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脱水症と輸液療法(小児科)

著者: 三浦健一郎 東京女子医科大学 腎臓小児科

監修: 五十嵐隆 国立成育医療研究センター

著者校正/監修レビュー済:2021/09/08
参考ガイドライン:
  1. 米国小児科学会Clinical Practice Guideline: Maintenance Intravenous Fluids in Children. Pediatrics. 2018; 142. pii: e20183083.
  1. 英国NICEガイドラインIV fluids in children. https://www.ncbi.nlm.nih.gov/books/NBK338141/pdf/Bookshelf_NBK338141.pdf
患者向け説明資料

概要・推奨   

  1. 理学所見で5%脱水を予測するのに特に有用なのはcapillary refill time、皮膚ツルゴール低下、呼吸パターンの異常である(推奨度1S)。
  1. 中等度までの脱水症においては、経口補水療法は経静脈輸液と同等の脱水是正効果がある(推奨度2R)。
  1. 中枢神経症状を伴う重篤な低Na血症では最初の数時間で血清Naを5mEq/L程度上昇させることを目標とする(推奨度2OG)。
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  1. 閲覧にはご契約が必要となります。閲覧にはご契約
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要とな
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
三浦健一郎 : 特に申告事項無し[2021年]
監修:五十嵐隆 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 米国小児科学会ガイドラインおよび英国NICEガイドラインに基づいて輸液の種類と速度について改訂した。

病態・疫学・診察

疫学情報・病態・注意事項  
  1. 脱水症とは細胞内外を問わず体内から水分が急性に失われた状態である。
  1. 小児では体表面積あたりの尿量、不感蒸泄、便中水分量が多く、1日に必要な水分(体表面積あたり)が成人に比べて多い。すなわち代謝回転が速い。また細胞外液の占める割合が大きいため、循環を維持するために必要な水分量が多い。さらに経口摂取が少なくなるような急性疾患の罹患率が高い。
  1. これらの理由によって小児は容易に脱水に陥りやすく、日常診療においては、疾患の種類によらず、まず脱水への対応が求められる場面が多い。
  1. 等張性脱水(血清Na 130~150 mEq/L)では、水と溶質(Na+K)が均等に(等張性に)失われている。ほとんどの脱水症患者がこれに相当する。
  1. 高張性脱水(血清Na >150 mEq/L)は、嘔吐・下痢が大量にあって経口摂取がほとんどできていない場合に生じる。これは、嘔吐、下痢、不感蒸泄、尿といったアウトプットが一般に低張性であることによる。生後間もない新生児で、母乳の分泌が悪いために経口摂取が十分できていない場合も、高張性脱水になる(母乳性高Na血症)。出生体重からの体重減少率が10%以上になるとリスクが高まる。
  1. 低張性脱水(血清Na<130mEq/L)は、嘔吐や下痢の量が多い状態で、Naがほとんど含まれていない水分のみを補給している場合に生じやすい。嘔吐や発熱、脱水、呼吸障害などがnon-osmotic stimulantとなってバソプレシン(ADH)の分泌が促進され、自由水の排泄が障害されることも機序として重要である[1][2]
問診・診察のポイント  
  1. 脱水の程度は一般に体重に対する水分喪失の割合で表す(<図表>)。3~5%の喪失を軽症脱水、6~9%を中等症脱水、10%以上を重症脱水とする分類が一般的であるが、病前の体重は不明であることが多く、問診や診察で脱水の程度を推察する必要がある。

