背景:医源性低钠血症是住院儿童静脉维持液治疗(IV-MFT)后的常见并发症。尽管美国儿科学会2018年的建议,IV-MFT处方实践仍然有很大差异。
目的:本荟萃分析旨在比较等渗和低渗IV-MFT在住院儿童中的安全性和有效性。
方法:我们搜索了PubMed,Scopus,WebofScience,和CochraneCentral从成立到2022年10月1日。
方法:我们纳入了在住院儿童中比较等渗和低渗IV-MFT的随机对照试验(RCT),无论是医疗还是手术条件。我们的主要结果是IV-MFT后低钠血症。次要结果包括高钠血症,血清钠,血清钾,血清渗透压,血液pH值,血糖,血清肌酐,血清氯化物,尿钠,住院时间,和不良后果。
方法:使用随机效应模型汇集提取的数据。我们根据液体给药的持续时间进行了分析(即,≤24且>24小时)。建议评估发展和评估等级(GRADE)量表用于评估建议证据的强度和水平。
结果:总共33项RCT,包括5049名患者。等渗IV-MFT显著降低≤24h时轻度低钠血症的风险(RR=0.38,95%CI[0.30,0.48],P<0.00001;证据质量高)和>24小时(RR=0.47,95%CI[0.37,0.62],P<0.00001;证据质量高)。在大多数检查的亚组中,等渗液的这种保护作用得以维持。等渗IV-MFT显著增加新生儿高钠血症的风险(RR=3.74,95%CI[1.42,9.85],P=0.008)。此外,在≤24h时血清肌酐显着增加(MD=0.89,95%CI[0.84,0.94],P<0.00001)和血液pH降低(MD=-0.05,95%CI[-0.08至-0.02],P=0.0006)。平均血清钠,血清渗透压,在≤24h时,低张组的血清氯化物较低。两种液体在血清钾方面具有可比性,住院时间,血糖,以及不良后果的风险。
结论:我们研究的主要限制是纳入研究的异质性。
结论:在降低住院儿童医源性低钠血症的风险方面,等渗性IV-MFT优于低渗性IV-MFT。然而,它增加了新生儿高钠血症的风险,并可能导致肾功能不全。鉴于高钠血症的风险即使在新生儿中也不重要,我们建议在住院儿童中使用平衡等渗IV-MFT,因为与0.9%生理盐水相比,肾脏对MFT的耐受性更好.
■CRD42022372359。图形摘要更高分辨率的图形摘要版本可作为补充信息提供。
BACKGROUND: Iatrogenic hyponatremia is a common complication following intravenous maintenance fluid therapy (IV-MFT) in hospitalized children. Despite the American Academy of Pediatrics\' 2018 recommendations, IV-MFT prescribing practices still vary considerably.
OBJECTIVE: This meta-analysis aimed to compare the safety and efficacy of isotonic versus
hypotonic IV-MFT in hospitalized children.
METHODS: We searched PubMed, Scopus, Web of Science, and Cochrane Central from inception to October 1, 2022.
METHODS: We included randomized controlled trials (RCTs) comparing isotonic versus
hypotonic IV-MFT in hospitalized children, either with medical or surgical conditions. Our primary outcome was hyponatremia following IV-MFT. Secondary outcomes included hypernatremia, serum sodium, serum potassium, serum osmolarity, blood pH, blood sugar, serum creatinine, serum chloride, urinary sodium, length of hospital stay, and adverse outcomes.
METHODS: Random-effects models were used to pool the extracted data. We performed our analysis based on the duration of fluid administration (i.e., ≤ 24 and > 24 h). The Grades of Recommendations Assessment Development and Evaluation (GRADE) scale was used to evaluate the strength and level of evidence for recommendations.
RESULTS: A total of 33 RCTs, comprising 5049 patients were included. Isotonic IV-MFT significantly reduced the risk of mild hyponatremia at both ≤ 24 h (RR = 0.38, 95% CI [0.30, 0.48], P < 0.00001; high quality of evidence) and > 24 h (RR = 0.47, 95% CI [0.37, 0.62], P < 0.00001; high quality of evidence). This protective effect of isotonic fluid was maintained in most examined subgroups. Isotonic IV-MFT significantly increased the risk of hypernatremia in neonates (RR = 3.74, 95% CI [1.42, 9.85], P = 0.008). In addition, it significantly increased serum creatinine at ≤ 24 h (MD = 0.89, 95% CI [0.84, 0.94], P < 0.00001) and decreased blood pH (MD = -0.05, 95% CI [-0.08 to -0.02], P = 0.0006). Mean serum sodium, serum osmolarity, and serum chloride were lower in the
hypotonic group at ≤ 24 h. The two fluids were comparable in terms of serum potassium, length of hospital stay, blood sugar, and the risk of adverse outcomes.
CONCLUSIONS: The main limitation of our study was the heterogeneity of the included studies.
CONCLUSIONS: Isotonic IV-MFT was superior to the
hypotonic one in reducing the risk of iatrogenic hyponatremia in hospitalized children. However, it increases the risk of hypernatremia in neonates and may lead to renal dysfunction. Given that the risk of hypernatremia is not important even in the neonates, we propose to use balanced isotonic IV-MFT in hospitalized children as it is better tolerated by the kidneys than 0.9% saline.
UNASSIGNED: CRD42022372359. Graphical abstract A higher resolution version of the Graphical abstract is available as Supplementary information.