Avoiding Isolyte P in kids
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vibha naik
Mar 14, 2010, 8:19:34 AM3/14/10
to isan...@googlegroups.com
Hi All,
I am forwarding a mail sequence from our discussion on 'smileanesthesia' on the use of Isolyte P in children perioperatively. We at Smile Train have recently sent an advisory to avoid using Isolyte P in children to avoid its consequences of hyponatremia. Following is the information in the advisory and its explanation in the previous mail.
AVOID ROUTINE USE OF HYPOTONIC SOLUTIONS LIKE ISOLYTE-P IN CHILDREN
For the notice of Smile Train Center In charge and concerned Anesthesiologists
It is recommended for all Smile Train Centers to avoid using hypotonic solutions like Isolyte-P during the perioperative fluid therapy of children. Isolyte – P has 80% free water and hence becomes hypotonic once the glucose gets metabolized. Infusion of such hypotonic solutions can lead to iatrogenic hyponatremia with its serious consequences of morbidity and mortality, including intractable seizures due to cerebral oedema and encephalopathy.
In 2004, a recommendation to avoid the use of a solution of 4% dextrose with 0.18% Normal Saline similar to Isolyte P was made by the Royal College of Paediatrics and Child Health,UK so as to prevent the occurrence of hyponatremia.
Hence, we suggest that
· All fluids should be carefully calculated and aliquots dispensed in small volume ie. 100ml burette sets or by infusion pump to children below 15 kg body weight so as to avoid accidental fluid overload.
· All intraoperative fluid replacement should be with isotonic solutions (Ringer lactate).
· Children with anticipated additional fluid losses should have them replaced with isotonic solutions only (sodium chloride 0.9% or Ringer lactate).
· Maintenance i.v. fluids should only be administered postoperatively if the child is unable to take fluids by mouth.
· If hypotonic fluids (5%D or Isolyte-P) are given postoperataively for maintenance, fluid balance and electrolytes (serum Na and K) must be monitored 12 hrly.
· If the baby has been starved for a long time or the baby is undernourished he may require dextrose. Check blood sugar and give dextrose slowly. Monitor electrolytes
· There is, however, agreement that sodium chloride 0.18% solutions at standard
maintenance rates are unacceptable and should be abandoned as a replacement or maintenance fluid for children in the peri operative period.
Hoping that this influences your clinical practice too.
:)
Dr Vibhavari Naik, MD
Consultant Anesthesiologist,
Smile Train Project,
Nizams Institute of Medical Sciences,
Hyderabad, India.
E-mail: vib...@yahoo.co.in
Mobile: +91 9959189958
I am forwarding a mail sequence from our discussion on 'smileanesthesia' on the use of Isolyte P in children perioperatively. We at Smile Train have recently sent an advisory to avoid using Isolyte P in children to avoid its consequences of hyponatremia. Following is the information in the advisory and its explanation in the previous mail.
AVOID ROUTINE USE OF HYPOTONIC SOLUTIONS LIKE ISOLYTE-P IN CHILDREN
For the notice of Smile Train Center In charge and concerned Anesthesiologists
It is recommended for all Smile Train Centers to avoid using hypotonic solutions like Isolyte-P during the perioperative fluid therapy of children. Isolyte – P has 80% free water and hence becomes hypotonic once the glucose gets metabolized. Infusion of such hypotonic solutions can lead to iatrogenic hyponatremia with its serious consequences of morbidity and mortality, including intractable seizures due to cerebral oedema and encephalopathy.
In 2004, a recommendation to avoid the use of a solution of 4% dextrose with 0.18% Normal Saline similar to Isolyte P was made by the Royal College of Paediatrics and Child Health,UK so as to prevent the occurrence of hyponatremia.
Hence, we suggest that
· All fluids should be carefully calculated and aliquots dispensed in small volume ie. 100ml burette sets or by infusion pump to children below 15 kg body weight so as to avoid accidental fluid overload.
