Use Of Isotonic Solution Research Articles

A balancing act: drifting away from the reflexive use of "ab"normal saline.

Maintenance intravenous fluids are the most frequently ordered medications for hospitalized children. Since the American Association of Pediatrics published national guidelines, there has been an increased reflexive use of isotonic solutions, especially 0.9% saline, as a prophylaxis against hyponatremia. In this educational review, we discuss the potential deleterious effects of using 0.9% saline, including the development of hyperchloremia, metabolic acidosis, acute kidney injury, hyperkalemia, and a proinflammatory state. Balanced solutions with anion buffers cause relatively minimal harm when used in most children. While the literature supporting one fluid choice over the other is variable, we highlight the benefits of balanced solutions over saline and the importance of prescribing fluid therapy that is individualized for each patient.

Dysnatremia and subsequent sodium level changes following various intravenous treatments in infants with acute gastroenteritis.

Acute gastroenteritis is one of the main causes of electrolyte imbalance in infants. We aimed to determine the frequency of and factors associated with dysnatremia at presentation and establish the ideal intravenous treatment scheme. The records of hospitalized infants aged 1-12months with community-acquired acute gastroenteritis between January 2017 and March 2021 were retrospectively reviewed. Factors associated with dysnatremia at presentation were analyzed by multivariable logistic regression analysis. Subsequent sodium levels 4-24h after intravenous fluid treatments, which were categorized into 2 groups, were determined in the subgroup of infants with normal sodium levels at presentation. A total of 347 infants with a median age of 8.0 (5.0-10.0) months were included. The frequency of dysnatremia at presentation was 14% (hyponatremia 12% and hypernatremia 2.0%). Severe dehydration was associated with dysnatremia at presentation (p = 0.048). Among 68 infants with normal sodium levels at presentation, the median sodium change was highest in the 5% dextrose in saline group, with changes of + 3 (0.5-5) and + 1 (- 2 to 2) mmol/L in infants who received 5% dextrose in saline and 5% dextrose in 1/3-1/2 saline, respectively (p = 0.001). Four out of 47 infants (8.5%) developed hyponatremia while receiving 5% dextrose in 1/3-1/2 saline. None of those who received 5% dextrose in saline developed subsequent dysnatremia. Conclusion:The frequency of dysnatremia at presentation among infants with acute gastroenteritis was 14%. Severe dehydration was associated with dysnatremia at presentation, so electrolyte levels need to be assessed in these patients. The use of isotonic solution did not promote acquired dysnatremia. This study supports once more that current guidelines recommending isotonic solution for children, and, especially, infant rehydration, are important also for infants in Thailand. What is Known: • There were a wide variation in the incidence of dysnatremia at presentation in children with acute gastroenteritis in previous pediatric series. • The AAP guidelines recommend using isotonic solution in children with acute illness from 28days to 18years of age to prevent acquired hyponatremia. What is New: • The incidence of dysnatremia at presentation in infants with acute gastroenteritis was 14% (hyponatremia 12% and hypernatremia 2.0%). • The use of isotonic solution did not promote acquired dysnatremia in infants with acute gastroenteritis.

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.

Elimination and irrigation therapy to optimize the state of the nasal microbiome in children

The article summarizes the results of the work of domestic and foreign researchers on the study of homeostasis of the nasal cavity, including the state of the microbiota of the nasal mucosa in healthy children and in inflammatory diseases of the upper respiratory tract. The normal microbiota of the nasal cavity is represented by corynebacteria (diphtheroids), neisseria, coagulasenegative staphylococci, alpha-hemolytic streptococci. From among the transient species, such species as Staphylococcus aureus, Escherihia coli, beta-hemolytic streptococci would be found in the specified biotope. The main attention is paid to the features of the nasal microbiota in newborns and young children (dependence of the nasal microbiota on the type of feeding, age and season). The role of hypercolonization by opportunistic microflora and its persistent potential (ability to biofilm formation, degradation of lysozyme, interferon) in the pathogenesis of inflammatory diseases of the upper respiratory tract is noted. The pathogenetic mechanisms providing multilevel protection of the organism from pathogens are considered. The expediency of using elimination-irrigation therapy as a hygienic means of sanitizing the nasal cavity in young children has been determined. The questions about the advantages of the use of isotonic solutions, their effectiveness for ensuring normal colonization resistance of the nasal mucosa are discussed. In conclusion, we must say that for hygienic care and sanitation purposes it is recommended only to rinse the nasal mucosa in newborns and infants using drops of isotonic saline solution and an aspirator to avoid aspiration and inflow of liquid into the cavity of Eustachian tube and middle ear, and also for the preventive purposes, as it allows to maintain homeostasis of the nasal mucosa and prevent the development of acute respiratory diseases.

