Children. Reduction on Introduction of Isotonic Maintenance Fluids? - - PowerPoint PPT Presentation

Hyponatremia in Hospitalized Infants and

• Children. Reduction on Introduction of

Isotonic Maintenance Fluids?

Authors: Dipen Patel1, MD, Shikha Y Kothari1, MBBS, Somashekhar Nimbalkar, MD1,2, Rajendra Desai, MSc2 and A. Phatak, MPH2. Affiliations: 1Department of Pediatrics, Pramukhswami Medical College, Karamsad, 388325, India and 2Central Research Services, Charutar Arogya Mandal, Karamsad, 388325, India.

No Conflicts of Interest to Disclose

None of the authors have any conflict of interest to disclose. I wish there were some fancy ones though! (If there were, one slide will ever be enough)

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Background



Dietary intake of water and electrolytes is closely matched by renal and extrarenal excretion, and body composition remains essentially constant.



Regulation of sodium balance through varying sodium excretion is central to the control of effective circulatory volume.



Hyponatremia is the most common electrolyte abnormality found in hospitalized children, and is an independent predictor

• f increased medical costs, along with being an independent

risk factor for patient mortality.

Hyponatremia

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BMJ 1992;304:1218-22

Over a period of six years (1984- 90) about 16 previously healthy children (aged under 16) who had developed symptomatic hyponatraemia and either died or suffered permanent brain damage. Hyponatraemic seizures and excessive intake of hypotonic fluids in young children BMJ 1999; 319 Case series of acute hyponatremia and convulsions caused by excessive intake of oral fluids with sodium levels as low as 116 mmol/L.

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Intravenous fluids for seriously ill children: Time to reconsider Duke, Trevor;Molyneux, Elizabeth M The Lancet; Oct 18, 2003; 362, 9392;

Intravenous fluids for seriously ill children Time to reconsider

• Hypotonic iv fluids given at maintenance rates might be

unsafe, especially in developing countries as serum sodium concentration is not monitored

• Sick patients have reduced free-water clearance, and

hypotonic saline solutions at maintenance rates or greater put patients at risk of hyponatraemia and encephalopathy-the syndrome of water intoxication.

• Safest empirical iv fluid for most children with serious

infections, who cannot take enteral fluids, is 0.9% sodium chloride with dextrose

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Main Mechanisms of Hyponatremia

• 1. Dilution of extracellular fluid due impaired free-water

excretion (AVP excess)

• 2. Increased urinary sodium losses

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1/30/2014 Companion 2014 Vadodara

How Common is it?

• Hyponatraemia arises in between 20% and 45% of

children with meningitis, pneumonia, encephalitis, septicaemia, cerebral malaria and somewhat less often in those with bronchiolitis.

• 70% of infants with acute bronchiolitis had impaired free-

water excretion; at recovery, free-water clearance was up to 15 times more than at the time of admission

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So have organizations taken note?

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30 September 2007

Institute for Safe Medication Practices (ISMP) of both Canada (2008) and the USA (2009)

Objectives



Objective: To compare incidence of hyponatremia and hypernatremia in children admitted to PICU, after the shift in maintenance I.V. fluid administration practices.



Before 2010, department protocol entailed initial administration

• f a hypotonic solution, 5% dextrose with 0.2% sodium chloride,

to all patients upon hospital admission after correction of shock, etc



After 2010, department practices changed. All patients were administered an isotonic solution with the advised composition

• f 5% dextrose and 0.9% sodium chloride.

Methods

• Study Site:

Pediatric Intensive Care Unit (PICU), Shree Krishna Hospital, Karamsad-Gujarat-India

• Inclusion Criteria:

All children hospitalized to the PICU of SKH and administered intravenous fluids from January 2009 to December 2010, except those on an oral diet/nasogastric feed providing more than 20% of daily requirement.

Karamsad, Anand District, Gujarat

Methods

• Patients admitted from January 2009 to December 2009 were

administered hypotonic maintenance fluid (5% Dextrose with 0.2%NaCl)

• January 2010 onwards, patients were administered isotonic

maintenance fluid (5%Dextrose with 0.9%NaCl)

• Medical records of these patients were studied.
• All demographic details and sodium level values were recorded,

along with date and time of sending investigation.

• Data was entered with Microsoft Excel, and Chi-square test with

help of SPSS was used for analysis.

