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Clinical Review Lesson of the week

Acute hyponatraemia in children admitted to hospital: retrospective analysis of factors contributing to its development and resolution

BMJ 2001; 322 doi: (Published 31 March 2001) Cite this as: BMJ 2001;322:780
  1. Michael Halberthal, fellowa,
  2. Mitchell L Halperin, professorb,
  3. Desmond Bohn, professor (
  1. a Department of Critical Care Medicine, Hospital for Sick Children, Toronto, Ontario, Canada M5G 1X8
  2. b Division of Nephrology, St Michael's Hospital Toronto, Toronto, Ontario, Canada M5B 1A6
  3. c Department of Critical Care Medicine, Hospital for Sick Children, Toronto
  1. Correspondence to: D J Bohn
  • Accepted 26 July 2000

Do not infuse a hypotonic solution if the plasma sodium concentration is less than 138 mmoVl

Hyponatraemia (plasma sodium concentration less than 136 mmol/l) is acute if the decrease in natraemia occurs within 48 hours. The major dangers from this are brain cell swelling and herniation. 1 2 Two factors are required for hyponatraemia to develop: a source of electrolyte free water and vasopressin to prevent the excretion of that water.3 Electrolyte free water is given routinely as maintenance fluids based on formulas developed in studies in healthy children more than 40 years ago. 4 5 There are many reasons to anticipate that vasopressin will be released in sick patients (box).6 Patients with an acute illness may arrive in hospital with a low plasma sodium concentration because of previous water intake. Hence, to minimise the potential threat of brainstem herniation it is important to measure the plasma sodium concentration if intravenous solutions are to be given.

Causes of vasopressin release

  • Hypernatraemia (most important stimulus, but not in these patients)

  • Low “effective” circulating volume (greater than 7% decrease in extracellular fluid volume)

  • Nausea, pain, anxiety

  • Drugs (some act through inducing nausea)

  • Afferent stimuli by way of the vagus nerve—for example, lung lesions

  • Disturbances of the central nervous system (meningitis, encephalitis)

  • Metabolic and endocrine disorders—for example, hypothyroidism, hypoadrenalism, porphyria

We describe symptomatic hyponatraemia developing over 48 hours in children. In each patient, hypotonic solutions were infused using current guidelines.7 We related the volume of electrolyte free water given to the decrease in natraemia and assessed whether actions of vasopressin persisted to guide emergency corrective therapy.8

We reviewed all patient charts (306 charts) with a recorded diagnosis of hyponatraemia for the …

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