Hyopna 9090909

1. By Dr:-FATIMA EYAD AL GLAD

2. • • • • • • • • Definition Epidemiology Physiology Pathophysiology Types Clinical Manifestations Diagnosis Treatment

3. • Definition: – Commonly defined as a serum sodium concentration 135 meq/L – Hyponatremia represents a relative excess of water in relation to sodium.

4. : Epidemiology ocw.jhsph.edu Frequency Hyponatremia is the most common electrolyte disorder incidence of approximately 1% prevalence of approximately 2.5% surgical ward, approximately 4.4% of patients treated in the intensive care unit 30%

5. . Epidemiology Cont  Mortality/Morbidity › Acute hyponatremia (developing over 48 h or  less) are subject to more severe degrees of cerebral edema sodium level is less than 105 mEq/L, the mortality is  over 50% Chronic hyponatremia (developing over more  than 48 h) experience milder degrees of cerebral edema Brainstem herniation has not been observed in  patients with chronic hyponatremia

6. . Epidemiology Cont  Age › Infants  fed tap water in an effort to treat symptoms of  gastroenteritis Infants fed dilute formula in attempt to ration  Elderly patients with diminished sense of thirst,  especially when physical infirmity limits independent access to food and drink

7. Physiology  Serum sodium concentration › :regulation stimulation of thirst  secretion of ADH  feedback mechanisms of the  renin-angiotensin-aldosterone system renal handling of filtered sodium 

8. . Physiology Cont  Stimulation of thirst › Osmolality increases  Main driving force  Only requires an increase of 2% - 3%  Blood volume or pressure is reduced  Requires a decrease of 10% - 15%  Thirst center is located in the anteriolateral  center of the hypothalamus Respond to NaCL and angiotensin II 

11. www.merricks.com/tech_electrolyte_new.htm

12. . Physiology Cont  extracellular-fluid and intracellular-fluid › compartments make up 40 percent and 60 percent of total body water renal handling of water is sufficient to › excrete as much as 15-20 L of free water per day sodium is the predominant osmole in the › extracellular fluid (ECF) compartment and serum

13. Pathophysiology  hyponatremia can only occur when some › condition impairs normal free water excretion :acute drop in the serum osmolality › neuronal cell swelling occurs due to the water  shift from the extracellular space to the intracellular space Swelling of the brain cells elicits 2 responses for  :osmoregulation, as follows It inhibits ADH secretion and hypothalamic thirst  center immediate cellular adaptation 

14. Types  Hypovolemic hyponatremia  Euvolemic hyponatremia  Hypervolemic hyponatremia  Redistributive hyponatremia  Pseudohyponatremia 

15. develops as sodium and free water are lost and/or replaced by inappropriately hypotonic fluids Sodium can be lost through renal or non-renal routes www.grouptrails.com/.../0-Beat-Dehydration.jpg

16. Nonrenal loss GI losses › Vomiting, Diarrhea, fistulas, pancreatitis  Excessive sweating › Third spacing of fluids › ascites, peritonitis, pancreatitis, and burns  Cerebral salt-wasting syndrome › traumatic brain injury, aneurysmal  subarachnoid hemorrhage, and intracranial surgery Must distinguish from SIADH  www.jupiterimages.com

17. Renal Loss › Acute or chronic renal insufficiency  Diuretics  www.ct-angiogram.com/images/renalCTangiogram2.jpg

19. Normal sodium stores and a total body excess of free water Psychogenic polydipsia, often in psychiatric patients Administration of hypotonic intravenous or irrigation fluids in the immediate postoperative period

20. administration of hypotonic maintenance › intravenous fluids Infants who may have been given › inappropriate amounts of free water bowel preparation before colonoscopy or › colorectal surgery

21. SIADH  downward resetting of the osmostat › Pulmonary Disease › Small cell, pneumonia, TB, sarcoidosis  Cerebral Diseases › CVA, Temporal arteritis, meningitis,  encephalitis Medications › SSRI, Antipsychotics, Opiates, Depakote,  Tegratol

22. Total body sodium increases, and TBW . increases to a greater extent Can be renal or non-renal acute or chronic renal failure dysfunctional kidneys are unable to excrete the ingested sodium load cirrhosis, congestive heart failure, or nephrotic syndrome

