!!!! Fluid!Management!in!Hospitalized! Children!!!!! Preventing!Hospital!Acquired!Hyponatremia!!!!!!!!!!!!!!!!!!

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1 FluidManagementinHospitalized Children PreventingHospitalAcquiredHyponatremia "#$%&'$()*$+),-%().)*/0)($+1/**-2/3-4$/+,$4#5)($-43$16+-)%4#)%$-75)($-43$1 8+(/13$+/*/&975)($-43$1:)0#3/*/&97;)+)3-*5)($-43$1%75)($-43$1<'3&)39-+(5)($-43$1 A)3%$/+BCD)1)E2)3BFGH

2 5)4)3%I$00)+ 5-&)B GBJGFJBFGH HospitalAcquiredHyponatremia:GeneralIntroductoryStatements KeyPoints: <9E04/E-4$1#90/+-43-)E$-$%-E)($1-*)E)3&)+19K )+4)3-*N-(E$+$%43-4$/+$+-1'4)*9$**#/%0$4-*$Q)(1#$*(3)+K PreventingHospitalAcquiredHyponatremia(HAH)inAcutelyIllChildren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`REE/*)%J*$43)KP4 $% $E0/ /4 4/ &)4 1/+O'%)( 2)4,))+ 4/+$1$49 -+( /%E/*-3$49K "/+$1$49 3)O)3% 4/ 4#) /%E/4$1 03)%%'3) )[)34)( -13/%% - %)E$S0)3E)-2*) E)E23-+) -+( $% $+O*')+1)( /+*9 29 4#/%)/%E/*)%4#-41-++/413/%%4#)E)E23-+)Ka/3)[-E0*)7RZ&*'1/%)#-%-+/%E/*-*$49 /OBRBE/%E/*JX2'4-4/+$1$49/OQ)3//+1)4#)&*'1/%)$%E)4-2/*$Q)(/34-I)+'0291)**% _$4$%-%/'31)/O0'3),-4)3K PA %/*'4$/+% -3) +/4 4#) /+*9 1/+43$2'4/3% 6** )+4)3-* O))(% -3) #90/4/+$1K "#)9 #-.) 2))+ ()%$&+)( O/3 +/3E-* 1#$*(3)+,$4# /03$-4) +/3E-* (-$*9 -**/,-+1) /O )*)143/*94)%-+(/4#)3+'43$4$/+-*%'00*)E)+4%K<$1I1#$*(3)+,$**3)4-$+4#))[43-O3)),-4)3 2

3 5)4)3%I$00)+ 5-&)H GBJGFJBFGH -(E$+$%4)3)(73)%'*4$+&$+#90/+-43)E$-K</($'E-+(0/4-%%$'E%'00*)E)+4-4$/+/.)3-+( -2/.) +/3E-* 3)L'$3)E)+4% -3) /O4)+ 3)L'$3)( $+ -1'4)*9 $** #/%0$4-*$Q)( 1#$*(3)+K D-$*9 )*)143/*94)% %#/'*( 2) 0)3O/3E)( $+ 4#)%) 1#$*(3)+ '+4$* %)3'E )*)143/*94)% -+( %'00*)E)+4-*-(($4$.)%#-.)%4-2$*$Q)(K BodyFluidLosses a*'$( */%%)% -3) E/%4 1/EE/+*9 O3/E 4#) ;P '4 -*%/ O3/E 1#)%4 (3-$+-&)J1#9*/4#/3-[7b4#$3(%0-1$+&c7/33)+-**/%%)%Ka-$*'3)4/'+()3%4-+(4#))*)143/*94) 1/E0/%$4$/+ /O 2/(9 O*'$( */%%)% $% -+/4#)3 03).)+4-2*) 1-'%) /O #90/+-43-)E$-K P4 $% $E0/ / 3)0*-1) */%%)% O3/E - 2/(9 1-.$49,$4# - %/*'4$/+ 1/+4-$+$+& *$I) )*)143/*94) 1/E0/%$4$/+K BodyFluidComposition Secretion Na + (mmol/l) K + (mmol/l) Cl " (mmol/l) HCO 3 "(mmol/l) <-*$.- YF BF YF F ;-%43$1^'$1) dfsgbf GFSHF GFF F >$*) GYF RSGF GFF HFSYF 5-+13)-4$1^'$1) GYF RSGF dr dfsggf <E-**$+4)%4$+) GBFSGYF RSGF GFF HFSYF :/3E-*%4//* BFSHF RRSdR GRSBR F D$-33#)- RFSGYF GRSeF RFSGRF GFSdR <,)-4 HFSdF FSR HFSdF F IntravenousFluidChoices TypeofFluid Na + (mmol/l) K + (mmol/l) Cl " (mmol/l) HCO 3 "(mmol/l) 62c:/3E-*c%-*$+) GRY F GRY F f+/3e-*%-*$+) dd F dd F g$+&)3?%x-14-4) GHF Y GFT X-14-4)B` 5*-%E-*94) GYF R T` 61)4-4)Bd DRh F F F F RZ-*2'E$+ GYF F GF` F 5g>= GHFSGRF YSGF TFSGFF GFSBR a3/q)+0*-%e- GRSG`F Y GFF BR IntravenousFluidTonicity TypeofFluid Osmolality Tonicity :/3E-*0*-%E- B`RSBTR ]+c:/3e-*c%-*$+) HF` #90)34/+$1 f+/3e-*%-*$+) GRY #90/4/+$1 g$+&)3?%x-14-4) BdH $%/4/+$1 5*-%E-*94) BTY $%/4/+$1 DRh BRF #90/4/+$1 RZ-*2'E$+ HGF $%/4/+$1 3