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 …

Iatrogenic Dysnatremias in Children with Acute Gastroenteritis in High-Income Countries: A Systematic Review.

Acute gastroenteritis (AGE) causing dehydration with or without dysnatremias is a common childhood health challenge. While it is accepted that oral rehydration therapy is preferred, clinical factors or parent and healthcare provider preferences may lead to intravenous rehydration (IVR). Isotonic solutions are increasingly recommended in most scenarios requiring IVR. Nevertheless, children with AGE, having ongoing losses of water and electrolytes, represent a unique population. To evaluate the association between acquired dysnatremias and IVR in children with AGE. A systematic search of MEDLINE database was conducted through September 14, 2016. Observational studies and clinical trials conducted in high-income countries were included. The Grades of Recommendation, Assessment, Development, and Evaluation approach was used to evaluate the overall quality of evidence for each outcome. 603 papers were identified of which 6 were included (3 randomized controlled trials and 3 observational studies). Pooling of patient data was not possible due to significantly different interventions or exposures. Single studies results demonstrated that within 24 h, administration of isotonic saline was not associated with a significant decline in serum sodium while hypotonic solutions (0.2-0.45% saline) were associated, in one study, with mean serum sodium declines from 1.3 mEq/L (139.2, SD 2.9-137.9, SD 2.5) in 133 young infants (aged 1-28 months), to 5.7 (SD 3.1) mEq/L in a subgroup of 18 older children (age mean 5.8, SD 2.7 years). Both isotonic and hypotonic saline were shown to be associated with improvement of baseline hyponatremia in different studies. Baseline hypernatremia was corrected within 4-24 h in 81/83 (99.6%) children using hypotonic saline IVR. There is a paucity of publications assessing the risk for acquired dysnatremias associated with IVR in children with AGE. Current high-quality evidence suggests that, short-term use of isotonic solutions is safe and effective in most children with AGE; hypotonic solutions may also be appropriate in some subpopulations, however, the quality of available evidence is low to very low. Further research investigating outcomes associated with IVR use beyond 24 h focusing on specific age groups is required.

Comparison of two maintenance electrolyte solutions in children in the postoperative appendectomy period: a randomized, controlled trial

ObjectiveTo compare two electrolyte maintenance solutions in the postoperative period in children undergoing appendectomy, in relation to the occurrence of hyponatremia and water retention. MethodsA randomized clinical study involving 50 pediatric patients undergoing appendectomy, who were randomized to receive 2,000mL/m2/day of isotonic (Na 150 mEq/L or 0.9% NaCl) or hypotonic (Na 30 mEq/L NaCl or 0.18%) solution. Electrolytes, glucose, urea, and creatinine were measured at baseline, 24h, and 48h after surgery. Volume infused, diuresis, weight, and water balance were analyzed. ResultsTwenty‐four patients had initial hyponatremia; in this group, 13 received hypotonic solution. Seventeen patients remained hyponatremic 48h after surgery, of whom ten had received hypotonic solution. In both groups, sodium levels increased at 24h (137.4±2.2 and 137.0±2.7mmol/L), with no significant difference between them (p=0.593). Sodium levels 48h after surgery were 136.6±2.7 and 136.2±2.3mmol/L in isotonic and hypotonic groups, respectively, with no significant difference. The infused volume and urine output did not differ between groups during the study. The water balance was higher in the period before surgery in patients who received hypotonic solution (p=0.021). ConclusionsIn the post‐appendectomy period, the use of hypotonic solution (30 mEq/L, 0.18%) did not increase the risk of hyponatremia when compared to isotonic saline. The use of isotonic solution (150 mEq/L, 0.9%) did not favor hypernatremia in these patients. Children who received hypotonic solution showed higher cumulative fluid balance in the preoperative period.

