Niels Van Regenmortel1,2, Lynn Moers3, Thomas Langer4,5, Ella Roelant6,7, Tim De Weerdt8, Pietro Caironi9, Manu L N G Malbrain10, Paul Elbers11, Tim Van den Wyngaert12,13, Philippe G Jorens14,13. 1. Department of Intensive Care Medicine, Antwerp University Hospital, Wilrijkstraat 10 Edegem, B-2650, Antwerp, Belgium. niels.vanregenmortel@uza.be. 2. Department of Intensive Care Medicine, Ziekenhuis Netwerk Antwerpen Campus Stuivenberg, Lange Beeldekensstraat 267, B-2060, Antwerp, Belgium. niels.vanregenmortel@uza.be. 3. Department of Pharmacy, Ziekenhuis Netwerk Antwerpen Campus Stuivenberg, Lange Beeldekensstraat 267, B-2060, Antwerp, Belgium. 4. Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy. 5. Department of Anaesthesia and Intensive Care Medicine, Niguarda Ca' Granda, Milan, Italy. 6. StatUa, Center for Statistics, University of Antwerp, Prinsstraat 13, B-2000, Antwerp, Belgium. 7. Clinical Trial Center (CTC), CRC Antwerp, Antwerp University Hospital, University of Antwerp, Wilrijkstraat 10, B-2650, Edegem, Belgium. 8. Department of Nephrology, Kliniek Sint-Jan, Kruidtuinlaan 32, B-1000, Brussels, Belgium. 9. Department of Anesthesia and Critical Care, AOU S. Luigi Gonzaga, Department of Oncology, University of Turin, Turin, Italy. 10. Faculty of Engineering, Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, 1090, Jette, Belgium. 11. Department of Intensive Care Medicine, Research VUmc Intensive Care (REVIVE), Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Sciences (ACS), Amsterdam Infection and Immunity Institute (AI&II), Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands. 12. Department of Nuclear Medicine, Antwerp University Hospital, Wilrijkstraat 10 Edegem, B-2650, Antwerp, Belgium. 13. Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1 Wilrijk, B-2610, Antwerp, Belgium. 14. Department of Intensive Care Medicine, Antwerp University Hospital, Wilrijkstraat 10 Edegem, B-2650, Antwerp, Belgium.
Abstract
PURPOSE: Iatrogenic fluid overload is a potential side effect of intravenous fluid therapy in the hospital. Little attention has been paid to sodium administration as a separate cause of harm. With this narrative review, we aim to substantiate the hypothesis that a considerable amount of fluid-induced harm is caused not only by fluid volume, but also by the sodium that is administered to hospitalized patients. METHODS: We show how a regular dietary sodium intake is easily surpassed by the substantial amounts of sodium that are administered during typical hospital stays. The most significant sodium burdens are caused by isotonic maintenance fluid therapy and by fluid creep, defined as the large volume unintentionally administered to patients in the form of dissolved medication. In a section on physiology, we elaborate on the limited renal handling of an acute sodium load. We demonstrate how the subsequent retention of water is an energy-demanding, catabolic process and how free water is needed to excrete large burdens of sodium. We quantify the effect size of sodium-induced fluid retention and discuss its potential clinical impact. Finally, we propose preventive measures, discuss the benefits and risks of low-sodium maintenance fluid therapy, and explore options for reducing the amount of sodium caused by fluid creep. CONCLUSION: The sodium burdens caused by isotonic maintenance fluids and fluid creep are responsible for an additional and avoidable derailment of fluid balance, with presumed clinical consequences. Moreover, the handling of sodium overload is characterized by increased catabolism. Easy and effective measures for reducing sodium load and fluid retention include choosing a hypotonic rather than isotonic maintenance fluid strategy (or avoiding these fluids when enough free water is provided through other sources) and dissolving as many medications as possible in glucose 5%.
PURPOSE: Iatrogenic fluid overload is a potential side effect of intravenous fluid therapy in the hospital. Little attention has been paid to sodium administration as a separate cause of harm. With this narrative review, we aim to substantiate the hypothesis that a considerable amount of fluid-induced harm is caused not only by fluid volume, but also by the sodium that is administered to hospitalized patients. METHODS: We show how a regular dietary sodium intake is easily surpassed by the substantial amounts of sodium that are administered during typical hospital stays. The most significant sodium burdens are caused by isotonic maintenance fluid therapy and by fluid creep, defined as the large volume unintentionally administered to patients in the form of dissolved medication. In a section on physiology, we elaborate on the limited renal handling of an acute sodium load. We demonstrate how the subsequent retention of water is an energy-demanding, catabolic process and how free water is needed to excrete large burdens of sodium. We quantify the effect size of sodium-induced fluid retention and discuss its potential clinical impact. Finally, we propose preventive measures, discuss the benefits and risks of low-sodium maintenance fluid therapy, and explore options for reducing the amount of sodium caused by fluid creep. CONCLUSION: The sodium burdens caused by isotonic maintenance fluids and fluid creep are responsible for an additional and avoidable derailment of fluid balance, with presumed clinical consequences. Moreover, the handling of sodium overload is characterized by increased catabolism. Easy and effective measures for reducing sodium load and fluid retention include choosing a hypotonic rather than isotonic maintenance fluid strategy (or avoiding these fluids when enough free water is provided through other sources) and dissolving as many medications as possible in glucose 5%.