23. Water shifts from the intracellular to the › extracellular compartment, with a resultant dilution of sodium. The TBW and total body . sodium are unchanged This condition occurs with hyperglycemia  Administration of mannitol 

24. Pseudohyponatremia The aqueous phase is diluted by excessive › proteins or lipids. The TBW and total body . sodium are unchanged hypertriglyceridemia  multiple myeloma  

25. Clinical Manifestations most patients with a serum sodium concentration exceeding 125 mEq/L are asymptomatic Patients with acutely developing hyponatremia are typically symptomatic at a level of approximately 120 mEq/L Most abnormal findings on physical examination are characteristically neurologic in origin patients may exhibit signs of hypovolemia or hypervolemia › › › › 

26. Diagnosis CT head, EKG, CXR if symptomatic Repeat Na level Correct for hyperglycemia Laboratory tests provide important initial information in the differential diagnosis of hyponatremia Plasma osmolality  Urine osmolality  Urine sodium concentration  Uric acid level  FeNa  › › › › 

27. .Laboratory tests Cont Plasma osmolality › normally ranges from 275 to 290 mosmol/kg  : If >290 mosmol/kg  Hyperglycemia or administration of mannitol  :If 275 – 290 mosmol/kg  hyperlipidemia or hyperproteinemia  :If <275 mosmol/kg  Eval volume status  

28. .Laboratory tests Cont  Plasma osmolality < 275 mosmol/kg › :Increased volume  CHF, cirrhosis, nephrotic syndrome  Euvolemic  SIADH, hypothyroidism, psychogenic polydipsia, beer  potomania, postoperative states Decreased volume  GI loss, skin, 3rd spacing, diuretics 

29. .Laboratory tests Cont Urine osmolality › Normal value is > 100 mosmol/kg  :Normal to high  Hyperlipidemia, hyperproteinemia, hyperglycemia,  SIADH mosmol/kg 100> hypoosmolar hyponatremia  Excessive sweating Burns Vomiting Diarrhea Urinary loss       

30. .Laboratory tests Cont  Urine Sodium › mEq/L 20<  SIADH, diuretics  mEq/L 20>  cirrhosis, nephrosis, congestive heart failure, GI loss,  skin, 3rd spacing, psychogenic polydipsia Uric Acid Level › mg/dl consider SIADH 4>  FeNa › Help to determine pre-renal from renal causes 

31. Treatment four issues must be addressed › Asymptomatic vs. symptomatic  (acute (within 48 hours  (chronic (>48 hours  Volume status  1st step is to calculate the total body water › total body water (TBW) = 0.6 × body weight 

32. . Treatment Cont • next decide what our desired correction rate › should be Symptomatic › immediate increase in serum Na level by 8 to 10  meq/L in 4 to 6 hours with hypertonic saline is recommended acute hyponatremia › more rapid correction may be possible  to 10 meq/L in 4 to 8 hours 8  chronic hyponatremia slower rates of correction meq/L in 24 hours 12  › 

33. Symptomatic or Acute › !!!Treatment Cont. - Here comes the Math  estimate SNa change on the basis of the amount of  Na in the infusate (ΔSNa = {[Na + K]inf − SNa} ÷ (TBW + 1  ΔSNa is a change in SNa  Na + K]inf is infusate Na and K concentration in 1 liter of]  solution !!!!!!!!!!!!!!!!!!OH MY GOD, what did he just say 

34. IV Fluids :One liter of Lactated Ringer's Solution contains › mEq of sodium ion = 130 mmol/L 130  mEq of chloride ion = 109 mmol/L 109  mEq of lactate = 28 mmol/L 28  mEq of potassium ion = 4 mmol/L 4  mEq of calcium ion = 1.5 mmol/L 3  :One liter of Normal Saline contains › mEq/L of Na+ and Cl 154  − :One liter of 3% saline contains › mEq/L of Na+ and Cl 514  − 

35. :Example  a 60 kg women with a plasma sodium of 110 › meq/L :Formula › (ΔSNa = {[Na + K]inf − SNa} ÷ (TBW + 1  ?What is the TBW › How high will 1 liter of normal saline raise the › ? plasma sodium :Answer TBW is 30 L › Serum sodium will increase by approximately › 1.4 meq/L for a total SNa of 111.4 meq/L 

