Hyponatremia Treatment Guidelines - Have They Gone Too Far?

Hyponatremia is a common electrolyte abnormality affecting hospitalized patients.1 It is an independent predictor for mortality and is associated with increased length of hospital stay and higher costs. The most serious potential complication is hyponatremic encephalopathy, a medical emergency that can result in death or irreversible brain injury if inadequately treated.2 Hypertonic saline is a safe and effective means of correcting hyponatremia.2-4 A rare yet serious complication from excessive correction of chronic hyponatremia is the development of cerebral demyelination.

Administration of 3% Sodium Chloride and Local Infusion Reactions.

Three-percent sodium chloride (3% NaCl) is a hyperosmolar agent used to treat hyponatremic encephalopathy or other cases of increased intracranial pressure. A barrier to the use of 3% NaCl is the perceived risk of local infusion reactions when administered through a peripheral vein. We sought to evaluate reports of local infusion reactions associated with 3% NaCl over a 10-year period throughout a large healthcare system. A query was conducted through the Risk Master database to determine if there were any local infusion reactions associated with peripheral 3% NaCl administration throughout the entire UPMC health system, which consists of 40 hospitals with 8400 licensed beds, over a 10-year time period from 14 May 2010 to 14 May 2020. Search terms included infiltrations, extravasations, phlebitis, IV site issues, and IV solutions. There were 23,714 non-chemotherapeutic and non-contrast-associated intravenous events, of which 4678 (19.7%) were at UPMC Children's Hospital. A total of 2306 patients received 3% NaCl, of whom 836 (35.8%) were at UPMC Children's Hospital. There were no reported local infusion reactions with 3% NaCl. There were no reported local infusion reaction events associated with 3% NaCl in a large healthcare system over a 10-year period. This suggests that 3% NaCl can be safely administered through a peripheral IV or central venous catheter.

Association of early hyponatremia and the development of acute kidney injury in critically ill children.

BACKGROUND: Hyponatremia is an independent prognostic factor for mortality; however, the reason for this remains unclear. An observed relationship between hyponatremia and the development of acute kidney injury (AKI) has been reported in certain disease states, but hyponatremia has not been evaluated as a predictor of AKI in critically ill patients or children. METHODS: This is a single-center retrospective cohort study of critically ill children admitted to a tertiary care center. We performed regression analysis to assess the association between hyponatremia at ICU admission and the development of new or worsening stage 2 or 3 (severe) AKI on days 2-3 following ICU admission. RESULTS: Among the 5057 children included in the study, early hyponatremia was present in 13.3% of children. Severe AKI occurred in 9.2% of children with hyponatremia compared to 4.5% of children with normonatremia. Following covariate adjustment, hyponatremia at ICU admission was associated with a 75% increase in the odds of developing severe AKI when compared to critically ill children with normonatremia (aOR 1.75, 95% CI 1.28-2.39). Evaluating sodium levels continuously, for every 1 mEq/L decrease in serum sodium level, there was a 0.05% increase in the odds of developing severe AKI (aOR 1.05, 95% CI 1.02-1.08). Hyponatremic children who developed severe AKI had a higher frequency of kidney replacement therapy, AKI or acute kidney disease at hospital discharge, and hospital mortality when compared to those without. CONCLUSIONS: Hyponatremia at ICU admission is associated with the development of new or worsening AKI in critically ill children. A higher resolution version of the Graphical abstract is available as Supplementary information.

A Survey of Hospital Pharmacy Guidelines for the Administration of 3% Sodium Chloride in Children.

Three percent sodium chloride (3% NaCl) is the treatment of choice for symptomatic hyponatremia. A barrier to the use of 3% NaCl is the perceived risk of both local infusion reactions and neurologic complications from overcorrection. We examine whether children's hospital pharmacies have policies or practice guidelines for the administration of 3% NaCl and whether these pharmacies have restrictions on the administration of 3% NaCl in terms of rate, route, volume and setting. An Internet survey was distributed to the pharmacy directors of 43 children's hospitals participating in the Children's Hospital Association (CHA) network. The response rate was 65% (28/43). Ninety-three percent (26/28) of pharmacy directors reported a restriction for the administration of 3% NaCl, with 57% restricting its use through a peripheral vein or in a non-intensive care unit setting, 68% restricting the rate of administration and 54% restricting the volume of administration. Seventy-one percent (20/28) reported having written policy or practice guidelines. Only 32% of hospital pharmacies allowed 3% NaCl to be administered through a peripheral IV in a non-intensive care unit setting. The majority of children's hospital pharmacies have restrictions on the administration of 3% NaCl. These restrictions could prevent the timely administration of 3% NaCl in children with symptomatic hyponatremia.

