Hypotonic Maintenance Research Articles

Impact of a Treatment Guide on Intravenous Fluids in Minimising the Risk of Hospital-Acquired Hyponatraemia in Denmark.

Hypotonic intravenous (IV) fluids are associated with an increased risk of hospital-acquired hyponatraemia, eventually leading to brain injury and death. We evaluated the effectiveness of a treatment guide to improve prescribing practices of IV fluids. We conducted a before-and-after cross-sectional survey among physicians working at Danish emergency departments. The primary outcome was prescribing practices of IV fluids. Participants were asked which IV fluid they would select in four clinical scenarios. We applied multivariate logistic regression models to estimate the odds ratio of selecting hypotonic fluids. Secondary outcomes included knowledge about IV fluids and hyponatraemia, and the receipt, reading, and usefulness of the treatment guide. After the intervention, about a third (47/154) reported that they would use hypotonic fluids in patients with increased intracranial pressure, and a quarter (39/154) would use hypotonic maintenance fluids in children, both of which are against guideline recommendations. A total of 46% selected the correct fluid, a 3% hypertonic saline solution for a patient with hyponatraemia and severe neurological symptoms. None of the knowledge questions met the predefined criteria of success of 80% correct answers. Of the respondents, 22% had received the treatment guide. Since the implementation failed, we recommend improving distribution by applying methods from implementation science.

Status Epilepticus in Meningoencephalitis Patients with Hyponatremia Associated with Use of Hypotonic Maintenance Solutions in Children: Is It the Time Switching to Isotonic Maintenance Solutions?

Hyponatremia is one of the complication of inpatient care which is quite common in the pediatric population. This condition often occurs due to the administration of intravenous fluids that are hypotonic and is exacerbated by the condition of SIADH (Syndrome of Inappropriate Anti Diuretic Hormone) which occurs in patients with pain, anxiety, stress, administration of anesthetic agents, narcotics, operative procedures and administration of positive pressure ventilation and infections, especially pneumonia and meningitis. In addition, this condition is also exacerbated by the addition of glucose into the administration of pediatric maintenance fluids. when glucose is metabolized it will leave free water which will affect plasma osmolality. In 2018, the AAP released strong recommendations in administering isotonic fluids as maintenance fluids in pediatric patients in addition to the addition of glucose and potassium. but in clinical practice in hospitals, the use of hypotonic fluids that have been used for a long time is still difficult to abandon because practitioners feel they have not found enough cases of complications. This case report describes a meningoencephalitis patient with status epilepticus who experienced hyponatremia after being given hypotonic fluids according to local guidelines and improved after sodium correction

Postoperative free water administration is associated with dysnatremia after congenital heart disease surgery in infants.

Dysnatremia after congenital heart disease (CHD) surgery is common. European guidelines on intraoperative fluid therapy in children recommend isotonic solutions to avoid hyponatremia, but prolonged cardiopulmonary bypass and administration of high sodium-containing solutions (i.e., blood products and sodium bicarbonate) are associated with postoperative hypernatremia. The aim of the study was to describe fluid composition prior to and during the development of postoperative dysnatremia. A retrospective observational, single-center study including infants undergoing CHD surgery. Demographics and clinical characteristics were registered. Highest and lowest plasma sodium values were recorded and associations with perioperative fluid administration, blood products, crystalloids, and colloids were explored in relation to three perioperative periods. Postoperative dysnatremia occurred in nearly 50% of infants within 48 h after surgery. Hypernatremia was mainly associated with administration of blood products (median [IQR]: 50.5 [28.4-95.5] vs. 34.5 [18.5-61.1]mL/kg; p= 0.001), and lower free water load (1.6 [1.1-2.2]mL/kg/h; p= 0.01). Hyponatremia was associated with a higher free water load (2.3 [1.7-3.3] vs. 1.8 [1.4-2.5] mL/kg/h; p= 0.001) and positive fluid balance. On postoperative day 1, hyponatremia was associated with higher volumes of free water (2.0 [1.5-2.8] vs. 1.3 [1.1-1.8]mL/kg/h; p< 0.001) and human albumin, despite a larger diuresis and more negative daily fluid balance. Postoperative hyponatremia occurred in 30% of infants despite restrictive volumes of hypotonic maintenance fluid, whereas hypernatremia was mainly associated with blood product transfusion. Individualized fluid therapy, with continuous reassessment to reduce the occurrence of postoperative dysnatremia is mandatory in pediatric cardiac surgery. Prospective studies to evaluate fluid therapy in pediatric cardiac surgery patients are warranted.