Results

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Particulars Isotonic Non Isotonic p-value Male gender 293(67.7%) 148(65.5%) 0.27 2009 113(26.1%) 187(82.7%) <0.001 2010 320(73.9%) 39(17.3%) Consciousness Conscious 122(28.17%) 64(28.3%) 0.96 Altered 311(71.8%) 162(72.3%) Inotropes required 224(51.7%) 99(43.8%) 0.18 Sodium imbalance Hyponatremia 145(33.5%) 116(51.3%) <0.001 Hypernatremia 91(21.0%) 40(17.7%) NS Mean(SD) Mean(SD) Sodium Level 139.45(11.14) 136.37(11.04) 0.001 Potassium Level 4.03(1.14) 4.29(1.04) 0.006 Outcome N= 425 N=221 Discharge 221(52.0%) 118(53.4%) NS DAMA 151(35.5%) 85(38.5%) Expired 53(12.5%) 18(8.1%)

Results

• Of 448 admitted children, 169 were female.
• Of 198 admitted children in 2009, 99 (50%) had hyponatremia, as

compared to 101 (40.4%) of 250 admitted children in 2010.

• Incidence of hyponatremia after 24 hours’ intravenous hypotonic

fluid administration was 23 (63.9%) out of 36

• This incidence was significantly higher than the group

administered isotonic fluids: 27 (30.7%) out of 88 children (p=0.0013).

Results

• Incidence of hypernatremia was 8 (22.2%) of 36 in children

receiving hypotonic fluids, which did not significantly differ from incidence in children receiving isotonic fluids [17(19.3%) of 88, p=0.9].

• Effect on outcome did not significantly differ between two groups:
• 20 (55.6%)of 36 children receiving hypotonic fluids either expired
• r took discharge against medical advice, as compared to 39

(44.3%)of the 88 receiving isotonic fluids (p=0.347).

Box Plot (Comparing the incidence

• f hyponatremia in each group)

(p=0.0013).

Discussion

• Most work on maintenance fluid requirements was done in the

1950`s, when children had a diet much lower in sodium.

• The basis for using hypotonic fluids is an assumption that the

sodium concentration in intravenous fluids should reflect that found in the diet of a healthy child.

• But hospitalized children present numerous stimuli that augment

production of ADH.

Is 0.9% Saline of Use?

• Relation between arginine vasopressin levels and

hyponatremia following percutaneous renal biopsy in children receiving hypotonic or isotonic intravenous fluids. RCT

• Minimally invasive procedure is associated with high AVP

levels resulting in hyponatremia & normal saline can effectively prevent hyponatremia even in presence of elevated AVP levels.

• Even a minimal positive balance of hypotonic fluids can lead to

water retention, vasoconstriction, antidiuresis and eventually fatal symptomatic hyponatremia that precipitates pulmonary edema, cerebral edema, transtentorial herniation, respiratory arrest, coma and death.

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• Kanda K, Nozu K, Kaito H, et al. in Pediatr Nephrol 2011; 26:99–104.

Intravenous fluid regimen and hyponatraemia among children: a RCT.

• First large prospective randomized fluid trial conducted in general

pediatric patients who are nonsurgical and not admitted to the ICU.

• 14.3% (8/56) of the children administered 0.18% saline in 5%

dextrose at the standard maintenance rate (Group B) developed hyponatraemia compared with 1.72% of the children in Group A (0.9% saline in 5% dextrose at the standard maintenance rate) and 3.8% of those in Group C (0.18% saline in 5% dextrose at two-thirds

• f the standard maintenance rate).
• Hypotonic fluids result in hyponatremia and that 0.9% sodium

chloride prevents the development of hyponatremia.

• This was at 72 h or till IV fluids while we had at 24 h a high 63%

hyponatremic

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Kannan L, Lodha R, Vivekanandhan S, et al. in Pediatr Nephrol 2010; 25:2303–2309.

Many Systematic reviews in the previous three years

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Foster BA, Tom D, Hill V Hypotonic versus isotonic fluids in hospitalized children: a systematic review and meta-analysis. J Pediatr. 2014 Jul;165(1):163-169.e2.

Foster BA, Tom D, Hill V Hypotonic versus isotonic fluids in hospitalized children: a systematic review and meta-analysis. J Pediatr. 2014 Jul;165(1):163- 169.e2.

