Childhood Kidney Diseases

Korean Society of Pediatric Nephrology (대한소아신장학회)
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Acute Hyponatremia in Pneumonia and CNS Infections of Children

소아의 폐렴과 중추신경계 감염에서 급성 저나트륨혈증의 발생 양상

  • Shin, Sung Hyun (Department of Pediatrics, Pusan National University Children's Hospital) ;
  • Um, Tea Min (Department of Pediatrics, Pusan National University Children's Hospital) ;
  • Lee, Yun Jin (Department of Pediatrics, Pusan National University Children's Hospital) ;
  • Son, Seung Kook (Department of Pediatrics, Pusan National University Children's Hospital) ;
  • Kim, Seong Heon (Department of Pediatrics, Pusan National University Children's Hospital) ;
  • Kim, Su Yung (Department of Pediatrics, Pusan National University Children's Hospital)
  • 신성현 (양산부산대학교 어린이병원 소아청소년과학) ;
  • 엄태민 (양산부산대학교 어린이병원 소아청소년과학) ;
  • 이윤진 (양산부산대학교 어린이병원 소아청소년과학) ;
  • 손승국 (양산부산대학교 어린이병원 소아청소년과학) ;
  • 김성헌 (양산부산대학교 어린이병원 소아청소년과학) ;
  • 김수영 (양산부산대학교 어린이병원 소아청소년과학)
  • Received : 2012.09.15
  • Accepted : 2012.10.14
  • Published : 2012.10.31
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Abstract

Purpose: The option of selecting isotonic rather than hypotonic fluids for maintenance fluid in children has been advocated by some authors. Pneumonia and CNS infections are frequent clinical settings for acute hyponatremia because of nonosmotic anti-diuretic hormone stimuli in children. We conducted the present study to identify the incidence of hyponatremia in pneumonia and CNS infection of children and to determine the importance of maintenance intravenous fluid therapy regimen and other related factors. Methods: The study included 1,992 patients admitted to the Department of Pediatrics at Pusan National University Children's Hospital between November 2008 and August 2011, who were diagnosed with pneumonia or CNS infections and checked for serum sodium concentration. Their clinical data including laboratory findings were reviewed retrospectively. Results: During the study period, 218 patients were identified to have acute hyponatremia among 1,992 patients. The overall incidence of hyponatremia was 10.9%. The incidence of hyponatremia in encephalitis (37.3%) was highest and the incidence in bacterial meningitis (27.4%), viral meningitis (20.0%), bacterial pneumonia (11.1%), mycoplasma pneumonia (9.2%), and viral pneumonia (6.8%) were in descending order. The mean age was higher in hyponatremic patients than in isonatremic patients. The incidence of hyponatremia was higher in who had 0.18% NaCl in 5% dextrose (D5 0.18% NS) than 0.45% NaCl in 5% dextrose infusion (D5 1/2NS) (9.0% vs. 2.2%). SIADH was identified in 20.5% among hospital acquired hyponatremic patients after adequate evaluation for SIADH. Conclusion: We recommend D5 1/2NS rather than D5 0.18% NS as the maintenance fluid given to children with pneumonia or infectious CNS diseases.

목적: 소아 입원 환자에서 유지용액을 기존의 저장성 수액 대신 등장성 수액으로 대체해야 된다는 주장이 제기되어왔다. 소아에서의 폐렴과 중추신경계 감염은 항이뇨 호르몬의 분비 자극으로 인해 저나트륨혈증이 흔히 발생할 수 있는 임상적인 상황으로 알려져 있다. 이에 저자들은 소아에서 폐렴과 중추신경계 감염질환에서 저나트륨혈증의 발생률을 확인하고 유지용액 선택의 중요성과 관련 인자들에 대해 조사하고자 본 연구를 시행하게 되었다. 방법: 부산대학교 어린이병원에 2008년 11월부터 2011년 8월까지 폐렴과 중추신경계 감염질환진단하에 입원하여 유지용액을 투여받고 혈장 나트륨 농도가 측정된 1992명의 환아를 대상으로 하였다. 저나트륨혈증은 혈장 나트륨 농도가 135 mEq/L 미만일 때로 정의하였다. 검사결과를 포함한 임상적 자료는 후향적으로 분석되었다. 결과: 연구기간 동안 1,992명 중 218명의 환아가 급성 저나트륨혈증으로 확인되었다. 따라서 총 발생률은 10.9%였다. 저나트륨혈증의 발생률은 뇌염에서 가장 높았고 세균성 뇌수막염, 바이러스성 뇌수막염, 세균성 폐렴, mycoplasma성 폐렴, 바이러스성 폐렴 순으로 발생률의 차이를 나타내었다. 세균성 폐렴에서의 발생률은 바이러스성 폐렴의 발생률에 비해 의미있게 높은 결과를 보였다. 또한 뇌염에서의 발생률은 바이러스성 뇌수막염의 발생률에 비해 의미있게 높은 결과를 보였다. 평균발생연령은 저나트륨혈증 환아군이 정상나트륨혈증 환아군에 비해 의미있게 높았다. 저나트륨혈증의 발생률은 D5 0.18% NS 투여군이 D5 1/2NS 투여군에 비해 의미있게 높았다. 입원기간 중 저나트륨혈증이 발생한 82명의 환아 중 78명이 SIADH의 진단에 필요한 모든 검사를 시행하였고, 이중 20.5%에서 진단되었다. 결론: 저나트륨혈증의 발생률은 폐렴과 중추신경계 감염질환에서 높게 나타나며 저장성 수액의 투여는 입원 후에 발생하는 저나트륨혈증의 중요한 원인이다. 따라서 저자들은 폐렴과 중추신경계 질환이 있는 환아에서 유지용액으로 D5 0.18% NS 보다 D5 1/2NS의 투여를 권장하는 바이다.

