Occurrence Of Hypernatremia Research Articles

EBNEO commentary: Fluid balance as a critical factor in neonatal outcomes.

With this study, Starr and colleagues add to the growing body of literature recognising the importance of fluid status in neonates.1-3 Utilising the weight-change method for estimating fluid balance, which is the preferred method in neonates,4 they found that fluid balance is independently associated with the need for mechanical ventilation at post-natal day 14 and the composite outcome of severe bronchopulmonary dysplasia (BPD) or death. All neonates undergo a period of adaptation of fluid and electrolyte homeostasis after birth, with a contraction of the extracellular fluid (ECF) compartment, driven by natriuretic diuresis and transepidermal losses in preterm infants. This phase ends with maximum weight loss or negative fluid balance.5 Very low birth weight and extremely low birth weight infants can experience 10%–15% negative fluid balance, with this phase lasting up to 8 days.5, 6 Clinicians should allow for ECF contraction while maintaining intravascular fluid volume, achieving a negative sodium balance, maintaining normal serum electrolyte levels and providing sufficient calories to meet maintenance needs.5, 6 Achieving this requires close monitoring of daily intake and output, weight changes and electrolyte concentrations, while thoughtfully adjusting prescribed fluid intake. In the same patient cohort as the present study, Valentine and colleagues analysed weight loss and fluid administration.7 They found that a maximum weight loss of 5–15% within the first post-natal week was associated with decreased odds of developing necrotising enterocolitis (NEC), while an average total fluid administration of >150 mL/kg BW/day over the first post-natal week was associated with increased risk of NEC and patent ductus arteriosus (PDA) requiring surgery. They suggested cautious limitation of total fluid administration and allowing for moderate weight loss in the first post-natal week.7 A 2014 Cochrane review recommended careful restriction of fluid intake in preterm neonates to meet physiological needs without causing dehydration rather than a practice of liberal fluid intake, citing that restricted fluid intake significantly reduced the risks of PDA and NEC, with trends towards reduced risk of BPD, intra-ventricular haemorrhage and death.8 No discussion about fluid status is complete without addressing electrolytes, specifically sodium. Dysnatremias are common in critically ill patients and are associated with mortality and hospital length of stay.9 Preterm infants are at particular risk for dysnatremias given immature renal tubules, fluid shifts, insensible losses and exposure to parenteral nutrition. In an analysis of a contemporary large neonatal cohort, dysnatremias were common in the first week of life, occurring in half of the cohort.9 In adjusted models, the occurrence of hypernatremia and combined hypo- and hypernatremia in the first week of life was associated with an increased risk of mortality in neonates with normal renal function.9 Weight changes, fluid intake, electrolyte status—this is quite the fine balance. When does physiologic weight loss become pathologic? Clearly, there are many variables and outcomes to consider. Starr and colleagues provide potential targets for this complex problem. In efforts to reduce rates of BPD and other neonatal morbidities, fluid balance is emerging as a critical factor. URL LINK: https://ebneo.org/ebneo-commentary-fluid-balance-and-neonatal-outcomes/ None. None.

Improving Isotonic Maintenance Intravenous Fluid Use in the Emergency Department.

Maintenance intravenous fluids (IVFs) are commonly used in the hospital setting. Hypotonic IVFs are commonly used in pediatrics despite concerns about high incidence of hyponatremia. We aimed to increase isotonic maintenance IVF use in children admitted from the emergency department (ED) from a baseline of 20% in 2018 to >80% by December 2019. We included patients aged 28 days to 18 years receiving maintenance IVFs (rate >10 mL/hour) at the time of admission. Patients with active chronic medical problems were excluded. Interventions included institutional discussions on isotonic IVF based on literature review, education on isotonic IVF use per the American Academy of Pediatrics guideline (isotonic IVF use with appropriate potassium chloride and dextrose), electronic medical record changes to encourage isotonic IVF use, and group practice review with individual physician audit and feedback. Balancing measures were the frequency of serum electrolyte checks within 24 hours of ED admission and occurrence of hypernatremia. Data were analyzed by using statistical process control charts. Isotonic maintenance IVF use improved, with special cause observed twice; the 80% goal was met and sustained. No difference was noted in serum electrolyte checks within 24 hours of admission (P > .05). There was no increase in occurrence of hypernatremia among patients who received isotonic IVF compared with those who received hypotonic IVF (P > .05). The application of improvement methods resulted in improved isotonic IVF use in ED patients admitted to the inpatient setting. Institutional readiness for change at the time of the American Academy of Pediatrics guideline release and hardwiring of preferred fluids via electronic medical record changes were critical to success.

