[PDF] Effect of isotonic vs hypotonic maintenance fluid therapy on urine

Effect of isotonic versus hypotonic maintenance fluid therapy on

16 mai 2017 · Even at maintenance rate, isotonic solutions caused lower urine output, characterized by decreased aldoster- one concentrations indicating ( 

Effect of isotonic vs hypotonic maintenance fluid therapy on urine

28 avr 2017 · of a hypotonic solution 13 In the recently published SPLIT trial, over 2000 adults in the intensive care unit received isotonic fluids, and there 

PRODUCTION OF INCREASED RENAL SODIUM EXCRETION - JCI

THE HYPOTONIC EXPANSION OF EXTRACELLULAR FLUID VOLUME IN ally diminished urinary excretion of sodium (4), man albumin in 25 per cent solution, thereby in- creasing subjects is without significant effect on the renal

FACTORS INFLUENCING THE DIURETIC RESPONSE OF - JCI

considered to have little or no immediate effect on urine hypotonic to extracellular fluid OF 0 9 PER CENT SODIUM CHLORIDE SOLUTION ON URINARY

[PDF] Antidiuresis immediately caused by drinking a small volume of

water but also to other solutions In this study we report the effects of oropharyngeal and laryngeal stimulation with isotonic or hypertonic saline on urine 

[PDF] Isotonic versus hypotonic solutions for maintenance - UQ eSpace

Comparison 1 Isotonic versus hypotonic, Outcome 9 Urine osmolarity at T24 This fluid can cause rare but serious side effects due to the salt level in the body 

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valid conclusion, as they studied healthy volunteers who did not have stimuli for AVP production. Their results cannot be general- ized to acutely ill patients. Any fluid would be expected to be safe when used at maintenance rates in healthy individuals. They cannot conclude from this study that hypotonic fluids are safe to be used in acutely ill hospitalized patients, when all data suggests otherwise. Hyponatraemiais extremelyprevalent inhospitalized patients and is associated with increased mortality. 78

It has long been

known that acutely ill patients have stimuli for AVP release that lead to hyponatraemia, and this is particularly so in postoperative patients.910 The primary factor leading to hyponatraemia is the use of hypotonic fluids. There are over 20 prospective paediatric trials in almost 3000 patients that have consistently demon- strated that isotonic fluids significantly decrease the incidence of hyponatraemia in comparisonwithhyponatraemic fluids without any apparent harm. 11 12

A recent study of postoperative adults

demonstrated that the incidence of hyponatraemia could be decreased from 51% to 16% by using an isotonic solution in favour of a hypotonic solution.13

In the recently published SPLIT trial,

over 2000 adults in the intensive care unit received isotonic fluids, and there was no evidence that this approach was unsafe. 14 Regenmortel and colleagues suggested that isotonic fluids are associated with decreased urine output and a higher chloride concentration. Both the fluid retention and change in chloride were of no clinical significance though, and are not a sufficient justification to use a hypotonic fluid that is known to produce harm in acutely ill patients. Hypotonic fluids cannot be recom- mended in acutely ill adults as a result of significantly increased risk of producing hyponatraemia, and this is particularly so in the postoperative patients who are at the highest risk for hyponatraemia.Declaration of interest

None declared.

References

1. Moritz ML, Ayus JC. Maintenance intravenous fluids in

acutely ill patients.N Engl J Med2015;373: 1350-60

2. Moritz ML, Ayus JC. Prevention of hospital-acquired hypona-

tremia: a case for using isotonic saline.Pediatrics2003;111:

227-303. Moritz ML, Carlos Ayus J. Hospital-acquired hyponatremia-

why are hypotonic parenteral fluids still being used?Nat Clin

Pract Nephrol2007;3: 374-82

4. Arieff AI, Ayus JC, Fraser CL. Hyponatraemia and death or

permanent brain damage in healthy children.Br Med J1992;

304: 1218-22

5. Ayus JC, Wheeler JM, Arieff AI. Postoperative hyponatremic

encephalopathy in menstruant women.Ann Intern Med1992;

117: 891-7

6. Van Regenmortel N, De Weerdt T, Van Craenenbroeck AH,

et al. Effect of isotonic versus hypotonic maintenance fluid therapy on urine output, fluid balance, and electrolyte homeostasis: a crossover study in fasting adult volunteers.