Keywords

References

  1. Anderson RJ. Hospital-associated hyponatremia. Kidney Int 1986;29:1237-47. https://doi.org/10.1038/ki.1986.134
  2. Kennedy PG, Mitchell DM, Hoffbrand BI. Severe hyponatremia in hospital inpatients. BMJ 1978;2:1251-3. https://doi.org/10.1136/bmj.2.6147.1251
  3. Halperin ML., Goldstein MB. Sodium and Water. 3rd ed. Philadelphia. PA: WB Saunders: 1999
  4. Moritz ML, Ayus JC. Prevention of hospital-acquired hyponatremia: A case for using isotonic saline. Pediatrics 2003; 111:227-30. https://doi.org/10.1542/peds.111.2.227
  5. Moritz ML, Ayus JC. Hospital-acquired Hyponatremia: why are there still deaths? Pediatrics 2004;113:1395-6. https://doi.org/10.1542/peds.113.5.1395
  6. Moritz ML, Ayus JC. Hospital-acquired hyponatremia-why are hypotonic parenteral fluids still being used? Nat Clin Pract Nephrol 2007;3:374-82.
  7. Hoorn EJ, Geary D, Robb M, Halperin ML, Bohn D. Acute hyponatremia related to intravenous fluid administration in hospitalized children: an observational study. Pediatrics 2004;113:1279-84. https://doi.org/10.1542/peds.113.5.1279
  8. Armon K, Riordan A, Playfor S, Millman G, Khader A, Society PR. Hyponatremia and hypokalemia during intravenous fluid administration. Arch Dis Child 2008;93:285-7. https://doi.org/10.1136/adc.2006.093823
  9. Neville K, Verge C, Rosenberg A, O Meara M, Walker J. Isotonic is better than hypotonic saline for intravenous rehydration of children with gastroenteritis: a prospective randomized study. Arch Dis Child 2006;91:226-32. https://doi.org/10.1136/adc.2005.084103
  10. Brazel P, McPhee IP. Inappropriate secretion of antidiuretic hormone in postoperative scoliosis patients: the role of fluid management. Spine 1996;21:724-7. https://doi.org/10.1097/00007632-199603150-00013
  11. Wilkinson E, Rieff J, Rekate H, Beals S. Fluid, blood, and blood product management in the craniofacial patient. Pediatr Neurosurg 1992;18:48-52. https://doi.org/10.1159/000120641
  12. Choong K, Kho M, Menon K, Bohn D. Hypotonic versus isotonic saline in hospitalized children: a systematic review. Arch Dis Child 2006;91:828-35. https://doi.org/10.1136/adc.2005.088690
  13. Chung HM, Kluge R, Schrier RW, Anderson RJ. Postoperative hyponatremia. A prospective study. Arch Intern Med 1986; 146:333-6. https://doi.org/10.1001/archinte.1986.00360140159023
  14. Shann F, Germer S. Hyponatremia associated with pneumonia or bacterial meningitis. Arch Dis Child 1985;60:963-6. https://doi.org/10.1136/adc.60.10.963
  15. Moritz ML, Ayus JC. La crosse encephalitis in children. N Engl J Med 2001;345:148-9. https://doi.org/10.1056/NEJM200107123450216
  16. Holliday MA. Isotonic Saline Expands Extracellular Fluid and Is Inappropirate for Maintenance Therapy. Pediatrics 2005; 115:193-4.
  17. Holliday MA, Segar WE. The maintenance need for water in parenteral fluid therapy. Pediatrics 1957;19:823-32.
  18. Shaifee MAS, Bohn D, Horn E, Halperin ML. How to select optimal maintenance intravenous fluid therapy. Q J Med 2003;96:601-10. https://doi.org/10.1093/qjmed/hcg101
  19. Gerigk M, Gnehm H, Rascher W. Arginine vasopressin and rennin in acutely ill children: implication for fluid therapy. Acta Paediatr 1996;85:550-3. https://doi.org/10.1111/j.1651-2227.1996.tb14084.x
  20. Rosenow EC III, Segar We, Zehr JE. Inappropriate antidiuretic hormone secretion in pneumonia. Mayo Clin Proc 1972;47: 169-74.
  21. Rivers RPA, Forsling ML, Olver RP. Inappropriate secretion of antidiuretic hormone in infants with respiratory infections. Arch Dis Child 1981;56:358-63. https://doi.org/10.1136/adc.56.5.358
  22. Kannan L, Lodha R, Vivekanandhan S, Bagga A, Kabra SK, Kabra M. Intravenous fluid regimen and hyponatraemia among children: a randomized controlled trial. Pediatr Nephrol 2010; 25:2303-9. https://doi.org/10.1007/s00467-010-1600-4
  23. Powell KR, Sugarman LI, Eskenazi AE, Woodin KA, Kays MA, McCormick KL, et al. Normalization of plasma arginine vasopressin concentrations when children with meningitis are given maintenance plus replacement fluid therapy. J Pediatr 1990;117:515-22. https://doi.org/10.1016/S0022-3476(05)80682-1
  24. Hatherill M, Waggie Z, Salie S, Argent A. Hospital-acquired hyponatremia is associated with excessive administration of intravenous maintenance fluid. Pediatrics 2004;114:1368; author reply 1368-9.