· All intraoperative fluid replacement should be with isotonic solutions (Ringer lactate).
· Children with anticipated additional fluid losses should have them replaced with isotonic solutions only (sodium chloride 0.9% or Ringer lactate).
· Maintenance i.v. fluids should only be administered postoperatively if the child is unable to take fluids by mouth.
· If hypotonic fluids (5%D or Isolyte-P) are given postoperataively for maintenance, fluid balance and electrolytes (serum Na and K) must be monitored 12 hrly.
· If the baby has been starved for a long time or the baby is undernourished he may require dextrose. Check blood sugar and give dextrose slowly. Monitor electrolytes
· There is, however, agreement that sodium chloride 0.18% solutions at standard
maintenance rates are unacceptable and should be abandoned as a replacement or maintenance fluid for children in the peri operative period.
Hoping that this influences your clinical practice too.
:)
Consultant Anesthesiologist,
Smile Train Project,
Nizams Institute of Medical Sciences,
Hyderabad, India.
E-mail: vib...@yahoo.co.in
Mobile: +91 9959189958
----- Forwarded Message ----
From: vibha naik <vib...@yahoo.co.in>
To: Raghib Manzoor <ragh...@hotmail.com>
Cc: Satish Kalra <satish...@sify.com>; rebecca jacob <rebecc...@hotmail.com>; smileanesthesia <smilean...@yahoogroups.com>
Sent: Sat, 13 March, 2010 9:02:36 PM
Subject: [smileanesthesia] Re: Medical Advisory No 2
Your Mail works best with the New Yahoo Optimized IE8. Get it NOW!.
From: vibha naik <vib...@yahoo.co.in>
To: Raghib Manzoor <ragh...@hotmail.com>
Cc: Satish Kalra <satish...@sify.com>; rebecca jacob <rebecc...@hotmail.com>; smileanesthesia <smilean...@yahoogroups.com>
Sent: Sat, 13 March, 2010 9:02:36 PM
Subject: [smileanesthesia] Re: Medical Advisory No 2
Dear Dr. Raghib,
It is very nice to have inputs from Bangladesh. I completely understand your philosophy of 'I used it for many years and it was all ok' - infact I too thought the same a couple of months back before I switched from using Isolyte P routinely (here I exclude the exceptions) to Ringers lactate. Given below are a couple of points from evidence based medicine that influenced my decision.
1. The sodium content of Isolyte P is 23-30meq/L (different preparations) which is around 0.18%NaCl along with Dextrose 4-5% and other electrolytes. This solution is definitely hypoosmolar (osmo of 280 approx) and turns more hypoosmolar as the glucose gets metabolised. I am sure you have no doubts over the fact that this solution is hyponatremic too (as opposed to Sodium of 154 in normal saline and 130 in ringer lactate). We earlier always thought it was ok to give hyponatremic fluids to kids till we saw case reports mentioning convulsions and other side effects of hyponatremia in children.
http://www.ncbi. nlm.nih.gov/ pubmed/14680463? ordinalpos= 1&itool=EntrezSystem2 .PEntrez. Pubmed.Pubmed_ ResultsPanel. Pubmed_SingleIte mSupl.Pubmed_ Discovery_ RA&linkpos=5&log$=relatedreviews&logdbfrom=pubmed
http://www.ncbi. nlm.nih.gov/ pubmed/16398876
2. We probably never monitored sodium levels postoperatively (except for major cases) to know if fluids like isolyte p can cause hyponatremia. Here are some studies that did.
