Severe imported malaria involving hyperparasitemia (≥ 10%) in non-immune children: Assessment of French practices.

BACKGROUND: Plasmodium falciparum hyperparasitemia (over or equal to 10%), isolated or associated with other severity criteria, should be managed in a pediatric intensive care unit according to the French pediatric guidelines. The main objective of our study was to describe the management and course of these special cases. POPULATION AND METHODS: We conducted a retrospective study in eight French hospital facilities from January 2007 to December 2014. We reviewed the management of non-immune children aged 0-15 years, assessing the following: clinical and paraclinical data, type of care unit, treatment initiated, initial and long-term course. Data were analyzed for the whole population and for two groups according to the place of first-line management: group A (in pediatric intensive care unit), and group B (other places). RESULTS: A total of 61 children were included, 14 (23%) of whom were initially admitted to the intensive care unit (group A), all with neurological or hemodynamic disorders. Only 23 children (38%) overall received intravenous antimalarial treatment and the other patients received exclusively oral treatment. No deaths were reported. Median parasitemia was comparable in the two groups. In group B (n = 47/61, 77%), isolated hyperparasitemia, jaundice, and renal failure were predominant. The children who underwent initial intravenous treatment (n = 5/47, 11%) all progressed favorably, as did 92% of the children who received oral treatment (n = 42/47, 89%). CONCLUSION: A majority of children with Plasmodium falciparum hyperparasitemia were managed outside the pediatric intensive care unit via the oral route, against the French pediatric guidelines except when neurologic or hemodynamic disorders were present. Initial clinical evaluation and hospital supervision are essential for the best management of these patients.

Carbon monoxide poisoning from waterpipe (narghile) smoking in a child.

Shisha smoking has spread to many countries since the 1990s and is now a global phenomenon among adolescents. Notwithstanding the connotations of conviviality of shisha smoking, it is in fact highly dangerous since the smoke inhaled contains toxic substances. Carbon monoxide (CO) poisoning carries a high risk of neurological and neuropsychological sequelae such as memory loss, impaired concentration, mood disorders, and various other symptoms. We report a case of severe CO poisoning in a 13-year-old boy after smoking shisha that caused loss of consciousness and seizure. To our knowledge, there have as yet been no reports of cases involving children. We present some epidemiological data on shisha smoking in adolescents as well as on CO intoxication.

Acute gingivostomatitis in children: Epidemiology in the emergency department, pain, and use of codeine before its restriction.

Acute gingivostomatitis is relatively frequent in children; of viral origin, its diagnosis is usually straightforward. Acute gingivostomatitis is very painful and for many years, codeine, whose use was restricted in 2013, was widely employed in this context. The aim of this study was to ascertain the prevalence of acute stomatitis in pediatric emergency care, to evaluate the pain caused by stomatitis, and to determine the analgesic resources deployed both in the emergency department and at discharge, over the 5-year period preceding restriction of the use of codeine. METHODS: This was a retrospective study conducted in a pediatric emergency department (PED) of a university hospital between August 2008 and June 2013. RESULTS: A total of 702 children (372 herpetic gingivostomatitis [HGS], 149 herpangina [H], 181 hand, foot, and mouth disease [HFMD]) were included. Over the 5 years, one case of gingivostomatitis was identified for 303 visits to the PED. A total of 548 (78.1%) children were aged less than 36 months and the median age was 22 months. For 501 of 702 (71.4%) children, parents reported pain and/or feeding difficulties; in the HGS group, 314 of 372 (84.4%) patients had these symptoms. Of the 702 children, 48 (6.8%) were admitted to hospital. Overall, 457 (65.1%) of 702 children were given codeine before the PED visit, during the PED visit, or as a medication to take after discharge. The corresponding figures were 314 of 372 (84.4%) for the HGS group, 67 of 149 (45.0%) for the H group, and 76 of 181 (42.0%) for the HFMD group, P<0.001. CONCLUSIONS: Acute gingivostomatitis is a relative frequent reason for PED visits, and the pain and feeding difficulties that it elicits are a real challenge. Before codeine restriction, this medication played a major role in the analgesic strategy for this disease. It is essential that analgesic regimens at least as effective as codeine replace it. Morphine combined with paracetamol or the association of ibuprofen with paracetamol are options that are recommended by the French National Health Authority (HAS).

