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The purpose of this study is to compare the effects of two different ways of stopping incubator humidification on episodes of hypothermia, hyperthermia, hyponatraemia, hypernatraemia, or skin injury. The design is a single site, two-armed, parallel, randomised, clinical trial conducted between April 2019 and March 2022. The setting was a quaternary referral and teaching hospital in Queensland, Australia. There were 140 extremely preterm infants, born < 28 weeks gestational age (GA). Intervention groups were (1) cease humidity: incubator humidification turned from 80% to off at 00.01am on day 8 of life ( n  = 70); or (2) gradually reduce humidity: incubator humidification reduced by 5% at 00:01 of each day from day 8 until ceased on day 14 ( n  = 70). The primary outcome was episodes of temperature instability: defined as either hypothermia < 36.5 °C or hyperthermia > 37.5 °C. Secondary outcomes included episodes of hyponatraemia: hypernatraemia or skin injury. One hundred forty infants were enrolled, 70 in each group. No statistically significant differences for any outcomes. Hyperthermia: 77% ( n  = 54) in the cease group and 73% ( n  = 51) in the gradual reduction group ( P  = 0.70). Hypothermia: 53% ( n  = 37) in the cease group and 37% ( n  = 26) in the gradual reduction group ( P  = 0.09). The number of hyponatraemic events was similar for both groups ( P  = 0.73), as for hypernatraemic events ( P  = 0.3). Skin injury in week 2 of life: 63% in the cease group and 67% in the gradual reduction group ( P  = 0.72). Conclusions : Ceasing or gradually reducing incubator humidification after day 7 of life had no effect on the number of episodes of hypothermia or hyperthermia in this cohort of extremely preterm infants (EPTI). There was also no effect on the number of episodes of hyponatraemia or hypernatraemia. Trial registration : ANZCTR.org.au (Australia New Zealand Clinical Trials Registry). ACTRN 1261 9000 266167 Registered 21/2/2019. What is Known: • Incubator humidification is a widely accepted and routine practice in the management of EPTI as it influences transepidermal water loss (TEWL) and supports thermoregulation. However, weaning practices remain varied and inconsistent across the globe. • There remains a paucity of data to inform specific evidenced-based humidification practices. What is New: • Ceasing or gradually reducing incubator humidification after 7 days had no effect on temperature stability, serum sodium levels, or frequency of skin injury in this cohort of EPTI between day 8 and day 14. • There is no apparent benefit in prolonging incubator humidity beyond day 7 of life in these EPTI.

IntroductionHypernatraemia, defined as a plasma sodium concentration >145 mmol/L, is a frequent complication in critically ill patients treated in the intensive care unit (ICU) (= ICU-acquired hypernatraemia), with reported prevalence ranging from 4% to 26%. Hypernatraemia adversely affects various physiological functions and is associated with delirium, prolonged length of stay and increased ICU and post-discharge mortality. The sodium load from intravenous drug diluents significantly contributes to ICU-acquired hypernatraemia, with drug infusions comprising about 30% of the daily fluid volume of an average ICU patient. This study aims to investigate if using glucose 5% solution as the default drug diluent, instead of sodium chloride 0.9%, can reduce the prevalence of ICU-acquired hypernatraemia and improve patient outcomes.Methods and analysisTo test the effectiveness of glucose 5% solution as the default drug diluent, we will conduct a multicentre, pragmatic, embedded, open-label, stepped-wedge, cluster-randomised trial. The study will include twelve clusters (ICUs and one intermediate care unit) across six hospitals in Germany, with a projected total sample size of 4485 patients. In line with the stepped-wedge cluster-randomised design, one ICU will transition every 4 weeks, in a randomised sequence, from using sodium chloride 0.9% as the default drug diluent to glucose 5%.The primary endpoint is the prevalence of hypernatraemia >150 mmol/L through day 28. The number of days alive and free of the ICU through day 28 will be tested hierarchically as a key secondary endpoint. Other exploratory endpoints include ICU mortality, ICU-free days, hospital-free days and other clinical outcomes. The primary endpoint will be analysed using a logistic mixed-effects model.Ethics and disseminationThe trial was approved by the Charité—Universitätsmedizin Berlin Ethics Board and by the ethics board of each enrolled hospital. The results will be submitted for publication in a peer-reviewed journal and presented at one or more scientific conferences.Trial registration numberThe trial protocol was registered with the German Clinical Trials Register on 21 June 2024 prior to initiation of patient enrolment (DRKS00033397).