Comparison of two maintenance electrolyte solutions in children in the postoperative appendectomy period: a randomized, controlled trial

ObjectiveTo compare two electrolyte maintenance solutions in the postoperative period in children undergoing appendectomy, in relation to the occurrence of hyponatremia and water retention. MethodsA randomized clinical study involving 50 pediatric patients undergoing appendectomy, who were randomized to receive 2,000mL/m2/day of isotonic (Na 150 mEq/L or 0.9% NaCl) or hypotonic (Na 30 mEq/L NaCl or 0.18%) solution. Electrolytes, glucose, urea, and creatinine were measured at baseline, 24h, and 48h after surgery. Volume infused, diuresis, weight, and water balance were analyzed. ResultsTwenty-four patients had initial hyponatremia; in this group, 13 received hypotonic solution. Seventeen patients remained hyponatremic 48h after surgery, of whom ten had received hypotonic solution. In both groups, sodium levels increased at 24h (137.4±2.2 and 137.0±2.7mmol/L), with no significant difference between them (p=0.593). Sodium levels 48h after surgery were 136.6±2.7 and 136.2±2.3mmol/L in isotonic and hypotonic groups, respectively, with no significant difference. The infused volume and urine output did not differ between groups during the study. The water balance was higher in the period before surgery in patients who received hypotonic solution (p=0.021). ConclusionsIn the post-appendectomy period, the use of hypotonic solution (30 mEq/L, 0.18%) did not increase the risk of hyponatremia when compared to isotonic saline. The use of isotonic solution (150 mEq/L, 0.9%) did not favor hypernatremia in these patients. Children who received hypotonic solution showed higher cumulative fluid balance in the preoperative period

The efficacy of isotonic and hypotonic intravenous maintenance fluid for pediatric patients: a meta-analysis of randomized controlled trials.

This study aimed to analyze the effect of isotonic versus hypotonic solution as intravenous maintenance fluid on level of plasma sodium in hospitalized children. A fully recursive literature search in May 2013 was conducted in PubMed and EMBASE to identify potentially relevant randomized controlled trials. Jadad score and allocation concealment were adopted to evaluate the methodological quality of each trial. RevMan5.2 was used for statistical analysis. Eight randomized controlled trials with 752 patients were included. Combined analysis showed a significant lower risk of hyponatremia with isotonic solution (odds ratio, 0.36; 95% confidence interval, 0.26-0.51). The isotonic intravenous maintenance did not increase the possibility of hypernatremia (odds ratio, 0.86; 95% confidence interval, 0.36-2.06). The meta-analysis revealed that there was potential risk of hyponatremia for routine infusion of hypotonic maintenance fluid. The use of isotonic solution was warranted in hospitalized pediatric patients.

ABSTRACT 812

Background and aims: The cardiopulmonary resuscitation guidelines must be a standard procedure followed in response of cardiac arrest in PICU. In our hospital the training in this course is a stardard for any personnel. Aims: The cardiopulmonary resuscitation guidelines must be a standard procedure followed in response of cardiac arrest in PICU. In our hospital the training in this course is a stardard for any personnel. Methods: Descriptive, prospective, observational study. All the patients that were admitted in the pediatric critical care unit whom received pediatric advance life support between November 2011 and august 2012 were included. Age, medical degree, cardiac rhythm during arrest, use of isotonic solutions, airway management, drug administration and doses, hospitalization days, duration of the maneuvers and main diagnosis. There was used descriptive statistics for the analysis of qualitative data and the discontinuous variables; and central and dispersion measurements for the continuous variables (SPPS 10.0) Results: There were analyzed 121 cases of cardiac arrest, 89.5% died during the time of study; the survival of the first cardiac arrest was 2.8 +/- 1.5 (1.3, 4.3, C.I 95%). The most frequent diagnosis was infection (43%). 100% of the patients were under cardiovascular and respiratory monitoring during the arrest. Asystolia was the more frequent cardiac rythm. Conclusions: Any intervention followed in 100 % the algorithms described in the course.