[Pediatrician's experience in announcing bad news]. / Le vécu par le pédiatre de l'annonce d'une « mauvaise nouvelle ¼ à l'enfant et à l'adolescent.

Few studies are available on pediatricians' experience with announcing bad news. Announcing bad news is an important component of medical practice and is even more complex in pediatrics because parents must be associated. We had 20 hospital pediatricians complete a questionnaire containing 30 questions about their own experience announcing bad news to a child or a teenager. In spite of their experience and the time they have spent practicing medicine, there are many limitations stemming from different factors concerning children, teenagers, their families, and themselves. The difficulties encountered by pediatricians are mainly related to the timing of the announcement, the location, the choice of the words used, and the poor understanding of children and families, due to intellectual, cultural, or psychological limitations. Pediatricians question their own capacity to make such an announcement, wondering if the information has actually been well understood. They indicate that they are themselves affected. Most of them develop and implement strategies to refute the emotional instability caused by the announcement of bad news. Yet many of them feel weak, even talking about a deep sense of loneliness and guilt.

Children and screens: Groupe de Pédiatrie Générale (Société française de pédiatrie) guidelines for pediatricians and families.

The Groupe de Pédiatrie Générale (General Pediatrics Group), a member of the Société française de pédiatrie (French Pediatrics Society), has proposed guidelines for families and doctors regarding children's use of digital screens. A number of guidelines have already been published, in particular by the French Academy of Sciences in 2013 and the American Academy of Pediatrics in 2016. These new guidelines were preceded by an investigation into the location of digital screen use by young children in France, a survey of medical concerns on the misuse of digital devices, and a review of their documented benefits. The Conseil Supérieur de l'Audiovisuel (Higher Council on Audiovisual Technology) and the Union Nationale de Associations Familiales (National Union of Family Associations) have taken part in the preparation of this document. Five simple messages are proposed: understanding without demonizing; screen use in common living areas, but not in bedrooms; preserve time with no digital devices (morning, meals, sleep, etc.); provide parental guidance for screen use; and prevent social isolation.

[Extracorporeal membrane oxygenation in critically ill neonates and children]. / Place de l'assistance respiratoire et circulatoire extracorporelle de courte durée (ECMO), post-cardiotomie exclue, dans la prise en charge des défaillances graves du nouveau-né et de l'enfant.

Extracorporeal membrane oxygenation is used as a last resort during neonatal and pediatric resuscitation in case of refractory circulatory or respiratory failure under maximum conventional therapies. Different types of ECMO can be used depending on the initial failure. The main indications for ECMO are refractory respiratory failure (acute respiratory distress syndrome, status asthmaticus, severe pneumonia, meconium aspiration syndrome, pulmonary hypertension) and refractory circulatory failure (cardiogenic shock, septic shock, refractory cardiac arrest). The main contraindications are a gestational age under 34 weeks or birth weight under 2kg, severe underlying pulmonary disease, severe immune deficiency, a neurodegenerative disease and hereditary disease of hemostasis. Neurological impairment can occur during ECMO (cranial hemorrhage, seizure or stroke). Nosocomial infections and acute kidney injury are also frequent complications of ECMO. The overall survival rate of ECMO is about 60 %. This survival rate can change depending on the initial disease: from 80 % for meconium aspiration syndrome to less than 10 % for out-of-hospital refractory cardiac arrest. Recently, mobile ECMO units have been created. These units are able to perform ECMO out of a referral center for untransportable critically ill patients.

[Pain in neonates: pharmacological treatment]. / Douleur du nouveau-né: traitement pharmacologique.

Pain causes numerous physiological changes in neonates. All invasive procedures induce undesirable stress responses; theses responses can, however, be eliminated or reduced by a judicious use of analgesia. Even though a large number of analgesics and sedatives are currently available, most of them have not been studied in the neonate. At present, a precise understanding of the pharmacological mechanisms of analgesics is difficult because many interactions still remain unknown in the term and premature neonate. This article describes the main analgesics and sedative agents used in the neonate: morphine, fentanyl, sufentanil, alfentanil, nalbuphine, ketamine, midazolam, propofol, acetaminophen, and Emla cream. After a review of the literature regarding these drugs, some practical advices and suggestions for the treatment of procedure-induced pain, and background sedation/analgesia for ventilated neonates are given. It is also stated in this article that the best way to soothe pain in neonates is to combine non pharmacological and pharmacological strategies. At the national level, written guidelines should be prepared in order to improve pain management in the neonate.

