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Hypernatremia management

Hypernatremia management

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  • 1. Hypernatremia [Na]> 150 mEq/L
  • 2. Extracellular-Fluid andIntracellular-FluidCompartments underNormal Conditionsand during States ofHypernatremia.
  • 3. Effects of Hypernatremiaon the Brain and AdaptiveResponses.
  • 4. Clinical Signs of HypernatremicStates Related to Serum OsmolalityOsmolality (mOsm/kg) Manifestations350–375 Restlessness, irritability375–400 Tremulousness, ataxia400–430 Hyperreflexia, twitching, spasticity>430 Seizures and death
  • 5. Causes of Hypernatremia *Likely or important ED diagnostic considerations.Inadequate water intake* GI loss* Inability to obtain or swallow water Vomiting, diarrhea, intestinal fistula Renal loss Impaired thirst drive Central diabetes insipidus Increased insensible loss Impaired renal concentrating abilityExcessive sodium Osmotic diuresis (multiple causes)* Iatrogenic sodium administration – Hypercalcemia – Sodium bicarbonate – Decreased protein intake – Hypertonic saline – Prolonged, excessive water intake – Sickle cell disease Accidental/deliberate ingestion of large – Multiple myeloma quantities of sodium – Amyloidosis – Substitution of salt for sugar in infant – Sarcoidosis formula or tube feedings – Sjögren syndrome – Salt water ingestion or drowning – Nephrogenic diabetes insipidus Mineralocorticoid or glucocorticoid – Congenital excess* Drugs/medications – Primary aldosteronism Alcohol, lithium, phenytoin, propoxyphene, sulfonylureas, amphotericin, colchicine – Cushing syndrome Skin loss – Ectopic ACTH production Burns, sweating Peritoneal dialysis Essential hypernatremia – Loss of water in excess of sodium
  • 6. Most hypernatremia encountered in theED is related to severe volume loss.In otherwise healthy patients, hypovolemialeads to conservation of free water by thekidneys that results in low urine output(<20 mL/h) with high osmolality (usually>1000 mOsm/kg water).
  • 7. Diabetes Insipidus Diabetes insipidus is characterized by the failure of central or peripheral ADH response. Urine osmolality is low (200 to 300 mOsm/kg, with urinary [Na+] of 60 to 100 mEq/kg)
  • 8. Treatment The cornerstone of treatment is volume repletion. Volume should be replaced first with NS or lactated Ringers solution. Some practitioners inappropriately fear using NS solution from concern that an [Na+] of 154 mEq/L exceeds normal serum [Na+]. However, in most hypernatremic states, there is a total body [Na+] deficit, and the use of NS allows a more gradual decrease in serum [Na+]. Once perfusion has been established, the solution should be converted to 0.45% saline or another hypotonic solution until the urine output is at least 0.5 mL/kg/h. The reduction in [Na+] should not exceed 10~15 mEq/L per day.
  • 9. Calculation of Free Water Deficit measured[Na ] TBW 0.6 1 desired[Na ]Replacement Volume = TBW deficit × 1/(1-X)X= [Na+] of resuscitation fluid / [Na+] of isotonic saline
  • 10. 70 公斤的成人,抽血發現 [Na+] 160 mEq/L 計算式: TBW deficit = 0.6 ×70× [160/140-1]= 6 L 若使用 0.45NaCl 做為輸液 Replacement volume = 6 × 1/ (1-½)=12 L 水分缺損要在 48小時 補足 點滴速度大約每小時要 250 mL
  • 11. Reference Fluids and Electrolytes, Tintinalli‘s Emergency Medicine 2010:117-121 Hypernatremia, NEJM 2000; 342:1493-1499 Hyponatremia, NEJM 2000; 342:1581-158 Hypertonic and hypotonic Conditions, The ICU Book 2007: 595-602