JULY 2007 VOL 3 NO 7 MORITZ AND AYUS
NATURE CLINICAL PRACTICE
In 2003, we introduced the conceptof using 0.9% sodium chloride (NaCl) as a main-tenance parenteral fluid for the prevention of hospital-acquired hyponatremia in children.
This concept caused controversy in the pedi-atric literature about the most appropriate fluidtherapy for children.
The Royal College of Pediatrics has since issued a warning regardingthe use of 0.18% NaCl,
and critics have nowconceded that hypotonic fluids are overused andcan be dangerous.
Avoidance of hypotonicfluids, and use of 0.9% NaCl as prophylaxisagainst hospital-acquired hyponatremia, areequally relevant to adults and children.
In thisReview, we explore the question of why admin-istration of hypotonic fluids is unphysiologicand potentially dangerous, the settings in whichisotonic fluids should be administered to preventhyponatremia, and the appropriate managementof hyponatremic encephalopathy.
WHY ARE HYPOTONIC FLUIDS USED?
Hypotonic fluids are still the parenteral fluidmost commonly administered to both pedi-atric and adult hospitalized patients. Thepediatric literature specifically addresses the topicof maintenance parenteral fluid therapy andrecommends hypotonic fluid.
The adult litera-ture does not specifically address maintenanceparenteral therapy but does make recommen-dations for hypotonic fluids in total parenteralnutrition and in the perioperative setting.
We queried the adult inpatient pharmacy of the University of Pittsburgh Medical Center,and found that 0.45% NaCl with 20 mmol/lpotassium chloride in 5% dextrose is the mostcommonly prescribed fluid for parenteraltherapy. This practice seems to be common foradult patients throughout the world. The WHOrecommends using 5% dextrose in water in thepostoperative setting for one-third of main-tenance fluids in patients unable to drink.
In the UK, 0.18% NaCl in 4% dextrose is themost commonly used parenteral fluid.
Ina Brazilian study, about 50% of postoperativepatients received 5% dextrose in water.
In arecent Case Record of the Massachusetts GeneralHospital, 0.45% NaCl was administered to apatient with a central nervous system disorderand a serum sodium level of 131 mmol/l.
The use of hypotonic fluids in adults origi-nated in part from recommendations made by Talbot
. in 1953.
These authors generateda theoretical model of maximal and minimaltolerances for sodium and water in parenteralfluids, based on the ranges of normal renalconcentration and dilution. Their recommen-dation at the time was to use 40 mmol/l NaCl formaintenance fluid therapy. Hypotonic fluid usein children is partly based on recommendationsmade by Holliday and Segar in 1957.
Theseauthors recommended 30 mmol/l NaCl for main-tenance fluid in children. Their guidance wasbased in part on the recommendations of others,and also on the fact that 30 mmol/l NaCl approx-imates the sodium composition of human breastand cow’s milk. Both Talbot’s and Holliday’sgroups appreciated that AVP excess couldimpair water handling and that symptomatic
Clinical settings in which production of arginine vasopressinis increased.
Hemodynamic stimuli (decreased effective circulatory volume)
Renal salt wasting
Congestive heart failure
Nonhemodynamic stimuli (syndrome of inappropriate antidiuretic hormoneproduction)
Central nervous system disturbances such as meningitis, encephalitis,stroke, brain tumor, brain abscess, head injury and hypoxic brain injury
Pulmonary diseases such as pneumonia, asthma, tuberculosis, empyema,chronic obstructive pulmonary disease and acute respiratory failure
Cancers of the lung, brain, central nervous system, head, neck, breast,gastrointestinal tract, genitourinary tract, and leukemia, lymphoma, thymomaand melanoma
Medications such as cyclophosphamide, vincristine, morphine, selectiveserotonin reuptake inhibitors and carbamazepine
Nausea, emesis, pain and stress