Hypertonic Saline Infusion Research Articles

Apelin levels in patients with polyuria-polydipsia syndrome upon copeptin stimulation tests.

Differentiating between arginine vasopressin deficiency (AVP-D) and primary polydipsia (PP) requires a copeptin stimulation test. We aimed to characterize changes in apelin, an endogenous hormone antagonizing AVP, upon copeptin stimulation tests. Post hoc secondary analysis of a multi-centric cross-over diagnostic study (NCT03572166). Outpatients included at the University Hospital Basel. Patients with AVP-D and PP. Copeptin stimulation tests with hypertonic saline and arginine infusion. The primary outcome was the absolute difference in apelin between baseline and peak of copeptin stimulation tests. Secondary objectives included the diagnostic ability of apelin. Thirty-eight patients were analysed, 23 (60%) had PP and 15 (40%) had AVP-D. No difference was seen between baseline median (IQR) apelin levels in PP and AVP-D (1079 [912, 1225] and 910 [756, 1039] pmol/L, respectively). Upon hypertonic saline, apelin decreased by -241 (-326, -124) pmol/L in PP and -47.2 (-198, 5.86) pmol/L in AVP-D (P = .022). The area under the curve (AUC) to differentiate PP from AVP-D was 97.1% (95% CI, 90.5-100) for copeptin and 49.3% (95% CI, 30.4-68.1) for apelin (P < .001). Upon arginine, apelin decreased by -39.2 (-96.4, 39.8) pmol/L in PP and increased by 25.8 (2.8, 113.0) pmol/L in AVP-D (P = .1). The AUC was 97.1% (95% CI: 79.6-98.0) for copeptin and 60.5% (95% CI: 39.8-80.0) for apelin (P = .007). Our findings suggest that apelin decreases to a greater extent in PP compared with AVP-D upon copeptin stimulation tests. However, copeptin remains the best marker to differentiate AVP-D from PP.

Protocolo diagnóstico de la poliuria

Polyuria is defined as a urinary excretion volume > 3 l/24h or > 40-50ml/kg/24h. It is essential to differentiate it from symptoms such as nocturia and pollakiuria that are related to urologic pathology. To guide the diagnosis it is important to differentiate whether it is an osmotic or aqueous polyuria. The most frequent cause of osmotic diuresis is decompensated diabetes mellitus. The main causes of aqueous polyuria are primary polydipsia (PP), vasopressin deficiency (AVP-D) and vasopressin resistance (AVP-R). Making an accurate diagnosis of the different causes of polyuria is essential because the therapeutic plan varies. Once aqueous polyuria is confirmed, the cause of the polyuria-polydipsia syndrome must be established. Currently, it is recommended to start the study with a basal copeptin measurement to differentiate AVP-D from AVP-R and to differentiate AVP-D from PP to measure stimulated copeptin after infusion of arginine or hypertonic saline.

New diagnostic criterion for a 3% hypertonic saline infusion test for the differential diagnosis of diabetes insipidus and primary polydipsia

AIM: To determine the value of urine osmolality when conducting a test with 3% hypertonic sodium chloride solution, which allows for the differential diagnosis of diabetes insipidus (DI) and primary polydipsia (PP).METHODS: An interventional cross-sectional study was conducted at the (Endocrinology Research Center. The study included 90 patients with polyuria-polydipsia syndrome from September 2021 to September 2023. All patients underwent sequential two tests with osmotic stimulation: 3% hypertonic saline infusion test and a water deprivation test. The final diagnosis was established based on the results of a fluid deprivation test, the patient’s anamnestic data (previous operations, diseases of the hypothalamic-pituitary region, the presence of mental illnesses), MRI data (the presence of a hyperintense signal from the posterior pituitary on T1-weighted images, a detected tumor or infiltrative formation of the hypothalamic-pituitary area, presence of Rathke’s pouch cyst).RESULTS: 48 patients with a final diagnosis of DI and 42 with a final diagnosis of PP were analysed. A cut-off point for urine osmolality during infusion test with 3% hypertonic saline was found: values less than or equal to 377 mOsm/kg support the diagnosis of DI, and values higher than 377 mOsm/kg support the diagnosis of PP. The sensitivity of the criterion is 89%, 95% CI (77%; 97%), specificity — 98% (87%; 100%), PPV — 98% (88%; 100%), NPV — 89% (76%; 96%), accuracy 93% (86%; 98%).CONCLUSION: The proposed criterion for differential diagnosis has comparable diagnostic accuracy in relation to the differential diagnosis of DI and PP, while the safety of the test may be higher.