How Salty Are Your Fluids? Pediatric Maintenance IV Fluid Prescribing Practices Among Hospitalists.

Objective: The primary goal of this study was to assess current maintenance intravenous fluid (mIVF) prescribing practices of pediatric hospitalists after the release of the American Academy of Pediatrics Clinical Practice Guideline (AAP CPG), specifically assessing the rates of various isotonic vs. hypotonic solutions used in discrete age groups and in common clinical scenarios associated with anti-diuretic hormone (ADH) excess and hyponatremia. We hypothesized that isotonic fluids would be selected in most cases outside of the neonatal period. Methods: A voluntary and anonymous survey was distributed to the LISTSERV® for the AAP Section on Hospital Medicine. Results: There were 402 total responses (10.1% response rate) with the majority of respondents being pediatric hospitalists. Isotonic solutions were preferred by respondents in older children compared to younger age groups, at 87.8% for the 1-18 years age group compared to 66.3% for the 28 days to 1 year age group and 10.6% for the younger than 28 days age group (all p values <0.0001). When presented with disease states associated with ADH excess, isotonic fluids were preferred in higher percentages in all age groups except in children younger than 28 days when 0.45% sodium chloride was preferred; 0.2% sodium chloride was rarely chosen. Conclusions: Overall, based on survey responses, pediatric hospitalists are following the 2018 AAP CPG on mIVF and are more likely to choose isotonic fluids as their primary mIVF in pediatric patients outside of the neonatal period, including in scenarios of excess ADH. Isotonic fluids use seems to be higher with increasing age and hypotonic fluids are more commonly chosen in the neonatal period.

Management of hyponatremia in various clinical situations.

OPINION STATEMENT: Hyponatremia is the most common electrolyte abnormality in both inpatient and outpatient settings. The condition primarily results from the combination of impaired free water excretion due to elevated vasopressin levels in conjunction with a source of free water intake. Recent studies have revealed that even mild and asymptomatic hyponatremia is associated with deleterious consequences. It is an independent risk factor for mortality and is also associated with increased length of hospitalization and hospital costs. Even mild chronic hyponatremia can result in subtle neurologic impairment and bone demineralization, leading to falls and associated bone fractures in the elderly. Hyponatremia can be a difficult condition to treat, with varying therapeutic strategies based on the etiology, severity, duration, and extent of neurologic symptoms. The ideal magnitude of correction is also controversial, as both inadequate therapy and overly aggressive therapy can result in neurologic injury. Formulas that have been devised to aid in the treatment of hyponatremia can be inaccurate in that they fail to adequately account for the renal response to therapy. Hyponatremic encephalopathy is the most serious complication of hyponatremia, and can result in permanent neurologic impairment or death if left untreated. Individuals most at risk for developing hyponatremic encephalopathy are postmenarchal women, children under 16 years of age, patients with central nervous system disease or hypoxemia, and patients in the postoperative setting. The preferred therapy for hyponatremic encephalopathy is a 100-ml bolus of 3 % sodium chloride (513 mEq/L) administered in repeated doses until symptoms reverse, with the goal of increasing the serum sodium 5-6 mEq/L. Vasopressin (V2) antagonists (vaptans) are not appropriate for the management of acute hyponatremic encephalopathy, as the onset of action is not sufficiently rapid and the increase in sodium is not predictable. Vaptans are primarily indicated for the treatment of asymptomatic hyponatremia due to SIAD that is refractory to conventional measures.

Intravenous fluid management for the acutely ill child.

PURPOSE OF REVIEW: To review the principles of prescribing intravenous fluids (IVFs) to the acutely ill child and of adjusting sodium composition and fluid rate to prevent disorders in serum sodium or volume status from occurring. RECENT FINDINGS: Recent data have revealed that the historic approach of administering hypotonic IVFs results in a high incidence of hospital-acquired hyponatremia in children. The majority of hospitalized children requiring IVFs are at risk for developing hyponatremia from numerous stimuli for arginine vasopressin (AVP) production, such as volume depletion, pain, stress, nausea, vomiting, respiratory or central nervous system (CNS) disorders, or the postoperative state. Multiple recent prospective studies in over 600 children have demonstrated that hypotonic fluids cause acute hyponatremia, whereas 0.9% sodium chloride (NaCl) effectively prevents it. 0.9% NaCl is the most appropriate IVF for the majority of hospitalized children. Fluid and sodium restriction will be needed for children with edematous or oliguric states and hypotonic fluids needed for children with urinary or extra-renal free water losses or hypernatremia. SUMMARY: Hypotonic fluids should not be administered routinely in children due to the risk of hospital-acquired hyponatremia. 0.9% NaCl is the preferred IVF for the vast majority of hospitalized children.