid therapy for maintenance or replacement therapy after 48th postnatal hours were eligible for the study. Infants having specific diagnoses requiring extraordinary fluids were excluded. The primary outcome evaluated was the change in mean plasma Na (ΔpNa meq/L/h) at 24 h or at the end of intravenous (i.v.) fluid therapy. Secondary outcomes evaluated were the risk of hyponatremia, hypernatremia, and adverse events attributable to fluid administration. Results Among the 108 included newborns, 57 received hypotonic fluid (5% dextrose solution in 0.45% NaCl) and the remaining received isotonic fluid (5% dextrose solution in 0.9% NaCl) therapy. The hypotonic fluid group showed a greater ΔpNa compared to the isotonic group (0.48 ± 0.28 vs. 0.27 ± 0.21 meq/L/h, p = .001). The risk of experiencing unsafe plasma Na decrease in the hypotonic fluid group (ΔpNa >0.5 meq/L/h) was higher than the isotonic fluid group (odd ratio: 8.46; 95% confidence interval (CI): 2.3–30.06). Six mildly hypernatremic babies between 48 and 72 h of postnatal age showed insufficient Na reduction despite the appropriate amount of fluid. No significant difference was found between the two groups in terms of other outcomes. Conclusion The results of this study suggested that as maintenance or replacement fluid therapy in the newborn, hypotonic fluids, even 5% dextrose in 0.45% NaCl, can lead to unsafe plasma Na decreases in term newborns, while isotonic fluids are safe when started after the first few days of life. Although the results parallel NICE guidelines, before making recommendations regarding the removal of hypotonic fluids entirely from clinical practice in term newborns following the renal adaptation period; larger randomized controlled studies involving a wide range of babies are needed.

Osmotic demyelination syndrome: are patients with end-stage liver disease a special risk group?

The osmotic demyelination syndrome (ODS) is a serious neurological complication associated with the rapid correction of chronic hyponatremia and is associated with high morbidity and mortality. The incidence of ODS after liver transplantation (LT) is 0.8% to 1.4% and is higher than in the general population. Patients with end stage liver disease (ESLD) are very susceptible to ODS primarily because chronic hyponatremia is the most common electrolyte disorder in these patients. Impaired liver function also leads to disruption of astrocyte metabolism resulting in abnormalities of blood-brain barrier function and a decreased ability to generate new intracellular osmotically active compounds (osmolytes) in response to osmotic changes. LT is the only definitive treatment for hyponatremia in ESLD. Massive fluid shifts that occur intraoperatively can change serum sodium concentration (sNa) significantly. The severity of preoperative chronic hyponatremia is an important risk factor for ODS after LT. ODS after LT is most likely due to unintentional sodium administration intraoperatively. Measures to prevent ODS should cover the entire perioperative period. Chronic symptomatic hyponatremia should be carefully treated if LT is imminent. An intraoperative management strategy to minimize increases in sNa is vital and includes limiting fresh frozen plasma and cryoprecipitate administration by using concentrated clotting factors, administering hypotonic intravenous fluids and sodium-free buffering solutions, as well as using low-sodium continuous renal replacement therapy. sNa levels and urine output should be monitored frequently intraoperatively as well as postoperatively. Neurological symptoms are common after LT, and a high index of suspicion must be maintained to diagnose ODS.

How Salty Are Your Fluids? Pediatric Maintenance IV Fluid Prescribing Practices Among Hospitalists.

Objective: The primary goal of this study was to assess current maintenance intravenous fluid (mIVF) prescribing practices of pediatric hospitalists after the release of the American Academy of Pediatrics Clinical Practice Guideline (AAP CPG), specifically assessing the rates of various isotonic vs. hypotonic solutions used in discrete age groups and in common clinical scenarios associated with anti-diuretic hormone (ADH) excess and hyponatremia. We hypothesized that isotonic fluids would be selected in most cases outside of the neonatal period.Methods: A voluntary and anonymous survey was distributed to the LISTSERV® for the AAP Section on Hospital Medicine.Results: There were 402 total responses (10.1% response rate) with the majority of respondents being pediatric hospitalists. Isotonic solutions were preferred by respondents in older children compared to younger age groups, at 87.8% for the 1–18 years age group compared to 66.3% for the 28 days to 1 year age group and 10.6% for the younger than 28 days age group (all p values <0.0001). When presented with disease states associated with ADH excess, isotonic fluids were preferred in higher percentages in all age groups except in children younger than 28 days when 0.45% sodium chloride was preferred; 0.2% sodium chloride was rarely chosen.Conclusions: Overall, based on survey responses, pediatric hospitalists are following the 2018 AAP CPG on mIVF and are more likely to choose isotonic fluids as their primary mIVF in pediatric patients outside of the neonatal period, including in scenarios of excess ADH. Isotonic fluids use seems to be higher with increasing age and hypotonic fluids are more commonly chosen in the neonatal period.

Clinical Management of Patients with Dengue Infection in Japan: Results from National Database of Health Insurance Claims.