This is one prospective study that found out that the incidence of postoperative hyponatremia can be 20-30% progressively increasing over time.
http://www.ncbi. nlm.nih.gov/ pubmed/20124948
http://www.ncbi. nlm.nih.gov/ pubmed/17213261? ordinalpos= 1&itool=EntrezSystem2 .PEntrez. Pubmed.Pubmed_ ResultsPanel. Pubmed_SingleIte mSupl.Pubmed_ Discovery_ RA&linkpos=5&log$=relatedarticle s&logdbfrom=pubmed
3. The incidence of seizures with hyponatremia may not be high enough for us to suspect subclinical hyponatremia. I mean that the child may have hyponatremia but we thought that it was all ok just because he did not have convulsions. For us to stop using hypotonic fluids (like isolyte P) it should be enough to know that they cause significant hyponatremia than to wait till seizures.
This paper mentions 26 deaths and >50 cases of neurologic morbidity in 10years in a setup.
http://www.ncbi. nlm.nih.gov/ pubmed/12563043? ordinalpos= 1&itool=EntrezSystem2 .PEntrez. Pubmed.Pubmed_ ResultsPanel. Pubmed_SingleIte mSupl.Pubmed_ Discovery_ RA&linkpos=3&log$=relatedreviews&logdbfrom=pubmed
Infact even with Smile Train, in India we have completed over 2lakh procedures in 10 years. Out of which approx 10 deaths may have been retrospectively suspected due to this. In terms of percentage, it is a low mortality. But, does this let us continue with the preventable causes of death? I do not think so.
4. Systematic reviews published that substantiate the role of hypotonic fluids in increasing the morbidity and mortality in children (actually also in adults!).
http://www.ncbi. nlm.nih.gov/ pubmed/16754657? ordinalpos= 1&itool=EntrezSystem2 .PEntrez. Pubmed.Pubmed_ ResultsPanel. Pubmed_SingleIte mSupl.Pubmed_ Discovery_ RA&linkpos=3&log$=relatedreviews&logdbfrom=pubmed
http://www.ncbi. nlm.nih.gov/ pubmed/19955503
http://www.ncbi. nlm.nih.gov/ pubmed/16735810? ordinalpos= 1&itool=EntrezSystem2 .PEntrez. Pubmed.Pubmed_ ResultsPanel. Pubmed_SingleIte mSupl.Pubmed_ Discovery_ RA&linkpos=1&log$=relatedreviews&logdbfrom=pubmed
Consultant Anesthesiologist,
Smile Train Project,
Nizams Institute of Medical Sciences,
Hyderabad, India.
E-mail: vibnaik@yahoo. co.in
Mobile: +91 9959189958
From: Satish Kalra <satish_kalra@ sify.com>
To: rebecca jacob <rebeccajacob@ hotmail.com>
Cc: vibha naik <vibnaik@yahoo. co.in>
Sent: Sat, 13 March, 2010 6:48:22 PM
Subject: Fw: Medical Advisory No 2
Dear Mr. Satish/
Thank you for the Advisory 1 & 2 From the Medical Advisory Council, India. But along with the Advisory it would be more scientific approach if we get the scientific comparable study to evaluate our own cases done over the years.
All responsive yahoo group Anaesthesiologists may exchange their views on the basis of the Advisory decissions. In our series more than 2700 cases done with 5% Dextrose in 0.45 &/or 0.225% Normal Saline with single one very transient Convulsion, might had other reason. We have never tried 0.9% NS or Ringers Sol. below 12 years of age. I do not disagree with the Advisory but may need more scientific basis.
Best regards.
Dr. Raghib Manzoor
Central Hospital.
Dhaka.
Bangladesh
> Date: Fri, 12 Mar 2010 02:50:12 -0500
> To: raghib_m@hotmail. com
> Subject: Medical Advisory No 2
> CC: ajmsalek@yahoo. com
> From: skalra@smiletrain. org
>
> Dear all
>
> Attached with this message is the second of three Advisories
> formulated and issued by the Medical Advisory Board of Smile Train
> India.
>
> These Advisories have resulted from some adverse outcomes at some
> hospitals and are being issued to ensure the highest levels of Safety
> at our partner hospitals.