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Study Subjects Inclusion criteria and setting Interventions compared (all with dextrose ) Outcome data (Na <135 mmol/L) Coulthard et al 2012 n = 79; 4- 14 y PICU, postoperative (spinal or craniotomy) Hartmann's vs 0.45% saline 0 of 39 (0%) in isotonic; 7 of 40 (18%) in hypotonic Rey et al 2011 n = 84; 2- 10 y PICU, mixed postoperative (45%) and medical 156 mmoL/L tonicity vs 50-70 mmoL/L 8 of 45 (17.8%) in isotonic; 19 of 39 (48.7%) in hypotonic Yung and Keeley 2009 n = 61; 30 d- 18 y PICU, mixed postoperative and medical 0.9% saline vs 0.18% saline 3 of 29 (10.3%) in isotonic; 7 of 32 (21.9%) in hypotonic Montañana et al 2008 n = 122; 29 d-18 y PICU, postoperative in 84% (thoracic, cardiac, abdominal, CNS) Na 140 mmol/L, K 15 mmol/L tonicity vs 20- 100 mEq/L 3 of 59 (5.1%) in isotonic; 13 of 63 (20.6%) in hypotonic Saba et al 2011 n = 37; 3 mo-18 y Floor, mixed postoperative (67%) and medical 0.9% saline vs 0.45% saline 1 of 16 (6%) in isotonic; 1 of 21 (5%) in hypotonic Choong et al 2011 n = 218; 6 mo-16 y Mixed floor and PICU, postoperative 0.9% saline vs 0.45% saline, with or without KCl 26 of 106 (24.5%) in isotonic; 47 of 112 (42%) in hypotonic Neville et al 2006 n = 42; 6 mo-14 y Floor, gastroenteritis 0.9% saline vs 0.45% saline 0 of 20 (0%) in isotonic; 5 of 22 (22.7%) in hypotonic Brazel and McPhee 1996 n = 12; 12- 18 y PICU, postoperative Hartmann's vs 0.3% saline or 0.18% saline 1 of 5 (20%) in isotonic; 7 of 7 (100%) in hypotonic Neville et al 2010 n = 124; 6 mo-15 y Floor, postoperative 0.9% saline vs 0.45% saline 1 of 31 (3%) in isotonic; 9 of 31 (29%) in hypotonic Kannan et al 2010 n = 114; 3 mo-12 y Floor, medical 0.9% saline vs 0.18% saline 5 of 58 (8.6%) in isotonic; 13 of 56 (23%) in hypotonic

Other Reviews

• Isotonic versus hypotonic saline solution for maintenance

intravenous fluid therapy in children: a systematic review. Padua AP, Macaraya JR, Dans LF, Anacleto FE Jr. Pediatr Nephrol. 2015 Jul;30(7):1163-72. doi: 10.1007/s00467-014-3033-y. Epub 2015 Jan 11.

• Isotonic versus hypotonic solutions for maintenance

intravenous fluid administration in children. McNab S, Ware RS, Neville KA, Choong K, Coulthard MG, Duke T, Davidson A, Dorofaeff T. Cochrane Database Syst Rev. 2014 Dec 18;12:CD009457. doi: 10.1002/14651858.CD009457.pub2. Review. PMID: 25519949

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Discussion

• Robroch et.al. state that inadequate volume, rather than sodium

load, is critical to the development of hypernatremia in patients administered isotonic I.V. fluids; isotonic solutions can increase chances of hypernatremia and hyperchoremic acidosis only if administered below the maintenance dose levels, with dehydration as the mechanism, not sodium overload.

• According to Moritz and Ayus, 0.9% NaCl does not produce

hypernatremia when used in the absence of a renal concentrating defect or ongoing free water losses.

A.H. Robroch, M. van Heerde, D.G. Mancherst. Should isotonic infusion solutions routinely be used in hospitalized pediatric patients. Arch Dis Child, June 2011 Vol 96 No 6: 608-610 Michael M. Moritz, Juan C. Ayus. Maintenance intravenous fluids with 0.9% sodium chloride do not produce hypernatremia in children. Acta Paediatrica 2012 101, pp. 222-223

Conclusion

• Significant reduction in incidence of hyponatremia upon

change in intravenous fluid therapy practices.

• No change in Hypernatremia rates.
• Utilizing evidence to improve practice gives satisfying results.