Intensive Care Management of Severe Hyponatraemia-An Observational Study.

Background and Subject: Hyponatraemia is a common electrolyte disorder. For patients with severe hyponatraemia, intensive care unit (ICU) admission may be required. This will enable close monitoring and allow safe management of sodium levels effectively. While severe hyponatraemia may be associated with significant symptoms, rapid overcorrection of hyponatraemia can lead to complications. We aimed to describe the management and outcomes of severe hyponatraemia in our ICU and identify risk factors for overcorrection. Materials and Methods: This was a retrospective single-centre cohort that included consecutive adults admitted to the ICU with serum sodium < 120 mmol/L between 1 January 2017 and 8 March 2023. Anonymised data were collected from electronic records. We included 181 patients (median age 67 years, 51% male). Results: Median admission serum sodium was 113 mmol/L (IQR: 108-117), with an average rate of improvement over the first 48 h of 10 mmol/L/day (IQR: 5-15 mmol/L). A total of 62 patients (34%) met the criteria for overcorrection at 48 h, and they were younger, presented with severe symptoms (seizures/arrythmias), and had lower admission sodium concentration. They were more likely to be treated with hypertonic saline infusions. Lower admission sodium was an independent risk factor for overcorrection within 48 h, whereas the presence of liver cirrhosis and fluid restriction was associated with normal correction. No difference was identified between the normal and overcorrected cohorts for ICU/hospital length of stay or mortality. Conclusions: In some patients with severe hyponatraemia, overcorrection is inevitable to avoid symptoms such as seizures and arrhythmias, and consequently, we highlight the key factors associated with overcorrection. Overall, we identified that overcorrection was common and concordant with the current literature.

Pain related syndrome of inappropriate antidiuretic hormone secretion in a kitten

A 2-month-old domestic shorthair kitten was presented for evaluation of weakness, gait abnormalities, and signs of pain after trauma. On admission, the patient was found laterally recumbent with obvious gait abnormalities: difficulty rising from sitting and marked unilateral left hind limb lameness. On orthopedic examination, severe pain, crepitations, and swelling of the left hind limb were detected. Results of the first diagnostic work-up were all consistent with hyponatremia, hypochloremia and a Salter-Harris type I fracture.The kitten initially received isotonic fluids, analgesia, and antiemetic treatment. Twelve hours after admission, the analgesic plan was considered insufficient, and the general patient's condition worsened, showing severe mental depression. Blood and urine samples were collected for a more in-depth diagnostic evaluation; the patient showed worsening hyponatremia (113 mmol/L; [RR: 146,2-156,2]), severe plasma hypoosmolality (218.2 mOsm/kg; [RR: 287-307 mOsm/kg]), high natriuresis (Na: 74.9 mmol/L; [RR: <40 mmol/L]), and urinary hyperosmolality (630 mOsm/kg; [RR: <150 mOsm/kg]). Based on these new clinical findings syndrome of inappropriate antidiuretic hormone (SIADH) secretion was diagnosed.Emergency treatment with hypertonic saline was then instituted, a constant rate infusion of 3% hypertonic saline infusion to increase plasma sodium was initiated and a loop diuretic, furosemide (1 mg/kg/IV), was administered at 12-hour intervals to induce diuresis. Discharge occurred 4 days after admission as the patient was clinically stable and the hyponatremia progressively resolved. To the author's knowledge this is the first report of a kitten developing pain related SIADH associated to orthopedic trauma.

Syndrome of inappropriate antidiuresis/hyponatremia in COVID-19.