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文献 

著者: Kristen A Neville, Charles F Verge, Matthew W O'Meara, Jan L Walker
雑誌名: Pediatrics. 2005 Dec;116(6):1401-7. doi: 10.1542/peds.2004-2376.
Abstract/Text OBJECTIVES: Nonosmotic antidiuretic hormone (ADH) activity can cause severe hyponatremia during involuntary fluid administration. We looked for evidence of this before and during intravenous (IV) fluid administration in children treated for gastroenteritis.
METHODOLOGY: In this prospective observational study, plasma ADH, electrolytes, osmolality, and glucose were measured in 52 subjects before (T0) and 4 hours after (T4) starting 0.45% saline + 2.5% dextrose and subsequently when indicated. Hormonal markers of stress were measured at T0. Urine samples were collected to measure electrolytes and osmolality.
RESULTS: The nonosmotic stimuli of ADH secretion that we identified were vomiting (50 of 52), dehydration (median: 5%; range: 3-8%), hypoglycemia (2 of 52), and raised hormonal markers of stress (mean +/- SD: cortisol, 1094 +/- 589 nmol/L; reverse triiodothyronine, 792 +/- 293 pmol/L). At T0, half the children were hyponatremic (plasma sodium concentration of < 135 mmol/L; n = 27). The median plasma ADH concentration at T0 was significantly elevated (median: 7.4 pg/mL; range: < 1.9-85.6 pg/mL). ADH was high in both hyponatremic and normonatremic children and remained high at T4 in 33 of the 52 children, 22 of whom were concurrently hyponatremic. At T4, mean plasma sodium concentration was unchanged in the hyponatremic children but was 2.6 mmol/L (+/-2.0) lower in those who were initially normonatremic. Urine tonicity was high compared with 0.45% saline in 16 of 19 children at baseline and in 20 of 37 children after 3 to 12 hours of IV fluids.
CONCLUSIONS: Nonosmotic stimuli of ADH secretion are frequent in children with gastroenteritis. Their persistence during IV-fluid administration predisposes to dilutional hyponatremia. The use of hypotonic saline for deficit replacement needs to be reassessed.

PMID 16322164  Pediatrics. 2005 Dec;116(6):1401-7. doi: 10.1542/peds.2・・・
著者: Kristen A Neville, David J Sandeman, Alan Rubinstein, Guy M Henry, Michael McGlynn, Jan L Walker
雑誌名: J Pediatr. 2010 Feb;156(2):313-9.e1-2. doi: 10.1016/j.jpeds.2009.07.059. Epub 2009 Oct 9.
Abstract/Text OBJECTIVES: To determine the importance of sodium content versus administration rate of intravenous fluids in the development of hyponatremia in postoperative children.
STUDY DESIGN: In this prospective, randomized, nonblinded study, 124 children admitted for surgery received 0.9% (NS) or 0.45% (N/2) saline solution at 100% or 50% maintenance rates. Plasma electrolytes, osmolality, and ADH at induction of anesthesia were compared with values 8 hours (T(8)), and 24 hours (T(24); n = 67) after surgery. Blood glucose and ketones were measured every 4 hours. Electrolytes and osmolality were measured in urine samples.
RESULTS: Plasma sodium concentrations fell in both N/2 groups at T(8) (100%: -1.5 +/- 2.3 mmol/L 50%: -1.9 +/- 2.0 mmol/L; P < .01) with hyponatremia more common than in the NS groups at T(8) (30% vs 10%; P = .02) but not T(24). Median plasma antidiuretic hormone concentrations increased 2- to 4-fold during surgery (P < or = .001) and only reattained levels at induction of anesthesia by T(24) in the N/2 100% group. On multiple linear regression analysis, fluid type, not rate determined risk of hyponatremia (P < .04). Two children on 100% developed SIADH (1NS). Fourteen (23%; 7NS) on 50% maintenance were assessed as dehydrated. Dextrose content was increased in 18 for hypoglycemia or ketosis.
CONCLUSIONS: The risk of hyponatremia was decreased by isotonic saline solution but not fluid restriction.

