Severe hospital-acquired hyponatremia in acutely ill children receiving moderately hypotonic fluids

Background Hypotonic fluids have been associated with hospital-acquired hyponatremia. The incidence of life-threatening severe hyponatremia associated with hypotonic fluids has not been evaluated. Methods This was a population-based cohort study of 46,518 acutely ill children 15 years of age or under who visited the pediatric emergency department (ED) at Oulu University Hospital, Finland, between 2007 and 2017. We retrieved all electrolyte measurements from the comprehensive electronic laboratory system and reviewed medical records for all patients with severe hyponatremia. Results The overall occurrence of severe hyponatremia (serum sodium < 125 mmol/L) was found in 27 out of 46,518 acutely ill children (0.06%, 95% confidence interval 0.04-0.08%). After admission, severe hyponatremia developed in seven of 6,984 children receiving moderately hypotonic fluid therapy (0.1%, 95% confidence interval 0.04-0.2%), usually within 8 h of admission. All children who developed severe hyponatremia during hospitalization were severely ill. Conclusion In this register-based cohort study of children presenting to the ED, severe hyponatremia developed in one of 998 acutely ill children receiving moderately hypotonic fluid therapy.Peer reviewe

Severe hospital-acquired hyponatremia in acutely ill children receiving moderately hypotonic fluids

Background Hypotonic fluids have been associated with hospital-acquired hyponatremia. The incidence of life-threatening severe hyponatremia associated with hypotonic fluids has not been evaluated. Methods This was a population-based cohort study of 46,518 acutely ill children 15 years of age or under who visited the pediatric emergency department (ED) at Oulu University Hospital, Finland, between 2007 and 2017. We retrieved all electrolyte measurements from the comprehensive electronic laboratory system and reviewed medical records for all patients with severe hyponatremia. Results The overall occurrence of severe hyponatremia (serum sodium < 125 mmol/L) was found in 27 out of 46,518 acutely ill children (0.06%, 95% confidence interval 0.04-0.08%). After admission, severe hyponatremia developed in seven of 6,984 children receiving moderately hypotonic fluid therapy (0.1%, 95% confidence interval 0.04-0.2%), usually within 8 h of admission. All children who developed severe hyponatremia during hospitalization were severely ill. Conclusion In this register-based cohort study of children presenting to the ED, severe hyponatremia developed in one of 998 acutely ill children receiving moderately hypotonic fluid therapy.Peer reviewe

