Hyponatremia
Conditions
Keywords
maintenance fluids, hyponatremia, vasopressin, children
Brief summary
Hyponatraemia arises in between 20% and 45% of sick hospitalized children. An important reason for this high incidence could be use of hypotonic fluids in sick children for maintenance fluid therapy. There are no randomized controlled trials to evaluate the effect of various types of intravenous fluids on the incidence of hyponatremia in sick hospitalized children. Hypothesis: Use of normal saline in 5% dextrose or reduced (2/3) volume of N/5 saline in 5% dextrose reduces incidence of hyponatremia (serum sodium 130 mmol/L) by two-thirds when compared to N/5 saline in 5% dextrose at standard maintenance rate in hospitalized children receiving intravenous maintenance fluids.
Detailed description
Hyponatraemia arises in between 20% and 45% of sick hospitalized children. An important reason for this high incidence could be use of hypotonic fluids in sick children for maintenance fluid therapy. There are no randomized controlled trials to evaluate the effect of various types of intravenous fluids on the incidence of hyponatremia in sick hospitalized children. We therefore plan to conduct a randomized controlled trial to evaluate the effect of normal saline in 5% dextrose at standard maintenance rate, reduced volume (2/3 maintenance rate) of N/5 saline in 5% dextrose and N/5 saline in 5% dextrose at standard maintenance rate on the incidence of hyponatremia in hospitalized children, aged 3 months- 12 years. To determine serial plasma vasopressin levels in hospitalized children at baseline, 24 hours and 48 hours of intravenous fluid therapy and compare the values in the three fluid regimens. Study design: Randomized controlled trial. Hospitalized children who fulfill inclusion criteria and not having any of the exclusion criteria will be considered for the enrolment after written informed consent. Venous blood samples will be taken at enrollment for estimation of serum sodium, potassium, chloride, bicarbonate, blood gas, blood sugar, blood urea, serum creatinine, and plasma osmolality. A sample for estimation of plasma vasopressin will be collected at baseline. After randomization into three groups, one group of children will receive N/5 saline in 5% dextrose at standard maintenance rate (100 ml/kg for the first 10 kg of body weight, 50 ml/kg for the next 10 kg, and 20 ml/kg for body weight exceeding 20 kg).The second group of children will receive N/5 saline in 5% dextrose at 2/3 maintenance rate. The third group will receive dextrose normal saline at standard maintenance rate. Serum Na+, K+ and urine Na+, K+ will be estimated every 12 hourly till the patient is on intravenous fluid therapy and 12 hrs after stopping exclusive intravenous maintenance fluids. Serum and urine osmolality will be estimated every 24 hrs by an osmometer. Plasma vasopressin will be estimated in children in the 3 groups at 24, and 48 hours of intravenous fluid therapy. Children will be weighed every 24 hours. The fluid balance, sodium balance, free water clearance will be calculated in a subset of children. The study measurements will be carried out only till the time the child is on exclusive intravenous maintenance fluid therapy or 72 hrs of starting the intravenous fluid therapy. The decision to decrease/ stop intravenous fluid therapy will be left to the treating unit. The primary outcome measure will be incidence of hyponatremia (defined as serum Na+ less than 130 mmol/L). The secondary outcomes studied will be Plasma vasopressin levels at 24 hr and 48 hours and incidence of hypernatremia. Sample size: Based on literature review, the incidence of hyponatremia with standard intravenous fluid therapy is approximately 30%. Sample of 72 patients will be needed in each group to demonstrate the decrease in incidence of hyponatremia to 10%, with a beta of 0.2 (Power 80%) and alpha error of 0.05. Analysis: The data will be analyzed using STATA software. The outcomes (primary and secondary) in the 3 groups will be compared. For continuous variables, t test or Wilcoxon rank-sum test will be used to determine statistical significance. For categorical variables, chi square test will be used.