This article provides a comprehensive overview of electrolyte and water homeostasis in pediatric patients, focusing on some of the common serum electrolyte abnormalities encountered in clinical practice. Understanding pathophysiology, taking a detailed history, performing comprehensive physical examinations, and ordering basic laboratory investigations are essential for the timely proper management of these conditions. We will discuss the pathophysiology, clinical manifestations, diagnostic approaches, and treatment strategies for each electrolyte disorder. This article aims to enhance the clinical approach to pediatric patients with electrolyte imbalance-related emergencies, ultimately improving patient outcomes. Trial registration This manuscript does not include a clinical trial; instead, it provides an updated review of literature.

To explore the relationship between hypernatremia and 28-day mortality in elderly sepsis patients. A total of 179 elderly patients (age ≥65 years) with elevated serum sodium admitted to the Department of Critical Care Medicine of Nanjing Hospital affiliated with Nanjing Medical University from September 2021 to September 2022 were included in this retrospective observational study. The clinical data of all patients were collected, and the patients were divided into septic group and nonseptic groups according to the Sepsis 3.0 definition. The clinical features, acute physiological and chronic health II score (APACHE II score), mechanical ventilation time, serum sodium value and duration of serum sodium elevation were compared between the two groups. ROC curves were drawn to evaluate the predictive value of each index on the prognosis of sepsis patients, and Kaplan‒Meier survival analysis was carried out on patients with different serum sodium peaks. (1) The changes in serum sodium within 48 hours after admission in the sepsis group were small and statistically significant compared with those in the nonsepsis group (P = 0.039); however, the serum sodium elevation duration was longer (P = 0.018). (2) Compared with nonseptic patients, the 7-day mortality of septic patients was higher (15.8 vs. 7.7, P<0.001). The 28-day mortality of septic patients was higher than that of nonseptic patients, but there was no significant difference between the two groups (P = 0.086). (3) The serum sodium level in the sepsis group was higher than that in the nonsepsis group on the 1st, 3rd, 5th and 7th days (P<0.001). There was no significant difference in mechanical ventilation time or duration of stay in the ICU between the two groups. (4) The ROC curve analysis showed that the peak value of serum sodium had predictive value for the prognosis severity of elderly patients with sepsis. The area under the curve (AUC) was 0.753, the 95% confidence interval (95% CI) was 0.639~0.867, and the best cut-off value was 154.9 mmol/L. (5) According to the best cut-off value of the serum sodium peak, the septic patients were divided into two groups: the peak value of serum sodium was ≥154.9 mmol/L (group A), and the peak value of serum sodium was <154.9 mmol/L (group B). Among them, the case fatality rate was higher at 7 days and 28 days when the peak value of serum sodium was ≥154.9 mmol/L (group A) (22.0% vs. 8.6%); the χ2 value was 35.379, P<0.05; 75.6% vs. 37.1%, χ2 = 14.21, P = 0.003). There was no significant difference in mechanical ventilation time or duration of stay in the ICU between the two groups. (6) Kaplan‒Meier survival analysis showed that the median survival time of patients with a serum sodium peak ≥154.9 mmol/L (group A) was significantly shorter than that of patients with a serum sodium peak < 154.9 mmol/L (group B) (16.7±1.4 d vs. 24.8±1.2 d, P <0.05). The serum sodium increase in elderly sepsis patients lasts for a long time, and the serum sodium fluctuation is relatively small. The serum sodium peak value has predictive value for 28-day mortality.