>
> Please take a printout of the attached document, study it carefully
> and also share (preferably through hard copies) and discuss it with
> your medical colleagues including the nursing staff involved with
> post
> op care of pediatric patients.
>
> We count on you to take the leadership role in identifying and
> implenting the changes requred that should be discussed with the
> Smile Train Project Director and the hospital management.
>
> A copy of this Advisory should also be retained in the hospital
> records for future reference.
>
> Questions, comments and suggestions are most welcome and should be
> sent to the Program Manager responsible for your area or me.
> We\\\\\\\'ll ensure that they are passed on to the Medical Advisory
> Board for a suitable response.
>
> Thanking you for your cooperation and support, I remain with best
> regards
>
> Satish Kalra
Your E-mail and More On-the-Go. Get Windows Live Hotmail Free. Sign up now.
It is very nice to have inputs from Bangladesh. I completely understand your philosophy of 'I used it for many years and it was all ok' - infact I too thought the same a couple of months back before I switched from using Isolyte P routinely (here I exclude the exceptions) to Ringers lactate. Given below are a couple of points from evidence based medicine that influenced my decision.
1. The sodium content of Isolyte P is 23-30meq/L (different preparations) which is around 0.18%NaCl along with Dextrose 4-5% and other electrolytes. This solution is definitely hypoosmolar (osmo of 280 approx) and turns more hypoosmolar as the glucose gets metabolised. I am sure you have no doubts over the fact that this solution is hyponatremic too (as opposed to Sodium of 154 in normal saline and 130 in ringer lactate). We earlier always thought it was ok to give hyponatremic fluids to kids till we saw case reports mentioning convulsions and other side effects of hyponatremia in children.
http://www.ncbi. nlm.nih.gov/ pubmed/14680463? ordinalpos= 1&itool=EntrezSystem2 .PEntrez. Pubmed.Pubmed_ ResultsPanel. Pubmed_SingleIte mSupl.Pubmed_ Discovery_ RA&linkpos=5&log$=relatedreviews&logdbfrom=pubmed
http://www.ncbi. nlm.nih.gov/ pubmed/16398876
2. We probably never monitored sodium levels postoperatively (except for major cases) to know if fluids like isolyte p can cause hyponatremia. Here are some studies that did.
This is one prospective study that found out that the incidence of postoperative hyponatremia can be 20-30% progressively increasing over time.
http://www.ncbi. nlm.nih.gov/ pubmed/20124948
http://www.ncbi. nlm.nih.gov/ pubmed/17213261? ordinalpos= 1&itool=EntrezSystem2 .PEntrez. Pubmed.Pubmed_ ResultsPanel. Pubmed_SingleIte mSupl.Pubmed_ Discovery_ RA&linkpos=5&log$=relatedarticle s&logdbfrom=pubmed
3. The incidence of seizures with hyponatremia may not be high enough for us to suspect subclinical hyponatremia. I mean that the child may have hyponatremia but we thought that it was all ok just because he did not have convulsions. For us to stop using hypotonic fluids (like isolyte P) it should be enough to know that they cause significant hyponatremia than to wait till seizures.
This paper mentions 26 deaths and >50 cases of neurologic morbidity in 10years in a setup.
http://www.ncbi. nlm.nih.gov/ pubmed/12563043? ordinalpos= 1&itool=EntrezSystem2 .PEntrez. Pubmed.Pubmed_ ResultsPanel. Pubmed_SingleIte mSupl.Pubmed_ Discovery_ RA&linkpos=3&log$=relatedreviews&logdbfrom=pubmed
Infact even with Smile Train, in India we have completed over 2lakh procedures in 10 years. Out of which approx 10 deaths may have been retrospectively suspected due to this. In terms of percentage, it is a low mortality. But, does this let us continue with the preventable causes of death? I do not think so.