[Which sedation scale should be used in the paediatric intensive care unit? A comparative prospective study]. / Quelle échelle de sédation analgésie utiliser en réanimation pédiatrique? Etude comparative prospective.

OBJECTIVES: To compare pain and sedation assessments by nurses undertaken with the Objective Pain Scale (OPS) and a Visual Analogue Scale (VAS) to the current reference scale for paediatric intensive care that is the COMFORT scale. To compare the unmodified COMFORT scale to a COMFORT "behaviour" scale which does not include physiologic items. To evaluate the ease of use of these scales. METHODS: This prospective observational comparative study was carried out in children aged 1 year or older who were admitted in an intensive care unit. At 2 to 3 time points within 24 hours, a pain sedation assessment was carried out by the nurse in charge of the child with COMFORT scale, OPS and VAS. Correlation tests were used to compare the scores of each scale. RESULTS: Nurses recorded 55 assessments in 20 children. Correlation studies showed a poor correlation between OPS, VAS and the COMFORT scale (Spearman's r=0.54 and 0.53 respectively) and a strong correlation between the COMFORT scale and the COMFORT "behaviour" scale (Spearman's r=0.96). The COMFORT behaviour scale was the most frequently fully completed scale. CONCLUSION: Among the 3 scales compared to the COMFORT scale in this study, the COMFORT "behaviour" scale was the only one to show a strong correlation and it also seemed to be the easiest to use.

[Evaluation of pre-travel prevention and morbidity in child travelers]. / Enquêtes auprès des familles d'enfants voyageurs : évaluation des conseils de prévention et prévalence des maladies rencontrées lors d'un séjour hors d'Europe.

UNLABELLED: International travel is growing, but few data exist on prevention for children traveling. The aim of this study was to describe a population of children traveling from France to countries outside Europe and to evaluate the quality of prevention and healthcare services provided for these travelers. MATERIALS AND METHODS: We conducted a retrospective epidemiological study in three pediatric emergency departments in Paris from August to October 2009 and 2012. Data were collected retrospectively from anonymous questionnaires proposed to families consulting emergency services, irrespective of their reason, who had recently traveled (in the year preceding travel outside the European Union). RESULTS: Of the 166 children included, who for the most part had traveled to visit relatives and friends in Sub-Saharan Africa and North Africa, 76% of their families were from the destination countries, 78% had received prevention counseling, mostly with their doctor. They had been vaccinated against yellow fever, but the hepatitis A vaccine was neglected. The preventive measures had been difficult to achieve in practice. During travel, 54% of children had health problems (39% diarrhea, 29% vomiting, 31% fever) prompting medical care in 28%, 5% were admitted to a hospital, and 4% had return to France earlier than planned. In epidemic areas, 13% of children had malaria. CONCLUSION: There is poor counseling on basic prevention (hygiene, diarrhea, malaria, immunization). Time constraints in pediatricians and competing priorities could explain this problem. The challenge for healthcare providers to reduce these pathologies is to provide services of sufficient quality and clarity. All medical stakeholders have an important role to play.

[Nonpharmacologic management of pain in neonates]. / Traitement non pharmacologique de la douleur du nouveau-né.

It has taken a staggering amount of time for the medical community to realize that new-borns are able to feel pain. The treatment of neonatal pain during procedures has become mandatory, not only for humanitarian reasons which could alone justify the soothing of pain in these infants but also because repeated and prolonged pain may have long-term consequences in neonates. Nonpharmacological interventions which comprise environmental and behavioral interventions have a wide applicability for neonatal pain management alone or in combination with pharmacological treatments. These interventions are not necessarily substitutes or alternatives for pharmacological interventions but are complimentary. Nonpharmacological interventions can reduce neonatal pain indirectly by reducing the total amount of noxious stimuli to which infants are exposed and directly, by blocking nociceptive transduction or transmission or activation of descending inhibitory pathways or by activating attention and arousal systems that modulate pain. This article describes prevention, environmental interventions, and behavioral strategies. Within the behavioral strategies, sweet solutions, especially sucrose and glucose, with or without non-nutritive sucking, skin to skin contact, and breastfeeding during procedures have been studied and their analgesic efficacy has been shown. A practical approach is described hereafter. Give 1-2 ml of oral sucrose or glucose 30% at 2 min before a minor painful procedures in term neonates or neonates weighing more than 2500 g. The analgesic efficacy of sucrose and glucose seems similar. For preterm neonates weighing less than 2500 g, give 0.5 ml of oral sucrose or glucose 30%, and for those weighing less than 1500 g, 0.3 ml of oral sucrose or glucose 30%. Since a synergistic effect has been shown for the association of sweet solutions and pacifiers, give a pacifier together with sweet solutions. For term neonates that are breastfed, consider breastfeeding during procedures. These nonpharmacological interventions are suitable for minor procedures. They should not constitute the sole analgesic when performing more invasive procedures.