Hyponatremia is the most frequent electrolyte alteration among hospitalized patients and it has been reported in 20-40% of patients with SARS-CoV-2 (COVID-19) infection. Multiple causes of hyponatremia have been hypothesized in these patients. The syndrome of inappropriate antidiuresis (SIAD) has been considered one of the main reasons leading to hyponatremia in this condition. SIAD can be secondary to cytokines release, in particular IL-6. Positive pressure ventilation can be another cause of hyponatremia due to SIAD. Other possible etiologies of hyponatremia in COVID-19 patients can be related to secondary hypocortisolism, nausea, vomiting, heart and kidney damage. Similar to many other clinical conditions, there is strong evidence that hyponatremia is associated with a worse prognosis also in patients with COVID-19 infection. In particular, hyponatremia has been identified as an independent risk of ICU transfer, need of non-invasive ventilation and death. Hyponatremia in COVID-19 patients is in principle acute and symptomatic and should be treated as such, according to the published guidelines. Therefore, patients should be initially treated with i.v. hypertonic saline (3% NaCl) infusion and serum [Na+] should be frequently monitored, in order to remain within a safe rate of correction. There is evidence showing that serum [Na+] correction is associated with a better outcome in different pathologies, including COVID-19 infection.

Acute hypernatremia increases functional connectivity of NaCl sensing regions in the human brain: An fMRI pilot study

Rodent studies demonstrated specialized sodium chloride (NaCl) sensing neurons in the circumventricular organs, which mediate changes in sympathetic nerve activity, arginine vasopressin, thirst, and blood pressure. However, the neural pathways involved in NaCl sensing in the human brain are incompletely understood. The purpose of this pilot study was to determine if acute hypernatremia alters the functional connectivity of NaCl-sensing regions of the brain in healthy young adults. Resting-state fMRI scans were acquired in 13 participants at baseline and during a 30 min hypertonic saline infusion (HSI). We used a seed-based approach to analyze the data, focusing on the subfornical organ (SFO) and the organum vasculosum of the lamina terminalis (OVLT) as regions of interest (ROIs). Blood chemistry and perceived thirst were assessed pre- and post-infusion. As expected, serum sodium increased from pre- to post-infusion in the HSI group. The primary finding of this pilot study was that the functional connectivity between the SFO and a cluster within the OVLT increased from baseline to the late-phase of the HSI. Bidirectional connectivity changes were found with cortical regions, with some regions showing increased connectivity with sodium-sensing regions while others showed decreased connectivity. Furthermore, the functional connectivity between the SFO and the posterior cingulate cortex (a control ROI) did not change from baseline to the late-phase of the HSI. This finding indicates a distinct response within the NaCl sensing network in the human brain specifically related to acute hypernatremia that will need to be replicated in large-scale studies.

Diagnostic value of a 3% hypertonic saline infusion test in differential diagnosis between adh deficiency and primary polydipsia

Diagnostic value of a 3% hypertonic saline infusion test in differential diagnosis between adh deficiency and primary polydipsia

The 3% hypertonic saline infusion test for the differential diagnosis of diabetes insipidus and primary polydipsia: assessment of diagnostic accuracy

AIM: assessment of the diagnostic accuracy of a 3% hypertonic saline infusion test in relation to a set of clinical and laboratory data (including a water deprivation test and MRI data) for differential diagnoses of diabetes insipidus (DI) and primary polydipsia (PP).METHODS: An interventional cross-sectional study was carried out at Endocrinology Research Centre From September 2021 to September 2023 ninety patients with polyuria-polydipsia syndrome were included. In order to assess the diagnostic characteristics, all the subjects underwent two tests with osmotic stimulation: a 3% hypertonic saline infusion test and a water deprivation test. Adverse events were assessed.RESULTS: Based on the results of clinical, anamnestic, laboratory and instrumental data, and the results of a water deprivation test, a final diagnosis of DI was made in 48 (53%) patients and PP in 42 (47%) patients. The agreement between the two samples is significant — Kappa = 0.823, 95% CI (0.707, 0.939). The operational parameters of the 3% hypertonic saline infusion test are: sensitivity 98% (95% CI: 89%; 100%); specificity 98% (95% CI: 87%; 100%), positive and negative predictive values 98% (95% CI: 89%–100%) and 98% (95% CI: 87%–100%). Respectively. Chills occurred significantly more often (31% vs. 12%), and dizziness and headache were more pronounced during the 3% hypertonic saline infusion test. The median duration of the water deprivation test in patients was 11 hours, and median duration of 3% hypertonic saline infusion test was 1.5 hour (P&lt;0.001).CONCLUSION: The 3% hypertonic saline infusion test has a high overall diagnostic accuracy 98%; 95% CI 92% to 100%)) in relation to the classical set of clinical, laboratory and instrumental data of patients (including a water deprivation test), However, it is important the advantage of the latter is its short duration and, as a consequence, better tolerability and probably better compliance, while no significant differences in adverse events frequencies during the tests were identified.

