Iatrogenic Hyponatremia

Hyponatremia (serum sodium less than 135 mmol/L) and hypokalemia (serum potassium less
than 3.5 mmol/L) are common in hospitalized patients. However, both electrolyte disorders are
often unrecognized by clinicians owing to various reasons such as the absence of lab facility,
cost and awareness. Iatrogenic hyponatremia is generally caused by giving too much hypotonic
maintenance solutions or parenteral nutrition solutions which contain low or no sodium.
Typical maintenance solutions have been available in the market for many years which are
indicated to treat moderate dehydration or insufficient water intake. They contain potassium to
fulfill minimum requirement of potassium and aimed at preventing hypokalemia in patients
with insufficient food intake. The amount of sodium in traditional maintenance solution has
been devised to fulfil daily requirement of sodium and generally they are hypotonic. Recently ,
there is increasing evidence that hypotonic maintenance solution could trigger or predispose
iatrogenic hyponatremia. Hospital-acquired acute hyponatremia is increasingly recognized as a
cause of morbidity and mortality in children.
The routine practice of providing hypotonic maintenance IV solutions, usually containing 20
mmol/L to 30 mmol/L of Na, is based on Holliday and Segars seminal paper(13) published in
1957 and translatesto the use of 0.2% NaCl/dextrose 5%. These recommendations were based
on caloric expenditure in healthy children, and electrolyte composition was derived from that
of human and cows milk. Branded maintenance solutions are promoted by emphasizing the
potassium content rather than the sodium content.
Isotonic saline solution as maintenance intravenous fluid therapy to prevent acquired
hyponatremia in hospitalized children.
Current Findings
Reports of clinical studies in pediatric patients which confirmed iatrogenic hyponatremia
induced by hypotonic maintenance solutions
No
1

Title of Publication
Montaana PA, Modesto
i Alapont V, Ocn AP, et
al. Pediatr Crit Care Med
2008;9(6):589-97
Yung M, Keeley S.
Randomised controlled
trial of intravenous
maintenance fluids. J
Paediatr Child Health
2009;45(1-2):9-14

Design
A randomized 122 ICU
patients to receive isotonic
or hypotonic fluids.(21
randomized 50 ICU
patients to receive isotonic
fluids (normal saline) or
hypotonic fluids (0.18%
NaCl/4% dextrose), at
either the traditional
maintenance
rate or two-thirds of that
rate.

Results
At 24 h, 20.6% of patients in the
hypotonic group were
hyponatremic versus 5.1% in the
isotonic group (P=0.02).
The type of fluid (P=0.006) but
not the rate (P=0.12) was significantly
associated with the degree
of fall in serum Na

Rey C, Los-Arcos M,
Hernndez A, Snchez A,
Daz JJ, Lpez-Herce J.
Hypotonic versus isotonic
maintenance fluids in
critically ill children: A
multicenter prospective
randomized study. Acta
Paediatrica
2011;100(8):1138-43.
Kannan L, Lodha R,
Vivekanandhan S, Bagga
A, Kabra SK, Kabra
M. Intravenous fluid
regimen and
hyponatremia among
children:
A randomized controlled
trial. Pediatr Nephrol
2010;25(11):2303-9.

125 children from

three paediatric ICUs in
Spain. After adjusting for
age, weight and
Na at admission, those
receiving hypotonic fluids
(Na 50 mmol/L
to 70 mmol/L) versus
isotonic maintenance fluid

Hypotonic solutions resulted in a

decrease in Na of 3.2 mmol/L with a
5.8-fold
increased risk of hyponatremia
compared with patients receiving
isotonic maintenance fluids.(23

167 hospitalized
children.(24) Fourteen per
cent (8 of 56) of patients
randomized to
receive hypotonic IV
maintenance fluids (0.18%
NaCl/5% dextrose) or
isotonic IV fluid (0.9%
NaCl/5% dextrose)
(P=0.014).

Choong K, Arora S,
Cheng J, et al. Hypotonic
versus isotonic
maintenance fluids after
surgery in children: A
randomized controlled
trial. Pediatrics
2011;128(5):857-66

258 children enrolled at

the time of surgery in
Hamilton, Ontario,
Choong et al(25)

Fourteen per cent (8 of 56) of patients

randomized to
receive hypotonic IV maintenance
fluids (developed a plasma Na <130
mmol/L versus 1.7% (1 of 58) in the
group randomized to receive isotonic
IV fluid (P=0.014). Eight patients
developed hypernatremia (plasma
Na >150 mEq/L), none of whom were
reported to be clinically symptomatic,
and only two of whom had received
isotonic fluids
showed that isotonic fluids
were significantly safer than hypotonic
fluids in protecting against
acute postoperative hyponatremia.
Isotonic fluids did not increase
the risk of hypernatremia

Therefore, the selection of maintenance fluids need to be reconsidered especially in pediatric

patients.
In conclusion, clinicians should avoid indiscriminate use of maintenance solutions. The goal of
giving isotonic potassium containing solutions is to prevent hypokalemia without the risk of
hyponatremia.