4 5)4)3%I$00)+ 5-&)Y GBJGFJBFGH ReplacementFluids: i04$/+%-3)c P%/4/+$1139%4-**/$(%_FKTZ:-=*jg$+&)3?%*-14-4)j5*-%E-*94) Ringer slactatecontainscalcium,andtheremaybecompatibilityissuesduringslowinfusion ofpackedredbloodcells. =/**/$(%_RZ-*2'E$+K Starchproducts(HES)haverecentlybeenshowntoincreasetheriskofacutekidneyinjuryin adultsandhavebeenwithdrawnfromthemarketincanada. >*//(53/('14%_0-1I)(3)(2*//(1)**%M%'%0)+()($+<6;U_FKTZ:-=*7-()+$+)7&*'1/%)7 E-++$4/*Nj a5 MO3/Q)+ 0*-%E- M%'%0)+()( $+ 6=DH %/*'4$/+ _ 1$43-4)Nj 0*-4)*)4% M-% O/3 0*-%E-N ;)+)3-**971#$*(3)+%#/'*($+$4$-**92)03)%13$2)(FKTZ:-=*/3g$+&)3?%*-14-4)%/*'4$/+$O- 3)0*-1)E)+4O*'$($%3)L'$3)(K MaintenanceFluids: i04$/+%-3)m()[43/%)1-+2)-(()(4/-**4#)%)%/*'4$/+%nc P%/4/+$1 139%4-**/$(% _ FKTZ:-=*j g$+&)3?% *-14-4) M%*$&#4*9 #90/4/+$1 4/ +/3E-* 0*-%E-Nj %/*'4$/+% _ FKYRZ :-=*K "#)3) $% 3-3)*9 -+9 $+($1-4$/+ O/3 E/3) #90/4/+$1 %/*'4$/+% -+( %#/'*( /+*9 2) 03)%13$2)( $O )*)143/*94)% -3) I+/,+ -+( -O4)3 1-3)O'* ($%1'%%$/+,$4#%)+$/3E)($1-*%4-OOKDRh%#/'*(/+*92)03)%13$2)(,$4#-%-*4%/*'4$/+K a/3 3/'4$+) E-$+4)+-+1)7 4#) $+$4$-* 03)%13$04$/+ %#/'*( 2) )$4#)3 FKTZ :-=* /3 g$+&)3?% X-14-4) M,$4# -(()( GFZ ()[43/%) O/3 1#$*(3)+ '+()3 RI& -+( RZ ()[43/%) O/3 1#$*(3)+ /.)3Rk&-%-&)+)3-*3'*)/O4#'E2NKi+1)4#)1#$*(?%)*)143/*94)%-3)I+/,+7-+(4#)-1'4) $**+)%%$%$E03/.$+&/34#))*)143/*94)%#-.)%4-2$*$Q)(7-%/*'4$/+,$4#*)%%%/($'E1#*/3$() E-9 2) 1/+%$()3)(K )&K FKYRZ:-=*,$4# /3,$4#/'4 ()[43/%)K 8.)+ 4#/'&# -+ $%/4/+$1 %/*'4$/+%#/'*(-*,-9%$+$4$-**92)03)%13$2)(7)*)143/*94)7&*'1/%)-+(O*'$(3)L'$3)E)+4% %#/'*( %4$** 2) 1-*1'*-4)( O/3 -** 1#$*(3)+ 3)1)$.$+& PA O*'$(%7 -+( )%0)1$-**9 $O 4#) O*'$(./*'E)$%3)%43$14)(KM+/3E-*&*'1/%)3)L'$3)E)+4%O/3$+O-+4%-3)RS`E&JI&JE$+'4)N P+43-.)+/'%%/*'4$/+1#/$1)%#/'*(2)4-$*/3)(4/4#)0-4$)+4?%+))(%K</E)0-4$)+4%,$4#- O3)),-4)3 ()O$1$4 E-9 3)L'$3) 4#) -(E$+$%43-4$/+ /O #90/4/+$1 %/*'4$/+%7 O/**/,$+& ($%1'%%$/+,$4#-%)+$/3E)($1-*%4-OOE)E2)3K 4

