Impact of Dysnatremia on Pediatric Intensive Care Mortality

Year 2025, Volume: 19 Issue: 2, 82 - 86, 24.03.2025

Sevgin Taner , Nilgün Çakar

Abstract

Objective: Fragile nature of the patients in the pediatric intensive care unit (PICU) can lead to severe electrolyte imbalances with life-threatening consequences. Dysnatremia is one of the most common disorders in this setting. This study aimed to investigate the causes, severity and concomitant diseases of dysnatremia in the PICU and factors affecting mortality in these patients.

Material and Methods: This study was carried out between March 2013 and October 2014 in Ankara Children’s Hematology Oncology Training and Research Hospital. The patients admitted to PICU between 1 month and 18 years of age were included in the study. Hypernatremic patients were grouped as mild (145>Na≥160 mEq/L) and severe (Na>160 mEq/L); and hyponatremic patients were also grouped as mild (120≤Na <135 mEq/L) and severe (Na<120 mEq/L).

Results: Out of the 101 dysnatremic patients (57 male/ 44 female) with a mean age of 79±71 months, 60% had hypernatremia, 40% had hyponatremia. Eighty-nine (88.1%) of the dysnatremic patients had comorbid chronic diseases, with central nervous system (CNS) disorders as the leading cause. The overall mortality rate of PICU was 17%, and the mortality rate of dysnatremic patients was 53%. The presence of concomitant chronic diseases was associated with increased mortality [OR, 3.84 (CI %95, 0.9-15.1)]. Mortality was more common in patients with severe and uncorrected hypernatremia, respectively (p=0.005, p=0.010).

Conclusion: Dysnatremia is frequent in PICU. The presence of chronic comorbidities, severe and uncorrected dysnatremia increases the risk of mortality in the PICU. Awareness of this risk is important to improve survival in these vulnerable population.

