Use Of Hypotonic Fluids Research Articles

The efficacy and safety of isotonic and hypotonic fluids in intravenous maintenance fluid therapy in term newborns: national multicenter observational "neofluid" study.

The objective of this study was to evaluate the efficacy and safety of isotonic and hypotonic intravenous fluids in maintenance fluid therapy for term infants. This was a multi-centre, prospective, observational study conducted in 21 participating centres from December 30, 2020, to June 30, 2023. The study included term newborns requiring parenteral fluid therapy for maintenance (NCT04781361). The fluid treatment was divided into two groups based on the concentration of sodium in the parenteral fluid, designated as hypotonic (NaCl <130 mmol/L) and isotonic (NaCl = 130-154 mmol/L). The primary outcomes were the change in mean plasma sodium (pNa) levels per hour (∆pNa mmol/L/h), the incidence of hyponatremia (pNa <135 mmol/L) and hypernatremia (pNa >145 mmol/L), and the occurrence of clinically significant changes in sodium levels (∆pNa >0.5 mmol/L/h). A total of 420 patients from 21 centers were included. The ∆pNa was negative in the hypotonic fluid group and positive in the isotonic fluid group, with a significant difference between the groups [respectively -0.07 ± 0.03 (95% CI: -0.13 to -0.02); 0.04 ± 0.03 (95%CI: -0.02 to 0.09), p = 0.04]. There was no difference between the groups in terms of the development of hypernatremia or a clinically meaningful pNa increase. The hypotonic fluid group had a higher incidence of hyponatremia and a clinically meaningful sodium decrease compared to the isotonic fluid group [7.9% vs. 1.2% (OR:6.5, p:0.03)] and [12.2% vs.4.2% (OR:2.9, p = 0.03)]. Contrary to current understanding, this large-scale study is the first to demonstrate that the use of hypotonic fluids in maintenance fluid therapy for newborns poses a risk of hyponatremia development, whereas isotonic fluid therapy appears safe.

Hyponatremia as an underdiagnosed postpartum headache emergency: a case report

Postpartum headache is a common emergency department complaint with a wide differential diagnosis. Distinguishing primary from secondary, more sinister, causes of headache is an important skill for the emergency physician.&#x0D; We present a case of a 31-year-old G1P1 woman who presented at five days postpartum with a 48-hour headache and an otherwise uncomplicated pregnancy. She had several precipitating postpartum risk factors, including use of hypotonic fluids in labour, oxytocin to augment labour, changes in food and drink patterns, and was mildly hypertensive. Urgent investigations in the emergency department found her to be severely hyponatremic (sodium: 121 mmol/L (normal: 136-144)) without evidence of preeclampsia. She was admitted to hospital to correct her electrolyte imbalance.&#x0D; This case highlights the importance of remaining vigilant in differentiating concerning causes of postpartum headache, as well as identifying key precipitants which may put women at risk for postpartum hyponatremia.

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

Prescription practices related to maintenance intravenous fluid in children

Background: Maintenance intravenous fluids (IVFs) play a key role in patient management. However, the type of fluids that has to be used should be prudently selected. Past surveys depict the tendency of residents to prescribe hypotonic fluids, following the traditional practice. The increased incidence of hyponatremia has been reported with the use of hypotonic fluids. The study was conducted to investigate the composition and volume of maintenance IVFs prescribed by pediatricians in various clinical settings. Subjects and Methods: A predesigned questionnaire was generated online and distributed via E-mail to pediatricians from teaching institutes, general hospitals, and private clinics. Different clinical scenarios were created, and respondents were asked the composition and volume of IVFs to be prescribed. Results: A total of 438 responses were analyzed. Hypotonic fluids for maintenance therapy were selected by 47% of respondents irrespective of patient's age and clinical condition, whereas 83% opted for hypotonic fluids for infants &lt;2 months, and half of them prescribed very hypotonic fluids in these infants. Isotonic fluids were considered significant in central nervous system infections, head trauma, and as an initial fluid for the management of shock. Variability is evident for the preference of hypotonic versus isotonic fluids and is affected by the clinical position, experience, and workplace of the respondents. Conclusions: The outcome of this survey portrays that the participants are not well aware of the fluid management protocols for children. Formulation of universal guidelines and their implementation is required as the priority to overcome this uncertainty to provide the best care to pediatric patients.

