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Meta-Analysis
. 2014 Dec 18;2014(12):CD009457.
doi: 10.1002/14651858.CD009457.pub2.

Isotonic versus hypotonic solutions for maintenance intravenous fluid administration in children

Sarah McNab  1 , Robert S Ware, Kristen A Neville, Karen Choong, Mark G Coulthard, Trevor Duke, Andrew Davidson, Tavey Dorofaeff
Affiliations
Meta-Analysis

Isotonic versus hypotonic solutions for maintenance intravenous fluid administration in children

Sarah McNab et al. Cochrane Database Syst Rev. .

Abstract

Background: Maintenance intravenous fluids are frequently used in hospitalised children who cannot maintain adequate hydration through enteral intake. Traditionally used hypotonic fluids have been associated with hyponatraemia and subsequent morbidity and mortality. Use of isotonic fluid has been proposed to reduce complications.

Objectives: To establish and compare the risk of hyponatraemia by systematically reviewing studies where isotonic is compared with hypotonic intravenous fluid for maintenance purposes in children.Secondly, to compare the risk of hypernatraemia, the effect on mean serum sodium concentration and the rate of attributable adverse effects of both fluid types in children.

Search methods: We ran the search on 17 June 2013. We searched the Cochrane Injuries Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), MEDLINE (OvidSP), Embase (OvidSP), and ISI Web of Science. We also searched clinical trials registers and screened reference lists. We updated this search in October 2014 but these results have not yet been incorporated.

Selection criteria: We included randomised controlled trials that compared isotonic versus hypotonic intravenous fluids for maintenance hydration in children.

Data collection and analysis: At least two authors assessed and extracted data for each trial. We presented dichotomous outcomes as risk ratios (RR) with 95% confidence intervals (CIs) and continuous outcomes as mean differences with 95% CIs.

Main results: Ten studies met the inclusion criteria, with a total of 1106 patients. The majority of the studies were performed in surgical or intensive care populations (or both). There was considerable variation in the composition of intravenous fluid, particularly hypotonic fluid, used in the studies. There was a low risk of bias for most of the included studies. Ten studies provided data for our primary outcome, a total of 449 patients in the analysis received isotonic fluid, while 521 received hypotonic fluid. Those who received isotonic fluid had a substantially lower risk of hyponatraemia (17% versus 34%; RR 0.48; 95% CI 0.38 to 0.60, high quality evidence). It is unclear whether there is an increased risk of hypernatraemia when isotonic fluids are used (4% versus 3%; RR 1.24; 95% CI 0.65 to 2.38, nine studies, 937 participants, low quality evidence), although the absolute number of patients developing hypernatraemia was low. Most studies had safety restrictions included in their methodology, preventing detailed investigation of serious adverse events.

Authors' conclusions: Isotonic intravenous maintenance fluids with sodium concentrations similar to that of plasma reduce the risk of hyponatraemia when compared with hypotonic intravenous fluids. These results apply for the first 24 hours of administration in a wide group of primarily surgical paediatric patients with varying severities of illness.

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Conflict of interest statement

Sarah McNab, Trevor Duke and Andrew Davidson have been involved in the design and conduct of a trial (McNab 2014), which would potentially be eligible for future revisions of this Cochrane Review.

Mark Coulthard, Robert Ware, Karen Choong and Kristen Neville were involved in the design and conduct of studies included in this Cochrane Review. We did not extract outcome or quality data from the studies we co‐author.

Tavey Dorofaeff: None known.

Figures

1
1
Study flow diagram.
1.1
1.1. Analysis
Comparison 1 Isotonic versus hypotonic, Outcome 1 Hyponatraemia.
1.2
1.2. Analysis
Comparison 1 Isotonic versus hypotonic, Outcome 2 Hypernatraemia.
1.3
1.3. Analysis
Comparison 1 Isotonic versus hypotonic, Outcome 3 Mean serum sodium T6‐T12.
1.4
1.4. Analysis
Comparison 1 Isotonic versus hypotonic, Outcome 4 Mean serum sodium at T > T12 to T24.
1.5
1.5. Analysis
Comparison 1 Isotonic versus hypotonic, Outcome 5 Death.
1.6
1.6. Analysis
Comparison 1 Isotonic versus hypotonic, Outcome 6 Seizures.
1.7
1.7. Analysis
Comparison 1 Isotonic versus hypotonic, Outcome 7 Cerebral oedema.
1.8
1.8. Analysis
Comparison 1 Isotonic versus hypotonic, Outcome 8 Overhydration.
1.9
1.9. Analysis
Comparison 1 Isotonic versus hypotonic, Outcome 9 Urine osmolarity at T24.
1.10
1.10. Analysis
Comparison 1 Isotonic versus hypotonic, Outcome 10 Urinary sodium concentration at T24.
1.11
1.11. Analysis
Comparison 1 Isotonic versus hypotonic, Outcome 11 Hyponatraemia (by concentration of hypotonic fluid).
1.12
1.12. Analysis
Comparison 1 Isotonic versus hypotonic, Outcome 12 Hyponatraemia (surgical/medical).
1.13
1.13. Analysis
Comparison 1 Isotonic versus hypotonic, Outcome 13 Hyponatraemia (by fluid rate).
1.14
1.14. Analysis
Comparison 1 Isotonic versus hypotonic, Outcome 14 Hyponatraemia (by age).
1.15
1.15. Analysis
Comparison 1 Isotonic versus hypotonic, Outcome 15 Hyponatraemia (by severity of illness).
1.16
1.16. Analysis
Comparison 1 Isotonic versus hypotonic, Outcome 16 Sensitivity analysis ‐ balanced fluid rates.
1.17
1.17. Analysis
Comparison 1 Isotonic versus hypotonic, Outcome 17 Sensitivity analysis ‐ normonatraemic at baseline.
See this image and copyright information in PMC

Comment in

References

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