A randomized controlled trial of isotonic versus hypotonic maintenance intravenous fluids in hospitalized children

BMC Pediatrics

Bethany J Foster¹  Diane Laforte²  Fiona Houghton²  James Fairbairn³  Thomas G Saba² 

[1] Dept. of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada;Dept. of Pediatrics, Montreal Children's Hospital, McGill University, Montreal, QC, Canada;Faculty of Medicine, McGill University, Montreal, QC, Canada

关键词: isotonic fluid;    intravenous fluids;    sodium;    hyponatremia;   

Others  :  1172127
DOI  :  10.1186/1471-2431-11-82

 received in 2010-10-13, accepted in 2011-09-23,  发布年份 2011

【 摘 要 】

Background

Isotonic saline has been proposed as a safer alternative to traditional hypotonic solutions for intravenous (IV) maintenance fluids to prevent hyponatremia. However, the optimal tonicity of maintenance intravenous fluids in hospitalized children has not been determined. The objective of this study was to estimate and compare the rates of change in serum sodium ([Na]) for patients administered either hypotonic or isotonic IV fluids for maintenance needs.

Methods

This was a masked controlled trial. Randomization was stratified by admission type: medical patients and post-operative surgical patients, aged 3 months to 18 years, who required IV fluids for at least 8 hours. Patients were randomized to receive either 0.45% or 0.9% saline in 5.0% dextrose. Treating physicians used the study fluid for maintenance; infusion rate and the use of additional fluids were left to their discretion.

Results

Sixteen children were randomized to 0.9% saline and 21 to 0.45% saline. Baseline characteristics, duration (average of 12 hours) and rate of study fluid infusion, and the volume of additional isotonic fluids given were similar for the two groups. [Na] increased significantly in the 0.9% group (+0.20 mmol/L/h [IQR +0.03, +0.4]; P = 0.02) and increased, but not significantly, in the 0.45% group (+0.08 mmol/L/h [IQR -0.15, +0.16]; P = 0.07). The rate of change and absolute change in serum [Na] did not differ significantly between groups.

Conclusions

When administered at the appropriate maintenance rate and accompanied by adequate volume expansion with isotonic fluids, 0.45% saline did not result in a drop in serum sodium during the first 12 hours of fluid therapy in children without severe baseline hyponatremia. Confirmation in a larger study is strongly recommended.

Clinical Trial Registration Number

NCT00457873 (http://www.clinicaltrials.gov/ webcite)

【 授权许可】

   
2011 Saba et al; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

Figure 2.

