Are Further Interventions Needed to Prevent and Manage Hospital-Acquired Hyponatraemia? A Nationwide Cross-Sectional Survey of IV Fluid Prescribing Practices
Abstract
:1. Introduction
2. Methods
2.1. Setting and Study Population
2.2. Recruitment
2.3. Development of the Questionnaire
2.4. Outcome Measures
- A high-risk (potentially increased intracranial pressure) patient with hypovolaemia.
- A child in need of maintenance intravenous fluids without hypovolaemia and hyponatraemia.
- A hypovolaemic and hyponatraemic (P-Na = 110 mmol/L) patient without severe symptoms of hyponatraemia.
- A hyponatraemic (P-Na = 118 mmol/L) patient with severe symptoms of hyponatraemia.
- Renal water excretion in the acutely ill patient.
- Intravenous fluids impact on P-Na in the acutely ill patient.
- Hyperglycaemia and P-Na.
- Severe symptoms of hyponatraemia.
- Patients at high risk of severe symptoms.
- Prevention and treatment of over-correction of hyponatraemia.
2.5. Data Analysis
3. Results
3.1. Characteristics of Respondents
3.2. Response to Scenario and Knowledge Questions
3.3. Analyses of Prescribing Practice by Demographical Variables and Characteristics of EDs
4. Discussion
4.1. Main Findings
4.1.1. Use of Hypotonic Intravenous Fluids
4.1.2. Linking Hypotonic Intravenous Fluid Treatment and Hyponatraemia
4.1.3. Treatment of Hyponatraemia with Severe Symptoms
4.2. Strengths and Limitations
4.3. Clinical Implications
- The association between hyponatraemia and hypotonic intravenous fluids.
- Intravenous fluids’ impact on P-Na in patients with reduced water excretion.
- Treatment of patients with severe symptoms of hyponatraemia.
Supplementary Materials
Author Contributions
Funding
Acknowledgments
Conflicts of Interest
References
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Fluid Response Choices of the Scenarios * | Sodium Concentration | Tonicity After Injection |
---|---|---|
Glucose 5% isotonic | 0 mmol/L | Strongly hypotonic |
Darrow-glucose | 31 mmol/L | Strongly hypotonic |
Potassium-sodium-glucose | 40 mmol/L | Strongly hypotonic |
0.45% sodium chloride with 2.5% glucose isotonic | 77 mmol/L | Strongly hypotonic |
Ringer’s acetate | 130 mmol/L | Moderately hypotonic |
Isotonic saline solution | 154 mmol/L | Isotonic |
0.9% NaCl with 5% glucose | 154 mmol/L | Isotonic |
3% NaCl | 513 mmol/L | Strongly hypertonic |
Responded to One or More Scenarios | Responded to All Scenarios | Completed All Questions | ||||
---|---|---|---|---|---|---|
n | (%) | n | (%) | n | (%) | |
All | 215 | (100.0) | 201 | (93.4) | 159 | (74.0) |
Characteristics of respondents | ||||||
Gender | ||||||
Female | 126 | (58.6) | 119 | (59.2) | 88 | (55.3) |
Male | 89 | (41.4) | 82 | (40.8) | 71 | (44.7) |
Age | ||||||
18–34 years | 88 | (40.9) | 80 | (39.8) | 64 | (40.3) |
35–44 years | 57 | (26.5) | 54 | (26.9) | 43 | (27.0) |
≥45 years | 70 | (32.6) | 67 | (33.3) | 52 | (32.7) |
Number of weekly treated patients with intravenous fluids | ||||||
0 patients | 29 | (13.5) | 28 | (13.9) | 21 | (13.2) |
1–5 patients | 72 | (33.5) | 68 | (33.8) | 58 | (36.5) |
>5 patients | 113 | (52.6) | 104 | (51.7) | 80 | (50.3) |
Unknown | 1 | (0.5) | 1 | (0.5) | 0 | (0) |
Years of practice | ||||||
≤5 years | 86 | (40.0) | 78 | (38.8) | 61 | (38.4) |
>5 years | 127 | (59.1) | 121 | (60.2) | 97 | (61.0) |
Unknown | 2 | (0.9) | 2 | (1.0) | 1 | (0.6) |
Position | ||||||
Junior doctor | 121 | (56.3) | 111 | (55.2) | 89 | (56.0) |
FY1 * | 30 | (14.0) | 25 | (12.4) | 18 | (11.3) |
FY2 ** | 27 | (12.6) | 26 | (12.9) | 23 | (14.5) |