Br J Anaesth2017;118: 892-900

7. Holland-Bill L, Christiansen CF, Heide-Jørgensen U,et al.

Hyponatremia and mortality risk: a Danish cohort study of

279508 acutely hospitalized patients.Eur J Endocrinol2015;

173: 71-81

8. Wald R, Jaber BL, Price LL,et al. Impact of hospital-associated

hyponatremia on selected outcomes.Arch Intern Med2010;

170: 294-302

9. Anderson RJ, Chung HM, Kluge R, Schrier RW. Hyponatremia:

a prospective analysis of its epidemiology and the pathoge- neticroleofvasopressin.Ann Intern Med1985;102:164-8

10. Chung HM, Kluge R, Schrier RW, Anderson RJ. Postoperative

hyponatremia. A prospective study.Arch Intern Med1986;

146: 333-6

11. McNab S, Ware RS, Neville KA,et al. Isotonic versus hypo-

tonic solutions for maintenance intravenous fluid adminis- tration in children.Cochrane Database Syst Rev2014;12:

CD009457

12. McNab S, Duke T, South M,et al. 140mmol/L of sodium ver-

sus 77mmol/L of sodium in maintenance intravenous fluid therapy for children in hospital (PIMS): a randomised con- trolled double-blind trial.Lancet2015;385: 1190-7

13. Okada M, Egi M, Yokota Y,et al. Comparison of the incidences

of hyponatremia in adult postoperative critically ill patients receiving intravenous maintenance fluids with 140mmol/L or 35mmol/L of sodium: retrospective before/after observa- tional study.J Anesth2017; Advance Access published on

April 28, 2017, doi: 10.1007/s00540-017-2370-y

14. Young P, Bailey M, Beasley R,et al. Effect of a buffered crystal-

loid solution vs saline on acute kidney injury among patientsin the intensive care unit: the SPLIT randomized clinical trial.

JAMA2015;314: 1701-10

doi: 10.1093/bja/aex376Effect of isotonicvshypotonic maintenance fluid therapy on urine output, fluid balance, and electrolyte homeostasis: a crossover study in fasting adult volunteers. Reply from the authors

N. Van Regenmortel* and P. G. Jorens

Antwerp, Belgium

*E-mail: niels.vanregenmortel@uza.be Editor - We read with interest the comments by Leroy & Hoorn 1 and Moritz & Ayus, 2 mainly focusing on the occurrence ofhyponatraemia after the use of hypotonic maintenance solu- tions, an association extensively demonstrated in paediatric

Correspondence|1065Downloaded from https://academic.oup.com/bja/article/119/5/1065/4560273 by guest on 15 July 2023

populations. First and foremost, we set out to investigate whether, how and how much fluid retention could be induced by isotonic compared with hypotonic maintenance fluid therapy. 3 All prior studies systematically neglected this potential side- effect. Although the clinical impact remains to be judged in dedi- cated trials, fluid retention of the magnitude we observed will not be regarded as trivial by most physicians dealing with post- operative or critical care patients. 4-7