Effect of continuous hypertonic saline infusion on clinical outcomes in patients with traumatic brain injury.

Osmotic therapy has been recognized as an important treatment option for patients with traumatic brain injury (TBI). Nevertheless, the effect of hypertonic saline (HTS) remains unknown, as findings are primarily based on a large database. This study aimed to elucidate the effect of HTS on the clinical outcomes of patients with TBI admitted to the intensive care unit (ICU). We retrospectively identified patients with moderate-to-severe TBI from two public databases: Medical Information Mart for Intensive Care (MIMIC)-IV and eICU Collaborative Research Database (eICU-CRD). A marginal structural Cox model (MSCM) was used, with time-dependent variates designed to reflect exposure over time during ICU stay. Trajectory modeling based on the intracranial pressure evolution pattern allowed for the identification of subgroups. Overall, 130 (6.65%) of 1955 eligible patients underwent HTS. MSCM indicated that the HTS significantly associated with higher infection complications (e.g., urinary tract infection (HR 1.88, 95% CI 1.26-2.81, p = 0.002)) and increased ICU LOS (HR 2.02, 95% CI 1.71-2.40, p < 0.001). A protective effect of HTS on GCS was found in subgroups with medium and low intracranial pressure. Our study revealed no significant difference in mortality between patients who underwent HTS and those who did not. Increased occurrence rates of infection and electrolyte imbalance are inevitable outcomes of continuous HTS infusion. Although the study suggests slight beneficial effects, including better neurological outcomes, these results warrant further validation.

Paediatric perspectives in the diagnosis of polyuria-polydipsia syndrome.

The elucidation of the underlying cause of polyuria-polydipsia syndrome (PPS)is a challenging-especially in the differentiation of partial defects of arginine vasopressin (AVP)secretion or action from primary polydipsia. The water deprivation test has been utilized for many decades, and its application in the paediatric population has been applied using parameters predominantly established in adult cohorts. In more recent times, the development of automated commercial assays for copeptin, a surrogate marker for AVP, has represented a significant advancement in the diagnostic approach to PPS. Measurement of copeptin concentrations has major advantages and has essentially superseded measurement of AVP in diagnostic protocols for PPS. Additionally, stimulated-copeptin protocols utilizing hypertonic saline infusion, arginine, and glucagon have been investigated, and are promising. However, further studies are required in the population-incorporating the differences in physiological regulation of water homeostasis, and safety requirements-before there is widespread adoption into clinical practice.

Herpes simplex encephalitis complicated with cerebral salt wasting syndrome: a case study

A 78-year-old man was admitted to the hospital with a 4-day history of fever and confusion. Physical examination revealed oral dryness and decreased skin turgor. Blood tests showed hyponatremia (121.5 ‍mEq/l), and cerebrospinal fluid examination revealed positivity for herpes simplex virus 1 (HSV-1) via polymerase chain reaction. He was diagnosed with herpes simplex encephalitis and initiated acyclovir treatment. The hyponatremia was diagnosed as cerebral salt wasting syndrome (CSWS) and treated with hypertonic saline infusion and fludrocortisone. The cerebrospinal fluid HSV-1 DNA became negative, and the serum sodium levels normalized. Hyponatremia complicated with encephalitis is often caused by the syndrome of inappropriate secretion of antidiuretic hormone (SIADH), whereas CSWS is rare, mostly observed in tuberculous meningitis. Differentiating between the SIADH and CSWS is important as they require distinct therapeutic strategies.