Dengue guidelines for diagnosis, treatment, prevention, and control (WHO, 2011) recommend acetaminophen and isotonic fluid for patients with dengue infection but do not recommend nonsteroidal anti-inflammatory drugs (NSAIDs) and hypotonic fluid. Other research showed no evidence of efficacy of platelet infusion in prophylactic. This research aims to clarify to what extent dengue patients were managed in accordance with the guidelines in Japan. We extracted claim data of patients with either dengue fever (DF) or dengue hemorrhagic fever (DHF) from the National Database of Health Insurance Claims and Specific Health Checkups of Japan between 2011 and 2015. The total number of patients was 1,370, which consisted of 1,306 DF patients and 64 DHF patients; 185 patients were younger than (<) 20 years and 1,185 patients were aged 20 years or older (≥). Among them, 24.5% of DF patients and 48.4% of DHF patients received hypotonic intravenous fluid, 12.9% and 18.8% NSAIDs, and 1.3% and 17.2% platelet transfusion, respectively. Comparing patients aged < 20 years with patients aged ≥ 20 years, 57.8% and 54.5% received acetaminophen, 6.5% and 14.3% received NSAIDs, 40.0% and 38.3% received isotonic fluid, and 37.8% and 23.7% received hypotonic fluid, respectively. Platelet transfusion was used for 1.3% of DH and 17.2% of DHF patients. The study indicated that dengue patients in Japan might have increased risks of developing adverse events because of receiving the treatment that the guidelines do not recommend. More effort is needed to facilitate medical practitioners to follow the guidelines.

Red blood cells under varying extracellular tonicity conditions: an optical tweezers combined with micro-Raman study

Extracellular tonicity has a significant influence on human red blood cell deformation capability. Advancements in the area of laser physics and optical trapping have opened up a plethora of applications for understanding cell structure and dynamics. Here, Raman Tweezers technique was employed to investigate the impact of extracellular tonicity by exposing human red blood cells to both hypertonic and hypotonic intravenous fluids. Heme aggregation was observed in hypertonic saline solution, accompanied with damage in membrane protein. Loss of intracellular hemoglobin in hypotonic solution was evident from the decrease in porphyrin breathing mode present at 752 cm−1. Oxygen binding to the central iron in the red blood cell heme was also affected under both hyper/hypo tonicity conditions. Morphological deviation of discocytes to echinocytes/spherocytes were also evident from quantitative phase imaging. Principal component analysis have showed clear differentiation of samples in order to classify the control erythrocytes and the tonicity stressed erythrocytes. Present study has also demonstrated the application of Raman Tweezers spectroscopy as a potential tool for probing red blood cell under different stress conditions.

Risk factors for hyponatremia after hypotonic fluid infusion.

Hypotonic maintenance i.v. fluids (IVF) pose a higher risk of hyponatremia than isotonic maintenance IVF, but isotonic maintenance IVF can result in excess sodium (Na) load in children. This study analyzed the incidence and risk factors for hyponatremia in children given hypotonic fluids with different Na concentrations and different maintenance rates. We performed a retrospective analysis using medical charts of children aged 3months-15years. The children were normonatremic (Na ≥135mmol/L and <145mmol/L) before IVF, and given IVF containing 35mmol/L Na at a 100% maintenance rate (Na 35) or fluids containing 84mmol/L Na at a 70% maintenance rate (Na 84) for 24-48h. Of a total of 463 children, hyponatremia (Na <135mmol/L) occurred in 46/275 children (17%) given Na 35, and 16/188 (9%) given Na 84 (P = 0.01). On multivariate logistic regression analysis, Na 35 (OR, 2.19; 95%CI: 1.04-4.62), low clinical dehydration scale (CDS) score before IVF (OR, 0.17; 95%CI: 0.06-0.49), and high body temperature 24-48h after maintenance IVF (OR, 2.39; 95%CI: 1.79-3.18) were independent risk factors for hyponatremia. Maintenance IVF with low Na concentration at a 100% maintenance rate, low CDS before IVF, and a high body temperature 24-48h after maintenance IVF are independent risk factors for hyponatremia.

154 compared to 54\xa0mmol per liter of sodium in intravenous maintenance fluid therapy for adult patients undergoing major thoracic surgery (TOPMAST): a single-center randomized controlled double-blind trial

PurposeTo determine the effects of the sodium content of maintenance fluid therapy on cumulative fluid balance and electrolyte disorders.MethodsWe performed a randomized controlled trial of adults undergoing major thoracic surgery, randomly assigned (1:1) to receive maintenance fluids containing 154 mmol/L (Na154) or 54 mmol/L (Na54) of sodium from the start of surgery until their discharge from the ICU, the occurrence of a serious adverse event or the third postoperative day at the latest. Investigators, caregivers and patients were blinded to the treatment. Primary outcome was cumulative fluid balance. Electrolyte disturbances were assessed as secondary endpoints, different adverse events and physiological markers as safety and exploratory endpoints.FindingsWe randomly assigned 70 patients; primary outcome data were available for 33 and 34 patients in the Na54 and Na154 treatment arms, respectively. Estimated cumulative fluid balance at 72 h was 1369 mL (95% CI 601–2137) more positive in the Na154 arm (p < 0.001), despite comparable non-study fluid sources. Hyponatremia < 135 mmol/L was encountered in four patients (11.8%) under Na54 compared to none under Na154 (p = 0.04), but there was no significantly more hyponatremia < 130 mmol/L (1 versus 0; p = 0.31). There was more hyperchloremia > 109 mmol/L under Na154 (24/35 patients, 68.6%) than under Na54 (4/34 patients, 11.8%) (p < 0.001). The treating clinicians discontinued the study due to clinical or radiographic fluid overload in six patients receiving Na154 compared to one patient under Na54 (excess risk 14.2%; 95% CI − 0.2–30.4%, p = 0.05).ConclusionsIn adult surgical patients, sodium-rich maintenance solutions were associated with a more positive cumulative fluid balance and hyperchloremia; hypotonic fluids were associated with mild and asymptomatic hyponatremia.