Effect of a Quality Improvement Bundle to Standardize the Use of Intravenous Fluids for Hospitalized Pediatric Patients

Given that hypotonic maintenance intravenous fluids (IVF) may cause hospital-acquired harm, in November 2018, the American Academy of Pediatrics released a clinical practice guideline recommending the use of isotonic IVF for patients aged 28 days to 18 years without contraindications. No recommendations were made regarding laboratory monitoring; however, unnecessary laboratory tests may contribute to health care waste and harm patients. To examine the effect of a quality improvement intervention bundle on (1) increasing the mean proportion of hours per hospital day with exclusive isotonic IVF use to at least 80% and (2) decreasing the mean proportion of hospital days with laboratory tests obtained. This stepped-wedge, cluster randomized clinical trial (Standardization of Fluids in Inpatient Settings [SOFI]) was sponsored by a national quality improvement collaborative and was conducted across 106 US pediatric hospitals. The SOFI intervention period was from September 2019 to March 2020. Hospital sites were exposed to educational materials, a clinical algorithm and order set for IVF use, electronic medical record interventions to reduce laboratory testing, and "harms of overtesting" cards. Primary outcomes were mean proportion of hours per hospital day receiving exclusive isotonic IVF and mean proportion of hospital days with laboratory test values obtained. Secondary measures included total IVF duration per hospital day, daily patient weight measurement while receiving IVF, serum sodium testing, and adverse events. Baseline data were collected for 2 months; intervention period data, 7 months. Outcomes were analyzed using linear mixed-effects regression models. A total of 106 hospitals were randomly assigned to 1 of 3 intervention start dates (wedges), and 100 hospitals (94%) completed the study. In total, 5215 hospitalizations were reviewed before the intervention, and 6724 hospitalizations were reviewed after the intervention. Prior to interventions, the mean (SD) proportion of hours per day with exclusive isotonic IVF use was 88.5% (31.7%). Interventions led to an absolute increase of 5.4% (95% CI, 3.9%-6.9%) above baseline in exclusive isotonic IVF use but did not change the proportion of hospital days during which a laboratory test value was obtained (estimated difference, 0.1%; 95% CI, -1.5% to 1.7%; P = .90), IVF use duration (estimated difference, -1.2%; 95% CI, -2.9% to 0.4%), serum sodium testing, or adverse events. There was an absolute increase of 4.4% (95% CI, 2.6%-6.2%) in the mean proportion of hospital days with a patient weight measurement while receiving IVF. In this stepped-wedge, cluster randomized clinical trial, an intervention bundle significantly improved the use of isotonic maintenance IVF without a concomitant increase in adverse events or electrolyte testing. Further work is required to deimplement laboratory testing. ClinicalTrials.gov Identifier: NCT03924674.

Association Between Hyponatremia and Maintenance Intravenous Solutions in Critically Ill Children: A Retrospective Observational Study.

Objetive: We sought to determine the association between maintenance intravenous solutions and the presence of hyponatremia in children in pediatric intensive care (PICU).Materials and Methods: An analytical observational study in children hospitalized in the PICU between January 2015 and December 2018. Patients who received maintenance fluids within the first 48 h after admission and who had at least two serum sodium levels drawn during this time were included.Measurements and Main Results: A total of 1,668 patients were admitted to the PICU during the study period, 503 of whom met the inclusion criteria. The median age was 24 months (IQR 8–96) and 50.9% were female. Altogether, 24.1% of the children developed hyponatremia; it was more frequent in those who received hypotonic solutions (63 vs. 37%; OR 1.41 95% CI 0.92, 2.15 p = 0.106), who also had a longer hospital stay (20 vs. 14 days, difference in means 8 days, 95% CI 2.67, 13.3, p = 0.001). Children who received loop diuretics and those who were post-operative had a greater risk of developing hyponatremia if they received hypotonic solutions (aOR 2.1 95% CI 1.41, 3.0, p = 0.000). Those with balanced isotonic solutions had a lower risk of developing hyponatremia (aOR 0.59 95% CI 0.35, 0.99, p = 0.004) and hyperchloremia (aOR 0.51 95% CI 0.34, 0.77, p = 0.000), adjusted for disease severity. A greater risk of death was found in the group with severe hyponatremia <130 mEq/L (aOR 9.75 95% CI 1.64–58.15; p = 0.01).Conclusions: Hyponatremia associated with the use of hypotonic maintenance solutions occurs in one out of four children in intensive care. The use of these solutions is associated with a longer hospital stay, and the main risk groups are post-operative patients and those who receive loop diuretics. Clinical studies are needed to determine which maintenance solutions have the greatest efficacy and safety in critically ill children.

