Caracterización de recién nacidos a término con deshidratación hipernatrémica / Characterization of full term newborns with hypernatremic dehydration

INTRODUCCIÓN: La deshidratación hipernatrémica neonatal es una condición grave y su incidencia se ha incre mentado en los últimos años, repercutiendo en complicaciones que llevan a la hospitalización del recién nacido. OBJETIVO: Describir las características clínicas y de laboratorio de recién nacidos a término con diagnóstico de deshidratación hipernatremica. PACIENTES Y MÉTODO: Estudio observacional descriptivo de recién nacidos a término que se hospitalizaron por deshidratación hiperna trémica entre los años 2014 y 2016. Se incluyeron recién nacidos a término mayores de 37 semanas con signos clínicos de deshidratación (mucosas secas, fontanela deprimida, llanto sin lágrimas, signos de pliegue cutáneo) y/o pérdida excesiva de peso mayor de 7% y sodio sérico mayor a 145 mEq/L. Se registraron variables sociodemográficas y bioquímicas para su análisis. RESULTADOS: Se incluyeron 43 neonatos. El 60,5% de sus madres fueron primigestantes, el 90% de los neonatos recibieron lactancia materna exclusiva, las madres reportaron problemas en la lactancia materna en el 76,7%. La pérdida de peso al ingreso con respecto al peso de nacimiento fue de 15,3% en promedio. El 83,3% contaba con seguro de salud público. 65,1% presentó signos clínicos de deshidra tación al ingreso y 83,5% signos neurológicos transitorios. El promedio de sodio fue de 155 mEq/L al ingreso. El descenso de sodio en las primeras 24 horas de manejo fue 7,74 mEq/L (0,32mEq/L por hora). La corrección de la hipernatremia fue en el 55,8% por vía oral y la estancia hospitalaria de 4 días en promedio. CONCLUSIONES: Los problemas de alimentación se presentaron en un (76%) madres primigestantes en un (88,4%). El 90,6% de esta población administraban lactancia materna exclusiva, resultados que pueden contribuir para alertar al profesional de la salud a identificar de forma oportuna, signos de alarma y un control precoz posterior al alta del puerperio y a la toma de medidas preventivas.

INTRODUCTION: The hypernatremic neonatal dehydration is a severe condition whose incidence has increased in recent years resulting in complications leading to the hospitalization of the newborn. OBJECTIVE: Describe the clinical and laboratory characteristics of term-newborns with Hypernatremic Dehy dration diagnosis. PATIENTS AND METHOD: Descriptive observational study of hospitalized term- newborns due to hypernatremic dehydration between a period from 2014 to 2016. Term newborns over 37 weeks with clinical signs of dehydration (dry mucous membranes, depressed fontanel, tear less crying, signs of the cutaneous pleat), and/or excessive weight loss greater than 7% and serum sodium greater than 145 mEq/L were included. Sociodemographic and biochemical variables were recorded for analysis. RESULTS: 43 neonates were included. 60.5 percent of their mothers were pri- miparous, 90 percent of neonates received exclusive breastfeeding, mothers reported breastfeeding problems in 76.7 percent. Incoming neonates reported weight loss compared to birth weight at 15.3% on average. 83.3% had public health insurance. 65.1% had dehydration clinical signs at entry and 83.5% transient neurological signs. The average sodium was 155 mEq/L at revenue. The sodium decrease in the first 24 hours of handling was 7.74 mEq/L (0.32mEq/L per hour). The correction of the hypernatremia was 55.8% by oral intake and 4 days hospital stay on average. CONCLUSIONS: The feeding's problems came up in a (76%), primiparous mothers in an (88.4%). 90.6 percent of this population administered exclusive breastfeeding, results that can help to alert the health professional to timely identification, warning signs, and early post-discharge control and preventive measures.