Assessment of the knowledge and use of hypertonic saline among doctors working in paediatrics departments of tertiary institutions in the five states of South-East Nigeria

Objectives: This study aimed to evaluate the knowledge and use of hypertonic saline among doctors in the Southeast region of Nigeria. Methods: It was a cross-sectional study conducted amongst 182 doctors in the paediatric departments of the six tertiary institutions in South Eastern Nigeria. Data to assess knowledge and use of hypertonic saline were collected using self-administered, structured questionnaires. Results: After aggregating the knowledge questions (definition of hypertonic saline, knowledge of available concentrations and modes of administration) and categorizing knowledge into good or poor, 148 (81.3%) had good knowledge, while 34 (18.7%) had poor knowledge. Respondents who had ever seen an infusion of hypertonic saline were 93 (51.1%), while only 62 (34.1%) had ever used it during their practice. Among those who had used it, only 33 (18.1%) obtained it from their hospital pharmacy. Most respondents (91.2%) would support advocacy for its increased availability and use in Nigeria. Conclusions: Our study demonstrated good knowledge of hypertonic saline, however, there is low usage due to unavailability. There is a need for collaboration between paediatricians, pharmaceutical companies and other stakeholders to create demand and initiate the production of hypertonic saline.

The impact of hypertonic saline on damage control laparotomy after penetrating abdominal trauma.

The inability to achieve primary fascial closure (PFC) after emergency laparotomy increases the rates of adverse outcomes including fistula formation, incisional hernia, and intraabdominal infection. Hypertonic saline (HTS) infusion improves early PFC rates and decreases time to PFC in patients undergoing damage control laparotomy (DCL) after injury. We hypothesized that in patients undergoing DCL after penetrating abdominal injury, HTS infusion would decrease the time to fascial closure as well as the volume of crystalloid required for resuscitation without inducing clinically relevant acute kidney injury (AKI) or electrolyte derangements. We retrospectively analyzed all penetrating abdominal injury patients undergoing DCL within the University of Pennsylvania Health System (January 2015-December 2018). We compared patients who received 3% HTS at 30mL/h (HTS) to those receiving isotonic fluid (ISO) for resuscitation while the abdominal fascia remained open. Primary outcomes were the rate of early PFC (PFC within 72h) and time to PFC; secondary outcomes included acute kidney injury, sodium derangement, ventilator-free days, hospital length of stay (LOS), and ICU LOS. Intergroup comparisons occurred by ANOVA and Tukey's comparison, and student's t, and Fischer's exact tests, as appropriate. A Shapiro-Wilk test was performed to determine normality of distribution. Fifty-seven patients underwent DCL after penetrating abdominal injury (ISO n = 41, HTS n = 16). There were no significant intergroup differences in baseline characteristics or injury severity score. Mean time to fascial closure was significantly shorter in HTS (36.37h ± 14.21 vs 59.05h ± 50.75, p = 0.02), and the PFC rate was significantly higher in HTS (100% vs 73%, p = 0.01). Mean 24-h fluid and 48-h fluid totals were significantly less in HTS versus ISO (24h: 5.2L ± 1.7 vs 8.6L ± 2.2, p = 0.01; 48h: 1.3L ± 1.1 vs 2.6L ± 2.2, p = 0.008). During the first 72h, peak sodium (Na) concentration (146.2mEq/L ± 2.94 vs 142.8mEq/L ± 3.67, p = 0.0017) as well as change in Na from ICU admission (5.1mEq/L vs 2.3, p = 0.016) were significantly higher in HTS compared to ISO. Patients in the HTS group received significantly more blood in the trauma bay compared to ISO. There were no intergroup differences in intraoperative blood transfusion volume, AKI incidence, change in chloride concentration (△Cl) from ICU admit, Na to Cl gradient (Na:Cl), initial serum creatinine (Cr), peak post-operative Cr, change in creatinine concentration (△Cr) from ICU admission, creatinine clearance (CrCl), initial serum potassium (K), peak ICU K, change in K from ICU admission, initial pH, highest or lowest post-operative pH, mean hospital LOS, ICU LOS, and ventilator-free days. HTS infusion in patients undergoing DCL after penetrating abdominal injury decreases the time to fascial closure and led to 100% early PFC. HTS infusion also decreased resuscitative fluid volume without causing significant AKI or electrolyte derangement. HTS appears to offer a safe and effective fluid management approach in patients who sustain penetrating abdominal injury and DCL to support early PFC without inducing measurable harm. Level III.

