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Hiponatremia

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Aula apresentada no Mini Curso Aspectos Práticos de Nefrologia na UTI

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Hiponatremia

  1. 1. DISTÚRBIOS HIDRO-ELETROLÍTICOS HIPONATREMIA Luis Alcides Marinho UFRN
  2. 2. <ul><li>Na+ sérico < 135 mEq/l </li></ul><ul><ul><li>Ocorre devido um excesso de água corporal total em relação ao sódio corporal total </li></ul></ul><ul><ul><li>Se desenvolve quando a ingesta de água excede a habilidade do organismo para excretá-la, levando a diluição do sódio corporal total. </li></ul></ul>H I P O N A T R E M I A
  3. 3. HIPONATREMIA <ul><li>HIPONATREMIA = EXCESSO DE ÁGUA </li></ul><ul><li>HIPONATREMIA= NORMALMENTE INDICA BAIXA OSMOLARIDADE PLASMÁTICA </li></ul>
  4. 4. <ul><li>INCIDÊNCIA / PREVALÊNCIA </li></ul><ul><ul><li>É o DHE mais comum na prática clínica </li></ul></ul><ul><ul><li>Afeta principalmente pacientes hospitalizados e idosos </li></ul></ul><ul><ul><li>Em pacientes críticos pode atingir incidência de até 30 % </li></ul></ul><ul><ul><ul><li>Clin.Nephrol 34: 163 – 166,1990 </li></ul></ul></ul>H I P O N A T R E M I A
  5. 5. <ul><li>OSMOLARIDADE= 2 Na + glicose + uréia </li></ul><ul><li> 18 16 </li></ul><ul><li>Valor Normal = 280 – 290 mOsm/l </li></ul>H I P O N A T R E M I A
  6. 6. HIPONATREMIA = EXCESSO DE ÁGUA
  7. 8. HIPONATREMIA <ul><li>CLASSIFICAÇÃO </li></ul><ul><li>DE ACORDO COM A OSMOLARIDADE SÉRICA </li></ul><ul><li>NORMAL/BAIXA/ALTA </li></ul>
  8. 9. HIPONATREMIA (Na + < 135 meq / L) Normal (280-295 Osm/L) Reduzida (< 280 mOsm/L) Elevada (> 295 mOsm/L) HIPONATREMIA ISOTÔNICA HIPONATREMIA HIPOTÔNICA HIPONATREMIA HIPERTÔNICA Hiperglicemia Infusões de sorbitol, manitol, glicose Radiocontrastes Dosar lípides e proteínas Avaliar o status volêmico do pac Hiperlipidemia Hiperproteinemia Taquicardia, hipotensão, Turgor cutâneo reduzido Edema Pulso e PA normais Turgor normal e sem edema Hipovolêmico Hipervolêmico Euvolêmico Dosar Na Urinário Na + urina > 20 meq/L Na + urina < 10 meq/L FENa < 1% ICC Doença hepática Sd. Nefrótica IRC / IRA Sd. Secreção inapropriada do ADH (siadh) Hipotireoidismo Hiponatremia pós-op. Polidipsia psicogênica Reação idiossincrásica à drogas Potomania de cerveja PERDA RENAL Diuréticos IECA Nefropatias Deficiência de mineralocorticóides S. perda de sódio cerebral PERDA EXTRA-RENAL Vômitos Diarréia Sudorese Perda p/ 3º espaço (ascite, queimado) Pancreatite Osmolaridade Sérica Organograma diagnóstico para Hiponatremia
  9. 10. HYPONATREMIA Assess volume status Hypovolemia Total body water  Total body Na +  Euvolemia (no edema) Total body water  No change in total body Na + (> 20 mmol/L) Hypervolemia Total body water  Total body Na +  Mesasure urinary (Na + ) Mesasure urinary (Na + ) Renal losses Diuretic excess Mineralocorticoid deficiency Salt-losing nephropathy Bicarbonaturia with renal tubular acidosis and Metabolic alkalosis Ketonuria Osmotic diuresis Cerebral salt wasting Extrarenal losses Vomiting Diarhea Third spacing of fluids In bums, pancreatitis, trauma Glucocorticoid deficiency Hipothyroidism Stress Drugs Syndrome of inappropriate vasopressin secretion (SIADH) Acute of chronic Renal failure Nephrotic syndrome Cirrhosis Cardiac failure > 20 mmol/L < 20 mmol/L > 20 mmol/L < 20 mmol/L Diagnosis in Hyponatremia
