Fluid-induced harm in the hospital: look beyond volume and start considering sodium. From physiology towards recommendations for daily practice in hospitalized adults

Niels Van Regenmortel, Lynn Moers, Thomas Langer, Ella Roelant, Tim De Weerdt, Pietro Caironi, Manu L N G Malbrain, Paul Elbers, Tim Van den Wyngaert, Philippe G Jorens, Niels Van Regenmortel, Lynn Moers, Thomas Langer, Ella Roelant, Tim De Weerdt, Pietro Caironi, Manu L N G Malbrain, Paul Elbers, Tim Van den Wyngaert, Philippe G Jorens

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%.

Conflict of interest statement

Dr Van Regenmortel and Dr Malbrain report speaker’s fees from Baxter Belgium. Dr Van Regenmortel served on an advisory board on fluid therapy organized by Baxter (2017). Dr Van Regenmortel and Dr Malbrain are chairs of the International Fluid Academy, a non-profit organization promoting education on fluid management and hemodynamic monitoring that received sponsoring from the industry (https://urldefense.proofpoint.com/v2/url?u=http-3A__www.fluidacademy.org&d=DwIFAg&c=vh6FgFnduejNhPPD0fl_yRaSfZy8CWbWnIf4XJhSqx8&r=yAMxyalBUU6FWS_X92e5RF0qgu27J-fAum9UIH64Ji9P7WvInM6e9epg0HCgDPW7&m=QkZx0S146DbbMotw8ZpVlFdowG5dHDiMnpuTRIKNbmw&s=gNrZ_NCIF2Qwfo825mJDWgmsnIgJUrE5iladovTZjwE&e=). The other authors have nothing to disclose.

Figures

Fig. 1
Fig. 1
Cumulative fluid balance of the MIHMoSA and TOPMAST trials. Both in healthy volunteers (MIHMoSA) and in patients undergoing major surgery (TOPMAST), fluid retention was significantly higher in the treatment arm receiving maintenance fluids containing 154 mmol/L of sodium (compared to 54 mmol/L). Compared to healthy subjects, the patient cohort had a more positive fluid balance, no matter the study fluid, partly due to other net fluid input (± 1.5 L) and partly due to the physiological response to hypovolemia, capillary leakage, etc. For details: see text. Adapted from Van Regenmortel et al. and Van Regenmortel et al., with permission [7, 8]
Fig. 2
Fig. 2
Suggested maintenance fluid strategy for in-hospital patients, especially those who are at risk of fluid overload or hyponatremia

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