0.45% Versus 0.9% Saline in 5% Dextrose as Maintenance Fluids in Children Admitted With Acute Illness: A Randomized Control Trial.

The safety of giving intravenous (IV) maintenance fluids according to Holliday and Segar's recommendations of 1957 has recently been questioned after reports of complications caused by iatrogenic hyponatremia in children receiving hypotonic fluids. However, the current practice of choice of maintenance IV fluids for hospitalized children varies worldwide. This study was planned to compare 0.45% and 0.9% saline in 5% dextrose at standard maintenance rates in hospitalized children aged 3 months to 12 years. Primary objective was to study change in serum sodium level at 24 hours in children receiving total IV fluid maintenance therapy as 0.45% or 0.9% normal saline in 5% dextrose. Secondary objectives of this study were to estimate change in serum sodium levels from the baseline to 48 or 72 hours, if IV fluids were continued, and to find incidence of hyponatremia and hypernatremia after administering these 2 types of maintenance fluids. This study was an open-label, randomized control trial conducted at the Department of Pediatrics of a tertiary care hospital from July 22, 2019, to October 28, 2019. Two hundred children aged 3 months to 12 years admitted in pediatric emergency and requiring IV maintenance fluid were randomized into 2 groups (group A received 0.45% saline in 5% dextrose, group B received 0.9% normal saline in 5% dextrose) with 100 in each group. Both groups were comparable for baseline characteristics. Fall in mean serum sodium from baseline was more with increasing duration of IV fluids until 24 hours in 0.45% saline group as compared with 0.9% saline group, which was statistically significant (P < 0.001). The incidence of mild and moderate hyponatremia was significantly more in hypotonic group at 12 hours (P < 0.001) and 24 hours (P < 0.001). However, there was no significant difference at 48 hours. The fall in serum sodium values was significant, and there was significant risk of hyponatremia with the use of hypotonic fluids at 12 and 24 hours. Hence, the use of isotonic fluids seems to be more appropriate among the hospitalized children.Trial Registration: CTRI/2019/10/021791.

Use of normal saline and incidence of dyselectrolytaemia in children following kidney transplantation.

The use of hypotonic fluid, such as 0.45% saline, following kidney transplantation (KT) in children is associated with a high incidence of electrolyte imbalance, especially hyponatraemia. This can result in serious adverse events, such as cerebral oedema and seizures. The aim of this study was to investigate the incidence of electrolyte disturbance in children when 0.9% saline was the intravenous fluid used in the first 72h following KT. This is a retrospective, observational study of 50 consecutive KT undertaken between January 2017 and January 2019 at a single centre. The median age at KT was 9.2years (IQR 4-14) and 16 (32%) were females. Thirty-two (64%) were living related donor (LRD) KT and 22 (44%) were carried out in children < 20kg. The mean volume of fluid administered intra-operatively, and on Day 1, Day 2 and Day 3, were 73ml/kg, 124ml/kg, 97ml/kg and 86ml/kg, respectively. Hyponatraemia was noted in 4%, hypernatraemia in 18%, hyperkalaemia in 18%, hyperchloraemia in 68% and low bicarbonate was seen in 88%. Fifteen percent of the children had an episode of hyperglycaemia. None of the children developed symptomatic dyselectrolytaemia. There was delayed graft function (DGF) in 4 (8%) recipients - all deceased donor (DD) KT, including 2 who received donations after circulatory death. While the use of 0.9% saline is associated with a high incidence of electrolyte disturbances, including hyperkalaemia, it reduces the risk of hyponatraemia. None of the children developed a symptomatic electrolyte abnormality. A higher resolution version of the Graphical abstract is available as Supplementary information.