Manejo de deshidratación con alteración del sodio en pacientes pediátricos / Management of dehydration with sodium alteration in pediatric patients

Los cuadros de deshidratación son frecuentes en pediatría, muchos de ellos acompañados de alteraciones electrolíticas. La deshidratación asociada a trastornos del sodio puede implicar riesgos para la salud de los pacientes pediátricos tanto en el desarrollo del cuadro como en su tratamiento. Objetivo: crear un algoritmo de manejo de los cuadros de deshidratación asociados a lateraciones del sodio para manejo de pacientes pediátricos. Métodos: se realizó revisión de la literatura disponible sobre deshidratación con hiper e hiponatremia, en inglés y español, incluyendo libros y artículos de revistas. Se presenta en el actual documento los aspectos básicos sobre la fisiopatología de la deshidratación asociada a trastornos del sodio, su clínica, diagnóstico y manejo detallado, para el uso en la práctica clínica diaria.

Dehydration is common in pediatric patients, frequently accompanied with electrolite disturbances. Dehydration associated with sodium disturbances can involve risk for pediatric patient health during the development of the disease and during its treatment. Objective: to create an algorithm of management of dehydration with sodium disturbances in pediatric patients. Methods: review of literature about dehydration with hypernatremia and hyponatremia, in english and spanish, including books and published articles. We present in this document the basic aspects of physiopathology of dehydration with sodium disturbances, clinical presentation, diagnosis and detailed management, so it can be consulted for clinical practice.

The role of urea-induced osmotic diuresis and hypernatremia in a critically ill patient: case report and literature review / O papel da diurese osmótica induzida por ureia na geração de hipernatremia no paciente crítico: relato de caso e revisão da literatura

Abstract Hypernatremia is a common electrolyte problem at the intensive care setting, with a prevalence that can reach up to 25%. It is associated with a longer hospital stay and is an independent risk factor for mortality. We report a case of hypernatremia of multifactorial origin in the intensive care setting, emphasizing the role of osmotic diuresis due to excessive urea generation, an underdiagnosed and a not well-known cause of hypernatremia. This scenario may occur in patients using high doses of corticosteroids, with gastrointestinal bleeding, under diets and hyperprotein supplements, and with hypercatabolism, especially during the recovery phase of renal injury. Through the present teaching case, we discuss a clinical approach to the diagnosis of urea-induced osmotic diuresis and hypernatremia, highlighting the utility of the electrolyte-free water clearance concept in understanding the development of hypernatremia.

Resumo A hipernatremia é um distúrbio eletrolítico comum no ambiente de terapia intensiva, com uma prevalência que pode chegar a 25%. Está associada a maior tempo de internação hospitalar e é um fator de risco independente para a mortalidade. Este relato ilustra um caso de hipernatremia de origem multifatorial no ambiente de terapia intensiva. Destacaremos o papel da diurese osmótica por geração excessiva de ureia, uma causa de hipernatremia pouco conhecida e subdiagnosticada. Este cenário pode estar presente em pacientes em uso de elevadas doses de corticoides, com sangramento gastrointestinal, em uso de dietas e suplementos hiperproteicos e estado de hipercatabolismo, especialmente durante a fase de recuperação de injúria renal. A seguir, discutiremos uma abordagem clínica para o diagnóstico da hipernatremia secundária à diurese osmótica induzida por ureia, destacando a importância do conceito de clearance de água livre de eletrólitos nesse contexto.

Weight loss thresholds to detect early hypernatremia in newborns / Limites de perda de peso para detecção de hipernatremia precoce em recém-nascidos

ABSTRACT Objective: The literature indicates a single universal cut-off point for weight loss after birth for the risk of hypernatremia, without considering other factors. The aim of this study was to construct and internally validate cut-off points for the percentage weight loss associated with the risk of hypernatremia, taking into account risk factors. Methods: A prospective study with a three-day follow-up was conducted in 165 neonates with a gestational age ≥35 weeks. The main outcome variable was mild or moderate hypernatremia (serum sodium ≥ 145 mmol/L). Secondary variables (risk factors) were maternal and infant variables. A multivariate logistic regression model was constructed to predict hypernatremia, obtaining its probability and the optimal discriminant cut-off point for hypernatremia (receiver operating characteristic analysis). Based on this point, threshold weight loss values were obtained according to the other variables. These values were internally validated by bootstrapping. Results: There were 51 cases (30.9%) of hypernatremia. The mean percentage weight loss for hypernatremic infants was 8.6% and 6.0% for the rest. Associated variables in the multivariate model included greater weight loss, male gender, higher education level, multiparity, and cesarean delivery. The model had an area under the receiver operating characteristic curve of 0.84 (sensitivity = 77.6%; specificity = 73.2%). Similar values were obtained in the bootstrapping validation. The lowest percentage weight loss was 4.77%, for cesarean delivery in male infants of mothers with a higher education level. Conclusions: The weight loss percentage values depended on the type of delivery, parity, newborn gender, and level of maternal education. External studies are required to validate these values.

