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COMMENTARIES: Malcom A. Holliday, William E. Segar, and Aaron Friedman Reducing Errors in Fluid Therapy Management Pediatrics 2003; 111: 424-425 [Full text] [PDF]

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Errata

Leonard Levy, MD, FAAP   (1 February 2003)

Intravenous fluid management in children: Facts and Fiction

Michael L Moritz, J. Carlos Ayus   (14 February 2003)

Errata 1 February 2003
Leonard Levy, MD, FAAP, Private Practice Clinical associate professor, Department of Pediatrics, Upstate Medical University, Syracuse NY Send letter to journal: Re: Errata llevy1{at}twcny.rr.com Leonard Levy, MD, FAAP	In the commentary about "Reducing Errors in Fluid Therapy Management" by Drs. Holliday, Segar and Friedman (Pediatrics, 2003;111:424-425), there appears to be a serious typographical error in the second sentence of the second paragraph in the right hand column on page 424. The sentence as posted on www.pediatrics.org reads "The common cause of hyponatremia is excess salt intake." I believe that the authors meant that the common cause of HYPERNATREMIA is excess salt intake. Leonard Levy, MD, FAAP Fayetteville NY
Intravenous fluid management in children: Facts and Fiction 14 February 2003
Michael L Moritz, Pediatric Nephrologist Children's Hospital of Pittsburgh, J. Carlos Ayus Send letter to journal: Re: Intravenous fluid management in children: Facts and Fiction moriml{at}chp.edu Michael L Moritz, et al.	We appreciate Holliday et al’s1 commentary on our article2. Holliday et al have a justifiable concern about the safety of our recommendations and we welcome the scrutiny. As we state in our manuscript “no 1 fluid rate or composition will be appropriate for all children”. 2 Intravenous fluids should be viewed as an invasive procedure that can have serious complications. The focus of our paper was how best to prevent hospital acquired hyponatremia in patients who have impaired free water excretion due to excess ADH production. A significant proportion of hospitalized patients will fall into this group, mainly patients in the perioperative state and with pulmonary or central nervous system disorders. The administration of hypotonic fluids, as currently recommended by Holliday et al, is unphysiologic and unsound in the setting of excess ADH production, as this will predictably lead to hyponatremia. The literature review presented in our paper supports our contention. There have been numerous reported cases of death or brain damage resulting from hyponatremic encephalopathy in healthy children receiving hypotonic saline as recommended by Holliday et al. To our knowledge there have been no reported cases of death or brain damage resulting from hypernatremia in healthy children receiving isotonic saline. Holliday et al1 are incorrect in stating that “the common cause of hypernatremia is excess salt intake”. We have recently reported on this topic and the most common cause of hypernatremia in hospitalized children is fluid restriction in combination with free water losses3. Isotonic saline will not result in hypernatremia unless there are ongoing free water losses due to a renal concentrating defect or extrarenal losses, as the kidney is able to generate free water. We agree with Holliday et al that rapid expansion of the extracellular volume with isotonic saline is appropriate when overt signs of volume depletion are present, as this will decrease the hemodynamic stimulus for ADH production. What they fail to recognize is that there are numerous nonhemodynamic stimuli for ADH production and many patients receiving maintenance fluids have mild or subclinical volume depletion. Holliday et al are also incorrect in suggesting that our recommendation may be inappropriate for asthmatics. Asthmatics are one of the groups of patients that would benefit from receiving normal saline in parenteral fluids, as hypercarbia is a stimulus for ADH production4 and hypoxemia is a major risk factor for developing hyponatremic encephalopathy5. It is unclear to us why Holliday et al continue to feel that the sodium concentration in parenteral fluid should be twice the concentration of breast milk. The sodium concentration in parenteral fluid should be determined based on whether there is an impairment in renal water handling, a need for volume expansion or a free water requirement. We would like to reiterate that our recommendations do not apply to all patients. There are certain groups of patients with impaired water handling who will need particular care in their fluid management, and neither our nor Holliday et al’s recommendations apply. These are preterm and newborn infants, patients with renal concentrating defects, renal failure, acute glomerulonephritis, and edematous states such as nephrosis, cirrhosis, and congestive heart failure. The majority of hospitalized children requiring parenteral fluid therapy are at risk for developing hyponatremic encephalopathy from a nonosmotic stimulus for ADH production and isotonic saline would seem to be the preferred parenteral fluid in them. As is the case in all areas of medicine, advances over the past 45 years since Holliday and Segar first made their recommendations have introduced new factors to be considered in fluid management. We are indebted to them for their pioneering work, which has served the pediatric community well. However, their recommendations for using hypotonic fluids may no longer apply to the majority of hospitalized patients. 1. Holliday MA, Segar WE, Friedman A. Reducing errors in fluid therapy. Pediatrics 2003; 111:424-425. 2. Moritz ML, Ayus JC. Prevention of hospital -acquired hyponatremia: A case for using isotonic saline. Pediatrics 2003; 111:277-230. 3. Moritz ML, Ayus JC. The changing pattern of hypernatremia in hospitalized children. Pediatrics 1999; 104:435-9. 4. Robertson GL, Berl T. Pathophysiology of water metabolism. In: Brenner BM, ed. The Kidney. Vol. 1. Philadelphia: W.B. Saunders Company, 1996:873 - 928. 5. Ayus JC, Wheeler JM, Arieff AI. Postoperative hyponatremic encephalopathy in menstruant women. Ann Intern Med 1992; 117:891-7. 6. Holliday MA, Segar WE. The maintenance need for water in parenteral fluid therapy. Pediatrics 1957; 19:823-832.We appreciate Holliday et al’s1 commentary on our article2.