Interventions
DRUGIsotonic fluid
0.9% saline with 5% dextrose at standard maintenance rate
DRUGHypotonic fluid
Reduced volume (two thirds of standard maintenance rate) of N/5 saline in 5% dextrose
Sponsors
All India Institute of Medical Sciences
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
3 Months to 12 Years
Healthy volunteers
No
Inclusion criteria
* All children (3 months to 12 years) who are admitted to pediatric ward or pediatric ICU, who require exclusive intravenous maintenance fluid therapy for at least 24 hours will be eligible for the study
Exclusion criteria
* Children with illness that have primary fluid and electrolyte imbalance such as: * Shock: Defined as acute circulatory failure resulting in decreased tissue perfusion and manifesting as altered sensorium, hypothermia (\<35oC), tachycardia, prolonged capillary filling time (\>3 seconds), hypotension (BP \< 5th percentile for age), oliguria (\<0.5 ml/kg/hr), hypoxemia, hyperlactatemia, requirement of fluid bolus and/ or vasopressors. * Diarrhea and Dehydration: Children presenting with diarrhea and features of dehydration: lethargy, irritability and altered sensorium, thirst, decreased urine output, sunken eyes & dry mucous membranes, loss of skin elasticity.; children with ongoing diarrhea will be excluded even if there is no dehydration. * Fluid Overload: Cirrhosis, Congestive heart failure, Acute and Chronic renal failure, Nephrotic syndrome. * Abnormal serum sodium or Hyperglycemia at Presentation: * Hyponatremia : serum sodium \< 130 mmol/L. * Hypernatremia : serum sodium \>150 mmol/L. * Hyperglycemia: blood glucose \> 180 mg/ dl. * Severe Protein Energy Malnutrition: Defined as grade III (50-59% of expected weight for age) and grade IV (less than 50% of expected weight for age) as per IAP classification. * Child who is receiving drugs which cause abnormality in serum sodium such as diuretics, vasopressin, etc.
Design outcomes
Primary
| Measure | Time frame |
|---|---|
| Incidence of Hyponatremia (Defined as Serum Sodium Less Than 130 mmol/L) | 72 hrs |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Incidence of Hypernatremia (Serum Sodium >150 mmol/L) | 72 hrs | — |
| Incidence of Symptomatic Hyponatremia | 72 hrs | Defined as Hyponatremia (serum sodium \< 130 mnol/L)and presence of symptoms attributed to hyponatremia such as altered sensorium, seizure, headache, and vomiting which can not be explained otherwise. |
| Incidence of Symptomatic Hypernatremia | 72 hrs | Symptomatic hypernatremia is defined as serum sodium \> 150 mmol/L and the presence of symptoms like altered sensorium, seizure, headache and vomiting not explained otherwise. |
Countries
India
Participant flow
Recruitment details
Enrollment: September 2006 to April 2008 Analysis: May and June 2008 Pediatric ward and Pediatric intensive care unit in a tertiary care referral hospital in North India
Pre-assignment details
Patients were stratified based on their age in to three groups (age 3 months to 1 year, 1-5 years, 6-12 years) and stratified randomization was used.