4. Systematic reviews published that substantiate the role of hypotonic fluids in increasing the morbidity and mortality in children (actually also in adults!).
http://www.ncbi. nlm.nih.gov/ pubmed/16754657? ordinalpos= 1&itool=EntrezSystem2 .PEntrez. Pubmed.Pubmed_ ResultsPanel. Pubmed_SingleIte mSupl.Pubmed_ Discovery_ RA&linkpos=3&log$=relatedreviews&logdbfrom=pubmed
http://www.ncbi. nlm.nih.gov/ pubmed/19955503
http://www.ncbi. nlm.nih.gov/ pubmed/16735810? ordinalpos= 1&itool=EntrezSystem2 .PEntrez. Pubmed.Pubmed_ ResultsPanel. Pubmed_SingleIte mSupl.Pubmed_ Discovery_ RA&linkpos=1&log$=relatedreviews&logdbfrom=pubmed
I hope this must have atleast partly convinced you. If not, I am open for discussion.
With Warm regards,
Dr Vibhavari Naik, MD With Warm regards,
Consultant Anesthesiologist,
Smile Train Project,
Nizams Institute of Medical Sciences,
Hyderabad, India.
E-mail: vibnaik@yahoo. co.in
Mobile: +91 9959189958
From: Satish Kalra <satish_kalra@ sify.com>
To: rebecca jacob <rebeccajacob@ hotmail.com>
Cc: vibha naik <vibnaik@yahoo. co.in>
Sent: Sat, 13 March, 2010 6:48:22 PM
Subject: Fw: Medical Advisory No 2
Would you wish to
respond?
Satish
----- Original Message -----
From: RAGHIB MANZOOR
Sent: Saturday, March 13, 2010 5:07 PM
Subject: RE: Medical Advisory No 2
Dear Mr. Satish/
Thank you for the Advisory 1 & 2 From the Medical Advisory Council, India. But along with the Advisory it would be more scientific approach if we get the scientific comparable study to evaluate our own cases done over the years.
All responsive yahoo group Anaesthesiologists may exchange their views on the basis of the Advisory decissions. In our series more than 2700 cases done with 5% Dextrose in 0.45 &/or 0.225% Normal Saline with single one very transient Convulsion, might had other reason. We have never tried 0.9% NS or Ringers Sol. below 12 years of age. I do not disagree with the Advisory but may need more scientific basis.
Best regards.
Dr. Raghib Manzoor
Central Hospital.
Dhaka.
Bangladesh
> Date: Fri, 12 Mar 2010 02:50:12 -0500
> To: raghib_m@hotmail. com
> Subject: Medical Advisory No 2
> CC: ajmsalek@yahoo. com
> From: skalra@smiletrain. org
>
> Dear all
>
> Attached with this message is the second of three Advisories
> formulated and issued by the Medical Advisory Board of Smile Train
> India.
>
> These Advisories have resulted from some adverse outcomes at some
> hospitals and are being issued to ensure the highest levels of Safety
> at our partner hospitals.
>
> Please take a printout of the attached document, study it carefully
> and also share (preferably through hard copies) and discuss it with
> your medical colleagues including the nursing staff involved with
> post
> op care of pediatric patients.
>
> We count on you to take the leadership role in identifying and
> implenting the changes requred that should be discussed with the
> Smile Train Project Director and the hospital management.
>
> A copy of this Advisory should also be retained in the hospital
> records for future reference.
>
> Questions, comments and suggestions are most welcome and should be
> sent to the Program Manager responsible for your area or me.
> We\\\\\\\'ll ensure that they are passed on to the Medical Advisory
> Board for a suitable response.
>
> Thanking you for your cooperation and support, I remain with best
> regards
>
> Satish Kalra
Your E-mail and More On-the-Go. Get Windows Live Hotmail Free. Sign up now.
Your Mail works best with the New Yahoo Optimized IE8. Get it NOW!.
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__,_._,___
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NILESH TATAR
Mar 14, 2010, 9:01:22 AM3/14/10
to isan...@googlegroups.com
Imp. Information.
