doc - Pediatric Continuous Renal Replacement Therapy

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Hypernatremia in a pediatric patient with acute tubular necrosis
managed with continuous renal replacement therapy (CRRT) and
a concomitant 3% sodium infusion
E. Ong, R. Erickson, Holt T.
University of Saskatchewan, Saskatoon, Canada
The rapid correction of chronic hypernatremia is a risk factor for
neurological complications. In fact, it is recommended that the drop in
serum sodium should not exceed 10 mmol/L/day. However,
commercially available dialysis and replacement solutions are
relatively hyponatremic compared the serum sodium of hypernatremic
patients. Previous case reports examining the use of CRRT to effect
drop in serum sodium, have either not utilized a safe-guard to protect
against an overly rapid serum sodium decline, or have used a more
cumbersome method of customized dialysis and replacement
solutions. We hereby present the first case report of a child with acute
kidney injury, hypovolemia, metabolic acidosis, oliguria, and chronic
hypernatremia, successfully treated with CRRT and a concomitantly
titrated 3% saline infusion. Serum electrolytes were frequently
obtained during the dialysis course and the 3% saline infusion was
frequently adjusted to allow for a gradual drop in serum sodium. At
the start of CRRT, the patient had a serum sodium of 178 mmol/L,
urea of 30.9 mmol/L (3.7-7.0), and creatinine of 178 umol/L (15-37).
The serum sodium was gradually decreased over 88 hours to 152
mmol/L; a decline of about 7 mmol/L/24hrs. Dialysis was
successfully discontinued when the patient began to void. Three days
after stopping CRRT, serum electrolytes were stable: sodium 141
mmol/L (135-146), potassium 3.7 mmol/L (3.5-5.1); urea 2.2 mmol/L
(3.7-7.0); and creatinine 20 umol/L (15-37). His CT scan revealed no
evidence of cerebral edema.
Figure 1:
Figure 1: Our subject’s serum sodium (mmol/L) during admission at
our PICU is plotted against time in hours. The second line represents
the targeted maximum decrease in serum sodium of 10 mmol/L/24 hr.
CRRT was performed for the duration of the dashed line.
Eric Ong, Department of Pediatrics, University of Saskatchewan
103 Hospital Drive, Saskatoon, SK, S7N 0W8 Canada
[email protected] Fax: (306) 975-3767
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