Effect of Ascitic Media Formed by Glycerin on the Prevention of Peritoneal Adhesions

Aim: We aimed to investigate whether or not artificial ascites media formed using glycerin are effective in the prevention of intraperitoneal adhesions. Methods: Thirty-six Wistar albino male rats were used in the study. The rats were divided into 3 groups as follows. Group I: control group; group II (isotonic group): 3 ml of 0.9% NaCl was injected into the peritoneal cavity, and group III (glycerin group): 0.5 ml of liquid glycerin and 3 ml of 0.9% NaCl was injected into the peritoneal cavity. Results: There were serious adhesions in the control group. Adhesion rates were lower in the isotonic group compared with the control group, but the difference was not statistically significant (p > 0.05). When adhesion rates of the glycerin group were compared with the control and isotonic groups, significant differences were found, especially between the glycerin and control groups (p < 0.05). Conclusions: According to the results of our study, the use of isotonic solution and liquid glycerin decreases postoperative adhesions. We suggest that glycerin was more effective as it has the chemical ability to draw water to its media. As such, the formation of adhesions may be decreased by increasing the amount of physiological liquid inside the abdomen.

Sodium Concentration in Rehydration Fluids for Children with Ketoacidotic Diabetes: Effect on Serum Sodium Concentration

To analyze in a retrospective cohort if sodium concentration in the rehydration fluids influence natremia in children with diabetic ketoacidosis (DKA). Consecutive episodes of diabetic ketoacidosis admitted in a tertiary care referral center from 2000 to 2005. Rehydration was programmed for 48 hours with a 2-bag system. Initial rehydration was performed with isotonic fluids and thereafter with variable tonicity. Analysis of the influence of the different factors on natremia was performed with a multivariate linear regression analysis. Forty-two episodes of DKA were reviewed. Increased sodium content in rehydration fluids behaved as an independent variable, causing a positive tendency of natremia (P < .008). Sodium concentration in the rehydration fluids behaves as an independent factor that influences positively the trend of the serum concentration of sodium during DKA rehydration. We propose the use of isotonic solutions for rehydration in diabetic ketoacidosis.

Current Opinions in Pediatric Septic Shock

Objectives: Our aim is to describe the current clinical practice related to the management of septic shock (SS). Methods: Review of medical literature using the MEDLINE database. Articles were selected according to their relevancy to the objective and according to the author's opinion. Summary of the findings: The outcome from SS is dependent on an early recognition and a sequential implementation of time-sensitive goal-directed therapies. The goals of the resuscitation are rapid restoration of micro circulation and improved organ tissue perfusion. Clinical and laboratory markers are needed to assess the adequacy of the treatments. Initial resuscitation involves the use of isotonic solutions (>60ml/kg) either crystalloid (normal saline) or colloid infusion often followed by vasoactive medications. Altered pharmacokinetics and pharmacodynamics responses dictate that vasoactive agents should be adjusted to achieve predetermined goals. An assessment of central venous pressure complements clinical and serological findings to tailor therapies. Elective airway instrumentation and mechanical ventilation as well as adjunctive therapy with stress dose of corticosteroid are indicated in selected populations. In neonates, a special attention to the presence of electrolyte imbalance and increase pulmonary vascular resistance needs to be considered early. Conclusions: Septic shock hemodynamic is a changing process that requires frequent assessment and therapeutic adjustments.