Crown Copyright 2010. Published by Mosby, Inc. All rights reserved.
PMID 19818450  J Pediatr. 2010 Feb;156(2):313-9.e1-2. doi: 10.1016/j.j・・・
著者: Michael J Steiner, Darren A DeWalt, Julie S Byerley
雑誌名: JAMA. 2004 Jun 9;291(22):2746-54. doi: 10.1001/jama.291.22.2746.
Abstract/Text CONTEXT: The ability to assess the degree of dehydration quickly and accurately in infants and young children often determines patient treatment and disposition.
OBJECTIVE: To systematically review the precision and accuracy of symptoms, signs, and basic laboratory tests for evaluating dehydration in infants and children.
DATA SOURCES: We identified 1561 potential articles by multiple search strategies of the MEDLINE database through PubMed. Searches of bibliographies of retrieved articles, the Cochrane Library, textbooks, and private collections of experts in the field yielded an additional 42 articles.
STUDY SELECTION: Twenty-six of 1603 reviewed studies contained original data on the precision or accuracy of findings for the diagnosis of dehydration in young children (1 month to 5 years).
DATA EXTRACTION: Two of the 3 authors independently reviewed and abstracted data for estimating the likelihood ratios (LRs) of diagnostic tests. We eliminated 13 of the 26 studies because of the lack of an accepted diagnostic standard or other limitation in study design. The other 13 studies were included in the review.
DATA SYNTHESIS: The most useful individual signs for predicting 5% dehydration in children are an abnormal capillary refill time (LR, 4.1; 95% confidence interval [CI], 1.7-9.8), abnormal skin turgor (LR, 2.5; 95% CI, 1.5-4.2), and abnormal respiratory pattern (LR, 2.0; 95% CI, 1.5-2.7). Combinations of examination signs perform markedly better than any individual sign in predicting dehydration. Historical points and laboratory tests have only modest utility for assessing dehydration.
CONCLUSIONS: The initial assessment of dehydration in young children should focus on estimating capillary refill time, skin turgor, and respiratory pattern and using combinations of other signs. The relative imprecision and inaccuracy of available tests limit the ability of clinicians to estimate the exact degree of dehydration.

PMID 15187057  JAMA. 2004 Jun 9;291(22):2746-54. doi: 10.1001/jama.291・・・
著者: L Hartling, S Bellemare, N Wiebe, K Russell, T P Klassen, W Craig
雑誌名: Cochrane Database Syst Rev. 2006 Jul 19;(3):CD004390. doi: 10.1002/14651858.CD004390.pub2. Epub 2006 Jul 19.
Abstract/Text BACKGROUND: Dehydration associated with gastroenteritis is a serious complication. Oral rehydration is an effective and inexpensive treatment, but some physicians prefer intravenous methods.
OBJECTIVES: To compare oral with intravenous therapy for treating dehydration due to acute gastroenteritis in children.
SEARCH STRATEGY: We searched the Cochrane Infectious Diseases Group Specialized Register (March 2006), CENTRAL (The Cochrane Library 2006, Issue 1), MEDLINE (1966 to March 2006), EMBASE (1974 to March 2006), LILACS (1982 to March 2006), and reference lists. We also contacted researchers, pharmaceutical companies, and relevant organizations.
SELECTION CRITERIA: Randomized and quasi-randomized controlled trials comparing intravenous rehydration therapy (IVT) with oral rehydration therapy (ORT) in children up to 18 years of age with acute gastroenteritis.
DATA COLLECTION AND ANALYSIS: Two authors independently extracted data and assessed quality using the Jadad score. We expressed dichotomous data as a risk difference (RD) and number needed to treat (NNT), and continuous data as a weighted mean difference (WMD). We used meta-regression for subgroup analyses.
MAIN RESULTS: Seventeen trials (1811 participants), of poor to moderate quality, were included. There were more treatment failures with ORT (RD 4%, 95% confidence interval (CI) 1 to 7, random-effects model; 1811 participants, 18 trials; NNT = 25). Six deaths occurred in the IVT group and two in the ORT groups (4 trials). There were no significant differences in weight gain (369 participants, 6 trials), hyponatremia (248 participants, 2 trials) or hypernatremia (1062 participants, 10 trials), duration of diarrhea (960 participants, 8 trials), or total fluid intake at six hours (985 participants, 8 trials) and 24 hours (835 participants, 7 trials). Shorter hospital stays were reported for the ORT group (WMD -1.20 days, 95% CI -2.38 to -0.02 days; 526 participants, 6 trials). Phlebitis occurred more often in the IVT group (NNT 50, 95% CI 25 to 100) and paralytic ileus more often in the ORT group (NNT 33, 95% CI 20 to 100, fixed-effect model), but there was no significant difference between ORT using the low osmolarity solutions recommended by the World Health Organization and IVT (729 participants, 6 trials).
AUTHORS' CONCLUSIONS: Although no clinically important differences between ORT and IVT, the ORT group did have a higher risk of paralytic ileus, and the IVT group was exposed to risks of intravenous therapy. For every 25 children (95% CI 14 to 100) treated with ORT one would fail and require IVT.