【 参考文献 】

• [1]Holliday MA, Segar WE: The maintenance need for water in parenteral fluid therapy. Pediatrics 1957, 19(5):823-832.
• [2]Hatherill M: Rubbing salt in the wound. Arch Dis Child 2004, 89(5):414-418.
• [3]Duke T, Molyneux EM: Intravenous fluids for seriously ill children: time to reconsider. Lancet 2003, 362(9392):1320-1323.
• [4]Holliday MA, Segar WE, Friedman A: Reducing errors in fluid therapy management. Pediatrics 2003, 111(2):424-425.
• [5]Choong K, Kho ME, Menon K, Bohn D: Hypotonic versus isotonic saline in hospitalised children: a systematic review. Arch Dis Child 2006, 91(10):828-835.
• [6]Beck CE: Hypotonic versus isotonic maintenance intravenous fluid therapy in hospitalized children: a systematic review. Clin Pediatr (Phila) 2007, 46(9):764-770.
• [7]Bohn D: The problem of acute hyponatremia in hospitalized children: the solution is in the solution. Pediatr Crit Care Med 2008, 9(6):658-659.
• [8]Holliday MA, Segar WE, Friedman A, Chesney R, Finberg L: Intravenous fluids for seriously ill children. Lancet 2004, 363(9404):241; author reply 242.
• [9]Moritz ML, Ayus JC: Prevention of hospital-acquired hyponatremia: a case for using isotonic saline. Pediatrics 2003, 111(2):227-230.
• [10]Hoorn EJ, Geary D, Robb M, Halperin ML, Bohn D: Acute hyponatremia related to intravenous fluid administration in hospitalized children: an observational study. Pediatrics 2004, 113(5):1279-1284.
• [11]Au AK, Ray PE, McBryde KD, Newman KD, Weinstein SL, Bell MJ: Incidence of postoperative hyponatremia and complications in critically-ill children treated with hypotonic and normotonic solutions. J Pediatr 2008, 152(1):33-38.
• [12]Steele A, Gowrishankar M, Abrahamson S, Mazer CD, Feldman RD, Halperin ML: Postoperative hyponatremia despite near-isotonic saline infusion: a phenomenon of desalination. Ann Intern Med 1997, 126(1):20-25.
• [13]Arieff AI, Ayus JC, Fraser CL: Hyponatraemia and death or permanent brain damage in healthy children. BMJ 1992, 304(6836):1218-1222.
• [14]Paut O, Remond C, Lagier P, Fortier G, Camboulives J: [Severe hyponatremic encephalopathy after pediatric surgery: report of seven cases and recommendations for management and prevention]. Ann Fr Anesth Reanim 2000, 19(6):467-473.
• [15]Playfor S: Fatal iatrogenic hyponatraemia. Arch Dis Child 2003, 88(7):646-647.
• [16]McJunkin JE, de los Reyes EC, Irazuzta JE, Caceres MJ, Khan RR, Minnich LL, Fu KD, Lovett GD, Tsai T, Thompson A: La Crosse encephalitis in children. N Engl J Med 2001, 344(11):801-807.
• [17]McRae RG, Weissburg AJ, Chang KW: Iatrogenic hyponatremia: a cause of death following pediatric tonsillectomy. Int J Pediatr Otorhinolaryngol 1994, 30(3):227-232.
• [18]Soroker D, Ezri T, Lurie S, Feld S, Savir I: Symptomatic hyponatraemia due to inappropriate antidiuretic hormone secretion following minor surgery. Can J Anaesth 1991, 38(2):225-226.
• [19]Moritz ML, Ayus JC: Preventing neurological complications from dysnatremias in children. Pediatr Nephrol 2005, 20(12):1687-1700.
• [20]Rose BD: Clinical Physiology of Acid-Base Disorders. Fifth edition. McGraw-Hill; 2000.
• [21]Moritz ML, Ayus JC: Hospital-acquired hyponatremia: why are there still deaths? Pediatrics 2004, 113(5):1395-1396.
• [22]Moritz ML, Ayus JC: 0.9% saline solution for the prevention of hospital-acquired hyponatremia: why is there still doubt? J Pediatr 2008, 153(3):444. author reply 444-446; discussion 446-447
• [23]Wilkes NJ, Woolf R, Mutch M, Mallett SV, Peachey T, Stephens R, Mythen MG: The effects of balanced versus saline-based hetastarch and crystalloid solutions on acid-base and electrolyte status and gastric mucosal perfusion in elderly surgical patients. Anesth Analg 2001, 93(4):811-816.
• [24]Waters JH, Gottlieb A, Schoenwald P, Popovich MJ, Sprung J, Nelson DR: Normal saline versus lactated Ringer's solution for intraoperative fluid management in patients undergoing abdominal aortic aneurysm repair: an outcome study. Anesth Analg 2001, 93(4):817-822.
• [25]Neville KA, Verge CF, Rosenberg AR, O'Meara MW, Walker JL: Isotonic is better than hypotonic saline for intravenous rehydration of children with gastroenteritis: a prospective randomised study. Arch Dis Child 2006, 91(3):226-232.
• [26]Moritz ML: Urine sodium composition in ambulatory healthy children: hypotonic or isotonic? Pediatric Nephrology 2008, 23(6):955-957.
• [27]Yung M, Keeley S: Randomised controlled trial of intravenous maintenance fluids. J Paediatr Child Health 2009, 45(1-2):9-14.
• [28]Neville KA, Sandeman DJ, Rubinstein A, Henry GM, McGlynn M, Walker JL: Prevention of Hyponatremia during Maintenance Intravenous Fluid Administration: A Prospective Randomized Study of Fluid Type versus Fluid Rate. J Pediatr 2009.
• [29]Montanana PA, Modesto i Alapont V, Ocon AP, Lopez PO, Lopez Prats JL, Toledo Parreno JD: The use of isotonic fluid as maintenance therapy prevents iatrogenic hyponatremia in pediatrics: a randomized, controlled open study. Pediatr Crit Care Med 2008, 9(6):589-597.
• [30]Brazel PW, McPhee IB: Inappropriate secretion of antidiuretic hormone in postoperative scoliosis patients: the role of fluid management. Spine (Phila Pa 1976) 1996, 21(6):724-727.
• [31]Kannan L, Lodha R, Vivekanandhan S, Bagga A, Kabra SK, Kabra M: Intravenous fluid regimen and hyponatraemia among children: a randomized controlled trial. Pediatric Nephrology 2010, 25(11):2303-2309.
• [32]UK National Patient Safety Agency Alert NPSA/2007/22 accessed at: http://www.nrls.npsa.nhs.uk/resources/?entryid45=59809 webcite
• [33]Kliegman R, Nelson WE: Nelson textbook of pediatrics. 18th edition. Philadelphia: Saunders; 2007.
• [34]Endom EE: Treatment of hypovolemia (dehydration) in children. In UpToDate. Edited by Basow DE. Waltham, MA; 2010.
• [35]Sandhu BK: Rationale for early feeding in childhood gastroenteritis. J Pediatr Gastroenterol Nutr 2001, (33 Suppl 2):S13-16.
• [36]Rose BD: Clinical Physiology of Acid-Base and Electrolyte Disorders. 1994, 651-694.