Abstract Context Dysnatremia is an independent predictor of mortality in patients with bacterial pneumonia. There is paucity of data about the incidence and prognostic impact of abnormal sodium concentration in patients with coronavirus disease 2019 (COVID-19). Objective This work aimed to examine the association of serum sodium during hospitalization with key clinical outcomes, including mortality, need for advanced respiratory support and acute kidney injury (AKI), and to explore the role of serum sodium as a marker of inflammatory response in COVID-19. Methods This retrospective longitudinal cohort study, including all adult patients who presented with COVID-19 to 2 hospitals in London over an 8-week period, evaluated the association of dysnatremia (serum sodium < 135 or > 145 mmol/L, hyponatremia, and hypernatremia, respectively) at several time points with inpatient mortality, need for advanced ventilatory support, and AKI. Results The study included 488 patients (median age, 68 years). At presentation, 24.6% of patients were hyponatremic, mainly due to hypovolemia, and 5.3% hypernatremic. Hypernatremia 2 days after admission and exposure to hypernatremia at any time point during hospitalization were associated with a 2.34-fold (95% CI, 1.08-5.05; P = .0014) and 3.05-fold (95% CI, 1.69-5.49; P < .0001) increased risk of death, respectively, compared to normonatremia. Hyponatremia at admission was linked with a 2.18-fold increase in the likelihood of needing ventilatory support (95% CI, 1.34-3.45, P = .0011). Hyponatremia was not a risk factor for in-hospital mortality, except for the subgroup of patients with hypovolemic hyponatremia. Sodium values were not associated with the risk for AKI and length of hospital stay. Conclusion Abnormal sodium levels during hospitalization are risk factors for poor prognosis, with hypernatremia and hyponatremia being associated with a greater risk of death and respiratory failure, respectively. Serum sodium values could be used for risk stratification in patients with COVID-19.

BackgroundThe worldwide spread of SARS-CoV-2 has infected millions of people leading to over 0.3 million mortalities. The disruption of sodium homeostasis, tends to be a common occurrence in patients with COVID-19.Methods and resultsA total of 1,254 COVID-19 patients comprising 124 (9.9%) hyponatremic patients (under 135 mmol/L) and 30 (2.4%) hypernatremic patients (over 145 mmol/L) from three hospitals in Hubei, China, were enrolled in the study. The relationships between sodium balance disorders in COVID-19 patients, its clinical features, implications, and the underlying causes were presented. Hyponatremia patients were observed to be elderly, had more comorbidities, with severe pneumonic chest radiographic findings. They were also more likely to have a fever, nausea, higher leukocyte and neutrophils count, and a high sensitivity C-reactive protein (HS-CRP). Compared to normonatremia patients, renal insufficiency was common in both hyponatremia and hypernatremia patients. In addition, hyponatremia patients required extensive treatment with oxygen, antibiotics, and corticosteroids. The only significant differences between the hypernatremia and normonatremia patients were laboratory findings and clinical complications, and patients with hypernatremia were more likely to use traditional Chinese medicine for treatment compared to normonatremia patients. This study indicates that severity of the disease, the length of stay in the hospital of surviving patients, and mortality were higher among COVID-19 patients with sodium balance disorders.ConclusionSodium balance disorder, particularly hyponatremia, is a common condition among hospitalized patients with COVID-19 in Hubei, China, and it is associated with a higher risk of severe illness and increased in-hospital mortality.

Dysnatremias are among the most common electrolyte abnormalities encountered in hospitalized patients. In most cases, a dysnatremia results from improper fluid management. Dysnatremias can occasionally result in death or permanent neurological damage, a tragic complication that is usually preventable. In this manuscript, we discuss the epidemiology, pathogenesis and prevention and treatment of dysnatremias in children. We report on over 50 patients who have suffered death or neurological injury from hospital-acquired hyponatremia. The main factor contributing to hyponatremic encephalopathy in children is the routine use of hypotonic fluids in patients who have an impaired ability to excrete free-water, due to such causes as the postoperative state, volume depletion and pulmonary and central nervous system diseases. The appropriate use of 0.9% sodium chloride in parenteral fluids would likely prevent most cases of hospital-acquired hyponatremic encephalopathy. We report on 15 prospective studies in over 500 surgical patients that demonstrate that normal saline effectively prevents postoperative hyponatremia, and hypotonic fluids consistently result in a fall in serum sodium. Hyponatremic encephalopathy is a medical emergency that should be treated with hypertonic saline, and should never be managed with fluid restriction alone. Hospital-acquired hypernatremia occurs in patients who have restricted access to fluids in combination with ongoing free-water losses. Hypernatremia could largely be prevented by providing adequate free-water to patients who have ongoing free-water losses or when mild hypernatremia (Na>145 mE/l) develops. A group at high-risk for neurological damage from hypernatremia in the outpatient setting is that of the breastfed infant. Breastfed infants must be monitored closely for insufficient lactation and receive lactation support. Judicious use of infant formula supplementation may be called for until problems with lactation can be corrected.