PMID 16856044  Cochrane Database Syst Rev. 2006 Jul 19;(3):CD004390. d・・・
著者: Chike M Nzerue, Henry Baffoe-Bonnie, Wei You, Babajide Falana, Shifan Dai
雑誌名: J Natl Med Assoc. 2003 May;95(5):335-43.
Abstract/Text UNLABELLED: Severe hyponatremia is associated with increased morbidity and mortality. Clinicians treating patients with severe hyponatremia are often torn between a desire to promptly raise serum sodium concentration to a "safe range," and at the same time, to avoid excessively rapid correction of hyponatremia. The aim of this study was to assess the prevalence of severe hyponatremia in hospitalized patients, the etiologic factors involved, as well as treatment and outcome of the patients using a retrospective case series.
METHODS: Retrospective study of 168 patients with severe hyponatremia (< 115mmol/L) seen at Grady Memorial Hospital, a tertiary teaching hospital, in Atlanta, Georgia, from 1997-2001. The main outcome measures of interest were death during admission or occurrence of neurologic symptoms before, during or after therapy.
RESULTS: One hundred sixty-eight patients met the inclusion criteria out of a total of 5994 patients with hyponatremia treated at our hospital over the study period. Eighty-nine patients (52.9%) were symptomatic. The mean absolute serum sodium at 48-hours of therapy was 120.02 +/- 8.31 mmol/L. Respiratory failure and/or hypoxia was present in 28 patients (16.7%); sepsis was documented in 16 patients (9.5%). Mortality rate was high, 34 patients died (20.2%). On multivariate analysis factors with strong association with mortality of patients with severe hyponatremia were hypoxia, presence of neurologic symptoms, slow correction rates and a diagnosis of sepsis.
CONCLUSIONS: The mortality associated with severe hyponatremia remains high. Sepsis, respiratory failure and the presence of symptoms predict poor outcome in hospitalized patients with severe hyponatremia. More aggressive therapy with 3% saline may improve outcome in symptomatic patients. Our data suggest that a slow rate of correction in severe hyponatremia is associated with higher mortality than rapid correction, at least in the short-term.

PMID 12793790  J Natl Med Assoc. 2003 May;95(5):335-43.
著者: Goce Spasovski, Raymond Vanholder, Bruno Allolio, Djillali Annane, Steve Ball, Daniel Bichet, Guy Decaux, Wiebke Fenske, Ewout J Hoorn, Carole Ichai, Michael Joannidis, Alain Soupart, Robert Zietse, Maria Haller, Sabine van der Veer, Wim Van Biesen, Evi Nagler, Hyponatraemia Guideline Development Group
雑誌名: Nephrol Dial Transplant. 2014 Apr;29 Suppl 2:i1-i39. doi: 10.1093/ndt/gfu040. Epub 2014 Feb 25.
Abstract/Text Hyponatraemia, defined as a serum sodium concentration <135 mmol/l, is the most common disorder of body fluid and electrolyte balance encountered in clinical practice. It can lead to a wide spectrum of clinical symptoms, from subtle to severe or even life threatening, and is associated with increased mortality, morbidity and length of hospital stay in patients presenting with a range of conditions. Despite this, the management of patients remains problematic. The prevalence of hyponatraemia in widely different conditions and the fact that hyponatraemia is managed by clinicians with a broad variety of backgrounds have fostered diverse institution- and speciality-based approaches to diagnosis and treatment. To obtain a common and holistic view, the European Society of Intensive Care Medicine (ESICM), the European Society of Endocrinology (ESE) and the European Renal Association - European Dialysis and Transplant Association (ERA-EDTA), represented by European Renal Best Practice (ERBP), have developed the Clinical Practice Guideline on the diagnostic approach and treatment of hyponatraemia as a joint venture of three societies representing specialists with a natural interest in hyponatraemia. In addition to a rigorous approach to methodology and evaluation, we were keen to ensure that the document focused on patient-important outcomes and included utility for clinicians involved in everyday practice.