From hypotonic maintenance fluid to severe hyponatremia: a case report

BackgroundThe 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 presentationWe 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.ConclusionThis 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.

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...

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.

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.

Pediatric residents’ choice of maintenance intravenous fluids

Background: While hypotonic fluids were the standard of care for maintenance intravenous (IV) therapy in pediatrics for many years, evidence suggests an association with hyponatremia - an iatrogenic complication that can result in morbidity and mortality. Recent literature and guidelines support use of isotonic solutions in most clinical situations, as there is likely non-physiologic secretion of antidiuretic hormone (ADH) in hospitalized infants and children. However, a study of American pediatric residents found that the majority would prescribe hypotonic maintenance fluids in hypothetical clinical situations of likely excess ADH. Current prescribing practices in Canada are unknown, and it is unclear whether …

Acute Management of Ischemic Stroke During Pregnancy.

Acute stroke in pregnancy can be devastating. Although neurologists will at some point be involved in the management, most of these patients are likely to first be evaluated by an obstetric care provider. It is, therefore, important for obstetric care providers to have an understanding of the presentation and management of stroke, particularly in the initial period when the window of opportunity for therapy is critical. Once suspected, a head computed tomography (CT) without contrast media should be performed without delay to rule out a hemorrhagic component. Patients presenting within 4.5 hours of symptom onset and with an initial normal head CT scan are candidates for alteplase (tissue plasminogen activator [tPA]). Blood pressure (BP) control is paramount when administering tPA. During pregnancy, we recommend maintaining a BP between 140-160/90-110 mm Hg during tPA treatment. Pregnancy should not be a contraindication for mechanical thrombectomy in carefully selected patients. The use of therapeutic anticoagulation during the acute management of ischemic stroke is not indicated owing to an increased risk of hemorrhagic transformation. Supportive therapy should include aggressive treatment of fever, avoidance of hypotonic maintenance fluids, and maintenance of normal serum sodium levels. Serum glucose levels should be kept between 140 and 180 mg/dL. Antiplatelet agents are indicated for secondary prevention. The management of cerebral venous sinus thrombosis, carotid and vertebral dissections, and reversible cerebral vasoconstrictive disease should overall follow same guidelines as for nonpregnant individuals.

The impact of intravenous isotonic and hypotonic maintenance fluid on the risk of delirium in adult postoperative patients: retrospective before-after observational study.

To assess the impact of intravenous isotonic and hypotonic maintenance fluid on the risk of delirium in adult postoperative patients, we conducted retrospective before-after study in a tertiary teaching hospital. We examined all adult patients admitted ICU after an elective operation for head and neck cancer, or esophageal cancer from February 2014 to January 2017. From February 2014 to July 2015, patients were administered hypotonic fluid (sodium; 35mmol/L) as the National Institute for Health and Care Excellence (NICE) have recommended. From August 2015 to January 2017, patients were administered isotonic fluid (sodium; 140mmol/L). We defined the incidence of delirium as the primary outcome. The delirium was defined as the Intensive Care Delirium Screening Checklist during the ICU stay ≥ 4. A propensity score-matched model was used to adjust confounders. As postoperative intravenous maintenance fluid, hypotonic fluid was administered to 119 patients and isotonic fluid was administered to 92 patients. Among those total cohorts, the incidence of postoperative delirium in the hypotonic group was 21.8%, which was significantly higher than that (9.8%) in the isotonic group (p = 0.019). After propensity score matching, we selected 77 patients in each group. The incidence of delirium during the ICU stay in the hypotonic group was 26.0%, which was significantly higher than the incidence of 11.7% in the isotonic group (p = 0.023). In this study, the use of postoperative hypotonic maintenance fluid was associated with a higher risk of postoperative delirium than that when isotonic maintenance fluid was used.