Variability in Serum Sodium Concentration and Prognostic Significance in Severe Traumatic Brain Injury: A Multicenter Observational Study.

Dysnatremia is common in severe traumatic brain injury (TBI) patients and may contribute to mortality. However, serum sodium variability has not been studied in TBI patients. We hypothesized that such variability would be independently associated with mortality. We collected 6-hourly serum sodium levels for the first 7days of ICU admission from 240 severe TBI patients in 14 neurotrauma ICUs in Europe and Australia. We evaluated the association between daily serum sodium standard deviation (dNaSD), an index of variability, and 28-day mortality. Patients were 46 ± 19years of age with a median initial GCS of 6 [4-8]. Overall hospital mortality was 28%. Hypernatremia and hyponatremia occurred in 64% and 24% of patients, respectively. Over the first 7days in ICU, serum sodium standard deviation was 2.8 [2.0-3.9] mmol/L. Maximum daily serum sodium standard deviation (dNaSD) occurred at a median of 2 [1-4] days after admission. There was a significant progressive decrease in dNaSD over the first 7days (coefficient - 0.15 95% CI [- 0.18 to - 0.12], p < 0.001). After adjusting for baseline TBI severity, diabetes insipidus, the use of osmotherapy, the occurrence of hypernatremia, and hyponatremia and center, dNaSD was significantly independently associated with 28-day mortality (HR 1.27 95% CI (1.01-1.61), p = 0.048). Our study demonstrates that daily serum sodium variability is an independent predictor of 28-day mortality in severe TBI patients. Further prospective investigations are necessary to confirm the significance of sodium variability in larger cohorts of TBI patients and test whether attenuating such variability confers outcome benefits to such patients.

Choice of fluid therapy in patients of craniopharyngioma in the perioperative period: A hospital-based preliminary study.

Background:Electrolyte imbalance and acute diabetes insipidus (DI) are the most common complications in patients undergoing craniopharyngioma surgery. Improper management of water and electrolyte imbalance is common cause of morbidity and mortality. Data is sparse and controversial regarding the choice of fluid therapy in this population during perioperative period.Methods:In this retrospective-prospective study involving 73 patients (58 retrospective), the type of fluid therapy was correlated with occurrence of hypernatremia, hyponatremia, DI, morbidity, and mortality. In the retrospective study, 48 patients received normal saline and 10 received mixed fluids as per the prevailing practice. In the prospective group, five patients each received normal saline, half normal saline, and 5% dextrose randomly.Results:The sodium values were significantly higher in first 48 h in the group that received normal saline compared with other groups (P < 0.001). The use of normal saline was associated with higher incidence of hypernatremia, DI, and mortality (P = 0.05), while the group that received 5% dextrose was associated with hyponatremia, hypoglycemia, and seizures. There was no perioperative hypotension with use of any of the fluids.Conclusion:Our results indicate half normal saline was fluid of choice with diminished incidence of water and electrolyte abnormalities without increase in mortality during postoperative period.