  10. 11. HIPONATREMIA MECANISMOS FISIOPATOLÓGICOS <ul><li>Com osmolaridade plasm. Alta (translocacional) </li></ul><ul><ul><li>Subst. Osmoticamente ativas atraem água do intra p/o extracelular(ex.:Glicose) </li></ul></ul><ul><li>Com osmolaridade plasm. Normal (pseudohipon) </li></ul><ul><ul><li>Subs. Não osmoticamente ativas ocupam parte do volume aquoso do plasma,alterando a razão água/soluto do soro(ex.:hipertriglic. e paraproteinemia grave) </li></ul></ul>
  11. 12. HIPONATREMIA MECANISMOS FISIOPATOLÓGICOS <ul><li>Com osmolaridade plasm.baixa </li></ul><ul><ul><li>Hipovolemia </li></ul></ul><ul><ul><ul><li>Liberação de ADH em resposta à hipovolemia,causando retenção de água,diminuindo o sódio. </li></ul></ul></ul><ul><ul><li>Euvolemia </li></ul></ul><ul><ul><ul><li>Ocorre devido uma inadequada diluição urinária evidenciada por uma osmolaridade urinária inapropriadamente elevada(ex.:SIADH) </li></ul></ul></ul>
  12. 13. HIPONATREMIA MECANISMOS FISIOPATOLÓGICOS <ul><li>Com osmolaridade plasm.baixa </li></ul><ul><ul><li>Hipervolemia </li></ul></ul><ul><ul><ul><li>Diminuição do volume circulante efetivo resultando em excessiva sede e liberação de ADH, além de reduzida capacidade de excretar sódio(ex.:insuficiência renal crônica) </li></ul></ul></ul>
  13. 14. <ul><li>SIADH- Critérios diagnósticos </li></ul><ul><ul><li>Osmolaridade plasmática diminuída(< 270) </li></ul></ul><ul><ul><li>Osmolaridade urinária inapropriadamente elevada(> 100 mOsm/Kg de água) durante hipotonicidade </li></ul></ul><ul><ul><li>Concentração de sódio urinário elevada(> 20 mEq/l) </li></ul></ul><ul><ul><li>Ausência de insuficiência adrenal, tireoideana, hipofisária, renal ou uso de diuréticos </li></ul></ul>H I P O N A T R E M I A
  14. 15. <ul><li>Causas de SIADH </li></ul><ul><ul><li>Neoplasias-pulmão, pâncreas, linfomas </li></ul></ul><ul><ul><li>SNC- tumores, encefalite, meningite </li></ul></ul><ul><ul><li>Pulmões- pneumonias, tuberculose, aspergilose </li></ul></ul><ul><ul><li>Drogas- antidepressivos, antineoplásicos, clorpropamida, clofibrato </li></ul></ul>H I P O N A T R E M I A
  15. 16. <ul><li>Tratamento da SIADH </li></ul><ul><ul><li>Restrição hídrica < 1L/dia </li></ul></ul><ul><ul><li>Demeclociclina – Antibiótico com efeito de inibir o ADH. Dose 300 a 600 mg 2x ao dia </li></ul></ul><ul><ul><li>Antagonistas dos receptores da vasopressina </li></ul></ul><ul><ul><ul><li>Tolvaptan – Aumenta a excreção de água livre de eletrólitos </li></ul></ul></ul><ul><ul><li>Solução salina 3% associada a furosemida- nos casos sintomáticos </li></ul></ul>H I P O N A T R E M I A
  16. 17. <ul><li>Anamnese </li></ul><ul><ul><li>Náuseas e vômitos </li></ul></ul><ul><ul><li>Cefaléia, letargia </li></ul></ul><ul><ul><li>Cãimbras, tremores </li></ul></ul><ul><ul><li>Dist. do Comportamento </li></ul></ul><ul><ul><li>Alucinações, convulsões </li></ul></ul><ul><ul><li>Coma </li></ul></ul><ul><li>Exame físico </li></ul><ul><ul><li>Ataxia, hiporreflexia </li></ul></ul><ul><ul><li>Bradicardia, coma hipoventilação </li></ul></ul><ul><ul><li>Resp.Cheyne-stokes </li></ul></ul><ul><ul><li>Hipotermia </li></ul></ul><ul><ul><li>Anisocoria </li></ul></ul><ul><ul><li>Descerebração </li></ul></ul>Quadro clínico H I P O N A T R E M I A
