Correspondence
type of intravenous fluid can result in fluid over-
load if administered in excessive quantities (for
example, in patients with end-stage renal disease
or heart failure in whom both sodium excretion
and water excretion are impaired). Isotonic fluids
are otherwise incapable of producing hyperna-
tremia or fluid overload, because a normally
functioning kidney can generate free water by ex-
creting a hypertonic urine.1 This is a physiologic
response, as we have described previously in
healthy ambulatory children,2 and this response
explains why hyponatremia (rather than fluid
overload) develops in patients with a syndrome
of inappropriate secretion of antidiuretic hormone
(SIADH)like states in response to intravenous
fluids. The subclinical volume expansion associat-
ed with an excess of arginine vasopressin triggers
hemodynamic regulatory mechanisms to main-
tain plasma volume at the expense of plasm sodi-
um, which is in part due to a pressure-natriuresis
mechanism and a secondary release of natriuretic
peptides.3
As was stated in our article, in more than 15
randomized, prospective trials involving more
than 2000 patients, isotonic fluids were not as-
sociated with an increased risk of hypernatremia
or fluid overload. In Table 1 and Figure 2 of our
article, we outline the disease states that require
special considerations in fluid management, and
we provide an algorithm for adjusting the intra-
venous-fluid rate and composition in order to
prevent fluid overload and hypernatremia.
Chua and Lief raise an additional concern
regarding the high chloride concentration in
0.9% saline. After the publication of our article,
a randomized study by Young et al. compared
0.9% saline with a balanced electrolyte solution
in more than 2000 critically ill patients.4 They
In-Flight Medical Emergencies
To the Editor: Nable et al. (Sept. 3 issue)1 did
not mention that acute allergic reactions may oc-
cur on airplanes, probably triggered by a food,
especially peanuts (commonly served on flights),
a drug, or in rare cases, an insect bite or sting.
Food allergies among children increased by ap-
proximately 50% between 1997 and 2011.2
The first-line treatment for anaphylaxis, a severe
n engl j med 374;3nejm.org January 21, 2016
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Copyright 2016 Massachusetts Medical Society. All rights reserved.
found no significant between-group differences
in complications such as acute kidney injury, a
need for mechanical ventilation, electrolyte dis-
turbances, and death.
Lief questions the needs for maintenance
fluids in critically ill patients owing to the risk
of fluid overload. As stated in Figure 2 of our
article, maintenance fluids are indicated only
after the resuscitation phase of fluid therapy,
and we recommend fluid restriction to 25 ml per
hour for oligoanuric states in order to prevent
fluid overload.
Petzold et al. correctly point out the dangers
of hyperglycemia in patients with stroke. To the
best of our knowledge, 5% dextrose in mainte-
nance fluids is not associated with hyperglyce-
mia in the absence of diabetes.
MichaelL. Moritz, M.D.
Childrens Hospital of Pittsburgh
Pittsburgh, PA
moritzml@upmc.edu
JuanC. Ayus, M.D.
Renal Consultants of Houston
Houston, TX
Since publication of their article, the authors report no fur-
ther potential conflict of interest.
1. Andersen LJ, Norsk P, Johansen LB, Christensen P, Engstrom
T, Bie P. Osmoregulatory control of renal sodium excretion after
sodium loading in humans. Am J Physiol 1998;275:R1833-42.
2. Moritz ML. Urine sodium composition in ambulatory
healthy children: hypotonic or isotonic? Pediatr Nephrol 2008;
23:955-7.
3. Cogan E, Debieve MF, Pepersack T, Abramow M. Natriuresis
and atrial natriuretic factor secretion during inappropriate an-
tidiuresis. Am J Med 1988;84:409-18.
4. Young P, Bailey M, Beasley R, et al. Effect of a buffered crys-
talloid solution vs saline on acute kidney injury among patients
in the intensive care unit: the SPLIT randomized clinical trial.
JAMA 2015;314:1701-10.
DOI: 10.1056/NEJMc1513887
and often life-threatening reaction, is prompt ad-
ministration of epinephrine and a hospital visit.3,4
Because the need for treatment is often immedi-
ate (especially in persons with hypotension or
airway compromise) and death may occur before
transfer to a hospital, many states have passed
laws to ensure that epinephrine is available in
schools and other public buildings. Clearly,
291
 The n e w e ng l a n d j o u r na l of m e dic i n e