RESUMO Objetivo: A literatura indica um único ponto de corte universal na perda de peso após o nascimento para risco de hipernatremia, sem considerar outros fatores. Nosso objetivo foi criar e validar internamente pontos de corte para o percentual de perda de peso associado ao risco de hipernatremia considerando fatores de risco. Métodos: Foi feito um estudo prospectivo que incluiu 165 neonatos com idade gestacional ≥ 35 semanas, acompanhados por três dias. A principal variável de resultado foi hipernatremia leve ou moderada (sódio sérico ≥ 145 mmol/L). As variáveis secundárias (fatores de risco) foram variáveis maternas e dos neonatos. Um modelo multivariado de regressão logística foi criado para diagnosticar hipernatremia, obteve sua probabilidade e o ponto de corte discriminativo ideal para hipernatremia (análise da Característica de Operação do Receptor). Com base nesse ponto, obtivemos então os valores limites de perda de peso de acordo com as outras variáveis. Esses valores foram internamente validados por. Resultados: Há 51 casos (30,9%) de hipernatremia. O percentual de perda de peso para neonatos hipernatrêmicos foi 8,6% e 6,0% para o restante. As variáveis associadas no modelo multivariado incluíram maior perda de peso, sexo masculino, maior nível de escolaridade, multiparidade e cesárea. O modelo apresentou uma área sob a curva da Característica de Operação do Receptor de 0,84 (sensibilidade = 77,6%; especificidade = 73,2%). Valores semelhantes foram obtidos na validação da bootstrapping. O menor percentual de perda de peso foi 4,77% para cesárea em neonatos do sexo masculino de mães com maior nível de escolaridade. Conclusões: Os valores percentuais de perda de peso dependem do tipo de parto, paridade, sexo do recém-nascido e nível de escolaridade materna. São necessários estudos externos para validar esses valores.

Bases fisiopatológicas de los transtornos del sodio en pediatría / Pathophysiology of sodium disorders in children

Las disnatremias son el transtorno hidroelectrolítico prevalente en pacientes ambulatorios y hospitalizados. Su manejo inadecuado puede tener serias consecuencias, asociándose a un aumento en la morbimortalidad de los pacientes. El objetivo de este artículo es actualizar las bases fisiopatológicas de las disnatremias y revisar herramientas clínicas y de laboratorio que nos permitan realizar un enfrentamiento rápido y simple. Las disnatremias reflejan un transtorno del balance del agua, y el balance de agua tiene relación directa con la osmorregulación. Existen mecanismos para mantener el control de la osmolalidad plasmática, los cuales se gatillan con cambios de un 1-2 por ciento. A nivel hipotalámico existen osmorreceptores que censan cambios en la osmolalidad plasmática, regulando la secreción de Hormona Antidiurética (ADH), la que ejerce su acción a nivel renal, por lo cual el riñón es el principal regulador del balance hídrico. Cuando se está frente a una disnatremia, es fundamental evaluar cómo está funcionando este eje ADH-riñón. Dentro de las hiponatremias existen causas que son fáciles de identificar, sin embargo, diferenciar un síndrome de secreción inadecuada de ADH con un síndrome pierde sal cerebral suele ser más difícil. En el caso de las hipernatremias, sospechar una diabetes insípida y diferenciar su posible origen, central o nefrogénico, es fundamental para su manejo. En conclusión, el enfrentamiento de una disnatremia requiere conocer las bases fisiopatológicas de su desarrollo, para así poder realizar un diagnóstico certero y finalmente un tratamiento adecuado, evitando errores en su corrección que pueden poner en riesgo al paciente.