PMID 24569496  Nephrol Dial Transplant. 2014 Apr;29 Suppl 2:i1-i39. do・・・
著者: A Kahn, E Brachet, D Blum
雑誌名: Intensive Care Med. 1979 Mar;5(1):27-31.
Abstract/Text The aim of the study was to derive some practical measurements which might help in defining a "safe" infusion rate in order to avoid seizures during treatment of hypernatremic dehydration. Forty seven infants with hypernatremic dehydration were rehydrated on a 160 ml/kg/24 h basis: 9 developed seizures during treatment (group I), 22 matched for age did not convulse (group II). Nine subsequent cases were prescribed a 120 ml/kg/24 h regimen: none convulsed (group III). The three groups were comparable in many respects, including initial plasma Na and pH. Fluids were comparable regarding (Na), their rates of administration were respectively 216, 181 and 123 ml/kg/24 h. The rate of infusion affected slopes of decreases in natremia. It was suggested that the decrease in plasma Na should not exceed 0,5 mEq/1/h.

PMID 35558  Intensive Care Med. 1979 Mar;5(1):27-31.
著者: R H Sterns, J D Cappuccio, S M Silver, E P Cohen
雑誌名: J Am Soc Nephrol. 1994 Feb;4(8):1522-30.
Abstract/Text Severe, symptomatic hyponatremia is often treated urgently to increase the serum sodium to 120 to 130 mmol/L. Recently, this approach has been challenged by evidence linking "rapid correction" (> 12 mmol/L per day) to demyelinating brain lesions. However, the relative risks of persistent, severe hyponatremia and iatrogenic injury have not been well quantified. Data were sought on patients with serum sodium levels < or = 105 mmol/L from the membership of the American Society of Nephrology. Respondents were given a report form asking specific questions regarding the cause of hyponatremia, presenting symptoms, rate of correction, and neurologic sequelae. Data on 56 patients were analyzed. Fourteen developed posttherapeutic complications (10 permanent, 4 transient) after correction to a serum sodium > 120 mmol/L. Eleven of these 14 patients (including 3 with documented central pontine myelinolysis) had a biphasic course in which neurologic findings initially improved and then worsened on the second to sixth day. Posttherapeutic complications were not explained by age, sex, alcoholism, presenting symptoms, or hypoxic episodes. Increased chronicity of hyponatremia and a high rate of correction in the first 48 h of treatment were significantly associated with complications. No neurologic complications were observed among patients corrected by < 12 mmol/L per 24 h or by < 18 mmol/L per 48 h or in whom the average rate of correction to a serum sodium of 120 mmol/L was < or = 0.55 mmol/L per hour. It was concluded that patients with severe chronic hyponatremia are most likely to avoid neurologic complications when their electrolyte disturbance is corrected slowly.

PMID 8025225  J Am Soc Nephrol. 1994 Feb;4(8):1522-30.
著者: Michael L Moritz, Juan Carlos Ayus
雑誌名: Pediatrics. 2003 Feb;111(2):227-30.
Abstract/Text OBJECTIVE: The current standard of care in pediatrics is to administer hypotonic saline in maintenance parenteral fluids. The safety of this approach has never been evaluated.
METHODS: A review of the literature reveals that the administration of hypotonic fluids is potentially dangerous and may not be physiologic for the hospitalized child.
RESULTS: There have been >50 reported cases of neurologic morbidity and mortality, including 26 deaths, in the past 10 years resulting from hospital-acquired hyponatremia in children who were receiving hypotonic parenteral fluids. Common childhood conditions requiring parenteral fluids, such as pulmonary and central nervous system infections, dehydration, and the postoperative state, are associated with a nonosmotic stimulus for antidiuretic hormone production, which can lead to free water retention and hyponatremia. Children are at particularly high risk of developing symptomatic hyponatremia as they have a larger brain-to-skull size ratio.
CONCLUSIONS: The administration of isotonic saline in maintenance parenteral fluids is the most important prophylactic measure that can be taken to prevent the development of hyponatremia in children who receive parenteral fluids.