Syndrome of Inappropriate Secretion of Antidiuretic Hormone Associated with H1N1 Infection

The syndrome of inappropriate secretion of antidiuretic hormone (SIADH) is related to several conditions. However, there are few reports associated with H1N1 virus infection. We describe a 36 year old patient with SIADH admitted to our department if internal medicine with fever, cough and myalgias. The labooratory analysis showed serum hypo-osmolar hyponatremia and high level of urinary sodium concentration. All other biological analysis were within normal range. Moreover, All bacterial and fungal cultures, blood and urine cultures were all negative for any microbial pathogen. The thoraco-abdominal CT scan was normal. Rapid flu test was positive for influenza type A 15 days after. The patient recovered with intravenous infusion of hypertonic saline and fluid restriction and he did not received any anti-viral drug. Despite a strong relationship betwwen H1N1 virus infection and SIADH needs to be established, physicians should be aware of this potential seroius effect and should monitor the serum sodium closely.&#x0D; Keywords : H1N1 infection, inappropriate secretion of antidiuretic hormone, hyponatremia

Arginine-Stimulated Copeptin-Based Diagnosis of Central Diabetes Insipidus in Children and Adolescents

Introduction: Diagnosis of central diabetes insipidus (CDI) remains challenging. Water deprivation testing and hypertonic saline infusion, as established diagnostic tests, are mentally and physically demanding for patients. Arginine-stimulated copeptin has been shown as a putative parameter for the differential diagnosis of CDI in adults. Methods: In this single-centre retrospective study, we identified paediatric patients with suspected pituitary disorders who underwent standard arginine testing. Patients with CDI, matched controls, and primary polydipsia (PP) were identified. Diagnoses were confirmed retrospectively using comprehensive clinical and diagnostic characteristics. Serum copeptin concentrations were measured using a commercially available automated immunofluorescence assay (B.R.A.H.M.S Copeptin-proAVP KRYPTOR®) in samples stored for a median of 4.6 years (1.3–10.84) and collected before and 60 min after arginine infusion. Cut-off analyses were performed using ROC curves. Results: Serum samples from 32 patients with CDI, 32 matched controls, and 5 patients with PP (n = 69; 51 males, 18 females) were available for analysis. Median copeptin concentrations increased from 4.47 pmol/L (interquartile range [IQR]: 3.47–8.36) to 6.96 pmol/L (IQR: 4.51–12.89; p < 0.001) in controls, from 1.46 pmol/L (IQR: 1.21–2.12) to 1.44 (IQR: 1.10–1.87; p = 0.645, ns) in CDI, and from 4.40 pmol/L (3.95–6.33) to 9.58 pmol/L (8.19–11.42; p < 0.001) in PP. The published cut-off value of 3.8 pmol/L revealed a sensitivity of 100% and a specificity of 86.5% in confirming CDI. Conclusion: Our results suggest that arginine-stimulated serum copeptin concentrations are a sensitive and specific diagnostic tool for CDI in paediatric patients, which may replace and simplify the conventional diagnostic pathway of water deprivation testing and hypertonic saline infusion.