Specialty registrar | 50 | (23.3) | 47 | (23.4) | 39 | (24.5) |
Other *** | 14 | (6.5) | 13 | (6.5) | 9 | (5.7) |
Senior doctor (Consultant) | 94 | (43.7) | 90 | (44.8) | 70 | (44.0) |
Characteristics of EDs **** | ||||||
Size | ||||||
Large | 84 | (39.1) | 79 | (39.3) | 61 | (38.4) |
Medium | 111 | (51.6) | 104 | (51.7) | 85 | (53.5) |
Small | 20 | (9.3) | 18 | (9.0) | 13 | (8.2) |
Complexity | ||||||
High | 65 | (30.2) | 62 | (30.8) | 44 | (27.7) |
Medium | 150 | (69.8) | 139 | (69.2) | 115 | (72.3) |
Low | 0 | (0) | 0 | (0) | 0 | (0) |
Type | ||||||
Combined general population ED ***** | 31 | (14.4) | 29 | (14.4) | 23 | (14.5) |
Adult ED | 76 | (35.3) | 69 | (34.3) | 52 | (32.7) |
Pediatric ED | 106 | (49.3) | 101 | (50.2) | 82 | (51.6) |
Trauma center | 2 | (0.9) | 2 | (1.0) | 2 | (1.3) |
n | (%) | |
---|---|---|
Scenario 1 (n = 201) An otherwise healthy 18-year-old girl is hospitalised on suspicion of meningitis. She has thrown up and has diarrhoea. On examination, she appears pale with cold skin, a slightly increased heart rate, normal blood pressure, and with decreased level of consciousness (Glasgow Coma Scale = score 14). Laboratory tests are normal. | ||
Correct fluid | ||
Isotonic saline, [Na+] = 154 mmol/L | 144 | (76.1) |
Inappropriate fluids | ||
0.9% NaCl with 5% glucose, [Na+] = 154 mmol/L | 5 | (2.5) |
3% NaCl, [Na+] = 513 mmol/L | 0 | (0) |
Incorrect hypotonic fluids | ||
Glucose 5% isotonic | 1 | (0.5) |
Darrow-glucose, [Na+] = 31 mmol/L | 1 | (0.5) |
Potassium-sodium-glucose, [Na+] = 40 mmol/L | 14 | (7.0) |
0.45% sodium chloride with 2.5% glucose isotonic, [Na+] = 77 mmol/L | 6 | (3.0) |
Ringer’s acetate, [Na+] = 130 mmol/L | 28 | (13.9) |
Do not know | 2 | (1.0) |
Scenario 2 (n = 201) A 5-year-old boy arrives at the emergency department with a head injury after falling from a bike. He has headache and nausea, but no vomiting or signs of hypovolaemia. He has been unconscious for half an hour; however, the CT scan, clinical examination and laboratory results are all normal. | ||
Correct fluid | ||
0.9% NaCl with 5% glucose, [Na+] = 154 mmol/L | 21 | (10.4) |
Inappropriate fluid | ||
Isotonic saline, [Na+] = 154 mmol/L | 83 | (41.3) |
Ringer’s acetate, [Na+] = 130 mmol/L | 22 | (10.9) |
3% NaCl, [Na+] = 513 mmol/L | 1 | (0.5) |
Incorrect hypotonic fluids | ||
Glucose 5% isotonic | 3 | (1.5) |
Darrow-glucose, [Na+] = 31 mmol/L | 6 | (3.0) |
Potassium-sodium-glucose, [Na+] = 40 mmol/L | 42 | (20.9) |
0.45% sodium chloride with 2.5% glucose isotonic, [Na+] = 77 mmol/L | 8 | (4.0) |
Do not know | 15 | (7.5) |
Scenario 3 (n = 201) A 75-year-old woman arrives at the emergency department with hip fracture after a fall. There are no signs of head injury. The patient has had a poor appetite for a long time. Medical history includes thiazide diuretics for hypertension, but otherwise she is healthy. Clinical examination shows symptoms of hypovolaemia: cold and pale skin, heart rate at 100 bpm, and a slightly increased respiratory rate. Laboratory tests show P-Na = 110 mmol/L. | ||
Correct fluids | ||
Isotonic saline, [Na+] = 154 mmol/L | 120 | (59.7) |
Ringer’s acetate, [Na+] = 130 mmol/L | 16 | (8.0) |
Inappropriate fluids | ||
0.9% NaCl with 5% glucose, [Na+] = 154 mmol/L | 11 | (5.5) |
3% NaCl, [Na+] = 513 mmol/L | 16 | (8.0) |
Incorrect hypotonic fluids | ||
Glucose 5% isotonic | 4 | (2.0) |
Darrow-glucose, [Na+] = 31 mmol/L | 0 | (0) |
Potassium-sodium-glucose, [Na+] = 40 mmol/L | 10 | (5.0) |
0.45% sodium chloride with 2.5% glucose isotonic, [Na+] = 77 mmol/L | 7 | (3.5) |
Do not know | 17 | (8.5) |