Things We Do For No Reason: The Default Use of Hypotonic Maintenance Intravenous Fluids in Pediatrics.

The “Things We Do for No Reason” series reviews practices which have become common parts of hospital care but which may provide little value to our patients. Practices reviewed in the TWDFNR series do not represent “black and white” conclusions or clinical practice standards, but are meant as a starting place for research and active discussions among hospitalists and patients. We invite you to be part of that discussion.

Maintenance fluid therapy and fluid creep impose more significant fluid, sodium, and chloride burdens than resuscitation fluids in critically ill patients: a retrospective study in a tertiary mixed ICU population

PurposeResearch on intravenous fluid therapy and its side effects, volume, sodium, and chloride overload, has focused almost exclusively on the resuscitation setting. We aimed to quantify all fluid sources in the ICU and assess fluid creep, the hidden and unintentional volume administered as a vehicle for medication or electrolytes.MethodsWe precisely recorded the volume, sodium, and chloride burdens imposed by every fluid source administered to 14,654 patients during the cumulative 103,098 days they resided in our 45-bed tertiary ICU and simulated the impact of important strategic fluid choices on patients’ chloride burdens. In septic patients, we assessed the impact of the different fluid sources on cumulative fluid balance, an established marker of morbidity.ResultsMaintenance and replacement fluids accounted for 24.7% of the mean daily total fluid volume, thereby far exceeding resuscitation fluids (6.5%) and were the most important sources of sodium and chloride. Fluid creep represented a striking 32.6% of the mean daily total fluid volume [median 645 mL (IQR 308–1039 mL)]. Chloride levels can be more effectively reduced by adopting a hypotonic maintenance strategy [a daily difference in chloride burden of 30.8 mmol (95% CI 30.5–31.1)] than a balanced resuscitation strategy [daily difference 3.0 mmol (95% CI 2.9–3.1)]. In septic patients, non-resuscitation fluids had a larger absolute impact on cumulative fluid balance than did resuscitation fluids.ConclusionsInadvertent daily volume, sodium, and chloride loading should be avoided when prescribing maintenance fluids in view of the vast amounts of fluid creep. This is especially important when adopting an isotonic maintenance strategy.

Incidence of hyponatraemia following the use of three different intravenous fluids in paediatric surgery.

Background:It is a common practice to administer 4.3% dextrose in 0.18% saline peri-operatively and for routine fluid maintenance in the paediatric age group. Concerns have been expressed about the risk of hyponatraemia associated with the administration of hypotonic intravenous fluids, hence the need to re-evaluate our practice. This study aims to evaluate the relative incidence of intra-operative hyponatraemia following the use of isotonic and hyopotonic intravenous fluids.Patients and Methods:This randomised double-blind clinical trial recruited consecutive American Society of Anaesthesiologists physical status Class I and II children aged between 6 months and 17 years scheduled for various minor elective surgical procedures. The patients received one of 3 intravenous infusions for intra-operative fluid management. Group I received 4.3% dextrose in 0.18 saline (n = 25), Group II received normal saline (n = 20) and Group III received Ringer's lactate (n = 20). Blood samples were collected before the surgery and at the end of surgery for serum electrolytes.Results:One patient in each group developed moderate hyponatraemia intraoperatively. This constituted a 4% (1/25) incidence of intra-operative hyponatraemia among patients who had hypotonic maintenance fluid and a 5% (2/40) incidence in the isotonic maintenance groups. The incidence of hyponatraemia was therefore comparable between patients who had hypotonic and isotonic intra-operative maintenance fluids (P = 1.000).Conclusion:We conclude that healthy children who have intraoperative hypotonic maintenance fluids during minor elective surgeries are not exposed to the additional risk of hyponatraemia compared to those who have isotonic fluids. The study of a larger sample size is recommended to further validate our findings.