Hypernatremia is a common postoperative complication after pituitary adenoma surgery. Despite its prevalence, there is a significant gap in research regarding the construction of predictive models for assessing risk. Therefore, it is essential to create a robust model to accurately predict the risk of postoperative hypernatremia. To explore the risk factors for developing hypernatremia after pituitary adenoma surgery and establish a prediction model. From April 2022 to June 2024, 269 patients were admitted to the Department of Neurosurgery at Qilu Hospital as part of this cohort study. Initially, the sample was split into a training set and a validation set using a ratio of 3:1 randomly. Then, a univariable analysis was conducted for each variable in the training set. Subsequently, the Least Absolute Shrinkage and Selection Operator (LASSO) regression and stepwise regression were employed to identify the candidate variables for further examination. A multivariable logistic regression analysis was then performed to develop a risk prediction model. A nomogram was created to enhance the model’s utility, and the Hosmer-Lemeshow (HL) test was implemented to evaluate the model’s goodness of fit. The predictive efficiency of the model was assessed by calculating the area under the receiver operating characteristic curve (AUC), while model discrimination was determined using the calibration plot and decision curve analysis (DCA). This study indicated that the overall incidence of hypernatremia after pituitary surgery is 8.55%. We collected data on 46 potential risk factors. After LASSO regression, we constructed three models: LR model (LASSO regression), FR model (forward stepwise regression), and BR model (backward stepwise regression). The multivariable analysis identified that LR model, including pituitary stalk involvement, surgery time, and output 1st day, is the most effective at predicting postoperative hypernatremia. The HL test of LR model indicated a p -value of 0.448, and the AUC value was 0.813. In the test set, the AUC was 0.894. The calibration plots and DCA plots demonstrate substantial clinical relevance. Additionally, we developed a nomogram for predicting hypernatremia after pituitary surgery based on this regression model. The prediction model serves as a clinically valuable tool for identifying patients at heightened risk of postoperative hypernatremia following pituitary surgery, facilitating timely implementation of prophylactic management protocols to optimize clinical outcomes.

Introduction This clinical case reports a neonatal osmotic demyelination syndrome associated with iatrogenic hypernatremia. Case presentation A 13-day-old neonate initially admitted to the hospital with poorly tolerated fever due to enterovirus meningitis developed severe hypernatremia (184 mmol/L) following an error in fluid therapy, which was complicated by extra-pontine demyelination syndrome (subtype of osmotic demyelination syndrome). The child presented with nonspecific neurological symptoms of irritability, tremors and convulsions. Natremia was slowly corrected by hyperhydration within 26.5 h. Brain imaging revealed lesions consistent with extra-pontine demyelination. At 3 months, both clinical signs and MRI lesions had markedly regressed. Conclusion Sudden osmolar variations can induce osmotic demyelination syndrome. Few cases have been reported in the pediatric population but none in the neonatal period to our knowledge. Measures to prevent sudden changes in osmolarity are critical to prevent poor neurological outcomes. Dysnatremia correction rates must be strictly controlled and customized according to the presence of neurological symptoms, the severity of sodium fluctuation, and the course of tonicity imbalance.

Hyponatremia and hypernatremia are common findings in the inpatient and outpatient settings. Sodium disorders are associated with an increased risk of morbidity and mortality. Plasma osmolality plays a critical role in the pathophysiology and treatment of sodium disorders. Hyponatremia and hypernatremia are classified based on volume status (hypovolemia, euvolemia, and hypervolemia). Sodium disorders are diagnosed by findings from the history, physical examination, laboratory studies, and evaluation of volume status. Treatment is based on symptoms and underlying causes. In general, hyponatremia is treated with fluid restriction (in the setting of euvolemia), isotonic saline (in hypovolemia), and diuresis (in hypervolemia). A combination of these therapies may be needed based on the presentation. Hypertonic saline is used to treat severe symptomatic hyponatremia. Medications such as vaptans may have a role in the treatment of euvolemic and hypervolemic hyponatremia. The treatment of hypernatremia involves correcting the underlying cause and correcting the free water deficit.