Maintenance fluid management in pediatrics: Current practice and quality improvement achievements

The long-standing use of hypotonic fluids in pediatric maintenance fluids has been challenged in recent years due to concerns over iatrogenic hyponatremia causing morbidity and mortality. Newer research has highlighted the safety of isotonic fluid alternatives. The American Academy of Pediatrics published an evidenced-based Clinical Practice Guideline in December of 2018 (Feld etal., 2018) to support the routine use of isotonic solutions in pediatric maintenance fluids. This article will also highlight relevant history, current practice, and a quality improvement project to standardize isotonic fluid use in the inpatient pediatric setting.

Comparison of isotonic versus hypotonic intravenous fluid for maintenance fluid therapy in neonates more than or equal to 34 weeks of gestational age – a randomized clinical trial

Background and objectives The use of hypotonic fluids as maintenance therapy in the neonatal population has been in practice for a long time, but there is a lack of evidence for the choice of this fluid in neonates. This study compared isotonic (sodium chloride, 0.9%, and dextrose, 5%) versus hypotonic (sodium chloride, 0.15%, and dextrose, 5%) intravenous fluid for maintenance fluid therapy in neonates more than or equal to 34 weeks of gestational age. Methods In this triple-blind randomized clinical trial, we recruited 60 neonates admitted to a neonatal intensive care unit of a tertiary care children's hospital from June 2017 through May 2018 with normal baseline serum sodium levels, anticipated to require intravenous maintenance fluids for 24 hours or longer (intention-to-treat analyses). Patients were randomized to receive isotonic or hypotonic intravenous fluid at maintenance rates for 72 hours. The primary outcome was the incidence of hyponatremia (defined as serum sodium <135mEq/L) at 24 hours in both groups. The secondary outcomes were incidence of hypernatremia at 24 hours (defined as serum sodium >145 mEq/L), the incidence of hypo and hypernatremia at 48 and 72 hours, mean serum sodium at 24, 48, and 72 hours, rate of change of serum sodium during the study period, mean serum osmolality at the end of the study period, the absolute difference in osmolality during the study period, the absolute difference in weight during the study period and edema during the study period. Results Of 60 enrolled neonates, 31 received isotonic fluids and 29 received hypotonic fluids. Three patients in the hypotonic group developed hyponatremia and none in isotonic group at 24 h (RR = 0.13; 95% CI = 0.007 − 2.485; p = .106). Fourteen neonates developed hypernatremia in the isotonic group and one in hypotonic group at 24 h (RR = 13.09; 95% CI = 1.83 − 93.4; p = .0001). Conclusions Our study results do not support the hypothesis that isotonic fluid is superior to hypotonic fluid in reducing the proportion of neonates developing hyponatremia after 24 hours of intravenous fluid therapy. The proportion of neonates developing hypernatremia is significantly higher after using isotonic fluid for maintenance therapy. TRIAL REGISTRATION CTRI/2017/05/008585

Use of hypotonic fluids in the prescription of maintenance intravenous fluid therapy

IntroductionIsotonic fluids, in most cases, are the safest way to dispense fluids intravenously. The aim of this study was to determine the prescription of maintenance intravenous fluids and to study possible associated factors. Material and methodA descriptive, cross-sectional, multi-centre study was performed. A questionnaire was sent nationwide to several healthcare providers via an online survey, sent by email through different Medical Scientific Societies, and the Official Spanish Medical Association, between December 2016 and December 2017. ResultsA total of 487 questionnaires were received, of which 456 were submitted by paediatricians. More than one quarter (28.95%) (95% CI; 24.77–33.13) of the paediatricians usually dispense hypotonic fluids and 81.14% (95% CI; 77.54–84.74) prescribe infusion rates based on the Holliday and Segar protocol. The general profile of paediatricians who prescribe hypotonic fluids intravenously in Spain are medical residents, paediatricians working in paediatric non-intensive care units, in private hospitals, and those who recognise that no consensus exists among their direct work colleagues regarding this subject. ConclusionsMore than twenty-five per cent of all paediatricians in our country continue to use hypotonic fluids as maintenance intravenous fluid therapy. There might be several potential factors associated to this. These kind of studies provide evidence of the great difficulties in transferring scientific knowledge to clinical practice.