Dysnatremia is among the most common electrolyte disorders in clinical medicine and its improper management can have serious consequences associated with increased morbidity and mortality of patients. The aim of this study is to update the pathophysiology of dysnatremia and review some simple clinical and laboratory tools, easy to interpret, that allow us to make a quick and simple approach. Dysnatremia involves water balance disorders. Water balance is directly related to osmoregulation. There are mechanisms to maintain plasma osmolality control; which are triggered by 1-2 percent changes. Hypothalamic osmoreceptors detect changes in plasma osmolality, regulating the secretion of Antidiuretic Hormone (ADH), which travels to the kidneys resulting in more water being reabsorbed into the blood; therefore, the kidney is the main regulator of water balance. When a patient is suffering dysnatremia, it is important to assess how his ADH-renal axis is working. There are causes of this condition easy to identify, however, to differentiate a syndrome of inappropriate ADH secretion from cerebral salt-wasting syndrome is often more difficult. In the case of hypernatremia, to suspect insipidus diabetes and to differentiate its either central or nephrogenic origin is essential for its management. In conclusion, dysnatremia management requires pathophysiologic knowledge of its development in order to make an accurate diagnosis and appropriate treatment, avoiding errors that may endanger the health of our patients.

Hypernatremia among in-patients of a General Hospital in Kuwait

To determine the incidence and aetiology of Hypernatremia in adult patients admitted to a general hospital in Kuwait as it has not been studied as frequently as hyponatremia. A hospital based retrospective study carried out between July 2009 to Dec 2009. Medical inpatient wards, department of medicine, Al-Jahra hospital, Kuwait. 92 hypernatremia patients [41 males and 51 females] of the total 1825 patients were analyzed and their aetiology studied. Frequency, aetiology and outcome of Hypernatremia in adult inpatients. All blood samples were analyzed in biochemistry department on LX20 machine. Information regarding age, gender, highest serum sodium levels, clinical diagnoses and further clinical information suggesting causes of hypernatremia was gathered. Results: Of the total 1825 patients analyzed, 5.04% were diagnosed with hypernatremia with a mean serum sodium of 150.9 mmol/L. Among major causes of hypernatremia were hyperglycemia [21.7%], IV fluids [21.7%] and dehydration [17.4%] The overall incidence of hypernatremia in this hospital was 5.04%. Hyperglycemia and IV fluid administration were the commonest causes. Prompt treatment of hypernatremia is necessary but care should be taken to avoid excessively rapid correction or overcorrection, which increases the risk of iatrogenic cerebral edema

Hyponatremia and hypernatremia: disorders of water balance.

Total body water and tonicity is tightly regulated by renal action of antidiuretic hormone (ADH), reninangiotensin-aldosterone system, norepinephrine and by the thirst mechanism. Abnormalities in water balance are manifested as sodium disturbances--hyponatremia and hypernatremia. Hyponatremia ([Na+ < 136 meq/ l]) is a common abnormality in hospitalized patients and is associated with increased morbidity and mortality. A common cause of hyponatremia is impaired renal water excretion either due to low extracellular fluid volume or inappropriate secretion of ADH. Clinical assessment of total body water and urine studies help in determining cause and guiding treatment of hyponatremia. Acute and severe hyponatremia cause neurological symptoms necessitating rapid correction with hypertonic saline. Careful administration and monitoring of serum [Na+] is required to avoid overcorrection and complication of osmotic demyelination. Vasopressin receptor antagonists are being evaluated in management of euvolemic and hypervolemic hyponatremia. Hypematremia ([Na+] > 145 meq/l) is caused by primary water deficit (with or without Na+ loss) and commonly occurs from inadequate access to water or impaired thirst mechanism. Assessment of the clinical circumstances and urine studies help determine the etiology, while management of hypernatremia involves fluid resuscitation and avoiding neurological complications from hypernatremia or its correction. Frequent monitoring of [Na+] is of paramount importance in the treatment of sodium disorders that overcomes the limitations of prediction equations.