A patient with demyelination, laminar cortical necrosis, and rhabdomyolysis associated with hypernatremia

A 60-year-old man with renal failure and intraabdominal abscess formation probably due to perforation of the colon underwent laparotomy on the sixth hospital day. He developed respiratory infection, deterioration of renal failure, and heart failure resulting in severe respiratory insufficiency after laparotomy. He was placed on mechanical ventilation using sedatives and muscle relaxant and was treated with antibiotics, steroids, and a diuretic. The value of serum sodium jumped from 146 to 164 mEq/L in 2 days. Sodium infusion was discontinued, and hypernatremia decreased. He fell into a coma and demonstrated generalized convulsions after mechanical ventilation was discontinued. His head computed tomography did not indicate any pathologic findings, and his convulsions were not controlled so that he was again placed on mechanical ventilation. The laboratory findings revealed rhabdomyolysis (18936 IU/L) 5 days after the normalization of hypernatremia. Mechanical ventilation and hemodialysis were terminated after the convulsions were controlled and the renal failure improved on the 82nd hospital day. Head magnetic resonance imaging exhibited that multiple hyperintensity lesions in the white matter with linear signal changes in both occipital cortex. He remained unconscious for 6 months. This is the first case that demonstrated demyelination, laminar cortical necrosis, and rhabdomyolysis associated with hypernatremia. Rhabdomyolysis after rapid occurrence of hypernatremia might be a laboratory sign of concomitant demyelination.

Impact of hypernatremia on patients with severe traumatic brain injury

Hypernatremia is frequently encountered in the neurocritical ICU and its effect can badly affect mortality. The objective of this study was to verify whether the occurrence of hypernatremia during the ICU stay increases the risk of death in patients with severe traumatic brain injury (TBI).

The relation between the incidence of hypernatremia and mortality in patients with severe traumatic brain injury

IntroductionThe study was aimed at verifying whether the occurrence of hypernatremia during the intensive care unit (ICU) stay increases the risk of death in patients with severe traumatic brain injury (TBI). We performed a retrospective study on a prospectively collected database including all patients consecutively admitted over a 3-year period with a diagnosis of TBI (post-resuscitation Glasgow Coma Score ≤ 8) to a general/neurotrauma ICU of a university hospital, providing critical care services in a catchment area of about 1,200,000 inhabitants.MethodsDemographic, clinical, and ICU laboratory data were prospectively collected; serum sodium was assessed an average of three times per day. Hypernatremia was defined as two daily values of serum sodium above 145 mmol/l. The major outcome was death in the ICU after 14 days. Cox proportional-hazards regression models were used, with time-dependent variates designed to reflect exposure over time during the ICU stay: hypernatremia, desmopressin acetate (DDAVP) administration as a surrogate marker for the presence of central diabetes insipidus, and urinary output. The same models were adjusted for potential confounding factors.ResultsWe included in the study 130 TBI patients (mean age 52 years (standard deviation 23); males 74%; median Glasgow Coma Score 3 (range 3 to 8); mean Simplified Acute Physiology Score II 50 (standard deviation 15)); all were mechanically ventilated; 35 (26.9%) died within 14 days after ICU admission. Hypernatremia was detected in 51.5% of the patients and in 15.9% of the 1,103 patient-day ICU follow-up. In most instances hypernatremia was mild (mean 150 mmol/l, interquartile range 148 to 152). The occurrence of hypernatremia was highest (P = 0.003) in patients with suspected central diabetes insipidus (25/130, 19.2%), a condition that was associated with increased severity of brain injury and ICU mortality. After adjustment for the baseline risk, the incidence of hypernatremia over the course of the ICU stay was significantly related with increased mortality (hazard ratio 3.00 (95% confidence interval: 1.34 to 6.51; P = 0.003)). However, DDAVP use modified this relation (P = 0.06), hypernatremia providing no additional prognostic information in the instances of suspected central diabetes insipidus.ConclusionsMild hypernatremia is associated with an increased risk of death in patients with severe TBI. In a proportion of the patients the association between hypernatremia and death is accounted for by the presence of central diabetes insipidus.