Scenario 4 (n = 201) A 28-year-old woman is hospitalised on suspicion of medication poisoning and large intake of water. She vomits and complains about headaches. She exhibits strange behavior, has muscle rigidity, and a Glasgow Coma Scale score of 14. ABC is normal. Arterial blood gas shows P-Na = 118 mmol/L. | ||
Correct fluid | ||
3% NaCl, [Na+] = 513 mmol/L | 59 | (29.4) |
Inappropriate fluids | ||
Isotonic saline, [Na+] = 154 mmol/L | 76 | (37.8) |
0.9% NaCl with 5% glucose, [Na+] = 154 mmol/L | 6 | (3.0) |
Incorrect hypotonic fluids | ||
Glucose 5% isotonic | 3 | (1.5) |
Darrow-glucose, [Na+] = 31 mmol/L | 0 | (0) |
Potassium-sodium-glucose, [Na+] = 40 mmol/L | 12 | (6.0) |
0.45% sodium chloride with 2.5% glucose isotonic, [Na+] = 77 mmol/L | 4 | (2.0) |
Ringer’s acetate, [Na+] = 130 mmol/L | 14 | (7.0) |
Do not know | 27 | (13.4) |
n | (%) | |
---|---|---|
Q10: Which of the following sentences are correct? (n = 198) | 158 | (79.8) |
Most often acutely ill patients in need of IV fluids have increased renal water excretion Most often acutely ill patients in need of IV fluids have decreased renal water excretion Most often acutely ill patients in need of IV fluids have normal renal water excretion | ||
Q11a: How will Darrow-glucose ([Na+] = 31 mmol/L) affect the P-Na in a patient with decreased water excretion? (n = 184) | 85 | (46.2) |
Large increase in P-Na with a risk of sodium overload Slight increase in P-Na Unchanged Slight decrease in P-Na Large decrease in P-Na with a risk of hyponatriaemia | ||
Q11b: How will Potassium-sodium-glucose ([Na+] = 40 mmol/L) affect the P-Na in a patient with decreased water excretion? (n = 179) | 56 | (31.3) |
Large increase in P-Na with a risk of sodium overload Slight increase in P-Na Unchanged Slight decrease in P-Na Large decrease in P-Na with a risk of hyponatriaemia | ||
Q11c: How will Ringer’s lactate ([Na+] = 130 mmol/L) affect the P-Na in a patient with decreased water excretion? (n = 179) | 43 | (24.0) |
Large increase in P-Na with a risk of sodium overload Slight increase in P-Na Unchanged Slight decrease in P-Na Large decrease in P-Na with a risk of hyponatriaemia | ||
Q11d: How will 0.9% NaCl with 5% glucose ([Na+] = 154 mmol/L) affect the P-Na in a patient with decreased water excretion? (n = 176) | 55 | (31.1) |
Large increase in P-Na with a risk of sodium overload Slight increase in P-Na Unchanged Slight decrease in P-Na Large decrease in P-Na with a risk of hyponatriaemia | ||
Q12 (n = 173): In case of increased blood sugar (above 12 mmol/L), the measured plasma sodium (P-Na) must be corrected because the measured P-Na is: | 52 | (30.1) |
“Falsely low” “Falsely high” There is no need for correction Do not know | ||
Q13: Which of the following diseases/symptoms may be indicative of potentially increased intracranial pressure (ICP)? (n = 164) | 23 | (14.0) |
Meningitis Shortness of breath Concussion Chest pain Seizure Acute liver failure Acute abdomen Hip fracture | ||
Q14: Which of the following symptoms are indicative of severe symptoms of hyponatraemia and require acute treatment of hyponatraemia? (n = 163) | 71 | (43.6) |
Altered level of consciousness Seizure Infection Chest pain Muscle rigidity Anaemia | ||
Q15a: What is the maximum correction of P-Na for a patient at high risk of osmotic demyelination? (n = 162) | 54 | (33.3) |
6 mmol/L 8 mmol/L 16 mmol/L 20 mmol/L | ||
Q15b: What is the maximum correction of P-Na for a patient without high risk of osmotic demyelination? (n = 162) | 48 | (29.6) |
6 mmol/L 8 mmol/L 16 mmol/L 20 mmol/L | ||
