ORIGINAL ARTICLES
December 2013 21. Eldredge EA, Rockoff MA, Medlock MD, Scott RM, Millis MB. Postoperative cerebral edema occurring in children with slit ventricles. Pediatrics 1997;99:625-9. 22. McJunkin JE, de los Reyes EC, Irazuzta JE, Caceres MJ, Khan RR, Minnich LL, et al. La Crosse encephalitis in children. N Engl J Med 2001;344:801-7. 23. Hughes PD, McNicol D, Mutton PM, Flynn GJ, Tuck R, Yorke P. Postoperative hyponatremic encephalopathy: water intoxication. Aust N Z J Surg 1998;68:165. 24. Hatherill M, Waggie Z, Salie S, Argent A. Hospital-acquired hyponatremia is associated with excessive administration of intravenous maintenance fluid. Pediatrics 2004;114:1368-9. 25. Taylor D, Durward A. Pouring salt on troubled waters. Arch Dis Child 2004;89:411-4. 26. Moritz ML, Ayus JC. Prevention of hospital-acquired hyponatremia: do we have the answers? Pediatrics 2011;128:980-3. 27. Holliday M, Friedman A, Segar W, Chesney R, Finberg L. Acute hospitalinduced hyponatremia in children: a physiologic approach. J Pediatr 2004;145:584-7.
28. Holliday M, Ray P, Friedman A. Fluid therapy for children: facts, fashions and questions. Arch Dis Child 2007;92:546-50. 29. Holliday MA, Segar WE, Friedman A. Reducing errors in fluid therapy management. Pediatrics 2003;111:424-5. 30. Saba T, Fairbairn J, Houghton F, Laforte D, Foster B. A randomized controlled trial of isotonic versus hypotonic maintenance intravenous fluids in hospitalized children. BMC Pediatr 2011;11:82. 31. Yung M, Keeley S. Randomised controlled trial of intravenous maintenance fluids. J Paediatr Child Health 2009;45:9-14. 32. Singhi S, Jayashre M. Free water excess is not the main cause for hyponatremia in critically ill children receiving conventional maintenance fluids. Indian Pediatr 2009;46:577-83. 33. Arikan A, Zappitelli M, Goldstein S, Naipaul A, Jefferson L, Loftis L. Fluid overload is associated with impaired oxygenation and morbidity in critically ill children. Pediatr Crit Care Med 2012;13:253-8. 34. Sutherland S, Zappitelli M, Alexander S, Chua A, Brophy P, Bunchman T, et al. Fluid overload and mortality in children receiving continuous renal replacement therapy: the prospective pediatric continuous renal replacement therapy registry. Am J Kidney Dis 2010;55:316-25.
50 Years Ago in THE JOURNAL OF PEDIATRICS The Effect of Breathing 40 Per Cent Oxygen on the Arterial Blood Gas Tension of Babies With Bronchiolitis Reynolds EOR. J Pediatr 1963:63:1135
R
eynolds documents the therapeutic benefit of relatively low concentrations of supplemental oxygen in 10 infants with bronchiolitis. The newsworthiness of this report is difficult to appreciate 50 years later, but clinically useful machines that could measure the partial pressure of oxygen in blood had been introduced only in the mid-1950s, and the effects of oxygen in infants with respiratory distress were not well defined. After documenting that the average alveolar-arterial oxygen gradient in his subjects was approximately 10 times normal, Reynolds demonstrated that 40% face-mask oxygen was able to increase the partial pressure of oxygen in arterial blood from 40s and 50s to over 100. Moreover, the maneuver did not impede the exhalation of carbon dioxide. Using deductive reasoning based on his own and others’ observations, he concluded that most of the hypoxia in this entity was the result of ventilation– perfusion mismatching, which has proved to be largely correct. Respiratory syncytial virus (RSV) had been discovered only a few years before the article by Reynolds was published, and its profound importance as the primary cause of bronchiolitis in infants was just being uncovered. Since then, medical progress in treating and containing RSV infection has been both disappointing and modestly successful. Among the disappointments: a trial of formalin-inactivated RSV vaccine in the late 1960s resulted in enhanced disease severity among infants subsequently exposed to wild-type virus, and aerosolized therapy with the antiviral agent ribavirin had marginal effectiveness in immune-competent infants and was difficult to deliver. On the other hand, passive immunization with monoclonal antibodies has been able to mitigate disease in subpopulations of infants at risk for complicated RSV infection. Ultimately, definitive success in the battle against RSV bronchiolitis awaits the development of a vaccine. Both intranasally delivered live attenuated viral vaccines and subunit vaccines are in various stages of human trial, but, although promising, safety and protective efficacy, particularly in young babies, have yet to be established. Of course, if and when an RSV vaccine is successfully brought to market, the host of other viral pathogens responsible for bronchiolitis will remain. As a consequence, for the immediate future, supportive therapy composed of hydration and supplemental oxygen, as tested by Reynolds, will remain the cornerstones of the approach to bronchiolitis in the infant. Philip Toltzis, MD Department of Pediatrics Hadassah Medical Center Jerusalem, Israel http://dx.doi.org/10.1016/j.jpeds.2013.06.016
Association between Maintenance Fluid Tonicity and Hospital-Acquired Hyponatremia
1651
December 2013 21. Eldredge EA, Rockoff MA, Medlock MD, Scott RM, Millis MB. Postoperative cerebral edema occurring in children with slit ventricles. Pediatrics 1997;99:625-9. 22. McJunkin JE, de los Reyes EC, Irazuzta JE, Caceres MJ, Khan RR, Minnich LL, et al. La Crosse encephalitis in children. N Engl J Med 2001;344:801-7. 23. Hughes PD, McNicol D, Mutton PM, Flynn GJ, Tuck R, Yorke P. Postoperative hyponatremic encephalopathy: water intoxication. Aust N Z J Surg 1998;68:165. 24. Hatherill M, Waggie Z, Salie S, Argent A. Hospital-acquired hyponatremia is associated with excessive administration of intravenous maintenance fluid. Pediatrics 2004;114:1368-9. 25. Taylor D, Durward A. Pouring salt on troubled waters. Arch Dis Child 2004;89:411-4. 26. Moritz ML, Ayus JC. Prevention of hospital-acquired hyponatremia: do we have the answers? Pediatrics 2011;128:980-3. 27. Holliday M, Friedman A, Segar W, Chesney R, Finberg L. Acute hospitalinduced hyponatremia in children: a physiologic approach. J Pediatr 2004;145:584-7.