Evaluating mortality rate caused by electrolyte abnormalities in hospitalized patients

Adjustment of composition of body fluids and electrolytes is one of the most important aspects of patients care. Sodium and Potassium are the most important body cations, the improper adjustment of them will cause sever disorders in neuromuscular, gastrointestinal, respiratory and cardiovascular systems. Acute renal failure indicated by increase in creatinine and nitrogen urea, brings an accumulation of fluids, salts and metabolites of nitrogen in body. This study intends to assess the status of electrolyte abnormalities and mortality rates of the patients hospitalized in ICU wards in our country. This is a descriptive and retrospective study on the records of 378 patients hospitalized in ICU. A questionnaire was prepared and the data were entered in SPSS system. They were statistically analyzed by using chi-square and fisher's Exact test methods. Out of 378 patients hospitalized in ICU, over 2/3 of them were male and over half of them were>45 years old. Frequency distribution of electrolyte abnormalities was as follows: Hyponatremia 59% hypernatremia 23% hypokalemia 37% hyperkalemia 28%, 35% and 21% of patients had respectively BUN and creatinine more than the normal range. 26% of patients hospitalized in ICU had nonsurgical problems and 74% of the patients had surgical problems. Average time of hospitalization in ICU was 85 days and mortality rate was 35%. The most common electrolyte abnormality was related to variation in serum sodium levels in the form of hyponatremia. And the highest prevalence electrolyte abnormality in dead patients was hyponatremia. This study proves that the prevalence of electrolyte abnormalities is directly related to mortality and increase in hospitalization period and those having undergone surgical operations during hospitalization in ICU, manifested more abnormalities

Deshidratación hipernatremica en recién nacido por sales de rehidratación oral reporte de un caso / Hypernatremic deshydration in newborn by salts of oral rehydration: a case report

La deshidratación hipernatremica se define como una concentración sérica de sodio mayor de 150 mEq/L, representa el 20 por ciento de las deshidrataciones y refleja un déficit de agua extracelular con relación al contenido corporal de sodio con edema cerebral, hemorragia intracraneal, hidrocefalia y gangrena. Los factores de riesgo para deshidratación hipernatrémica son: niños menores de un año por inmadures renal y aumento del líquido extracelular, fiebre que aumenta la pérdida de agua libre y, fundamentalmente el ingreso incrementado de solutos con relación al contenido de agua libre, producto de la reshidratación oral con soluciones con alto contenido de sodio, formulas mal preparadas o alimentación al pecho exclusiva en madres con una aporte insuficiente de líquidos. Se trata de recién nacido de 13 días de vida quien presenta clínica de deshidratación y acidosis por síndrome diarreico agudo con antecedente de mala administración de Sales de rehidratación oral por parte de la madre con dilución inadecuada hiperosmolar. Hallazgos paraclínico, Hipernatremia, Hiperkalemia, acidosis metabólica e hipoxemia. Tratamiento: corrección de acidosis con solución 75 y rehidratación en 48 horas con solución hipoosmolar 0.22 por ciento. Presentamos este caso por ser una de las causas más frecuentes de deshidratación hipernatrémicas en recién nacidos, es importante exponer la necesidad de educación a las madres para la adecuada preparación de las sales de rehidratación oral, como método eficaz de prevenir la deshidratación. Y en aquellos casos de presentarse tal complicación, los médicos debemos conocer la adecuada correlación de las misma a modo de evitar las complicaciones.

Clinical presentation of hypernatremic dehydration in exclusively breast-fed neonates.