It was specifically told to avoid use of isolyte p in our monthly meet also by dr. Pradnya sawant. Wadia hosp.
Dr.Nilesh Tatar
From: vibha naik <vib...@yahoo.co.in>
Sent: 14 March 2010 05:49 PM
To: isan...@googlegroups.com
Subject: Avoiding Isolyte P in kids
It was specifically told to avoid use of isolyte p in our monthly meet also by dr. Pradnya sawant. Wadia hosp.
Dr.Nilesh Tatar
From: vibha naik <vib...@yahoo.co.in>
Sent: 14 March 2010 05:49 PM
To: isan...@googlegroups.com
Subject: Avoiding Isolyte P in kids
Hi All,
I am forwarding a mail sequence from our discussion on 'smileanesthesia' on the use of Isolyte P in children perioperatively. We at Smile Train have recently sent an advisory to avoid using Isolyte P in children to avoid its consequences of hyponatremia. Following is the information in the advisory and its explanation in the previous mail.
AVOID ROUTINE USE OF HYPOTONIC SOLUTIONS LIKE ISOLYTE-P IN CHILDREN
For the notice of Smile Train Center In charge and concerned Anesthesiologists
It is recommended for all Smile Train Centers to avoid using hypotonic solutions like Isolyte-P during the perioperative fluid therapy of children. Isolyte – P has 80% free water and hence becomes hypotonic once the glucose gets metabolized. Infusion of such hypotonic solutions can lead to iatrogenic hyponatremia with its serious consequences of morbidity and mortality, including intractable seizures due to cerebral oedema and encephalopathy.
In 2004, a recommendation to avoid the use of a solution of 4% dextrose with 0.18% Normal Saline similar to Isolyte P was made by the Royal College of Paediatrics and Child Health,UK so as to prevent the occurrence of hyponatremia.
Hence, we suggest that
· All fluids should be carefully calculated and aliquots dispensed in small volume ie. 100ml burette sets or by infusion pump to children below 15 kg body weight so as to avoid accidental fluid overload.
· All intraoperative fluid replacement should be with isotonic solutions (Ringer lactate).
· Children with anticipated additional fluid losses should have them replaced with isotonic solutions only (sodium chloride 0.9% or Ringer lactate).
· Maintenance i.v. fluids should only be administered postoperatively if the ch
I am forwarding a mail sequence from our discussion on 'smileanesthesia' on the use of Isolyte P in children perioperatively. We at Smile Train have recently sent an advisory to avoid using Isolyte P in children to avoid its consequences of hyponatremia. Following is the information in the advisory and its explanation in the previous mail.
AVOID ROUTINE USE OF HYPOTONIC SOLUTIONS LIKE ISOLYTE-P IN CHILDREN
For the notice of Smile Train Center In charge and concerned Anesthesiologists
It is recommended for all Smile Train Centers to avoid using hypotonic solutions like Isolyte-P during the perioperative fluid therapy of children. Isolyte – P has 80% free water and hence becomes hypotonic once the glucose gets metabolized. Infusion of such hypotonic solutions can lead to iatrogenic hyponatremia with its serious consequences of morbidity and mortality, including intractable seizures due to cerebral oedema and encephalopathy.
In 2004, a recommendation to avoid the use of a solution of 4% dextrose with 0.18% Normal Saline similar to Isolyte P was made by the Royal College of Paediatrics and Child Health,UK so as to prevent the occurrence of hyponatremia.
Hence, we suggest that
· All fluids should be carefully calculated and aliquots dispensed in small volume ie. 100ml burette sets or by infusion pump to children below 15 kg body weight so as to avoid accidental fluid overload.
· All intraoperative fluid replacement should be with isotonic solutions (Ringer lactate).
· Children with anticipated additional fluid losses should have them replaced with isotonic solutions only (sodium chloride 0.9% or Ringer lactate).
· Maintenance i.v. fluids should only be administered postoperatively if the ch
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