28. Holliday M, Ray P, Friedman A. Fluid therapy for children: facts, fashions and questions. Arch Dis Child 2007;92:546-50. 29. Holliday MA, Segar WE, Friedman A. Reducing errors in fluid therapy management. Pediatrics 2003;111:424-5. 30. Saba T, Fairbairn J, Houghton F, Laforte D, Foster B. A randomized controlled trial of isotonic versus hypotonic maintenance intravenous fluids in hospitalized children. BMC Pediatr 2011;11:82. 31. Yung M, Keeley S. Randomised controlled trial of intravenous maintenance fluids. J Paediatr Child Health 2009;45:9-14. 32. Singhi S, Jayashre M. Free water excess is not the main cause for hyponatremia in critically ill children receiving conventional maintenance fluids. Indian Pediatr 2009;46:577-83. 33. Arikan A, Zappitelli M, Goldstein S, Naipaul A, Jefferson L, Loftis L. Fluid overload is associated with impaired oxygenation and morbidity in critically ill children. Pediatr Crit Care Med 2012;13:253-8. 34. Sutherland S, Zappitelli M, Alexander S, Chua A, Brophy P, Bunchman T, et al. Fluid overload and mortality in children receiving continuous renal replacement therapy: the prospective pediatric continuous renal replacement therapy registry. Am J Kidney Dis 2010;55:316-25.
50 Years Ago in THE JOURNAL OF PEDIATRICS The Effect of Breathing 40 Per Cent Oxygen on the Arterial Blood Gas Tension of Babies With Bronchiolitis Reynolds EOR. J Pediatr 1963:63:1135
R
eynolds documents the therapeutic benefit of relatively low concentrations of supplemental oxygen in 10 infants with bronchiolitis. The newsworthiness of this report is difficult to appreciate 50 years later, but clinically useful machines that could measure the partial pressure of oxygen in blood had been introduced only in the mid-1950s, and the effects of oxygen in infants with respiratory distress were not well defined. After documenting that the average alveolar-arterial oxygen gradient in his subjects was approximately 10 times normal, Reynolds demonstrated that 40% face-mask oxygen was able to increase the partial pressure of oxygen in arterial blood from 40s and 50s to over 100. Moreover, the maneuver did not impede the exhalation of carbon dioxide. Using deductive reasoning based on his own and others’ observations, he concluded that most of the hypoxia in this entity was the result of ventilation– perfusion mismatching, which has proved to be largely correct. Respiratory syncytial virus (RSV) had been discovered only a few years before the article by Reynolds was published, and its profound importance as the primary cause of bronchiolitis in infants was just being uncovered. Since then, medical progress in treating and containing RSV infection has been both disappointing and modestly successful. Among the disappointments: a trial of formalin-inactivated RSV vaccine in the late 1960s resulted in enhanced disease severity among infants subsequently exposed to wild-type virus, and aerosolized therapy with the antiviral agent ribavirin had marginal effectiveness in immune-competent infants and was difficult to deliver. On the other hand, passive immunization with monoclonal antibodies has been able to mitigate disease in subpopulations of infants at risk for complicated RSV infection. Ultimately, definitive success in the battle against RSV bronchiolitis awaits the development of a vaccine. Both intranasally delivered live attenuated viral vaccines and subunit vaccines are in various stages of human trial, but, although promising, safety and protective efficacy, particularly in young babies, have yet to be established. Of course, if and when an RSV vaccine is successfully brought to market, the host of other viral pathogens responsible for bronchiolitis will remain. As a consequence, for the immediate future, supportive therapy composed of hydration and supplemental oxygen, as tested by Reynolds, will remain the cornerstones of the approach to bronchiolitis in the infant. Philip Toltzis, MD Department of Pediatrics Hadassah Medical Center Jerusalem, Israel http://dx.doi.org/10.1016/j.jpeds.2013.06.016
Association between Maintenance Fluid Tonicity and Hospital-Acquired Hyponatremia
1651
