Hyponatremia and Central Pontine Myelinolysis

1. Hyponatremia
&
Central Pontine Myelinolysis
(CPM)
Ade Wijaya

2. Hyponatremia
Clinical Approach

4. SEVERE
Acute or Chronic ?
MILD
ASYMPTOMATIC

5. MILD ASYMPTOMATIC HYPONATREMIA
126–134mEq/l
Treatment ???

7. ACUTE HYPONATREMIA

8. NaCl 3% Formulation

9. CHRONIC HYPONATREMIA
> 48 hours Mild symptoms
Search for etiology Avoid overcorrection
CPM !!

11. Central Pontine Myelinolysis

12. CPM
• First described by Adams et al in 1958
• Acute non-inflammatory demyelinating disease
• Precipitated by the rapid correction of severe chronic hyponatremia
• MRI is the imaging modality of choice
• 10 %  extrapontine

13. Clinical Manifestation
• Tremor
• Ataxia
• Mutism
• Spastic quadriparesis
• Locked-in syndrome
• Coma
• Death is common
• Ventilator dependency
• Aspiration pneumonia
• Venous thrombosis
• Pulmonary embolism
• Contractures
• Muscle wasting
• Decubitus ulcers
• Urinary tract infections
• Depression

15. CSF Analysis
• Not really necessary
• Only to rule out other conditions
Increased
opening
pressure
Mononuclear
pleocytosis
Elevated
protein

16. No Treatment
SUPPORTIVE
TREATMENT ONLY

17. Take Home Messages:
• In treating hyponatremia we should be able to recognize whether it’s
acute or chronic hyponatremia
• Acute severe hyponatremia (with seizure & coma) is an emergency
condition that need correction with hypertonic saline
• In chronic hyponatremia, we need to decide the etiology first and
then treat the hyponatremia based on the etiology
• CPM is a devastating complication of too rapid correction of
hyponatremia especially in chronic hyponatremia
• The treatment of CPM is supportive only with poor prognosis