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Perioperative water and electrolyte balance and water homeostasis regulation in children with acute surgery

Roberts, Daniel N. ; Vallén, Paula ; Cronhjort, Maria ; Alfvén, Tobias LU ; Sandblom, Gabriel ; Tönroth-Horsefield, Susanna LU ; Jensen, Boye L. ; Lönnqvist, Per Arne ; Frithiof, Robert and Carlström, Mattias , et al. (2023) In Pediatric Research 94(4). p.1373-1379
Abstract

Background: Hospital-acquired hyponatremia remains a feared event in patients receiving hypotonic fluid therapy. Our objectives were to assess post-operative plasma-sodium concentration and to provide a physiological explanation for plasma-sodium levels over time in children with acute appendicitis. Methods: Thirteen normonatremic (plasma-sodium ≥135 mmol/L) children (8 males), median age 12.3 (IQR 11.5–13.5) years participated in this prospective observational study (ACTRN12621000587808). Urine was collected and analyzed. Blood tests, including renin, aldosterone, arginine-vasopressin, and circulating nitric oxide substrates were determined on admission, at induction of anesthesia, and at the end of surgery. Results: On admission,... (More)

Background: Hospital-acquired hyponatremia remains a feared event in patients receiving hypotonic fluid therapy. Our objectives were to assess post-operative plasma-sodium concentration and to provide a physiological explanation for plasma-sodium levels over time in children with acute appendicitis. Methods: Thirteen normonatremic (plasma-sodium ≥135 mmol/L) children (8 males), median age 12.3 (IQR 11.5–13.5) years participated in this prospective observational study (ACTRN12621000587808). Urine was collected and analyzed. Blood tests, including renin, aldosterone, arginine-vasopressin, and circulating nitric oxide substrates were determined on admission, at induction of anesthesia, and at the end of surgery. Results: On admission, participants were assumed to be mildly dehydrated and were prescribed 50 mL/kg of Ringer’s acetate intravenously followed by half-isotonic saline as maintenance fluid therapy. Blood tests, urinary indices, plasma levels of aldosterone, arginine-vasopressin, and net water-electrolyte balance indicated that participants were dehydrated on admission. Although nearly 50% of participants still had arginine-vasopressin levels that would have been expected to produce maximum antidiuresis at the end of surgery, electrolyte-free water clearance indicated that almost all participants were able to excrete net free water. No participant became hyponatremic. Conclusions: The use of moderately hypotonic fluid therapy after correction of extracellular fluid deficit is not necessarily associated with post-operative hyponatremia. Impact: Our observations show that in acutely ill normonatremic children not only the composition but also the amount of volume infused influence on the risk of hyponatremia.Our observations also suggest that perioperative administration of hypotonic fluid therapy is followed by a tendency towards hyponatremia if extracellular fluid depletion is left untreated.After correcting extracellular deficit almost all patients were able to excrete net free water. This occurred despite nearly 50% of the cohort having high circulating plasma levels of arginine-vasopressin at the end of surgery, suggesting a phenomenon of renal escape from arginine-vasopressin-induced antidiuresis.

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organization
publishing date
type
Contribution to journal
publication status
published
subject
in
Pediatric Research
volume
94
issue
4
pages
1373 - 1379
publisher
International Pediatric Foundation Inc.
external identifiers
  • pmid:36759747
  • scopus:85147655372
ISSN
0031-3998
DOI
10.1038/s41390-023-02509-1
language
English
LU publication?
yes
id
0078ccb6-dbc1-4de0-8b98-7a7d6e3e454f
date added to LUP
2023-02-21 11:44:41
date last changed
2024-06-13 17:13:08
@article{0078ccb6-dbc1-4de0-8b98-7a7d6e3e454f,
  abstract     = {{<p>Background: Hospital-acquired hyponatremia remains a feared event in patients receiving hypotonic fluid therapy. Our objectives were to assess post-operative plasma-sodium concentration and to provide a physiological explanation for plasma-sodium levels over time in children with acute appendicitis. Methods: Thirteen normonatremic (plasma-sodium ≥135 mmol/L) children (8 males), median age 12.3 (IQR 11.5–13.5) years participated in this prospective observational study (ACTRN12621000587808). Urine was collected and analyzed. Blood tests, including renin, aldosterone, arginine-vasopressin, and circulating nitric oxide substrates were determined on admission, at induction of anesthesia, and at the end of surgery. Results: On admission, participants were assumed to be mildly dehydrated and were prescribed 50 mL/kg of Ringer’s acetate intravenously followed by half-isotonic saline as maintenance fluid therapy. Blood tests, urinary indices, plasma levels of aldosterone, arginine-vasopressin, and net water-electrolyte balance indicated that participants were dehydrated on admission. Although nearly 50% of participants still had arginine-vasopressin levels that would have been expected to produce maximum antidiuresis at the end of surgery, electrolyte-free water clearance indicated that almost all participants were able to excrete net free water. No participant became hyponatremic. Conclusions: The use of moderately hypotonic fluid therapy after correction of extracellular fluid deficit is not necessarily associated with post-operative hyponatremia. Impact: Our observations show that in acutely ill normonatremic children not only the composition but also the amount of volume infused influence on the risk of hyponatremia.Our observations also suggest that perioperative administration of hypotonic fluid therapy is followed by a tendency towards hyponatremia if extracellular fluid depletion is left untreated.After correcting extracellular deficit almost all patients were able to excrete net free water. This occurred despite nearly 50% of the cohort having high circulating plasma levels of arginine-vasopressin at the end of surgery, suggesting a phenomenon of renal escape from arginine-vasopressin-induced antidiuresis.</p>}},
  author       = {{Roberts, Daniel N. and Vallén, Paula and Cronhjort, Maria and Alfvén, Tobias and Sandblom, Gabriel and Tönroth-Horsefield, Susanna and Jensen, Boye L. and Lönnqvist, Per Arne and Frithiof, Robert and Carlström, Mattias and Krmar, Rafael T.}},
  issn         = {{0031-3998}},
  language     = {{eng}},
  number       = {{4}},
  pages        = {{1373--1379}},
  publisher    = {{International Pediatric Foundation Inc.}},
  series       = {{Pediatric Research}},
  title        = {{Perioperative water and electrolyte balance and water homeostasis regulation in children with acute surgery}},
  url          = {{http://dx.doi.org/10.1038/s41390-023-02509-1}},
  doi          = {{10.1038/s41390-023-02509-1}},
  volume       = {{94}},
  year         = {{2023}},
}