cause for concern is even greater on a flight
thousands of feet above the ground. Legislation
such as that recently introduced in the U.S. Senate
the Airline Access to Emergency Epinephrine
Act (S.1972) which would require airlines to
carry epinephrine autoinjectors on commercial
flights, is greatly needed.
ThomasB. Casale, M.D.
RobertF. Lemanske, Jr., M.D.
American Academy of Allergy, Asthma, and Immunology
Milwaukee, WI
Dr. Casale reports serving as a consultant for Genentech,
Teva, AstraZeneca, SanofiRegeneron, Capnia, and Circassia
and as an investigator for Genentech, Novartis, Teva, Sanofi
Regeneron, and Circassia, with all funding provided to his insti- DavidE. Aftergood, M.D.
tution. No other potential conflict of interest relevant to this
letter was reported.
1. Nable JV, Tupe CL, Gehle BD, Brady WJ. In-flight medical
emergencies during commercial travel. N Engl J Med 2015;373:
939-45.
2. Jackson KD, Howie LD, Akinbami LJ. Trends in allergic con-
ditions among children:United States, 19972011. NCHS data DOI: 10.1056/NEJMc1512716
brief. No. 121. Hyattsville, MD:National Center for Health Sta-
tistics. 2013.
3. Lieberman P, Nicklas RA, Oppenheimer J, et al. The diagno-
sis and management of anaphylaxis practice parameter: 2010 The authors reply: We agree with Casale and
update. J Allergy Clin Immunol 2010;126:477-80.
4. Casale TB, Burks AW. Hymenoptera-sting hypersensitivity. ing. Fortunately, it is a rare in-flight emergency
N Engl J Med 2014;370:1432-9.
DOI: 10.1056/NEJMc1512716
To the Editor: Over the years, fate has put me
on many airplanes where emergencies such as
those described by Nable et al. have occurred.
Astoundingly, many airlines still carry only man-
ual blood pressure cuffs, even though it is not
possible to hear the results on a moving airplane.
At the touch of a button, automated cuffs allow
hands-free repeat measurements and provide ac-
tual numbers.
Jack Jaffe, M.D., Ph.D.
15 Main St.
Watertown, MA
No potential conflict of interest relevant to this letter was re-
ported.
DOI: 10.1056/NEJMc1512716
To the Editor: On a recent flight, medical as-
sistance was requested for an 8-year-old boy who
had not urinated in several hours and was in pain
caused by a very full bladder and severe constipa-
tion. Another physician and I responded. We
considered that something similar to an enema,
to relieve the obstipation, might also allow the
child to empty his overfilled bladder. Forced to
be creative, we requested olive oil from the first-
class cabin and connected a syringe to an intra-
venous catheter in order to administer the olive
oil rectally. We spread out a large plastic body
bag and approached the screaming child, who
was being held by his mother. Fortunately, only
light pressure applied to the anal area resulted in
a prompt evacuation of feces onto the bag. The
boy was then able to void successfully. As Nable
et al. explained, one must be prepared for any-
thing in the medically austere environment of
airplane flight.
99 N. La Cienega Blvd.
Beverly Hills, CA
davidaftergood@hotmail.com
No potential conflict of interest relevant to this letter was re-
ported.
Lemanske that severe anaphylaxis is life-threaten-
(accounting for 2.2% of all incidents and 4.5% of
aircraft diversions).1 Although the Federal Avia-
tion Administration does require the inclusion of
epinephrine in the medical kits carried on board,2
an autoinjectable version is not required. We
agree that the inclusion of autoinjectable epi-
nephrine should be considered. The Airline Ac-
cess to Emergency Epinephrine Act would require
all commercial airlines to carry two epinephrine
autoinjectors on every plane and to train crew
members to recognize anaphylaxis and to ad-
minister autoinjectable epinephrine.
Jaffe notes that the ability to auscultate blood
pressure is difficult because of the ambient in-
flight noise and suggests the use of automated
equipment. We agree but also note that palpat-
ing blood pressure with the use of a standard
sphygmomanometer would be another alternative
that would provide readings of systolic pressure.
Finally, we commend Aftergood and his phy-
sician colleague for developing an approach to
constipation-related urinary retention at 36,000
feet. Their actions brought relief to a child in
great discomfort.
These three commentaries should make all of
us consider the potential for in-flight medical
emergencies and what might be the most appro-