Study of the serum sodium changes in children between 3 months and 5 years age receiving isotonic maintenance intravenous fluids

Background: Isotonic fluid is now the accepted standard of practice as maintenance intravenous fluids. The use of hypotonic fluids has been associated with electrolyte imbalance which could potentially lead to morbidity and mortality. The aim of this prospective study was to assess whether the use of isotonic fluids causes significant changes in the serum sodium concentration and is associated with any related complications in the age group between 3 months and 5 years. Methods: Serum sodium was measured at 0, 12, 24, and 48 h of commencement of isotonic intravenous fluids. Results were analyzed separately for groups between 3–12 months and 13–60 months. Results: All the children in the study group had sodium levels within normal range before the commencement of intravenous fluids. There was no significant change in the mean sodium levels at 12, 24, and 48 h of commencement of intravenous fluids in the age groups between 3–12 months and 13–60 months. There were no complications noted with the use of isotonic intravenous fluids. Conclusion: Use of isotonic intravenous fluids in the age group between 3 months and 5 years is not associated with significant changes in the serum sodium concentrations or adverse events. Hence, isotonic intravenous fluid can be used safely for maintaining hydration in children.

Fluid choice during perioperative care in children: A survey of present-day proposing practice by anesthesiologists in a tertiary care hospital.

Background:Perioperative fluid therapy in pediatrics has always been a challenging avenue for anesthesiologists. Inappropriate choice of fluid leads to multiple side effects, for instance iatrogenic hyponatremia. Our aim was to observe the current practice of perioperative fluid therapy in pediatric population undergoing surgery in a tertiary care hospital.Methods:After obtaining approval from the Departmental Research Review Committee, a survey form including questions was emailed to anesthesiologists from January 2015 to June 2015. Individual responses were recorded and analyzed.Results:Overall response was 100% from consultant and resident, and total 55 anesthesiologists were participated in this survey. Majority of anesthesiologist have used, 1/2 dextrose saline (52.7%) as fluid of choice in routine intraoperative maintenance, while Hartmann's solution (41.8%) and normal saline 0.9% (5.5%) were used for rest of the them. The Holliday-Segar method for maintenance fluid was mentioned by 92.7% of anesthesiologists.Conclusion:The use of hypotonic fluid in perioperative care in pediatric population is still being practiced despite the current guidelines. These results point to a considerable gap between the available evidence and practice.

Causes of hyponatraemia in traumatic brain injury patients in intensive care unit settings

The aim of this article is to describe the different causes of hyponatraemia in traumatic brain injury (TBI) patients in the intensive care unit (ICU). We carried out a retrospective observational analytical study in the ICU of 442 patients diagnosed with various TBIs, including 150 patients who developed hyponatraemia during their stay in the ICU. A diagnostic algorithm was followed to identify different causes of hyponatraemia. The data were collected using a convenience sampling technique. The results showed that 87% of patients were male and 13% were female. Fourteen per cent were paediatric patients (≤12 years) and the remaining 84% were adults. Sixty per cent of cases had severe head injuries. The predominant age group was 25–36 years (47/150). The incidence of hyponatraemia was 34%. The mean time to onset of hyponatraemia after TBI and ICU admission was 7.74 days. Syndrome of inappropriate antidiuretic hormone secretion (SIADH) was diagnosed in 34 (26%) patients and cerebral salt wasting (CSW) in 32 (21%) patients as a cause of hyponatraemia. Other causes were found in the remaining patients (79/150), mainly dehydration, during weaning and postextubation phase, overuse of fluids, use of hypotonic fluids, overtreatment with desmopressin acetate, postoperative phase, and use of diuretics. Comorbid conditions were found in only 10% of cases; all other patients (90%) were previously healthy. No cases of hyponatraemia as a result of adrenal insufficiency or hypothyroidism were found. In conclusion, SIADH and CSW are still the most common causes of hyponatraemia in TBI patients, but various other causes of hyponatraemia in the setting of the ICU exist.