PMID 12563043  Pediatrics. 2003 Feb;111(2):227-30.
著者: Ewout J Hoorn, Denis Geary, Maryanne Robb, Mitchell L Halperin, Desmond Bohn
雑誌名: Pediatrics. 2004 May;113(5):1279-84.
Abstract/Text OBJECTIVE: To develop hyponatremia (plasma sodium concentration [P(Na)] <136 mmol/L), one needs a source of water input and antidiuretic hormone secretion release to diminish its excretion. The administration of hypotonic maintenance fluids is common practice in hospitalized children. The objective of this study was to identify risk factors for the development of hospital-acquired, acute hyponatremia in a tertiary care hospital using a retrospective analysis.
METHODS: All children who presented to the emergency department in a 3-month period and had at least 1 P(Na) measured (n = 1586) were evaluated. Those who were admitted were followed for the next 48 hours to identify patients with hospital-acquired hyponatremia. An age- and gender-matched case-control (1:3) analysis was performed with patients who did not become hyponatremic.
RESULTS: Hyponatremia (P(Na) <136 mmol/L) was documented in 131 of 1586 patients with > or = 1 P(Na) measurements. Although 96 patients were hyponatremic on presentation, our study group consisted of 40 patients who developed hyponatremia in hospital. The case-control study showed that the patients in the hospital-acquired hyponatremia group received significantly more EFW and had a higher positive water balance. With respect to outcomes, 2 patients had major neurologic sequelae and 1 died.
CONCLUSION: The most important factor for hospital-acquired hyponatremia is the administration of hypotonic fluid. We suggest that hypotonic fluid not be given to children when they have a P(Na) <138 mmol/L.

PMID 15121942  Pediatrics. 2004 May;113(5):1279-84.
著者: Byron Alexander Foster, Dina Tom, Vanessa Hill
雑誌名: J Pediatr. 2014 Jul;165(1):163-169.e2. doi: 10.1016/j.jpeds.2014.01.040. Epub 2014 Feb 28.
Abstract/Text OBJECTIVE: To determine whether the use of hypotonic vs isotonic maintenance fluids confers an increased risk of hyponatremia in hospitalized children.
STUDY DESIGN: A search of MEDLINE (1946 to January 2013), the Cochrane Central Registry (1991 to December 2012), Cumulative Index for Nursing and Allied Health Literature (1990 to December 2012), and Pediatric Academic Societies (2000-2012) abstracts was conducted using the terms "hypotonic fluids/saline/solutions" and "isotonic fluids/saline/solutions," and citations were reviewed using a predefined protocol. Data on the primary and secondary outcomes were extracted from original articles by 2 authors independently. Meta-analyses of the primary and secondary outcomes were performed when possible.
RESULTS: A total of 1634 citations were screened. Ten studies (n = 893) identified as independent randomized controlled trials were included. Five studies examined subjects in the intensive care unit setting, including 4 on regular wards and 1 in a mixed setting. In hospitalized children receiving maintenance intravenous fluids, hyponatremia was seen more often in those receiving hypotonic fluids than in those receiving isotonic fluids, with an overall relative risk of 2.37 (95% CI, 1.72-3.26). Receipt of hypotonic fluids was associated with a relative risk of moderate hyponatremia (<130 mmol/L) of 6.1 (95% CI, 2.2-17.3). A subgroup analysis of hypotonic fluids with half-normal saline found a relative risk of hyponatremia of 2.42 (95% CI, 1.32-4.45).
CONCLUSION: In hospitalized children in intensive care and postoperative settings, the administration of hypotonic maintenance fluids increases the risk of hyponatremia when compared with administration of isotonic fluids. For patients on general wards, insufficient data are available based on the reviewed studies, and individual risk factors must be assessed.