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Copyright 2016 Massachusetts Medical Society. All rights reserved.
 Correspondence

priate approach to such situations should they
arise. However, we think that expecting airlines
to provide a complete set of medical supplies on
all commercial flights is not appropriate. A com-
mercial aircraft is, in fact, simply that a com-
mercial aircraft. Passengers must exercise good
judgment with regard to the advisability of air
travel if they have or expect to have illness or
injury that should preclude it. Of course, we
also understand that some events occur with-
out warning.
There is also the problem of training flight
attendants to use the supplies. In most instances,
the only training flight attendants receive in-
volves very basic first aid, which allows for only
limited interventions. Volunteer health care pro-
viders can provide assistance, but their range of
abilities may also limit care. Furthermore, an
airline assumes some liability by placing medi-
cal equipment on an aircraft that its personnel
are not sufficiently trained to use. If certain
equipment is mandated by law or a legitimate
standard of care exists, then the relevant equip-
ment or material must be provided. However, it
is important to bear in mind that in-flight
medical emergencies present a wide variety of
challenges that require not only the appropriate
equipment but also appropriate training in the
use of that equipment.
WilliamJ. Brady, M.D.
University of Virginia
Charlottesville, VA
BruceD. Gehle, J.D.
Piedmont Liability Trust
Charlottesville, VA
JoseV. Nable, M.D., N.R.P.
MedStar Georgetown University Hospital
Washington, DC
wb4z@virginia.edu
Since publication of their article, the authors report no fur-
ther potential conflict of interest.
1. Peterson DC, Martin-Gill C, Guyette FX, et al. Outcomes of
medical emergencies on commercial airline flights. N Engl J Med
2013;368:2075-83.
2. Federal Aviation Administration (FAA), DOT. Emergency
medical equipment: final rule. Fed Regist 2001;66:19028-46.
DOI: 10.1056/NEJMc1512716

Case 28-2015: A Man with Febrile Symptoms after Traveling

from Liberia
To the Editor: In the Case Record discussed by
Biddinger et al. (Sept. 10 issue),1 the authors de-
scribe the care of a febrile traveler who was re-
turning from an area in which malaria is highly
endemic and who was considered to be in the
low (but not zero) risk category for Ebola virus
disease (EVD).2 Modifications made to safely as-
sess the patient for EVD are reported, including
the use of only a rapid diagnostic test to diagnose
malaria. The Centers for Disease Control and
Prevention (CDC) recommends immediate micros-
copy of thin and thick blood smears for the diag-
nosis of malaria, which can be safely performed
by observing precautions against the transmis-
sion of EVD.3 Diagnosis by means of microscopy
allows for the identification of species and the
quantification of parasitemia, both of which are
needed to determine the most appropriate treat-
ment. Microscopy must always be performed af-
ter a rapid diagnostic test in order to confirm the
result and obtain this additional information.4
The patient discussed could have had undiag-
nosed hyperparasitemia, which requires paren-
teral therapy. In addition, without identifying the
species by means of microscopy or polymerase-
chain-reaction assay, the authors may have missed
a mixed infection, which could have been treated
with primaquine, thereby preventing a 6-week
relapse. Correct determination of the initial in-
fecting species is preferred over the reliance on
knowledge of the geographic distribution of spe-
cies that cause relapsing malaria and the use of
empirical therapy with primaquine.
KathrineR. Tan, M.D., M.P.H.
KarenA. Cullen, Ph.D.
PaulM. Arguin, M.D.
Centers for Disease Control and Prevention
Atlanta, GA
ktan@cdc.gov
No potential conflict of interest relevant to this letter was re-
ported.
1. Case Records of the Massachusetts General Hospital (Case
28-2015). N Engl J Med 2015;373:1060-7.
2. Centers for Disease Control and Prevention. Guidance for

n engl j med 374;3nejm.org January 21, 2016 293

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