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Cydni N. Williams, Jay Riva-Cambrin, Angela P. Presson and Susan L. Bratton

OBJECT

Pediatric intracranial neoplasms are common and cause substantial neurological morbidity. Postoperative hyponatremia is also common and may exacerbate neurological injury. The authors performed an exploratory analysis to evaluate an exposure-response relationship between hyponatremia severity and cognitive function at discharge.

METHODS

A retrospective cohort of patients 0–19 years old who underwent a first intracranial neoplasm surgery at a pediatric tertiary care hospital was reviewed. Outcome was assessed by Pediatric Cerebral Performance Category (PCPC) score of 1–6 at hospital discharge. Poor outcome was defined as PCPC score 3–6, corresponding to moderate or worse disability.

RESULTS

Of 319 total children, 80 (25%) had poor outcomes. One hundred thirty-seven children (43%) had serum sodium concentrations ≤ 131–135 mEq/L and 39 (12%) had serum sodium concentrations ≤ 130 mEq/L. Lower nadir sodium concentration and longer duration of hyponatremia were significantly associated with worsening PCPC score (p < 0.001). Rapid sodium decreases and more hyponatremic episodes were also significantly associated with worsening PCPC score (p < 0.001). After adjustment for patient factors, tumor characteristics, and measures of sodium disruption, multivariable analysis revealed noncortical tumor locations and lower nadir sodium concentration (adjusted odds ratio 0.86, 95% confidence interval 0.78–0.95) were important independent risk factors for poor cognitive outcome.

CONCLUSIONS

Neurocognitive disability and hyponatremia are common in children undergoing surgery for intracranial neoplasms. This study found a significant association between severity of hyponatremia and worsened cognitive outcome, with an apparent exposure-response relationship. These data support the need for careful postoperative monitoring of serum sodium. Further research is needed to determine if prevention and treatment of hyponatremia can improve outcomes in these children.

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Cydni N. Williams, Jennifer S. Belzer, Jay Riva-Cambrin, Angela P. Presson and Susan L. Bratton

Object

Intracranial tumors are common pediatric neoplasms and account for substantial morbidity among children with cancer. Hyponatremia is a known complication of neurosurgical procedures and is associated with higher morbidity among neurosurgical patients. The authors aimed to estimate the incidence of hyponatremia, identify clinical characteristics associated with hyponatremia, and assess the association between hyponatremia and patient outcome among children undergoing surgery for intracranial tumors.

Methods

This is a retrospective cohort study of children ranging in age from 0 to 19 years who underwent an initial neurosurgical procedure for an intracranial tumor between January 2001 and February 2012. Hyponatremia was defined as serum sodium ≤ 130 mEq/L during admission.

Results

Hyponatremia during admission occurred in 39 (12%) of 319 patients and was associated with young age and obstructive hydrocephalus (relative risk [RR] 2.9 [95% CI 1.3–6.3]). Hyponatremic patients were frequently symptomatic; 21% had seizures and 41% had altered mental status. Hyponatremia was associated with complicated care including mechanical ventilation (RR 4.4 [95% CI 2.5–7.9]), physical therapy (RR 4 [95% CI 1.8–8.8]), supplemental nutrition (RR 5.7 [95% CI 3.3–9.8]), and infection (RR 5.7 [95% CI 3.3–9.5]). Hyponatremic patients had a 5-fold increased risk of moderate or severe disability on the basis of their Pediatric Cerebral Performance Category score at discharge (RR 5.3 [95% CI 2.9–9.8]). Obstructive hydrocephalus (adjusted odds ratio [aOR] 3.24 [95% CI 1.38–8.94]) and young age (aOR 0.92 [95% CI 0.85–0.99]) were independently associated with hyponatremia during admission. Hyponatremia was independently associated with moderate or worse disability by Pediatric Cerebral Performance Category score at discharge (aOR 6.2 [95% CI 3.0–13.03]).

Conclusions

Hyponatremia was common, particularly among younger children and those with hydrocephalus. Hyponatremia was frequently symptomatic and was associated with more complicated hospital courses. Hyponatremia was independently associated with worse neurological outcome when adjusted for age and tumor factors. This study serves as an exploratory analysis identifying important risk factors for hyponatremia and associated sequelae. Further research into the causes of hyponatremia and the association with poor outcome is needed to determine if prevention and treatment of hyponatremia can improve outcomes in these children.