Assessment of Association between Rapid Fluctuations in Serum Sodium and Intraventricular Hemorrhage in Hypernatremic Preterm Infants Ronald E. Dechert, DPH, RRT1
1 Division of Neonatology, C. S. Mott Children’s Hospital, University of
Michigan Health System, Ann Arbor, Michigan Am J Perinatol 2015;32:795–802.
► extremely low birth weight ► preterm infants ► hypernatremia ► intraventricular hemorrhage
Subrata Sarkar, MD1 Address for correspondence Subrata Sarkar, MD, Division of Neonatology, C. S. Mott Children’s Hospital, University of Michigan Health System, 1540 East Medical Center Drive, 8-621 C&W Mott, Ann Arbor, MI 48109 (e-mail: [email protected]
Aim This study aims to determine the association between the rapid ﬂuctuations in serum sodium and intraventricular hemorrhage (IVH) or death in hypernatremic preterm infants. Study Design Single center observational study including 216 infants < 1,000 g birth weight and 200 mg/dL), and the ΔpCO2 (the difference between highest and lowest pCO2). Clinical outcomes that reﬂect the overall illness severity included presence or absence of any IVH, day of life of IVH detection on screening cranial ultrasound, grade of IVH, severe IVH or death by day 10, cystic periventricular leukomalacia, surgery for NEC, bronchopulmonary dysplasia deﬁned as a persistent oxygen requirement at postmenstrual age of 36 weeks corrected, and death before discharge. IVH on screening cranial ultrasounds was graded by the Papile classiﬁcation system, with grades III and IV being categorized as severe.22 Serum sodium levels were measured at least every 12 hours in the infants included in the study. The highest serum sodium level during the ﬁrst 10 days of life was recorded along with the day of life of the highest serum sodium level. In the hypernatremic infants with serum sodium 150 mmol/L, the maximum rate of rise and fall of serum sodium were also calculated. The rate of rise in serum sodium in hypernatremic infants was calculated by taking the difference between a series of two consecutive serum sodium values starting from a serum sodium of 150 mmol/L until the serum sodium reached maximum in a given patient and dividing this number by the time (in hours) between two sample collections. The maximum rate between two consecutive serum sodium values from the series of rates of rise in serum sodium was noted and this maximum rate was then multiplied by 24 to obtain the rate of rise in mmol/L/d. Similarly, the rate of fall in serum sodium was calculated by taking the difference between a series of two consecutive serum sodium values starting from the maximum serum sodium value until the time serum sodium decreased to 13 mmol/L over an extended period of 3 days. They deﬁned changes in the serum sodium level as the differences between the highest and lowest serum sodium levels in both hypernatremic and normonatremic infants observed during the ﬁrst 3 days of life. We looked at the changes in serum sodium levels in hours between a series of two consecutive serum sodium values only during the period of hypernatremia, and compared the development of IVH with and without rapid ﬂuctuation in serum sodium only in the hypernatremic cohort of infants during the ﬁrst 10 days of life, which may explain why our results are different from that study. From our data, although ﬂuctuation in serum sodium to the extent of 10 or 15 mmol/L/d did not appear to be associated with adverse primary or secondary outcomes, a more conservative strategy of correction of the serum sodium in hypernatremic ELBW infants not exceeding 10 to 15 mmol/ L/d (which falls within the safe range of changes in serum sodium recommended for term neonates and older infants during correction of hypernatremic dehydration) seems appropriate. Further prospective studies are preferable to conAmerican Journal of Perinatology
ﬁrm if such ﬂuctuation of serum sodium is safe for hypernatremic preterm infants. However, given the risk of IVH in association with hypernatremia it is unlikely that there will be a prospective trial to assess the risk of IVH by allowing stepwise increase in the severity of hypernatremia or with different rate of correction of hypernatremia in hypernatremic preterm infants. Data such as this may be the closest we get to assess the relationship between the degree of ﬂuctuation in serum sodium and the IVH in hypernatremic preterm infants. In conclusion, hypernatremia per se, but not the rate of rise or fall in serum sodium (not exceeding 10–15 mmol/L/d) was independently associated with any IVH, or severe IVH or death during the ﬁrst 10 days of life. It therefore seems appropriate to follow the same guidelines that have been used in term neonates and older infants to treat hypernatremia in ELBW preterm infants as well.
Conﬂict of Interest The authors declare no conﬂict of interest.
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Fluctuations in Serum Sodium and Intraventricular Hemorrhage