Keywords

hyponatremia, hypernatremia, cerebral salt wasting, diabetes insipidus

References

• Evans IVR, Joyce EL. Fluid and electrolyte issues in pediatric critical illness. In Zimmerman JJİ Zotta AT (eds). Fuhrman and Zimmerman’s Pediatric Critical Care. 6th ed. Philadelphia: Elsevier, 2021:866-81.
• Rosner MH, Ronco C. Dysnatremias in the intensive care unit. Contrib Nephrol 2010; 165:292-8.
• Pokaharel M, Block CA. Dysnatremia in the ICU. Curr Opin Crit Care 2011;17:581-93.
• Sterns RH. Disorders of plasma sodium--causes, consequences, and correction. N Engl J Med 2015;372:55-65.
• Darmon M, Pichon M, Schwebel C, Ruckly S, Adrie C, Haouache H, et al. Influence of early dysnatremia correction on survival of critically ill patients. Shock 2014;41:394-9.
• Hutto C, French M. Neurologic Intensive Care Unit Electrolyte Management. Nurs Clin North Am 2017;52:321-9.
• Darmon M, Diconne E, Souweine B, Ruckly S, Adrie C, Azoulay E, et al. Prognostic consequences of borderline dysnatremia: pay attention to minimal serum sodium change. Crit Care 2013;17:R12.
• Hauser GJ, Kulick AF. Electrolyte Disorders in the PICU. In Wheeler DS, Wong HR, Shanley TP eds. Pediatric Critical Care Medicine. 2nd ed. London: Springer Verlac, 2014;147-71.
• Lindner G, Funk G-C, Schwarz C, Kneidinger N, Kaider A, Schneeweiss B, et al. Hypernatremia in the critically ill is an independent risk factor for mortality. Am J Kidney Dis 2007:50:952-7.
• Greenbaum LA. Fluid and Electrolyte Disorders. In Kliegman RM, St Geme III JW (eds). Nelson Textbook of Pediatrics. 22nd ed. Philadelphia: Elsevier 2024:485-25.
• Thongprayoon C, Cheungpasitporn W, Petnak T, Miao J, Qian Q. Increased short-term and long-term mortality in community- and hospital-acquired hypernatraemia and in patients with delayed serum sodium correction. Int J Clin Pract 2021;75:e14590.
• Palevsky PM, Bhagrath R, Greenberg A. Hypernatremia in hospitalized patients. Ann Intern Med 1996;27:1041–2.
• Olsen MH, Møller M, Romano S, Andersson J, Mlodzinski E, Raines NH, Sherak R, Jeppesen AN. Association Between ICU-Acquired Hypernatremia and In-Hospital Mortality: Data From the Medical Information Mart for Intensive Care III and the Electronic ICU Collaborative Research Database. Crit Care Explor 2020;2:e0304.
• Moritz ML, Ayus JC. The changing pattern of hypernatremia in hospitalized children. Pediatrics 1999;104:435-9.
• Dunn K, Butt K. Extreme sodium derangement in a paediatric inpatient population. J Paediatr Child Health 1997;33:26 –30.
• Mapata L, Richards GA, Laher AE. Hypernatremia at a Tertiary Hospital Intensive Care Unit in South Africa. Cureus 2022;14:e22648.
• Waikar SS, Mount DB, Curhan GC. Mortality after hospitalization with mild, moderate, and severe hyponatremia. Am J Med 2009;122:857-65.
• Oude Lansink-Hartgring A, Hessels L, Weigel J, de Smet AMGA, Gommers D, Panday PVN, Hoorn EJ, Nijsten MW. Long-term changes in dysnatremia incidence in the ICU: a shift from hyponatremia to hypernatremia. Ann Intensive Care 2016;622.
• Karlsson J, Johansen M. Dysnatremia in children, why is it so hard to stay normal? Acta Anaesthesiol Scand 2022;66:548-9.
• Sümpelmann R, Becke K, Zander R, Witt L. Perioperative fluidmanagement in children: can we sum it all up now? Curr OpinAnaesthesiol 2019;32:384-91.
• Verbalis JG, Greenberg A, Burst V, Haymann JP, Johannsson G, Peri A, et al. Diagnosing and Treating the Syndrome of Inappropriate Antidiuretic Hormone Secretion. Am J Med 2016;129:537.
• Sachdev A, Pandharikar N, Gupta D, Gupta N, Gupta S, Venkatraman ST. Hospital-acquired Hyponatremia in Pediatric Intensive Care Unit. Indian J Crit Care Med 2017;21:599-603.
• Grim CCA, Termorshuizen F, Bosman RJ, Cremer OL, Meinders AJ, Nijsten MWN, et al. Association Between an Increase in Serum Sodium and In-Hospital Mortality in Critically Ill Patients. Crit Care Med 2021;49:2070-9.
• Mai G, Lee JH, Caporal P, Roa G JD, González-Dambrauskas S, Zhu Y, et al. Initial dysnatremia and clinical outcomes in pediatric traumatic brain injury: a multicenter observational study. Acta Neurochir 2024;166:82.
• Ng PY, Cheung RYT, Ip A, Chan WM, Sin WC, Yap DY. A retrospective cohort study on the clinical outcomes of patients admitted to intensive care units with dysnatremia. Sci Rep 2023;13:21236.
• Harrois A, Anstey JR, van der Jagt M, Taccone FS, Udy AA, Citerio G, et al. Variability in Serum Sodium Concentration and Prognostic Significance in Severe Traumatic Brain Injury: A Multicenter Observational Study. Neurocrit Care 2021;34:899-907.
• Pokaharel M, Block CA. Dysnatremia in the ICU. Curr Opin Crit Care 2011;17:581-93.
• Stelfox HT, Ahmed SB, Khandwala F, Zygun D, Shahpori R, Laupland K. The epidemiology of intensive care unit-acquired hyponatremia and hypernatremia in medical-surgical intensive care units. Critical Care 2008;12:R162.
• Arzhan S, Roumelioti ME, Litvinovich I, Bologa CG, Unruh ML. Outcomes of Hospital-Acquired Hypernatremia. Clin J Am Soc Nephrol 2023;18:1396-407.
• Alansari MA, Abdulmomen A, Hussein M, Zubaidi AM, Alswaiti JT. Acquired hypernatremia in a general surgical Intensive Care Unit: Incidence and prognosis. Saudi J Anaesth 2016;10:409-13.
• Güçyetmez B, Ayyıldız AC, Ogan A, Guder BY, Ozçobanoğlu S, Ayyıldız A, et al. Dysnatremia on intensive care unit admission is a stronger risk factor when associated with organ dysfunction. Minerva Anestesiol 2014;80:1096-104.
• Topjian AA, Stuart A, Pabalan AA, Clair A, Kilbaugh TJ, Abend NS, et al. Greater fluctuations in serumsodiumlevels are associated with increasedmortality in children with externalized ventriculostomy drains in a PICU. Pediatr Crit Care Med 2014;15:846–55.
• Tauseef A, Zafar M, Syed E, Thirumalareddy J, Sood A, Lateef N, et al. Prognostic importance of deranged sodium level in critically ill patients: A systemic literature to review. J Family Med Prim Care 2021;10:2477-81.
• Hu J, Wang Y, Geng X, Chen R, Zhang P, Lin J, et al. Dysnatremia is an Independent Indicator of Mortality in Hospitalized Patients. Med Sci Monit 2017;23:2408-25.
• Wang J, Zhou W, Yin X. Improvement of hyponatremia is associated with lower mortality risk in patients with acute decompensated heart failure: a meta-analysis of cohort studies. Heart Fail Rev 2019;24:209-17.