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Hyponatremia management

Hyponatremia management



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    Hyponatremia Hyponatremia Presentation Transcript

    • Hyponatremia[Na] < 135 mEq/L
    • Extracellular-Fluid andIntracellular-Fluid Compartmentsunder Normal Conditions andduring States of Hyponatremia.
    • Effects of Hyponatremia onthe Brain and AdaptiveResponses.
    • Clinical Signs of Hyponatrema Nausea, vomiting, anorexia, muscle cramps, confusion, and lethargy, and culminate ultimately in seizures and coma. Seizures are quite likely at [Na+] of 113 mEq/L or less.
    • Causes of Hyponatremia Hypertonic Hyponatremia – Osmotic Pressure >295 Isotonic Hyponatremia – Osmotic Pressure 275 to 295 Hypotonic Hyponatremia – Osmotic Pressure <275
    • Hypertonic hyponatremia (Posm >295) Hyperglycemia Mannitol excess Glycerol therapy
    • Isotonic (pseudo) hyponatremia(Posm 275–295) Hyperlipidemia Hyperproteinemia (e.g., multiple myeloma, Waldenström macroglobulinemia)
    • Hypotonic hyponatremia (Posm <275) Hypovolemic Euvolemic – Renal urine [Na+] usually > 20 mEq/L • Diuretic use – SIADH • Salt-wasting nephropathy (renal tubular – Hypothyroidism (possible increased ADH acidosis, chronic renal failure, interstitial nephritis) or deceased glomerular filtration rate) • Osmotic diuresis – Pain, stress, nausea, psychosis (glucose, urea, mannitol, hyperproteinemia) (stimulates ADH) – Drugs: • Mineralocorticoid (aldosterone) deficiency ADH, nicotine, sulfonylureas, morphine, – Extrarenal barbiturates, NSAIDs, acetaminophen, • Volume replacement with hypotonic fluids carbamazepine, phenothiazines, tricyclic • GI loss (vomiting, diarrhea, fistula, tube antidepressants, colchicine, clofibrate, suction) cyclophosphamide, isoproterenol, • Third-space loss (e.g., burns, hemorrhagic tolbutamide, vincristine, monoamine pancreatitis, peritonitis) oxidase inhibitor Hypervolemic – Water intoxication – Urinary [Na+] >20 mEq/L – Glucocorticoid deficiency • Renal failure (inability to excrete free water) – Positive pressure ventilation – Urinary [Na+] <20 mEq/L – Porphyria • Congestive heart failure – Essential (reset osmostat or sick cell • Nephrotic syndrome syndrome—usually in the elderly) • Cirrhosis
    • Diagnostic Criteria for Syndromeof Inappropriate Secretion of ADH Hypotonic hyponatremia Inappropriately elevated urine osmolality (usually >200 mOsm/kg) Elevated urine [Na+] (typically > 20 mEq/L) Clinical euvolemia Normal adrenal, renal, cardiac, hepatic, and thyroid function Correctable with water restriction
    • Total Body [Na+] Deficit= (desired plasma [Na+]-measured plasma [Na+]) ×TBW
    • Emergency Treatment of SevereHyponatremia Although specific or general treatment of hyponatremia for the condition discussed may be initiated in the ED, there is generally little urgency to address the hyponatremia immediately when [Na+] is 120 mEq/L. If hyponatremia is severe (<115 mEq/L or when the patient is symptomatic), treatment should be initiated.
    • Emergency Treatment of SevereHyponatremia Situations that warrant consideration of emergent treatment are hypovolemic patients and patients in extremis, (e.g., mental status changes or coma). In hypovolemic patients, the [Na+] deficit should be calculated and replaced with normal saline solution. Urine electrolytes are useful only before beginning treatment and therefore should be collected in the ED. The rise in [Na+] should be no greater than 0.5 to 1.0 mEq/L per hour.
    • ReferenceFluids andElectrolytes, Tintinalli‘sEmergency Medicine2010:117-121Hyponatremia, NEJM2000; 342:1581-158Hypertonic andhypotonicConditions, The ICUBook 2007: 595-602