Authors: Anders Perner; Nicolai Haase; Anne B Guttormsen; Jyrki Tenhunen; Gudmundur Klemenzson; Anders Åneman; Kristian R Madsen; Morten H Møller; Jeanie M Elkjær; Lone M Poulsen; Asger Bendtsen; Robert Winding; Morten Steensen; Pawel Berezowicz; Peter Søe-Jensen; Morten Bestle; Kristian Strand; Jørgen Wiis; Jonathan O White; Klaus J Thornberg; Lars Quist; Jonas Nielsen; Lasse H Andersen; Lars B Holst; Katrin Thormar; Anne-Lene Kjældgaard; Maria L Fabritius; Frederik Mondrup; Frank C Pott; Thea P Møller; Per Winkel; Jørn Wetterslev Journal: N Engl J Med Date: 2012-06-27 Impact factor: 91.245
Authors: Jean-Louis Vincent; Yasser Sakr; Charles L Sprung; V Marco Ranieri; Konrad Reinhart; Herwig Gerlach; Rui Moreno; Jean Carlet; Jean-Roger Le Gall; Didier Payen Journal: Crit Care Med Date: 2006-02 Impact factor: 7.598
Authors: John A Myburgh; Simon Finfer; Rinaldo Bellomo; Laurent Billot; Alan Cass; David Gattas; Parisa Glass; Jeffrey Lipman; Bette Liu; Colin McArthur; Shay McGuinness; Dorrilyn Rajbhandari; Colman B Taylor; Steven A R Webb Journal: N Engl J Med Date: 2012-10-17 Impact factor: 91.245
Authors: Matthew W Semler; Wesley H Self; Jonathan P Wanderer; Jesse M Ehrenfeld; Li Wang; Daniel W Byrne; Joanna L Stollings; Avinash B Kumar; Christopher G Hughes; Antonio Hernandez; Oscar D Guillamondegui; Addison K May; Liza Weavind; Jonathan D Casey; Edward D Siew; Andrew D Shaw; Gordon R Bernard; Todd W Rice Journal: N Engl J Med Date: 2018-02-27 Impact factor: 91.245
Authors: Wesley H Self; Matthew W Semler; Jonathan P Wanderer; Li Wang; Daniel W Byrne; Sean P Collins; Corey M Slovis; Christopher J Lindsell; Jesse M Ehrenfeld; Edward D Siew; Andrew D Shaw; Gordon R Bernard; Todd W Rice Journal: N Engl J Med Date: 2018-02-27 Impact factor: 91.245
Authors: Shailesh Bihari; Marino Festa; Sandra L Peake; Ian M Seppelt; Patricia Williams; Barry Wilkins; Andrew Bersten Journal: Crit Care Resusc Date: 2014-06 Impact factor: 2.159
Authors: N Van Regenmortel; T De Weerdt; A H Van Craenenbroeck; E Roelant; W Verbrugghe; K Dams; M L N G Malbrain; T Van den Wyngaert; P G Jorens Journal: Br J Anaesth Date: 2017-06-01 Impact factor: 9.166
Authors: Niels Van Regenmortel; Steven Hendrickx; Ella Roelant; Ingrid Baar; Karolien Dams; Karen Van Vlimmeren; Bart Embrecht; Anouk Wittock; Jeroen M Hendriks; Patrick Lauwers; Paul E Van Schil; Amaryllis H Van Craenenbroeck; Walter Verbrugghe; Manu L N G Malbrain; Tim Van den Wyngaert; Philippe G Jorens Journal: Intensive Care Med Date: 2019-10-01 Impact factor: 17.440
Authors: Niels Van Regenmortel; Walter Verbrugghe; Ella Roelant; Tim Van den Wyngaert; Philippe G Jorens Journal: Intensive Care Med Date: 2018-03-27 Impact factor: 17.440
Authors: Sine Wichmann; Marija Barbateskovic; Ning Liang; Theis Skovsgaard Itenov; Rasmus Ehrenfried Berthelsen; Jane Lindschou; Anders Perner; Christian Gluud; Morten Heiberg Bestle Journal: Ann Intensive Care Date: 2022-06-13 Impact factor: 10.318
Authors: Andrea Crosignani; Stefano Spina; Francesco Marrazzo; Stefania Cimbanassi; Manu L N G Malbrain; Niels Van Regenemortel; Roberto Fumagalli; Thomas Langer Journal: Ann Intensive Care Date: 2022-10-17 Impact factor: 10.318