Sistemik yangısal yanıt sendromlu bir köpekte %7.2’lik hipertonik salin solüsyonunun ekokardiyografik parametreler üzerine etkisi

We were aimed with this case report that evaluate the efficiency of 7.2% hypertonic saline infusion on echocardiographic parameters in a 5-months-old male Kangal Shepherd crossbreed dog with the systemic inflammatory response syndrome (SIRS). For this propose on initial referral to the clinic, SIRS was defined with clinical and laboratory finding. Hypertonic saline (7.2%) was administered at intravenously of 4 ml/kg (1.6 ml/kg/min) for fluid replacement. Echocardiography was performed at before (t=0 min), and after (t=5, 15 min) fluid infusion. An increase in systolic function, cardiac contractility and left ventricular preload in the dog were determineted with the administration of 7.2% hypertonic saline. Considering this case, systolic dysfunction was improved by infusion of 4 ml/kg 7.2% hypertonic saline solution.

RENAL8: Hypertonic Bicarbonate during Continuous Renal Replacement Therapy in Acute Liver Failure

Introduction: Acute liver failure (ALF) is particularly alarming when presenting with vasodilated shock and multi-organ system failure. Standard manufactured hemofiltration fluid (sodium [Na+] = 140 mEq/L) would result in hyponatremia in vivo. We present a case study of hypertonic NaHCO3 infusion to address simultaneous serum Na+ target and correction of acidemia during continuous therapy. Case Presentation: A 42-year-old female with a history of seizures, and heavy alcohol use presented from outside the hospital for evaluation of stroke-like symptoms and subsequent mechanical fall. Urgent head CT was non-contributory. She was found to be in acute liver failure with total bilirubin 4.7, AST: 15,525 ALT: 5,727, ammonia 267 umol/L [reference range: 18-72], acetaminophen level 29 mcg/mL [reference range 10-30], Na+ 128 mEq/L, lactate >20 mmol/L, PT INR 8.1, PH 7.0 on blood gas and a negative ethanol level/salicylate/urine drug screen. After emergent intubation for encephalopathy and multiorgan system failure, she required multiple vasopressors (epinephrine, vasopressin, and norepinephrine), and received N-acetylcysteine protocol, with intravenous bicarbonate infusion and broad-spectrum antibiotic. High dose continuous veno-venous hemodiafiltration (CVVHDF) was initiated via Baxter PrisMax platform and global effluent dosing of 58mL/kg/hr with post-filter 3% NaCl at a rate of 100 mL/hr to reach goal serum sodium of 140 mEq/dL. [3% NaCl infusion rate calculation: (target infused Na – 140 mEq/L)/ (513 mEq/L – 140 mEq/L) x hemofiltration rate (mL/h)]. She also received Therapeutic Plasma Exchange for ALF for 5 daily sessions using fresh frozen plasma. She continued to have ongoing acidosis with a lactate of 11.7 mmol/L, and serum bicarbonate of 17 mEq/L. On Hospital Day 6, 3% NaCl was changed to hypertonic NaHCO3 drip [4.2% NaHCO3 solution (500 mEq/L in 1L of D5W) at a rate of 100 mL/hr, replacing 3% NaCl on a 1:1 ratio mL/mL]. After 24 hours she had improvement in metabolic acidosis with improvement in serum bicarbonate from 17 to 24 mEq/L, pH of 7.34 to 7.40; pCO2 32 to 42, HCO3 17 to 25 mmHg and serum Na 133 to 140 mEq/L. Unfortunately, on hospital day 8 developed worsening shock requiring vasopressors; a repeat abdominal imaging noted high-grade small bowel obstruction with ischemic bowel and pneumatosis intestinalis and was transitioned to comfort care. Discussion: While CVVHDF can address elevated ammonia in ALF, infused standard therapy fluid (Na+ = 140 mEq/L) would equilibrate serum Na+ to 133 - 135 mEq/L, in the presence of plasma proteins. Post-filter hypertonic saline infusion during CVVHDF would enable simultaneous clamping of serum Na+ to the appropriate target level. Due to heavier molecular size, 4.2% NaHCo3 results in identical Na+ delivery of 3% saline along with the added benefit of improving acidosis. Clinical studies are desirable to define optimal serum Na+ concentrations during CVVDF in various clinical settings.

Optic nerve sheath diameter and pulsatility index for the diagnosis and follow-up in pediatric traumatic brain injury: a prospective observational cohort study.

