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Prescribe a maintenance IV fluid
 Age 2 years, wt. 10 kg admitted for pneumonia
With resonably stable vitals except mild tachypnea.
Answer :
1litre of IVF over 24 hrs.
 ISOLYTE – P : Dextrose 5% + 26 Na + + 20 K +
A Maulik Shah Presentation
NPSA – Patient safety alert 22: Reducing the risk of hyponatraemia
when administering intravenous infusions to children (Alert 5 of 5)

Applies to all paediatric patients from 1 month to 16 years 28th March 2007

 Remove 0.18% NaCl / 4%Dextrose from general stock

 Produce and disseminate clinical guidelines for the fluid management of paediatric patients

 Adequate training and supervision of staff

 Reinforce safe practice

 Promote the recording and reporting of hospital acquired hyponatraemia

 Audit programme to ensure that the NPSA recommendations are being adhered to
A Maulik Shah Presentation
Recommendation -NPSA
 Oral fluids preferable to ivf
 Resuscitation Fluids –
bolus of 0.9% saline
 Deficit – calculated and replaced as
 0.9% saline or 0.9% saline with 5% dextrose
 Replace over 24 hours
 Maintenance – do not use 0.18% saline with 4% dextrose
0.45%saline with 5%dextrose(D5-½NS)
A Maulik Shah Presentation
What about other countries…?
 Royal children hospital, Melbourne.
 Which Fluid?

 0.18% NaCl with 4% glucose with KCl 20mmol/L is NOT the appropriate
initial fluid for unwell children.
 Three good fluid solutions for sick children include:

Fluid Alternative names

0.9 NaCl Normal Saline
0.9 NaCl with 5% Dextrose Normal saline with glucose
0.45 NaCl with 5% Dextrose ½Normal saline with glucose A Maulik Shah Presentation
But Why do we require to change…
 Hoorn et al. Hoorn et al. Pediatrics 2004
“the most important factor contributing to hospital acquired
hyponatremia was administration of hypotonic fluid (case control) “

 Choong et al Choong et al. Arch Dis child 2006

”the use of hypotonic fluids increased the odds of developing
hyponatremia by 17 times when compared to isotonic
(systematic review).
A Maulik Shah Presentation
Hazards of Hypotonic Fluids
Acute Hospital Acquired Hyponatraemia
 Acute Hyponatraemia
 Na < 136mmols/L occurring within 48 hours

 Severe hyponatraemia if Na < 130mmols/L

 Or any level of hyponatraemia associated with clinical signs

 Hyponatraemic encephalopathy

 50% of children with Na<125mmol/L

 8% mortality rate

 Children have a poorer outcome than adults for a given level of

A Maulik Shah Presentation
Acute Hospital Acquired Hyponatraemia – children at risk

Common symptoms
 Headache
 Nausea & vomiting
 Weakness
Advanced signs
 Seizures
 Respiratory arrest
 Dilated pupils
 Decorticate posturing
Slide courtesy:
child’s brain has a higher  Coma Heinrich Werner, M.D.
Pediatric Critical Care
brain /intracranial volume ratio  Pulmonary oedema University of Kentucky
Hyponatremic encephlalopathy kills…!

Slide courtesy: A Maulik Shah Presentation

Heinrich Werner, M.D. Pediatric Critical Care University of Kentucky
That means...
 Hypotonic fluids are not benign but potentially
 Isotonic fluids offer a safe alternative to hypotonic
fluids with no risk of hypernatraemia
 Fluid regimes should be tailored to the individual
 Appropriate monitoring
 Weight, baseline U&E’s

A Maulik Shah Presentation

Most common cause of hyponatremia
Volume Status

in hospitalized patients
Hypovolemia Euvolemia Hypervolemia

Renal losses Extrarenal losses

“”””” “””””
“”””” “””””” SIADH “””””
“”””” “””””
Slide courtesy:
Heinrich Werner, M.D. Pediatric Critical Care University of Kentucky
SIADH and Hyponatremia

Inappropriate AVP level Free water intake exceeds output

Typically done by
Symptomatic Hyponatremia
you and me !
Appropriate ADH Secretion Inappropriate ADH Secretion

Decreased Renal Water Secretion

Hypotonic Fluid

Osmolality : ADH level and Thirst

Osmolality is the prime

stimulus for ADH release or

Berl T, Robertson GL. Pathophysiology of Water
Metabolism. In: Brenner AM, ed. Brenner and Rector's
The Kidney. 6th ed. Philadelphia: W.B. Saunders;
2000:873. A Maulik Shah Presentation
Non Osmotic Stimuli for ADH Secretion
 Stress Drugs
 Pain  Morphine
 Post-operative period  NSAID’s
 Sepsis  SSRI’s
 Pyrexia  Barbiturates
 Nausea & vomiting  Carbamazepine
 Co-existing medical conditions  Clofibrate
 CNS infections
 Isoprenaline
 Respiratory disorders
 Metabolic & endocrine disorders
 Chlorpropamide
 Vincrisitine
A Maulik Shah Presentation
Which hospitalized
child is not at risk
for SIADH ?
Slide courtesy:
Heinrich Werner, M.D. Pediatric Critical Care University of Kentucky A Maulik Shah Presentation
But why hypotonic fluid held responsible ?
5% Dextrose 0 100
ISOLYTE -P 26 84%
0.45% NS 77 50%
0.45 % NS in 5% Dextrose 77 50%
0.9 % NS in 5% Dextrose 154 0
Ringer Lactate 131 16%
0.9% NS 154 0

EFW = Electrolyte Free Water A Maulik Shah Presentation

But what does EWF do ?

Sodium Principles
Sodium ions do
not cross cell H2O H 2O
membranes as H2O H O
quickly as water Na+
does Na+

A Maulik Shah Presentation

So do we accept the change ?
Not fully – Why…?
 We live in tropics-hot climate –free water loss more.

 Our children are treated most often in non A/C ICU.

 Our indian data is in-sufficient for conclusion.

 BUT then summer and winter fluid has to be

A Maulik Shah Presentation
So is “ISOLYTE- P” out ??
Not fully – Why…?
 Hypotonic solutions should be administered if the goal is to create a positive balance
for EFW:
1. To match daily loss of EFW in sweat in a patient with PNa > 138mM
2. PNa > 145
3. Ongoing free water losses (Renal, GI, skin) or a free water deficit
so use in
 Established third space overload : e.g. congestive heart failure,
nephrotic syndrome, cirrhosis A Maulik Shah Presentation
Let’s Share our views on this…