Electrolyte disturbances and intravenous fluid therapy in acutely ill children

Abstract Traditionally the amount of fluid and electrolytes needed in intravenous fluid therapy in children has been calculated by using Holliday-Segar method published in 1957. By using Holliday-Segar method, the concentration of sodium in intravenous fluids is markedly less compering to plasma. Due to concern of risk for severe hyponatremia there is an increased use of isotonic intravenous fluid therapy that contians the same amount of sodium as plasma among acutely ill children. According to our clinical experience mild hyponatremia is common among acutely ill children, whereas severe hyponatremia (serum sodium less than 125 mmol/l) is rare though hypotonic intravenous fluid therapy was used in our clinic. The increasing use of isotonic intravenous fluid therapy among acutely ill children also increased use of commercially available plasma-like fluids, though there are only limited evidence of the use of plasma-like commercially available intravenous fluids in children. To get more evidence of the use of plasma-like isotonic fluid therapy in acutely ill children, we set up a randomized clinical trial. We compared traditionally used intravenous fluid therapy (G5% with 80 mmol/l of sodium and 20 mmol/l of potassium) to commercially available plasma-like isotonic fluid therapy (Plasmalyte glucose containing 140 mmol/l of sodium and 5 mmol/l of potassium). We also set up a retrospective register-based cohort study to evaluate the occurrence and risk factor for electrolyte abnormalities. 614 children were enrolled to randomized clinical trial. According to randomized clinical trial, the use of plasma-like isotonic fluid therapy caused an increased risk for electrolyte abnormalities (20% vs 2.9 %, 95% CI 12–22%), most notably for hypokalemia (19% vs 2.9%, 95 CI 11–21%). In randomized trial, the use of plasmalike isotonic fluid therapy did not decreas the risk for hyponatremia. However, in cohort study including 10-year period, 0.1% of children receiving hypotonic intravenous fluid therapy developed severe hyponatremia. According to 10-year cohort study, the occurence of severe hyponatremia among acutely ill children is low (0.1%) whereas mild hyponatremia is common (11.5%). Severe hyponatremia was associated to mortality and neurological symptoms, whereas mild hyponatremia was not.Tiivistelmä Perinteisesti lasten neste- ja elektrolyyttitarve on laskettu vuonna 1957 julkaistun Holliday-Segarin metodin mukaisesti, jolloin suonensisäinen nestehoito sisältää vähemmän natriumia kuin plasma. Viime aikoina lapsipotilaiden nestehoidossa on siirrytty suosimaan aiemmin käytettyä nestehoitoa enemmän natriumia sisältävää nestettä, sillä perinteisen nestehoidon on ajateltu altistavan vaikean hyponatremian kehittymiselle. Aiempi kliininen kokemuksemme on, että äkillisesti sairastuneilla lapsipotilailla on usein lievä hyponatremiaa, mutta vaikea hyponatremia (natrium alle 125 mmol/l) on harvinainen myös perinteisen nestehoidon aikana. Uusien suonensisäisten nestehoitosuositusten myötä kaupallisten plasman kaltaisten valmisnesteiden käyttö lasten suonensisäisessä nestehoidossa on lisääntynyt, vaikka näyttö niiden hyödystä lapsipotilailla on rajallinen. Jotta saisimme lisää tietoa plasmankaltaisten valmisnesteiden käytöstä äkillisesti sairailla lapsilla, suunnittelimme satunnaistetun kliinisen tutkimuksen, jossa vertasimme perinteisempää nestehoitoa (G5%, jossa natriumia 80 mmol/l ja kaliumia 20 mmol/l) kaupalliseen, plasmankaltaiseen valmisnesteeseen (Plasmalyte glukoosi, natriumia 140 mmol/l ja kaliumia 5 mmol/l). Lisäksi selvitimme elektrolyyttihäiriöiden esiintyvyyttä- ja riskitekijöitä 10 vuoden retrospektiivisellä seurantatutkimuksella. Satunnaistettuun kliiniseen tutkimukseemme rekrytoitiin yhteensä 614 lasta. Tutkimuksemme perusteella elektrolyyttisisällöltään plasmantyyppisen valmisnesteen käyttö lisäsi elektrolyyttihäiriöiden ilmaantuvuutta verrattuna perinteisesti käytettyyn nestehoitoon (20 % vs 2.9 %, 95 % CI 12–22 %). Erityisesti plasmantyyppinen valmisneste altisti hypokalemian kehittymiselle (19 % vs 2.9 %, 95 % CI 11–21 %). Seurantatutkimuksessa havaitsimme, että vaikea hyponatremia on hyvin harvinainen äkillisesti sairastuneilla lapsipotilailla (0.2 %) kun taas lievä hyponatremia on yleinen (11.5 %). Satunnaistetussa kliinisessa tutkimuksessamme plasmankaltaisen valmisnesteen käyttö ei vähentänyt hyponatremian esiintyvyyttä. Toisaalta 10 vuoden retrospektiivisessä seuranta-aineistossamme 0.1 % perinteisellä nestehoidolla hoidetuista lapsista kehittyi nestehoidon aikana vaikea hyponatremia. Vaikea hyponatremia yhdistyi kuolleisuuteen ja neurologisiin oireisiin, lievä hyponatremia ei

The incidence, hospitalisations and deaths in acutely ill children with dysnatraemias

Abstract Aim: The aim was to evaluate the incidence, hospitalisations and deaths in acutely ill children with dysnatraemias. Methods: This was a register-based cohort study of 46 518 acutely ill children aged &lt;16 years who visited a paediatric emergency department. Risk factors were assessed using two nested case–control studies. Results: Moderate to severe hypernatraemia occurred in 92 children (0.20%; 95% confidence interval [CI]: 0.16%–0.24%) and moderate to severe hyponatraemia in 131 children (0.28%; 95% CI: 0.24%–0.33%). Underlying medical conditions increased the risk of both moderate to severe hypernatraemia (odds ratio [OR]: 17; 95% 5.5–51) and moderate to severe hyponatraemia (OR: 3.5; 95% CI: 2.0–5.9). The use of a feeding tube (OR: 14; 95% CI: 3.2–66) and intellectual disability (OR: 7.3; 95% CI: 3.0–18) was associated with moderate to severe hypernatraemia. The risk of death was associated with moderate to severe hypernatraemia (OR: 19; 95% CI: 2.0–2564) and moderate to severe hyponatraemia (OR: 33; 95% CI: 3.7–4311). Conclusions: Severe dysnatraemias were more prevalent in acutely ill children with underlying medical conditions and were markedly associated with the risk for death