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Preventing neurological complications from dysnatremias in children
Michael L Moritz1, J Carlos Ayus
1Division of Nephrology, Department of Pediatrics, Children's Hospital of Pittsburgh, The University of Pittsburgh School of Medicine, PA 15213-2538, USA. Michael.Moritz@chp.edu
Insights
Hospital-acquired dysnatremias, like hyponatremia and hypernatremia, are common and preventable electrolyte disorders. Proper fluid management, particularly using 0.9% sodium chloride, can prevent severe neurological injury in children.
Area of Science:
- Pediatric Nephrology
- Internal Medicine
- Critical Care Medicine
Background:
- Dysnatremia (hyponatremia and hypernatremia) is a frequent electrolyte disorder in hospitalized patients, often stemming from inadequate fluid management.
- These conditions can lead to severe outcomes, including death and permanent neurological damage, particularly in children.
- Hospital-acquired dysnatremias are largely preventable with appropriate clinical interventions.
Purpose of the Study:
- To discuss the epidemiology, pathogenesis, prevention, and treatment of dysnatremias in pediatric patients.
- To highlight the risks associated with hospital-acquired hyponatremia and hypernatremia.
- To emphasize evidence-based strategies for preventing and managing these electrolyte imbalances.
Main Methods:
- Review of epidemiological data and pathogenesis of dysnatremias.
- Analysis of over 50 patient cases of death or neurological injury from hospital-acquired hyponatremia.
- Evaluation of 15 prospective studies involving over 500 surgical patients examining fluid management strategies.
- Assessment of treatment protocols for hyponatremic encephalopathy and hypernatremia.
Main Results:
- Hypotonic fluid use in patients with impaired free-water excretion is a primary cause of hyponatremic encephalopathy in children.
- Prospective studies demonstrate that 0.9% sodium chloride effectively prevents postoperative hyponatremia, while hypotonic fluids lower serum sodium levels.
- Hospital-acquired hypernatremia is linked to fluid restriction and free-water losses; adequate free-water provision is key to prevention.
- Breastfed infants are a high-risk group for hypernatremia due to potential insufficient lactation.
Conclusions:
- The routine use of isotonic fluids (0.9% sodium chloride) can prevent most cases of hospital-acquired hyponatremic encephalopathy in children.
- Hyponatremic encephalopathy requires urgent treatment with hypertonic saline, not fluid restriction alone.
- Preventing hypernatremia involves ensuring adequate free-water intake for at-risk patients and close monitoring of breastfed infants for lactation issues.
Abstract:
Dysnatremias are among the most common electrolyte abnormalities encountered in hospitalized patients. In most cases, a dysnatremia results from improper fluid management. Dysnatremias can occasionally result in death or permanent neurological damage, a tragic complication that is usually preventable. In this manuscript, we discuss the epidemiology, pathogenesis and prevention and treatment of dysnatremias in children. We report on over 50 patients who have suffered death or neurological injury from hospital-acquired hyponatremia. The main factor contributing to hyponatremic encephalopathy in children is the routine use of hypotonic fluids in patients who have an impaired ability to excrete free-water, due to such causes as the postoperative state, volume depletion and pulmonary and central nervous system diseases. The appropriate use of 0.9% sodium chloride in parenteral fluids would likely prevent most cases of hospital-acquired hyponatremic encephalopathy. We report on 15 prospective studies in over 500 surgical patients that demonstrate that normal saline effectively prevents postoperative hyponatremia, and hypotonic fluids consistently result in a fall in serum sodium. Hyponatremic encephalopathy is a medical emergency that should be treated with hypertonic saline, and should never be managed with fluid restriction alone. Hospital-acquired hypernatremia occurs in patients who have restricted access to fluids in combination with ongoing free-water losses. Hypernatremia could largely be prevented by providing adequate free-water to patients who have ongoing free-water losses or when mild hypernatremia (Na>145 mE/l) develops. A group at high-risk for neurological damage from hypernatremia in the outpatient setting is that of the breastfed infant. Breastfed infants must be monitored closely for insufficient lactation and receive lactation support. Judicious use of infant formula supplementation may be called for until problems with lactation can be corrected.
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