Q16: How would you prevent plasma sodium from rising too rapidly and thus exceeding the recommended limits for P-Na correction? (n = 161) | 62 | (38.5) |
I record the administration of IV fluids I recommend fluid restriction I record the first low P-Na level I monitor P-Na regularly I administer 5% glucose I record the maximum recommended increase of P-Na I encourage the patient to drink water | ||
Q17: Which of the following treatments would you initiate if a patient’s plasma sodium raises too rapidly? (n = 159) | 89 | (56.0) |
Water per os Fluid restriction (fluid intake is limited to less than 1 L/day) Isotonic saline (1 L contains 9 g [154 mmol] sodium chloride) Ringer’s acetate (1 L contains 130 mmol sodium [4.1 g sodium acetate and 5.9 g sodium chloride], 0.295 g calcium chloride, 0.3 g potassium chloride, 0.2 g magnesium chloride) 3% NaCl (1 L contains 30 g [513 mmol] sodium chloride) Glucose 5% isotonic (1 L contains 55 g [278 mmol] glucose) | ||
Q18: What is the most common cause of over-correction? (n = 159) | 14 | (8.8) |
Large diuresis Increased sodium secretion Increased water intake Inadequate water intake Increased sodium intake Reduced renal water excretion |
Variable | Prescribing Practice (Correct Responses) | Odd Ratio | 95%CI | p-Value | |||
---|---|---|---|---|---|---|---|
Critical (correct < 2) n (%) | Non-critical (correct ≥ 2) n (%) | ||||||
Age | |||||||
18–34 years | 31 | (38.8) | 49 | (61.3) | 1.4 | 0.8–2.5 | 0.3 |
≥35 years | 38 | (31.4) | 83 | (68.6) | (ref *) | ||
Number of weekly treated patients with intravenous fluids ** | |||||||
0–5 patients | 36 | (37.5) | 60 | (62.5) | 1.4 | 0.8–2.4 | 0.3 |
>5 patients | 32 | (30.8) | 72 | (69.2) | (ref) | ||
Years of practice ** | |||||||
≤5 years | 29 | (37.2) | 49 | (62.8) | 1.2 | 0.6–2.2 | 0.6 |
>5 years | 40 | (33.1) | 81 | (66.9) | (ref) | ||
Position *** | |||||||
Junior | 39 | (35.1) | 72 | (64.9) | 1.1 | 0.6–1.9 | 0.8 |
Senior | 30 | (33.3) | 60 | (66.7) | (ref) | ||
Size | |||||||
Small/Medium | 43 | (35.2) | 79 | (64.8) | 1.1 | 0.6–2.0 | 0.7 |
Large | 26 | (32.9) | 53 | (67.1) | (ref) | ||
Complexity | |||||||
Medium | 52 | (37.4) | 87 | (62.6) | 1.6 | 0.8–3.0 | 0.2 |
High | 17 | (27.4) | 45 | (72.6) | (ref) | ||
Type **** | |||||||
Pediatric ED | 35 | (34.7) | 66 | (65.3) | 1.0 | 0.4–2.4 | 1.0 |
Adult ED | 23 | (33.3) | 46 | (66.7) | 1.0 | 0.4–2.4 | 0.9 |
Combined general population ED ***** | 10 | (34.5) | 19 | (65.5) | (ref) |
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Sindahl, P.; Overgaard-Steensen, C.; Wallach-Kildemoes, H.; De Bruin, M.L.; Leufkens, H.G.; Kemp, K.; Gardarsdottir, H. Are Further Interventions Needed to Prevent and Manage Hospital-Acquired Hyponatraemia? A Nationwide Cross-Sectional Survey of IV Fluid Prescribing Practices. J. Clin. Med. 2020, 9, 2790. https://doi.org/10.3390/jcm9092790
Sindahl P, Overgaard-Steensen C, Wallach-Kildemoes H, De Bruin ML, Leufkens HG, Kemp K, Gardarsdottir H. Are Further Interventions Needed to Prevent and Manage Hospital-Acquired Hyponatraemia? A Nationwide Cross-Sectional Survey of IV Fluid Prescribing Practices. Journal of Clinical Medicine. 2020; 9(9):2790. https://doi.org/10.3390/jcm9092790
Chicago/Turabian StyleSindahl, Per, Christian Overgaard-Steensen, Helle Wallach-Kildemoes, Marie Louise De Bruin, Hubert GM Leufkens, Kaare Kemp, and Helga Gardarsdottir. 2020. "Are Further Interventions Needed to Prevent and Manage Hospital-Acquired Hyponatraemia? A Nationwide Cross-Sectional Survey of IV Fluid Prescribing Practices" Journal of Clinical Medicine 9, no. 9: 2790. https://doi.org/10.3390/jcm9092790