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. Graphical abstract A higher resolution version of the Graphical abstract is available as Supplementary information

HYPONATREMIA: IS IT RELATED TO THE SEASONS?

Objectıve: Hyponatremia is a common electrolyte disorder in inpatients and related with morbidity and mortality. In this study we aimed to examine whether there is a relationship between incidence of hyponatremia among patients hospitalized in our nephrology department and the seasons. Material and Methods: Inpatients in our Nephrology Department between 2012-2015 were retrospectively analyzed. Patients with serum sodium levels below 135 mEq / L were included in the study. Hyponatremia incidence was calculated as the proportion of inpatients with low sodium levels in a season to total number of inpatients in the same season. Results: Out of 1950 inpatients in four-years period, 509 were found to have hyponatremia (26.1%). Mean serum sodium level of the patients was 129.7±4.7 mEq/L. Hyponatremia incidences in autumn, winter, spring and summer were found to be 28.7%, 15.4%, 20.4% and 36.6% respectively. Comparing the incidence of hyponatremia in patients hospitalized in winter and summer seasons, there was a significantly higher incidence of hyponatremia in summer (p <0.001). We found a positive correlation between hyponatremia incidence and temperature (r = 0.867, p = 0.001). However, there was a negative correlation between hyponatremia incidence and relative humidity (r =-0.735, p = 0.001). Conclusion: The highest hyponatremia incidence was observed in summer in four-year period. Loss of sodium by perspiration along with increased temperature and/or excessive hypotonic fluid intake might contribute to development of hyponatremia.

Hyperglycaemic hyperosmolar state: first presentation of type 1 diabetes mellitus in an adolescent with complex medical needs

This is a case of hyperglycaemic hyperosmolar state (HHS) as first presentation of type 1 diabetes mellitus in a 14-year-old girl with background complex medical needs. She presented with marked hyperglycaemia (56 mmol/L) without significant ketonaemia (2.6 mmol/L) and serum hyperosmolality (426 mOsm/kg). Managing her profound hypernatraemic (>180 mmol/L) dehydration was challenging but resulted in good outcome. Paediatric patients with HHS will likely be treated with the diabetes ketoacidosis (DKA) protocol because of perceived rarity of HHS leading to inadequate rehydration and risk of vascular collapse. Hence, emphasis on the differences in the management protocols of DKA and HHS is paramount. Prompt recognition and adequate management are crucial to avert complications. The undesirable rate of decline of hypernatraemia due to the use of hypotonic fluid was captured in this case. We describe the pivotal role of liberal fluid therapy with non-hypotonic fluids.

Effect of Environmental Temperature on Serum Sodium Level in Hospitalized Non-critically Ill Children

Background Intravenous hypotonic fluid administered in children is associated with an increased risk of developing hyponatremia. This finding has been reported from temperate countries where climate is relatively cold. But whether this risk also occurs in tropical countries has not been elucidated. Objective The objective of this study was to determine the relationship between environmental temperature and serum sodium in non-critically ill children. Methods A retrospective study. Results A total of 1061 hospitalized children were enrolled. Incidences of hyponatremia were not different between patients who received isotonic and hypotonic fluids (29% vs. 31%). Subgroup analysis showed a trend of higher incidence of hyponatremia in patients who received hypotonic fluid than isotonic fluid only in patients admitted to the air-conditioned wards (29% vs. 21%, p = 0.08). Conclusion Children admitted to the air-conditioned wards who received hypotonic fluid seemed to carry a higher risk of developing hyponatremia than those admitted to the non-air-conditioned ward.

Heme-pigment nephropathy after transurethral resection of prostate cancer

Introduction: Transurethral resection of the prostate is one of the most common surgical procedures performed in men to relieve bladder outlet obstruction, most often due to benign prostatic hyperplasia. However, transurethral resection of the prostate may also be used in patients with metastatic prostate cancer who have bladder outlet obstruction. Acute kidney injury after transurethral resection of the prostate has been described and attributed to a variety of mechanisms, including acute tubular necrosis, rhabdomyolysis, and hemolysis with heme-pigment nephropathy. However, to our knowledge, no case of kidney biopsy-proven heme-pigment nephropathy due to hemolysis from a transurethral resection of the prostate procedure has been published to date. Case description: We describe a case of an 82-year-old man with metastatic prostate cancer who presented with severe oliguric renal failure 2 weeks after transurethral resection of the prostate for bladder outlet obstruction. Laboratory studies showed evidence of hemolysis, and a kidney biopsy showed heme-pigment cast nephropathy. Conclusions: We hypothesize that the patient’s kidney injury was induced by hemolysis resulting from rapid absorption of hypotonic fluid administered during the transurethral resection of the prostate procedure. Patients with prostate cancer undergoing transurethral resection of the prostate for bladder outlet obstruction may experience severe complications related to rapid absorption of hypotonic fluid. Our case illustrates the importance of nephrology evaluation and kidney biopsy in patients with benign and malignant prostate conditions who experience post-transurethral resection of the prostate syndrome and acute kidney injury in order to better characterize these complications, and to develop preventative strategies for future cases.

Hyponatraemia in Female Athletes

Purpose of the PaperPrevious research has evaluated the prevalence and aetiology of hyponatraemia in athletes, particularly for ultra endurance events. However, few papers have focused specifically on the incidence and effects of hyponatraemia in female athletes. The aim of this paper was to review and collate previous research that has investigated hyponatraemia in female athletes and explain how excessive retention of free fluid may influence female performance and health status.Design/Methodology/ApproachThe most up-to-date and pertinent studies within the literature have been included and summated in this review.FindingsThe findings from this overview indicate that women participating in endurance events are particularly susceptible to developing hyponatraemia. It is important that women do not have depleted sodium concentrations prior to an athletic event, hypotonic fluid should not been consumed in excess and carbohydrate solutions (4-8g carbohydrate per 100ml fluid) should be consumed when women participate in intense exercise, lasting for longer than 1 hour. It is fundamentally important that up-to-date rehydration guidelines are imparted to active females and the dangers of over-ingesting fluid need to be emphasized within this vulnerable population.OriginalityThis paper gives a concise, up-to-date overview on how hyponatraemia can affect female athletic performance and health status.