36. :Example  a 90 kg man with a plasma sodium of 110 › meq/L :Formula › (ΔSNa = {[Na + K]inf − SNa} ÷ (TBW + 1  ?What is the TBW › How high will 1 liter of 3% saline raise the › ? plasma sodium :Answer TBW is 54 L › Serum sodium will increase by approximately › 7.3 meq/L for a total SNa of 117.3 meq/L 

37. Asymptomatic or Chronic SIADH › response to isotonic saline is different in the SIADH In hypovolemia both the sodium and water are retained sodium handling is intact in SIADH administered sodium will be excreted in the urine, while some of the water may be retained possible worsening the hyponatremia      

38. Asymptomatic or Chronic  SIADH › Water restriction  liter/day 0.5-1  Salt tablets  Demeclocycline  Inhibits the effects of ADH  Onset of action may require up to one week 

39. :Example y/o male with weakness and head ache 85 SNa is 118 mEq/L Plasma osmolality is 254 mosmol/kg Urine osmolality is 130 mosmol/kg Urine sodium >20 mEq/L Uric acid is 3mg/dl What type of hyponatremia does this ?patient have What additional labs/studies would you ?want  – – – – – – • •

40. Ouch!!!!! .:Example Cont  Noncontrast CT › :Head Tx Call Neurology › and neurosurgery Free water › restriction  trismus1.wordpress.com

41. :Example • y/o female at 75 Kg with N/V/D for 4 days 63 – SNa is 108 mEq/L – She has had one seizure in the ambulance – • Plasma osmolality is 251 mosmol/kg • Urine osmolality is 47 mosmol/kg Uric acid is 6mg/dl • hollywoodphony.files.wordpress.com What type of hyponatremia does this • ?patient have What additional labs/studies would • ?you want

42. ?How will you Tx her  Calculate the total body water x weight = 37.5 L 0.5 ›  ?What rate of correction do you want to 10 mEq/L in 6 to 8 hours 8 ?What fluid will you use Saline 3% ›  ›  How will you calculate the amount of sodium › ?to give her (ΔSNa = {[Na + K]inf − SNa} ÷ (TBW + 1  How will her sodium increase after 1 liter of 3% › ?saline By 10.8 mEq/L to 118.8 mEq/L 

43. ?What other medication will she need  Lasix and a foley › Her sodium increases to 118.8 mEq/L over the next 8-10 hours. How will you continue to ?correct her hyponatremia  (ΔSNa = {[Na + K]inf − SNa} ÷ (TBW + 1 › ΔSNa = 154mEq/L – 118.8mEq/L ÷ 38.5L = 0.9 › mEq/L So 2 liters of normal saline over the next 14 hours 

44. The syndrome of inappropriate antidiuretic hormone secretion or SIADH (other names: Schwartz-Bartter syndrome, SIAD—syndrome of immoderate antidiuresis) is characterized by excessive release of antidiuretic hormone from the posterior pituitary gland or another source. The result is often dilutional hyponatremia in which Athe sodium remains normal but total body fluid increases. It was originally described in people with small-cell carcinoma of the lung, but it can be caused by a number of underlying medical conditions. The treatment may consist of fluid intake restriction, various medicines, And management of the underlying cause.

45. Gastro-intestinal •Anorexia • Nausea Skeleto-muscular Muscle aches •Generalised muscle weakness Neuro-muscular •Myoclonus •Hyporeflexia •Ataxia •Pathological reflexes •Tremor Asterixi Respiratory •Cheyne-Stokes respiration Neurologica •Dysarthria •Lethargy •Confusion •Delirium •Seizures

46. Some common causes of SIADH include:[ citation needed] •Meningitis •Head injury • Subarachnoid hemorrhage •Cancers • Lung cancer (especially small-cell lung cancer, as well as other smallcell malignancies of other organs) •Infections • Brain abscess • Pneumonia • Lung abscess •Guillain-Barré syndrome •Drugs • Chlorpropamide • Ciprofloxacin[2] • Clofibrate • Moxifloxacin[2] Phenothiazine

49. !Congrats!!!!!!!! You saved her  ????Questions 

Hyopna 9090909

Hyopna 9090909

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Hyopna 9090909