Grissenger, published case reports of hyponatremia and death in two healthy children who were administered plain dextrose and hypotonic saline after surgery. First child underwent tonsillectomy and adenoidectomy. The child was given maintenance fluid of 5% Dextrose 200ml/hr instead of 75ml/hr due to calculation error. The child vomited several times, became lethargic and threw seizures. The secondchild underwent repair of coarctation of aorta and was given IV frusemide 1mg/hr as the child's urine output was low. On postoperative day-2 child developed hyponatremia and sodium chloride infusion was started as per physician's order. In the morning the child became less responsive and by afternoon he developed seizures and vomiting. In both cases by the time the intensivist could recognize hyponatremia and start treatment, the child became unresponsive to pain stimuli. Despite intubation, ventilatory support, aggressive sodium correction and treatment of cerebral edema both the children died.