The effect size after being

exposed to salt-rich solutions for more than 48h, as frequently encountered in clinical practice, can be expected to be even more substantial. There is no reason to suppose that our findings on fluid retention would be different in a situation of non- osmotic stimulation of antidiuretic hormone (ADH). We fully acknowledge that iatrogenic hyponatraemia is an important phenomenon, at least when viewed in the right per- spective. The largest of the mentioned trials, of which we do not seek to minimize the findings, reported a significant difference in symptomatic hyponatraemia: 0.3% of cases when using iso- tonic maintenance solutions, compared to 2% with hypotonic treatment. 8 The question that needs to be answered urgently is whether it is clinically acceptable to induce unnecessary salt and fluid overload in the vast majority of patients (98%, using the same data) to protect 1.7% from harm. This is especially true when putting non-osmotic ADH-stimulation and subsequent hyponatraemia in perioperative or critical care into their right context, by regarding them as markers of an underlying problem rather than an issue with the fluid itself. This is illustrated by the fact that hyponatraemia was repeatedly found to be associated with worse outcomes, while symptoms of fluid-induced hypona- traemia are rarely encountered, especially in adults. Also in this debate, association seems to have been confused with causality. Regular assessments of serum and urine sodium are key to iden- tify patients at risk and protect them from harm by treating the underlying problem. Together with others, we believe the most important cause of non-osmotic stimulation of ADH is hypovo- laemia, occurring sometimes very subtly and thus frequently remaining undetected. 9

This situation prompts treatment with

isotonic resuscitation fluids before even considering administra- tion of maintenance fluids. One of the other concerns raised is the challenge imposed by the injudicious extrapolation of findings in healthy individuals to the clinical setting, thereby overlooking the issue of non- osmotic stimuli of ADH-production. In our view, our study setting resembles at least part of the stress of certain clinical situations in which maintenance fluids are prescribed. Being a study subject in an elaborate 48-h, intensively supervised experi- ment, spending a total of four sleep-deprived nights in a research facility with noisy volumetric pumps and bothersome infusion catheters in both arms, experiencing hunger, thirst and weight loss, being venipunctured and weighed every few h while having every drop of urine collected precisely, is not what many would regard as a normal, unstressful situation. Nevertheless, we agree with this limitation of our study and therefore designed the double blind randomized controlled TOPMAST trial (clinicaltrials.gov identifier NCT03080831) to assess not only fluid balance, but also the occurrence of electrolyte disorders as a result of maintenance fluids in a setting of major surgery in adult patients. Currently, half of the subjects are recruited and the first results are to be expected in the beginning of 2018. Regarding our choice of study solutions, Leroy & Hoorn con- sider NaCl 0.9% with an added 40mmol litre ?1 of potassium as inferior and advocate use of balanced solutions because of their lower chloride content. Common examples of such fluids are

Hartmann solution (chloride 111mmol litre

?1 ), Ringer's acetate(112mmol litre ?1 ) and PlasmaLyte VR (98mmol litre ?1 ). Besides com- monly not containing glucose, not one of these solutions contains more than 4-5mmol litre ?1 potassium. This is far less than recom- mended by guidelines and necessary to protect patients from hypokalaemia. To prevent or treat this important electrolyte disor- der, most clinicians will choose to administer extra potassium chloride, thereby renouncing the advantages of these low-chloride solutions. Our hypotonic comparator combines the advantages of a low chloride content (55mmol litre ?1 ), while supplementing enough potassium and still being a balanced solution because of its strong ion difference of around 30 mEq litre ?1

Moritz & Ayus

10 hint at the safety of isotonic fluids used in the SPLIT-trial. We would like to point out that only fluids for resuscitation were evaluated in this study, while the prescription of maintenance fluids remained at the discretion of the treating clinician. This was reflected in the overall very low volumes of the study solutions (median 2000ml during the whole ICU stay). In these amounts, it is unlikely that the slightly different chlor- ide content would have caused a detectable difference in harm, especially as over two litres of isotonic fluids were already administered before enrollment. The clinical importance of chloride loading and/or hyperchloraemia remains a matter of debate, but it should be unwise to minimize the abundant recent safety signals. 11-13

Declaration of interest

None declared.

References

1. Leroy PL, Hoorn EJ. Should we use hypotonic or isotonic main-

tenance intravenous fluids in sick patients? Why a study in healthy volunteers will not provide the answer.Br J Anaesth

2017;119:836-7

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