OBJECTIVE: To identify the clinical presentation of dehydration related to failure of lactation in exclusively breast-fed term infants. METHOD: A prospective study was performed between January 2000 and June 2003 in Al Qassimi Hospital in the Emirate of Sharjah. Enrollment criteria included term neonates whose birth weight of > 2000 g with no underlying organic illness causing poor feeding admitted for clinical manifestations of dehydration with weight loss of > 10% during the first 2 weeks of life. The control group, a non-randomized sample included healthy full term neonates, seen in Sharjah maternal and child health care center at 4-7 days old for their routine Guthrie screening test. For each dehydrated neonate we took two neonates as controls. Mother's age, parity, length of pregnancy, any pathologic conditions, breastfeeding history and her level of knowledge of lactation was recorded. Neonatal information included mode of delivery, percentage of weight loss, clinical examination, and stool and urine output the previous day. Data was analyzed with Student 't' test and chi-square test. RESULTS: Out of 17208 live births, 29 neonates between the ages of 2-13 days were admitted with weight loss of between 12 and 29% (dehydrated group). 27 patients had hypernatremic dehydration with serum sodium level ranging from 150 to 195 mmol/l. Mean age of admission was 4.9 days. Reasons for admission were: signs of dehydration (55%); hyperthermia (55%); hypoglycemia (27%) and jaundice (59%). The control group included 58 healthy neonates. Their birth weight and age were comparable to those in the dehydrated group. In comparison with the control group, delivery by cesarean section (P< 0.0001), lower level of maternal breastfeeding knowledge (P=0.03), transient inadequate breast milk quantity (P=0.005) and nipple anomalies (P=0.001) was significantly more common in the dehydrated group. Fewer voidings of urine (< 6 times /day) and stool (< 3 times/day) in the previous 24 hours before admission was more frequently observed in the dehydrated group (P < 0.0001). CONCLUSION: Low level of maternal knowledge in lactation, cesarean section and failure of early postnatal follow up was associated with the neonatal dehydration. Decreased urine and stool frequency might be considered as a warning for failure of lactation.

Correção dos desvios da concentração de sódio e potássio na infância / Treatment of the sodium and potassium disturbances in childhood

Este artigo tem por objetivo abordar os aspectos mais relevantes da correção das alterações da concentração de sódio e potássio na infância. Sao abordados inicialmente os distúrbios do sódio, hipernatremia e hiponatremia. A hipernatremia é considerada clinicamente relevante se a concentração de sódio exceder a 160 mEq/I e a hiponatremia rio caso de ser inferior a 120 mEq/1. Para a correção dos distúrbios do sódio devem ser levados em conta a volemia do paciente, o tempo de instalação do distúrbio e a intensidade do mesmo. É importante evitar as complicações decorrentes da correção inadequada dos desvios da concentração de sódio que são o edema cerebral, no caso da hipernatremia, e a mielinólise pontina central, em relação à hiponatremia. Os distúrbios do potássio são abordados na segunda parte do texto. Tanto na hiperpotassemia quanto na hipopotassemia é importante avaliar a distribuição do potássio entre os compartimentos intra e extracelular, a capacidade do rim em excretar esse ion e o conteúdo de potássio corporal total. As manifestações clínicas mais graves decorrentes dos desvios da concentração de potássio dizem respeito a seus efeitos sobre o miocárdio e outros tecidos excitáveis. A correção desses desvios deve priorizar a reversão dos efeitos eletrofisiológicos tanto da hiper quanto da hipopotassemia e, posteriorrnente, a normalização dos níveis séricos deste íon.

The aim of this paper is to establish some guidelines for the treatment of sodium and potassium disturbances in childhood. First, sodium disorders, such as hypernatremia and hyponatremia, are discussed. The hypernatremia is considered clinically relevant if the sodium concentration is above 160 mEq/1. Regarding hyponatremia, the inferior limit for sodium concentration is 120 mEq/1. The patient's extracellular fluid volume, the duration of the disturbance and the magnitude of the alteration in sodium levels must be taken into account in order to correct the hydroelectrolyte imbalance. It is important to avoid the complications due to an inadequate correction of sodium disarrangement such as brain edema in hypernatremia and central pontine myelinolysis in hyponatremia. The disorders of potassium metabolism are discussed in the second part of this article. For the appropriate treatment of hyperkalemia and also hypokalemia, it is important to evaluate the distribution of potassium between extra and intracellular fluid, its renal excretion and the total amount of this ion in the body. The most severe clinical features are due to the effect of potassium disorders on the cell membranes. The treatment of potassium disarrangement must emphasize the correction of electrophysiological effects of the hyperkalemia and also hypokalemia. The normalization of potassium levels should be obtained afterward.