[Pain in neonatology. Non-pharmacological treatment]. / Douleur en néonatologie. Traitements non médicamenteux.

Diagnostic and therapeutic skin-breaking procedures have become ubiquitous in current medical practice and neonatology does not constitute an exception. One of the main sources of neonatal pain is procedure-induced pain. It has recently become clear that pain prevention must be a health care priority. Non-pharmacological approaches constitute a first option for the analgesia of common procedures performed in neonatology. This article reviews the non-pharmacological treatments most frequently used in this context: swaddling, tucking, containment, sweet solutions, non-nutritive sucking (NNS), breastfeeding analgesia, breast milk and music. In practice, the dose of 1 to 2mL of 24% or 30% sucrose solution or 30% glucose solution immediately followed by NNS can be given for minor painful procedures in term neonates or those weighing more than 2500g. In the preterm, 0.3mL of a sweet solution (sucrose or glucose) can be given for infants weighing less than 1500g and 0.5mL for those weighing between 1500 and 2500g. The synergistic effect of sweet solutions and NNS has been clearly shown and thus their association is largely justified in practice. For breast-fed term neonates, breastfeeding can be given to sooth procedure-induced pain. All these non-pharmacological options can be effective to relieve pain from minor or moderate procedures. However, when more painful procedures are performed, stronger analgesics must be used.

[Sedation and analgesia practices among Spanish neonatal intensive care units]. / Manejo de la sedación y la analgesia en unidades de cuidados intensivos neonatales españolas.

INTRODUCTION: Pain management and sedation is a priority in neonatal intensive care units. A study was designed with the aim of determining current clinical practice as regards sedation and analgesia in neonatal intensive care units in Spain, as well as to identify factors associated with the use of sedative and analgesic drugs. METHOD: A multicenter, observational, longitudinal and prospective study. RESULTS: Thirty neonatal units participated and included 468 neonates. Of these, 198 (42,3%) received sedatives or analgesics. A total of 19 different drugs were used during the study period, and the most used was fentanyl. Only fentanyl, midazolam, morphine and paracetamol were used in at least 20% of the neonates who received sedatives and/or analgesics. In infusions, 14 different drug prescriptions were used, with the most frequent being fentanyl and the combination of fentanyl and midazolam. The variables associated with receiving sedation and/or analgesia were, to have required invasive ventilation (P<.001; OR=23.79), a CRIB score >3 (P=.023; OR=2.26), the existence of pain evaluation guides in the unit (P<.001; OR=3.82), and a pain leader (P=.034; OR=2.35). CONCLUSIONS: Almost half of the neonates admitted to intensive care units receive sedatives or analgesics. There is significant variation between Spanish neonatal units as regards sedation and analgesia prescribing. Our results provide evidence on the "state of the art", and could serve as the basis of preparing clinical practice guidelines at a national level.

Randomised trial of analgesic effects of sucrose, glucose, and pacifiers in term neonates.