Effect of isotonic versus hypotonic maintenance fluid therapy on urine output, fluid balance, and electrolyte homeostasis: a crossover study in fasting adult volunteers

BackgroundDaily and globally, millions of adult hospitalized patients are exposed to maintenance i.v. fluid solutions supported by limited scientific evidence. In particular, it remains unclear whether fluid tonicity contributes to the recently established detrimental effects of fluid, sodium, and chloride overload. MethodsThis crossover study consisted of two 48 h study periods, during which 12 fasting healthy adults were treated with a frequently prescribed solution (NaCl 0.9% in glucose 5% supplemented by 40 mmol litre−1 of potassium chloride) and a premixed hypotonic fluid (NaCl 0.32% in glucose 5% containing 26 mmol litre−1 of potassium) at a daily rate of 25 ml kg−1 of body weight. The primary end point was cumulative urine volume; fluid balance was thus calculated. We also explored the physiological mechanisms behind our findings and assessed electrolyte concentrations. ResultsAfter 48 h, 595 ml (95% CI: 454–735) less urine was voided with isotonic fluids than hypotonic fluids (P<0.001), or 803 ml (95% CI: 692–915) after excluding an outlier with ‘exaggerated natriuresis of hypertension’. The isotonic treatment was characterized by a significant decrease in aldosterone (P<0.001). Sodium concentrations were higher in the isotonic arm (P<0.001), but all measurements remained within the normal range. Potassium concentrations did not differ between the two solutions (P=0.45). Chloride concentrations were higher with the isotonic treatment (P<0.001), even causing hyperchloraemia. ConclusionsEven at maintenance rate, isotonic solutions caused lower urine output, characterized by decreased aldosterone concentrations indicating (unintentional) volume expansion, than hypotonic solutions and were associated with hyperchloraemia. Despite their lower sodium and potassium content, hypotonic fluids were not associated with hyponatraemia or hypokalaemia. Clinical trial registrationClinicalTrials.gov (NCT02822898) and EudraCT (2016-001846-24).

Use of Hypotonic Maintenance Intravenous Fluids and Hospital-Acquired Hyponatremia Remain Common in Children Admitted to a General Pediatric Ward.

To evaluate maintenance intravenous fluid-prescribing practices and the incidence of hospital-acquired hyponatremia in children admitted to a general pediatric ward. This is a prospective observational study conducted over a 2-month period in children ages 2 months to 5 years who were admitted to a general pediatric ward and who were receiving maintenance intravenous fluids. The composition, rate, and duration of intravenous fluids were chosen at the discretion of the treating physician. Serum biochemistries were obtained at baseline and 24 h following admission. Patients who were at high risk for developing hyponatremia or hypernatremia or had underlying chronic diseases or were receiving medications associated with a disorder in sodium and water homeostasis were excluded. Intravenous fluid composition and the incidence of hyponatremia (sodium <135 mEq/L) were assessed. Fifty-six children were enrolled. All received hypotonic fluids; 87.5% received 0.18% sodium chloride (NaCl) and 14.3% received 0.45% NaCl. Forty percent of patients (17/42) with a serum sodium (SNa) less than 140 mEq/L experienced a fall in SNa with 12.5% of all patients (7/56) developing hospital-acquired or aggravated hyponatremia (126-134 mEq/L) with fall in SNa between 2 and 10 mEq/L. Administration of hypotonic fluids was a prevalent practice in children admitted to a general pediatric ward and is associated with acute hospital-acquired hyponatremia.

A prospective trial comparing isotonic with hypotonic maintenance fluids for prevention of hospital-acquired hyponatraemia