Copyright © 2014 Elsevier Inc. All rights reserved.
PMID 24582105  J Pediatr. 2014 Jul;165(1):163-169.e2. doi: 10.1016/j.j・・・
著者: Sarah McNab, Trevor Duke, Mike South, Franz E Babl, Katherine J Lee, Sarah J Arnup, Simon Young, Hannah Turner, Andrew Davidson
雑誌名: Lancet. 2015 Mar 28;385(9974):1190-7. doi: 10.1016/S0140-6736(14)61459-8. Epub 2014 Dec 1.
Abstract/Text BACKGROUND: Use of hypotonic intravenous fluid to maintain hydration in children in hospital has been associated with hyponatraemia, leading to neurological morbidity and mortality. We aimed to assess whether use of fluid solutions with a higher sodium concentration reduced the risk of hyponatraemia compared with use of hypotonic solutions.
METHODS: We did a randomised controlled double-blind trial of children admitted to The Royal Children's Hospital (Melbourne, VIC, Australia) who needed intravenous maintenance hydration for 6 h or longer. With an online randomisation system that used unequal block sizes, we randomly assigned patients (1:1) to receive either isotonic intravenous fluid containing 140 mmol/L of sodium (Na140) or hypotonic fluid containing 77 mmol/L of sodium (Na77) for 72 h or until their intravenous fluid rate decreased to lower than 50% of the standard maintenance rate. We stratified assignment by baseline sodium concentrations. Study investigators, treating clinicians, nurses, and patients were masked to treatment assignment. The primary outcome was occurrence of hyponatraemia (serum sodium concentration <135 mmol/L with a decrease of at least 3 mmol/L from baseline) during the treatment period, analysed by intention to treat. The trial was registered with the Australian New Zealand Clinical Trials Registry, number ACTRN1260900924257.
FINDINGS: Between Feb 2, 2010, and Jan 29, 2013, we randomly assigned 690 patients. Of these patients, primary outcome data were available for 319 who received Na140 and 322 who received Na77. Fewer patients given Na140 than those given Na77 developed hyponatraemia (12 patients [4%] vs 35 [11%]; odds ratio [OR] 0·31, 95% CI 0·16-0·61; p=0·001). No clinically apparent cerebral oedema occurred in either group. Eight patients in the Na140 group (two potentially related to intravenous fluid) and four in the Na77 group (none related to intravenous fluid) developed serious adverse events during the treatment period. One patient in the Na140 had seizures during the treatment period compared with seven who received Na77.
INTERPRETATION: Use of isotonic intravenous fluid with a sodium concentration of 140 mmol/L had a lower risk of hyponatraemia without an increase in adverse effects than did fluid containing 77 mmol/L of sodium. An isotonic fluid should be used as intravenous fluid for maintenance hydration in children.
FUNDING: National Health and Medical Research Council, Murdoch Childrens Research Institute, The Royal Children's Hospital, and the Australian and New Zealand College of Anaesthetists.

Copyright © 2015 Elsevier Ltd. All rights reserved.
PMID 25472864  Lancet. 2015 Mar 28;385(9974):1190-7. doi: 10.1016/S014・・・
著者: Leonard G Feld, Daniel R Neuspiel, Byron A Foster, Michael G Leu, Matthew D Garber, Kelly Austin, Rajit K Basu, Edward E Conway, James J Fehr, Clare Hawkins, Ron L Kaplan, Echo V Rowe, Muhammad Waseem, Michael L Moritz, SUBCOMMITTEE ON FLUID AND ELECTROLYTE THERAPY
雑誌名: Pediatrics. 2018 Dec;142(6). doi: 10.1542/peds.2018-3083.
Abstract/Text Maintenance intravenous fluids (IVFs) are used to provide critical supportive care for children who are acutely ill. IVFs are required if sufficient fluids cannot be provided by using enteral administration for reasons such as gastrointestinal illness, respiratory compromise, neurologic impairment, a perioperative state, or being moribund from an acute or chronic illness. Despite the common use of maintenance IVFs, there is high variability in fluid prescribing practices and a lack of guidelines for fluid composition administration and electrolyte monitoring. The administration of hypotonic IVFs has been the standard in pediatrics. Concerns have been raised that this approach results in a high incidence of hyponatremia and that isotonic IVFs could prevent the development of hyponatremia. Our goal in this guideline is to provide an evidence-based approach for choosing the tonicity of maintenance IVFs in most patients from 28 days to 18 years of age who require maintenance IVFs. This guideline applies to children in surgical (postoperative) and medical acute-care settings, including critical care and the general inpatient ward. Patients with neurosurgical disorders, congenital or acquired cardiac disease, hepatic disease, cancer, renal dysfunction, diabetes insipidus, voluminous watery diarrhea, or severe burns; neonates who are younger than 28 days old or in the NICU; and adolescents older than 18 years old are excluded. We specifically address the tonicity of maintenance IVFs in children.The Key Action Statement of the subcommittee is as follows:1A: The American Academy of Pediatrics recommends that patients 28 days to 18 years of age requiring maintenance IVFs should receive isotonic solutions with appropriate potassium chloride and dextrose because they significantly decrease the risk of developing hyponatremia (evidence quality: A; recommendation strength: strong).

Copyright © 2018 by the American Academy of Pediatrics.
PMID 30478247  Pediatrics. 2018 Dec;142(6). doi: 10.1542/peds.2018-308・・・

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