OBJECTIVES: To assess and compare the analgesic effects of orally administered glucose and sucrose and pacifiers. To determine the synergistic analgesic effect of sucrose and pacifiers. DESIGN: Randomised prospective study with validated behavioural acute pain rating scale. SETTING: Maternity ward. PARTICIPANTS: 150 term newborns undergoing venepuncture randomly assigned to one of six treatment groups: no treatment; placebo (2 ml sterile water); 2 ml 30% glucose; 2 ml 30% sucrose; a pacifier; and 2 ml 30% sucrose followed by a pacifier. RESULTS: Median (interquartile) pain scores during venepuncture were 7 (5-10) for no treatment; 7 (6-10) for placebo (sterile water); 5 (3-7) for 30% glucose; 5 (2-8) for 30% sucrose; 2 (1-4) for pacifier; and 1 (1-2) for 30% sucrose plus pacifier. Mann-Whitney U test P values for comparisons of 30% glucose, 30% sucrose, pacifier, and 30% sucrose plus pacifier versus placebo (sterile water) were 0.005, 0.01, <0.0001, and <0.0001, respectively. Differences between group median pain scores for these comparisons were 2 (95% confidence interval 1 to 4), 2 (0 to 4), 5 (4 to 7), and 6 (5 to 8), respectively. P values for comparisons of 30% glucose, 30% sucrose, and 30% sucrose plus pacifier versus pacifier were 0.0001, 0.001, and 0.06, respectively. Differences between group medians for these comparisons were 3 (2 to 5), 3 (1 to 5), and 1 (0 to 2), respectively. CONCLUSION: The analgesic effects of concentrated sucrose and glucose and pacifiers are clinically apparent in newborns, pacifiers being more effective than sweet solutions. The association of sucrose and pacifier showed a trend towards lower scores compared with pacifiers alone. These simple and safe interventions should be widely used for minor procedures in neonates.

[Analgesia using a (50/50) mixture of nitrous oxide/oxygen in children]. / Analgésie par mélange (50/50) de protoxyde d'azote/oxygène chez l'enfant.

Nitrous oxide is a gas that has been used to provide analgesia to patients for more than a century. Its modern use started in the late sixties when a mixture of 50% nitrous oxide/50% oxygen was prepared. Nitrous oxide/oxygen provides analgesia within 3 minutes of inhalation and this analgesic effect disappears in less than 4 minutes after cessation. Its administration is very easy and a complete or partial pain relief is observed in 75 to 81% of patients. The gas mixture has been found to be safe with few side effects and no significant adverse reactions. Diffusion hypoxia which could lead to hypoxemia was reported in 1955, but recent work does not confirm this complication. Nitrous oxide/oxygen mixture constitutes an excellent drug to control procedure-related pain in children. This articles describes the history, the pharmacology, and the clinical uses of nitrous oxide/oxygen in children.

[Pulse oximetry in pediatrics]. / L'oxymétrie de pouls en pédiatrie.

Pulse oximetry has become the leading technique for monitoring hemoglobin oxygen saturation whenever a risk of hypoxia exists. It is based upon the principle of light absorbance of pulsatile arterial blood. Since it uses 2 wavelengths, it can only measure oxyhemoglobin and reduced hemoglobin. Thus, in case of increased methemoglobin or carboxyhemoglobin, pulse oximetry values are not reliable. Low tissue perfusion can also be responsible for inaccurate values. Nevertheless pulse oximetry is a reliable and easy-to-use technique in most of the clinical situations. This article reviews the physical basis, the reliability, the pediatric aspects, and the limitations of the technique.

[Sedation and analgesia in children]. / Sédation et analgésie chez l'enfant.

This article describes the most current and effective means for providing sedation and analgesia for the pediatric patient. Three basic levels for sedation can be defined: conscious sedation, deep sedation and general anesthesia. Treatment of pain is also established according to an analgesic ladder. Providing safe and effective sedation and analgesia to children requires appropriate selection of drugs and dosage, proper monitoring, knowledge of potential side effects, and adequate airway management equipment and personnel. Agents available for sedation and analgesia of children and therapeutic options according to different clinical situations are described.

[Meningitis and osteitis caused by Pasteurella multocida in a three-month-old infant]. / Méningite et ostéite à Pasteurella multocida chez un nourrisson de 3 mois.

Pasteurella multocida is usually responsible for local infections occurring after animal bites. It can also be responsible for meningitis in infants. A three-month old infant was admitted to hospital with a diagnosis of bacterial meningitis and hip osteitis. Cultures of cerebrospinal fluid, blood and joint liquid were positive to Pasteurella multocida. Licking from the family dog was the transmission mode in this case. Despite initial neurological complications, clinical evolution was favourable after three weeks of intravenous antibiotic therapy followed by an oral administration for three months. Pasteurella multocida meningitis is rare in infants. It can be associated with arthritis, osteitis and septicaemia. Besides animal bites, licking is also a mode of contamination.

[Post-lumbar puncture headache in children. Treatment with epidural autologous blood (blood patch)]. / Céphalées post-ponction lombaire chez l'enfant. Intérêt de l'injection péridurale de sang autologue (blood patch).