Impact of perioperative hyponatremia in children: A narrative review.

For more than 50 years, hypotonic fluids (crystalloids) have been the standard for maintenance fluid used in children. In the last decade, several studies have evaluated the risk of hyponatremia associated with the use of hypotonic vs isotonic fluids, which has lead to an intense debate. Children undergoing surgery have several stimuli for release of antidiuretic hormone, which controls renal water handling, including pain, nausea, vomiting, narcotic use and blood loss. The body's primary defense against the development of hyponatremia is the ability of the kidneys to excrete free water and dilute urine. Increased levels of antidiuretic hormone can result in hyponatremia, defined as a plasma sodium level < 136 mmol/L, which causes cells to draw in excess water and swell. This manifests as central nervous system symptoms such as lethargy, irritability and seizures. The risk for symptomatic hyponatremia is higher in children than in adults. It represents an emergency condition, and early diagnosis, prompt treatment and close monitoring are essential to reduce morbidity and mortality. The widespread use of hypotonic fluids in children undergoing surgery is a matter of concern and more focus on this topic is urgently needed. In this paper, we review the literature and describe the impact of perioperative hyponatremia in children.

Hyponatremia

Hyponatremia

Balanced maintenance fluids in PICU are safe and cost effective

IntroductionThe use of hypotonic intravenous fluid in children is acknowledged as a cause of iatrogenic harm.1 Fatalities have been documented since 1992.2 In 2007 the National Patient Safety Agency (NPSA)...

The use of hypotonic fluids in paediatric practice

BackgroundThe use of hypotonic intravenous fluids in children has been associated with significant electrolytes abnormalities. In particular, 0.18% sodium chloride with 4% glucose has been linked with hyponatraemia, even death....

Syndrome of inappropriate secretion of antidiuretic hormone as a leading cause of hyponatremia in children who underwent chemotherapy or stem cell transplantation

Hyponatremia is a common metabolic disorder in cancer patients. However, little information is available for patients receiving chemotherapy or stem cell transplantation (SCT). We analyzed the frequency, characteristics, and various causes of hyponatremia including routine use of hypotonic fluids in children following chemotherapy or SCT. We reviewed the clinical and laboratory data of 63 children who received chemotherapy or SCT at the Department of Pediatrics, Hanyang University Medical Center from July 2005 to July 2008. All 63 patients at admission received routine parenteral fluids of 0.25% or 0.45% NaCl and 82 episodes of hyponatremia were observed in 40 (63.5%) patients. Of these 82 episodes, 50 episodes of hyponatremia developed in 29 children following chemotherapy and 32 episodes in 16 children following SCT. Seventy-six out of 82 episodes (92.7%) of hyponatremia developed in 37 patients receiving hypotonic fluids with NaCl concentrations between 30 and 150 mEq/L. The frequency of SIADH in the SCT setting was more frequent (14/21, 66.6%) than in the chemotherapy setting (18/58, 31.0%) (P = 0.02), even though the leading cause of hyponatremia was SIADH in both settings. SIADH is a leading cause of hyponatremia in children following chemotherapy or SCT, and more frequent in SCT settings than in chemotherapy settings. Furthermore, the routine use of hypotonic fluids which could aggravate the development of hyponatremia for these patients should be avoided and then switched to isotonic fluids.