Physiological manipulation and formulation of the biocontrol yeast Pichia anomala for control of Penicillium verrucosum and ochratoxin A contamination of moist grain

The major hurdle in the production of commercial biocontrol agents (BCAs) has been the lack of production of appropriate formulations. Of particular importance is the conservation of viability and ecological competence after application. With this in mind studies were conducted to develop formulations of P. anomala which would have these attributes. Cells were grown in molasses-based medium modified with proline to different water availability levels (0.98 and 0.96) which significantly increased (up to 50%) the content of trehalose and arabitol in the yeast cells during liquid broth fermentation. The use of isotonic solutions for harvesting the yeast cells further increased the endogenous content of these compatible solutes as well as glycerol. Fluidised bed drying of cells at 30–80°C was carried out for 10 and 20 min and showed that viability was significantly decreased at 70–80°C. A temperature of 50°C for 20 min was found to be best for viability (70%) and moisture content of <10%. Several additives for conservation of viability showed that cotton seed flour+skimmed milk was the best treatment when dried at 50°C. The biocontrol efficacy of formulated P. anomala cells was tested in laboratory scale studies and this showed that they inhibited growth of Penicillium verrucosum and reduce ochratoxin A production in moist wheat grain under some combinations of water availability. Physiologically modified formulated yeast cells with increased levels of trehalose and arabitol gave similar efficacy as fresh cells. This suggests that ecophysiological manipulation of such BCAs can result in improved ecological competence of such formulations and effective biocontrol.

“Maintenance” of a traditional stance

The past few years have been witness to a very disturbing series of articles, which have promoted a dangerous approach to pediatric fluid therapy based upon a fundamental misunderstanding of physiology. In brief, the articles in question advocated the use of isotonic solutions as the “maintenance” fluid in children. The rationale for this departure from decades of teaching has been a misinterpretation of some cases of severe hyponatremia developing in children receiving more dilute fluid. Specifically, most of these cases were in children with some degree of volume contraction, for whom “routine maintenance” fluids would not have been appropriate anyway. In this issue of The Journal, several distinguished experts in pediatric fluid therapy, including some who were involved in the very early development of our current concepts, review this controversy. This is a timely discussion of the topic. It should serve as a nice review of the basic physiology involved for the beginning student of pediatric fluid therapy. For the seasoned practitioner, it outlines in a compelling fashion why such a major change in our approach to maintenance fluid therapy is unwise and unwarranted. Acute hospital-induced hyponatremia in children: A physiologic approachThe Journal of PediatricsVol. 145Issue 5PreviewPhysicians giving children fluid therapy today seldom encounter overt dehydration or signs of shock that call for rapid and aggressive extracellular fluid (ECF) expansion. Physicians in the era when severe diarrheal dehydration was common first restored ECF with isotonic saline,a then planned maintenance and replacement therapies, using hypotonic saline. Today, physicians plan fluid therapy mostly for children with pneumonia, meningitis, other acute disorders, or for children scheduled for surgery. Full-Text PDF

Renal Dialysis during Coronary Artery Revascularization: A Case Study

A diabetic, uremic patient maintained on chronic hemodialysis underwent coronary artery revascularization with successful intraoperative dialysis. A portable sorbent dialyzer and hollow fiber artificial kidney were used in conjunction with the extracorporeal heart pump and oxygenator to dialyze the patient's blood during cardiopulmonary bypass. Conservative fluid management and use of isotonic solution with dialyzable solutes prevented fluid imbalances. Cold cardioplegia without potassium combined with core hypothermia (26°C) protected the myocardium while minimizing the risk of hyperkalemia. Alterations in the serum potassium level were adjusted with changes in the infusate bath of the dialyzer during bypass-dialysis. Intraoperative dialysis in this case optimized chemistries and fluid balance and prevented the hazards of hemodialysis during the immediate post-operative period when bleeding and hypotension could limit effectiveness and jeopardize the patient's condition.

Hemolysis of Erythrocytes in Various Iso-osmotic Solutions

A study has been made of the degree of hemolysis of human erythrocytes that occurs when the red blood cells are incubated in many different pharmaceutically employed iso-osmotic solutions. Many distinct differences were noted which further demonstrate the frequent dissimilarities between iso-osmotic and isotonic concentrations. In addition to the hemolytic differences, one of the other main factors in the consideration of the use of isotonic solutions versus iso-osmotic solutions is clearly that of the quantities and proportions of the substances used and the resulting rapidity and ease of dilution of the medicinal solution by the body fluids.

LXI. On the use of Isotonic Solutions for Nasal Administration

LXI. On the use of Isotonic Solutions for Nasal Administration