5 5)4)3%I$00)+ 5-&)R %/*'4$/+% E-9 2) 1/+%$()3)( $+ 4#) O/**/,$+& 1/+($4$/+%7 -O4)3 1-3)O'* 1/+%$()3-4$/+-+(1/+%'*4-4$/+,$4#-+-44)+($+&0#9%$1$-+C GK<)3'E%/($'El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ecommendedFluidVolumes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g)1)+4 3-+(/E$Q)( 1/+43/**)( 43$-*% $+ #/%0$4-*$Q)( 1#$*(3)+ #-.) %#/,+ 4#-4 $4 $% +/4 ^'%4 O*'$(./*'E) 2'4 4/+$1$49 4#-4 $% $E0/34-+4 $+ 3)('1$+& 4#) 1#-+1)% /O ().)*/0$+& #/%0$4-* -1L'$3)(#90/+-43-)E$-K Dailyassessmentofclinicalstatus,dailyweightsfrequentandaccuratemeasurementoffluid intake and losses from all sources and measurement of daily electrolytes are important measurestoadoptforacutelyillchildrenk PotassiumRequirements 6** 1#$*(3)+ %#/'*( 3)1)$.) E-$+4)+-+1) 0/4-%%$'E 3)0*-1)E)+4 O/**/,$+& 3)%'%1$4-4$/+ 03/.$($+&+/3E-*3)+-*O'+14$/+#-%2))+()E/+%43-4)(M'3$+)/'40'4-+(+/3E-*'3)--+( 13)-4$+$+)NK 5

6 5)4)3%I$00)+ 5-&)e GBJGFJBFGH TreatmentofAcuteHyponatremia "3)-4E)+4/O#90/+-43)E$-()0)+(%'0/+,#)4#)3$4$%-1'4)MWY`#/'3%N/31#3/+$1K 6%9E04/E-4$1-1'4)#90/+-43)E$-E-9/+*93)L'$3)O3)),-4)33)%43$14$/+K <9E04/E-4$1-1'4) #90/+-43)E$- M./E$4$+&7 #)-(-1#)7 1#-+&) $+ %)+%/3$'E7 %)$Q'3)%7 ($*-4)(0'0$*%70/%4'3$+&N3)L'$3)%'3&)+443)-4E)+4KHZ%/($'E1#*/3$()$%4#)43)-4E)+4 /O 1#/$1) 2'4 %#/'*( /+*9 2) &$.)+ -O4)3 1/+%'*4-4$/+,$4# -+ $+4)+%$.$%4K M'%'-* (/%) $% $+13)E)+4%/OBE*%JI&2/*'%N Exclusions 6*4#/'&# 3)1/&+$Q$+& 4#-4 4#)3),$** 2) %'2%)4% /O 0-4$)+4% $+ 4#) +)/+-4-* $+4)+%$.) 1-3) '+$4,#)3) 4#)%) 1/+%$()3-4$/+% -00*97 4#$% &'$()*$+) )[1*'()% 4#) :)/+-4-* P=]K P4 -*%/ )[1*'()%1#$*(3)+,$4#Dk67,$4#1#3/+$1*$.)3($%)-%)7#90)3I-*)E$--+(3)+-*O-$*'3)K References Moritz M et al. Prevention of Hospital"Acquired Hyponatremia: A Case for Using Isotonic Saline.Pediatrics2003;111;227"230 HollidayMetal.Fluidtherapyforchildren:facts,fashionsandquestions. ArchDisChild2007;92: Hospital"acquiredacutehyponatremia:tworeportsofpediatricdeaths. ISMPCanadaSafetyBulletin.2009;9 ChoongKetal.Hypotonicversusisotonicsalineinhospitalizedchildren:asystematicreview. ArchDisChild2006;91: Moritz M et al. Prevention of Hospital"Acquired Hyponatremia: Do We Have the Answers? Pediatrics2011;128;980"983 6

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