Hyponatraemia induced by low-dose intravenous pulse cyclophosphamide

Cyclophosphamide is an alkylating agent and was traditionally known to potentiate the renal action of vasopressin. Although low-dose intravenous pulse cyclophosphamide therapy is being used extensively in the treatment of malignant and rheumatological diseases, there have been only a few case reports of cyclophosphamide-induced hyponatraemia. Clinical data were retrospectively analysed from 84 patients (42 lupus nephritis; 42 non-Hodgkin's lymphoma; a total of 112 treatment episodes) admitted for intravenous pulse cyclophosphamide (500-750 mg/m(2)) therapy. In all patients, half-isotonic saline was used for prophylactic hydration. Cyclophosphamide-induced hyponatraemia was defined as serum sodium concentration <135 mEq/L at 24 hours after the therapy in patients whose basal serum sodium concentrations were normal. After the low-dose intravenous pulse cyclophosphamide, serum sodium concentration significantly decreased from 139.9 +/- 3.5 to 137.9 +/- 5.1 mEq/L (P < 0.001). Cyclophosphamide-induced hyponatraemia occurred in 15 treatment episodes (13.4%) from 12 patients (14.3%). Patients with hyponatraemia were significantly older than those without hyponatraemia (57.3 +/- 14.7 vs. 40.0 +/- 17.0 years, P < 0.01). Hyponatraemia was associated with male sex on univariate analysis (P < 0.05), but not on multivariate analysis. No factors were found to independently predict the occurrence of cyclophosphamide-induced hyponatraemia when multivariate analysis was performed including parameters age, sex, underlying disease, presence or absence of comorbidities associated with hyponatraemia, presence or absence of concurrent medications associated with hyponatraemia and dose of cyclophosphamide. Hyponatraemia occurring after low-dose intravenous pulse cyclophosphamide is not rare, especially when hypotonic solutions are adopted for hydration protocol. Thus, the use of hypotonic fluids should be avoided when using cyclophosphamide. Instead, isotonic solutions should be used if a forced diuresis is required.

The use of isotonic fluid as maintenance therapy prevents iatrogenic hyponatremia in pediatrics: A randomized, controlled open study*

Hypotonic fluids are widely used in pediatrics. Several articles have reported the risk of iatrogenic hyponatremia secondary to this practice. We primarily intend to determine whether the use of isotonic fluids prevents hyponatremia and, secondly, whether these fluids increase the incidence of adverse events. One hundred twenty-two pediatric patients hospitalized in intensive care unit requiring maintenance fluid therapy were randomized to receive isotonic fluids (isotonic group, NaCl = 140 mEq/L) or hypotonic fluids (hypotonic group, NaCl <100 mEq/L). Electrolyte blood concentration, glycaemia, and blood pressure were measured at 0, 6, and 24 hrs after the beginning of fluid therapy. Plasma creatinine, urine specific gravity, and urine electrolyte concentration were measured at 6 hrs. Standard intention-to-treat analysis and Bayesian analysis were conducted to assess the probability of hyponatremia and hypernatremia in each group. At the time of admission to hospital, no differences in natremia or the percentage of hyponatremia were found between groups. At 24 hrs, the percentage of hyponatremia in the hypotonic group was 20.6% as opposed to 5.1% in the isotonic group (p = 0.02). No differences in the number of adverse events other than hyponatremia were observed between groups. The use of hypotonic fluids increases the risk of hyponatremia when compared with isotonic fluids at 24 hrs following infusion (number needed to harm [confidence interval 95%] = 7[4;25]). In our sample, the use of isotonic fluids did not increase the incidence of adverse events compared with hypotonic fluids.

Peri‐operative iv fluids in diabetic patients – don’t forget the salt

Peri‐operative iv fluids in diabetic patients – don’t forget the salt