Background:Recent literature suggests that hypotonic fluids increase the risk of hospital-acquired hyponatraemia; despite this, hypotonic fluids are widely used.Objectives:To compare the change in serum sodium following the use of hypotonic (0.3% saline, 0.45% saline) or isotonic (0.9% saline) intravenous (IV) maintenance solutions in hospitalised children.Study design:This was a randomised controlled trial. Children aged 3 months to 15 years with medical or surgical disorders were randomised to receive one of three maintenance IV fluids: two hypotonic solutions (3.3% dextrose in 0.3% saline or 5% dextrose in 0.45% saline) and one isotonic solution (5% dextrose in 0.9% saline). The primary outcome was serum sodium levels at 8 hours. Secondary outcomes included the incidence of hospital-acquired hyponatraemia, adverse events attributable to IV solutions and length of hospital stay.Results:151 children were assigned randomly to receive 0.3% saline (n = 49), 0.45% saline (n = 50) or 0.9% saline (n = 52). Baseline characteristics were similar for the three groups. At 8 hours, mean (SD) serum sodium was lower in the hypotonic solutions groups [0.3% saline 134.65 (1.9) mmol/L, 0.45% saline 134.90 (2.3) mmol/L than 0.9% saline 137.98 (2.8) mmol/L] (P < 0.0001). The incidence of hospital-acquired hyponatraemia was higher in the hypotonic groups [0.3% saline 10/49 (20.4%), 0.45% saline 11/50 (22%) than 0.9% saline 1/52 (1.9%), P = 0.006). There were no differences in other adverse effects or length of hospital stay between the groups.Conclusion:Hypotonic IV solutions increase the incidence of hospital-acquired hyponatraemia. Isotonic solutions are a safer alternative.

A prospective trial comparing isotonic with hypotonic maintenance fluids for prevention of hospital-acquired hyponatraemia

Recent literature suggests that hypotonic fluids increase the risk of hospital-acquired hyponatraemia; despite this, hypotonic fluids are widely used.To compare the change in serum sodium following the use of hypotonic (0.3% saline, 0.45% saline) or isotonic (0.9% saline) intravenous (IV) maintenance solutions in hospitalised children.This was a randomised controlled trial. Children aged 3 months to 15 years with medical or surgical disorders were randomised to receive one of three maintenance IV fluids: two hypotonic solutions (3.3% dextrose in 0.3% saline or 5% dextrose in 0.45% saline) and one isotonic solution (5% dextrose in 0.9% saline). The primary outcome was serum sodium levels at 8 hours. Secondary outcomes included the incidence of hospital-acquired hyponatraemia, adverse events attributable to IV solutions and length of hospital stay.151 children were assigned randomly to receive 0.3% saline (n = 49), 0.45% saline (n = 50) or 0.9% saline (n = 52). Baseline characteristics were similar for the three groups. At 8 hours, mean (SD) serum sodium was lower in the hypotonic solutions groups [0.3% saline 134.65 (1.9) mmol/L, 0.45% saline 134.90 (2.3) mmol/L than 0.9% saline 137.98 (2.8) mmol/L] (P < 0.0001). The incidence of hospital-acquired hyponatraemia was higher in the hypotonic groups [0.3% saline 10/49 (20.4%), 0.45% saline 11/50 (22%) than 0.9% saline 1/52 (1.9%), P = 0.006). There were no differences in other adverse effects or length of hospital stay between the groups.Hypotonic IV solutions increase the incidence of hospital-acquired hyponatraemia. Isotonic solutions are a safer alternative.

Acute Hyponatremia following Hypotonic Intravenous Fluid in a 4-year-old Child

ABSTRACT Hyponatremia is the most frequently encountered electrolyte disorder in hospitalized patients. It develops due to either surplus water or decreased sodium in the extracellular fluid. In children, the source of excess water is frequently the administration of hypotonic intravenous fluids. The current recommendations of hypotonic maintenance fluids may be appropriate for a healthy child, but may not apply to hospitalized children who are more likely to have a nonosmotic stimulus for antidiuretic hormone (ADH) production, such as anxiety, stress, pain, etc. Fall in plasma sodium concentration acutely to &lt; 130 mmol/L leads to brain cell swelling and devastating neurological outcome. Previous studies have reported the potential harm with these solutions and the need to reconsider their routine use in children. We present a case report of 4-year-old child, admitted with head injury and normal CT brain, who developed hyponatremic convulsions following administration of Isolyte-P as maintenance fluid as per standard guidelines. How to cite this article Rustagi P, Dalvi NP, Tendolkar BA, Kotak S. Acute Hyponatremia following Hypotonic Intravenous Fluid in a 4-year-old. Res Inno in Anesth 2016;1(2):63-64.