Participants by arm
| Arm | Count |
|---|---|
| Dextrose Normal Saline Normal saline in 5% dextrose at standard maintenance rate | 58 |
| Fluid Restriction Group Reduced volume (2/3 maintenance rate) of N/5 saline in 5% dextrose | 53 |
| Hypotonic Saline N/5 saline in 5% dextrose at standard maintenance rate | 56 |
| Total | 167 |
Baseline characteristics
| Characteristic | Fluid Restriction Group | Hypotonic Saline | Dextrose Normal Saline | Total |
|---|---|---|---|---|
| Age, Categorical <=18 years | 53 Participants | 56 Participants | 58 Participants | 167 Participants |
| Age, Categorical >=65 years | 0 Participants | 0 Participants | 0 Participants | 0 Participants |
| Age, Categorical Between 18 and 65 years | 0 Participants | 0 Participants | 0 Participants | 0 Participants |
| Age Continuous | 3 years STANDARD_DEVIATION 0.36 | 4 years STANDARD_DEVIATION 0.28 | 3 years STANDARD_DEVIATION 0.44 | 3.33 years STANDARD_DEVIATION 0.56 |
| Region of Enrollment India | 53 participants | 56 participants | 58 participants | 167 participants |
| Sex: Female, Male Female | 35 Participants | 43 Participants | 36 Participants | 114 Participants |
| Sex: Female, Male Male | 18 Participants | 13 Participants | 22 Participants | 53 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk | EG002 affected / at risk |
|---|---|---|---|
| deaths Total, all-cause mortality | — / — | — / — | — / — |
| other Total, other adverse events | 2 / 58 | 4 / 53 | 2 / 56 |
| serious Total, serious adverse events | 1 / 58 | 1 / 53 | 0 / 56 |
Outcome results
Primary
Incidence of Hyponatremia (Defined as Serum Sodium Less Than 130 mmol/L)
Time frame: 72 hrs
Population: 432 patients were eligible. 203 patients were excluded and 62 patients declined consent . Out of 167 patients, 58 patients were randomized to Arm 1, 53 to arm 2 and 56 to arm 3.Intention to treat analysis was used.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Dextrose Normal Saline | Incidence of Hyponatremia (Defined as Serum Sodium Less Than 130 mmol/L) | 1 participants |
| Fluid Restriction Group | Incidence of Hyponatremia (Defined as Serum Sodium Less Than 130 mmol/L) | 2 participants |
| Hypotonic Saline | Incidence of Hyponatremia (Defined as Serum Sodium Less Than 130 mmol/L) | 8 participants |
Comparison: The incidence of hospital-acquired hyponatremia with current standard intravenous fluid therapy was approximately 30%. Sample of 72 patients would be needed in each group to demonstrate the decrease in incidence of hyponatremia (defined as plasma sodium\< 130 mEq/L) to 10%, with a power of 80 percent and alpha error of 0.05. In view of short study period and feasibility it was planned a priori to enroll at least 50 patients in each treatment limb.p-value: <0.0595% CI: [0.016, 0.93]Fisher Exact
Secondary
Incidence of Hypernatremia (Serum Sodium >150 mmol/L)
Time frame: 72 hrs
Population: Intention To Treat analysis
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Dextrose Normal Saline | Incidence of Hypernatremia (Serum Sodium >150 mmol/L) | 2 participants |
| Fluid Restriction Group | Incidence of Hypernatremia (Serum Sodium >150 mmol/L) | 4 participants |
| Hypotonic Saline | Incidence of Hypernatremia (Serum Sodium >150 mmol/L) | 2 participants |
Secondary
Incidence of Symptomatic Hypernatremia
Symptomatic hypernatremia is defined as serum sodium \> 150 mmol/L and the presence of symptoms like altered sensorium, seizure, headache and vomiting not explained otherwise.
Time frame: 72 hrs
Population: Intention to Treat analysis
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Dextrose Normal Saline | Incidence of Symptomatic Hypernatremia | 0 participants |
| Fluid Restriction Group | Incidence of Symptomatic Hypernatremia | 0 participants |
| Hypotonic Saline | Incidence of Symptomatic Hypernatremia | 0 participants |
Secondary
Incidence of Symptomatic Hyponatremia
Defined as Hyponatremia (serum sodium \< 130 mnol/L)and presence of symptoms attributed to hyponatremia such as altered sensorium, seizure, headache, and vomiting which can not be explained otherwise.
Time frame: 72 hrs
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Dextrose Normal Saline | Incidence of Symptomatic Hyponatremia | 0 participants |
| Fluid Restriction Group | Incidence of Symptomatic Hyponatremia | 1 participants |
| Hypotonic Saline | Incidence of Symptomatic Hyponatremia | 0 participants |