UNLABELLED: Post-lumbar puncture headaches (PLPH) are uncommon in children, but when they occur treatment is challenging. PLPH in adults have been successfully treated by the use of the epidural blood patch. This treatment has been very rarely reported in children. CASE REPORT: A 13-year-old boy, weighing 64 kg, had a lumbar puncture as part of a work-up for a 4-day history of right hemithorax pain. This pain was associated with hypoesthesia; there were no cutaneous vesicles. Neurological examination revealed decreased strength in the left upper extremity. A magnetic resonance imaging of the cervicodorsolumbar spine was normal. Three hours after lumbar puncture, the patient complained of bifrontal headaches. The headaches worsened in the upright position and they prevented the boy from ambulating. Treatment with acetaminophen was unsatisfactory. On day 9, the initial symptoms that had motivated the lumbar puncture had disappeared, but PLPH persisted. Therefore, an epidural blood patch was performed (EBP). A 18-gauge 1 Perican needle was introduced into the peridural space at the L3-L4 interspace using the loss of resistance technique. Fifteen milliliters of blood were drawn in a sterile fashion and without anticoagulant from the patient's forearm and injected slowly through the epidural needle. The patient experienced immediate, complete, and definite relief of his PLPH. Follow-up did not show any complication. CONCLUSION: EBP can be useful in the treatment of PLPH lasting more than 5 days in children.

[APN: evaluation behavioral scale of acute pain in newborn infants]. / DAN: une échelle comportementale d'évaluation de la douleur aiguë du nouveau-né.

AIM: This study was designed to validate a behavioral acute pain rating scale for term and preterm neonates (APN). METHODS: From January through June 1996, neonates requiring a heel lance or a venous puncture for blood sampling at the intensive care unit and the nursery of Poissy Hospital were recruited into the study. After a pilot study, a pain rating scale was developed. The scale score pain ranged from 0 to 10 and it evaluated three items: facial expression, limb movements, and vocal expression with ratings per item ranging from 0 to 4, 0 to 3 and 0 to 3, respectively. Two observers evaluated independently each infant during a painful procedure (puncture for a blood sample) and during a dummy procedure (rubbing the thigh softly). RESULTS: Forty-two neonates born between 25 and 41 weeks gestational age were included in the study. Medians (quartiles) of gestational age, birth weight, and corrected postmenstrual age at time of investigation were 34 (29-39) weeks, 1,850 (1,055-3,093) g, and 35.5 (31-39) weeks, respectively. Ten infants were intubated. The scale showed to be sensitive because all possible scores were obtained; during painful procedures scores ranged from 1 to 10, with 95% of scores > or = 3 while during dummy procedures they ranged from 0 to 5, with 88% of scores < or = 2. The medians (95% confidence interval) of scores were for painful procedures 5 (5 to 7) and for dummy procedures 1 (0 to 1). This indicates a good specificity of the scale. High intercorrelation of items (internal consistency) was confirmed by a Cronbach's coefficient alpha of 0.88. Inter-rater agreement was high since the Krippendorff R test was 91.2. CONCLUSION: This behavioral acute pain rating scale for newborns demonstrated a good specificity and sensitivity, internal consistency and inter-rater reliability. This scale could be used to test the analgesic effects of different therapies during painful procedures.

[Water intoxication following preparation for barium enema]. / Intoxication par l'eau après une préparation pour un lavement baryté.

BACKGROUND: Induction of water intoxication from tap water enemas was reported a few years ago. Its treatment is still debated. CASE REPORT: A 4 1/2 year-old boy was admitted because he suffered from coma grade I. A barium enema had been prescribed for fecal incontinence and the patient had been given orally about 4 liters of water during the 24 hours preceding this investigation. Blood examination showed;: Na 122 mEq/l; K 3 mEq/l; Cl 87 mEq/l. Brain CT scan was normal. The patient was placed under restriction of fluid and was given i.v. 5.8% NaCl solution (2 mM/kg) for 3 hours. Convulsions appeared despite this treatment requiring intubation and ventilation plus increasing doses of NaCl: 20% solution (2 mM/kg) for 30 minutes followed by 2 mM/kg for 3 hours, associated with mannitol and furosemide infusion. CONCLUSION: Use of hypertonic saline solutions in the treatment of water intoxication is discussed. Acute hyponatremia must be rapidly corrected using hypertonic saline solution plus restriction of fluid and diuretic.