Invasive neuromonitoring could be difficult in children with traumatic brain injury (TBI). This study aimed to determine whether noninvasive intracranial pressure (nICP), calculated via pulsatility index (PI) and optic nerve sheath diameter (ONSD) had correlated with each other and patient outcome. All moderate-severe TBI patients were eligible. Patients with a diagnosis of intoxication that did not affect the mental status or cardiovascular system were enrolled as controls. The PI measurements were routinely performed bilaterally on the middle cerebral artery. A software (QLAB's Q-Apps) was used to calculate PI, which further placed the ICP equation of Bellner et al. Linear probe with a 10MHz frequency transducer to measure ONSD, which further placed the ICP equation of Robba et al. All measurements were performed by a point-of-care ultrasound certified pediatric intensivist under the supervision of a neurocritical care specialist, before and 30min after a hypertonic saline (HTS) infusion for every 6h when the patient's mean arterial pressure, heart rate, body temperature, hemoglobin, and blood CO2 levels were within normal ranges. The secondary outcome was the effect of hypertonic saline (HTS) on nICP. Delta-sodium values of each HTS infusion were calculated as a difference between pre- and post-measurements. Twenty-five TBI patients (200 measurements) and 19 controls (57 measurements) were included. Median nICP-PI and nICP-ONSD on admission were significantly higher in the TBI group (11.03 (9.98-12.63), p = 0.004, and 13.14 (12.27-14.64), p < 0.001, respectively). Median nICP-ONSD of severe TBI patients were higher than moderate TBI patients (13.58 (13.14-15.71) and 12.30 (9.83-13.14), respectively, p = 0.013). The median nICP-PI was the same across the type of injury (falls and motor vehicle accidents), while the median nICP-ONSD of the motor vehicle accident group was higher than falls. The first nICP-PI and nICP-ONSD measurements in PICU and admission pGCS were negatively correlated (r = - 0.562, p = 0.003 and r = - 0.582, p = 0.002, respectively). The mean nICP-ONSD during the study period and admission pGCS and GOS-E peds score significantly correlated. However, the Bland-Altman plots showed significant bias between the two methods of ICP except after 5th dose of HTS. All nICP values significantly decreased in time, and it was most obvious after the 5th dose of HTS. No significant correlations were found between delta sodium levels and nICP. Noninvasive estimation of ICP is helpful for the management of pediatric severe TBI patients. nICP driven by ONSD is more consistent with clinical findings of increased ICP but not useful as a follow-up tool in acute management because of slow circulation of CSF around the optic sheath. The correlation between admission GCS scores and GOS-E peds score favors ONSD as a good candidate for determining disease severity and predicting long-term outcomes.

Early and prolonged continuous hypertonic saline infusion in patients with acute liver failure

PurposeTo study patient characteristics, physiological changes, and outcomes associated with prolonged continuous hypertonic saline (HTS) infusion in acute liver failure (ALF). Materials and methodsRetrospective observational cohort study of adult patients with ALF. We collected clinical, biochemical, and physiological data six hourly for the first week, daily until day 30 or hospital discharge, and weekly, when documented, until day 180. ResultsOf 127 patients, 85 received continuous HTS. Compared with non-HTS patients they were more likely to receive continuous renal replacement therapy (CRRT) (p < 0.001) and mechanical ventilation (p < 0.001). Median HTS duration was 150 (Interquartile range (IQR): 84–168) hours, delivering a median 2244 (IQR: 979–4610) mmol sodium load. Median peak sodium concentration was 149 mmol/L vs 138 mmol/L in non-HTS patients (p < 0.001). The median rate of sodium increase with infusion was 0.1 mmol/L/h and median rate of decrease during weaning was 0.1 mmol/L every 6 h. Median lowest pH value was 7.29 vs. 7.35 in non-HTS patients. Survival of HTS patients was 72.9% overall and 72.2% without transplantation. ConclusionsIn ALF patients, the prolonged administration of HTS infusion was not associated with severe hypernatremia or rapid shifts in serum sodium upon commencement, delivery, or weaning.