  17. 18. HIPONATREMIA - DIAGNÓSTICO <ul><li>Calcular a osmolaridade sérica </li></ul><ul><li>Dosar o sódio urinário ou a fração de excreção do sódio </li></ul><ul><li>Determinar o estado volêmico do paciente </li></ul><ul><li>FENa+ = Na+urin X Cr.plasm/Na+plasm X Cr.urin </li></ul><ul><li>X 100 </li></ul>
  18. 19. H I P O N A T R E M I A <ul><li>Tratamento </li></ul><ul><ul><li>Baseado nos sintomas </li></ul></ul><ul><ul><li>A velocidade de correção não deve ultrapassar 12mEq/l/dia,pelo risco de desmielinização cérebro-pontina (mielinólise pontina cerebral) </li></ul></ul><ul><ul><li>Nos casos sintomáticos graves a correção inicial pode ser até de 1 a 2 mEq/l/hora mas respeitando o limite máximo nas 24h </li></ul></ul>
  19. 20. HIPONATREMIA <ul><li>FÓRMULAS PARA CORREÇÃO </li></ul><ul><li>Fórmula 1 </li></ul><ul><li>Mudança no Na+ sérico= [Na infusão–Na+ sér.] </li></ul><ul><li>H2O corp.total + 1 </li></ul><ul><li>Fórmula 2 </li></ul><ul><li>Déficit de Na=H2O corp.tot. x(Na desej-Na enc.) </li></ul><ul><li>H20 corporal total=Peso x 0.6 homens ou 0.5 em mulheres </li></ul>
  20. 21. HIPONATREMIA <ul><li>Conteúdo de sódio das soluções </li></ul><ul><li>NaCl 5% 855mEq/l </li></ul><ul><li>NaCl 3% 513mEq/l </li></ul><ul><li>SF 0.9% 154mEq/l </li></ul><ul><li>Ringer lactato 130mEq/l </li></ul><ul><li>NaCl 0.45% 77mEq/l </li></ul><ul><li>NaCl 0.2% + SG 5% 34mEq/l </li></ul><ul><li>SG 5% 0 </li></ul><ul><li>Obs.:ABD 850 ml + 15 amp NaCl 20%=NaCl 3% </li></ul>
  21. 22. HIPONATREMIA Hiponatremia Isotônica Hiponatremia Hipertônica Hiponatremia Hipotônica Não tratar – Na sérico é normal Corrigir a hiperlipidemia e hiperproteinemia Correção da hiperglicemia Solução a 0,45% Reposição da perda de volume com riger lactato ou SF a 0,9% Corticóide (se hipocortisolismo) Restrição da ingesta de água (1 l / dia) Uso de diuréticos de alça Salina a 3% se sódio abaixo de 110 meq/L Ultrafiltração Corrigir doença de base SF a 0.9% (150 meq/L + Nacl a 20% (10 ml = 34 meq) Restrição de água (1 L / dia) Fludrocortisona (para sd. Perda de sódio cerebral) Hipovolêmica Euvolêmica Hipervolêmica SINTOMÁTICA (geralmente Na < 120) ASSINTOMÁTICA Calcular Déficit de Sódio 0,6 x peso x (140-Na encontrado) Reposição de Na Natremia não deve elevar > 0,5-1 meq / L / h Tempo = 125-Na enc. / 0,5 Solução a 3% 500 ml SF 3% = 450 mlSF a 0,9% + 50 ml NaCl a 20% Fazer em BIC) / 500 ML = 256 meq (Empírico 1 ml / Kg / h) Associar furosemia 0,5 a 1 mg / Kg Dosar Na + 4/4 h Organograma para Tratamento da Hiponatremia
  22. 23. SEVERE HYPONATREMIA (< 125 mmol/L) Asymptomatic Simptomatic Chronic Rarely < 48 hours Acute Durations < 48 hours Chronic Durations > 48 hours No immediate Correction needed Emergency Correction needed Hipertonic saline 1-2 mL/h per Kg body weight Caoadminstration of furosemide (frusemide) Some immediate correction needed Hypertonic saline 1-2 mL/H PER Kg body weight Coadminstration of furosemide Change to water restriction upon 10% increase in (Na + ) or if symptoms resolve Perform frequent measurement of serum and urine electrolytes Do not exceed 1.0-1.5 mmol/L/h Long-term management SYMPTOMATIC HYPONATREMIA
  23. 24. Caso clínico <ul><li>CMA,SEXO FEM.,35 ANOS,PESO:60 KG,PROCUROU O PRONTO ATENDIMENTO DO HOSPITAL COM QUADRO DE DIARRÉIA,NÁUSEAS E VÔMITOS,APÓS UM JANTAR NA CASA DE UMA AMIGA. TRÊS DAS QUATRO PESSOAS QUE ESTAVAM PRESENTES APRESENTARAM OS MESMOS SINTOMAS. AO EXAME FÍSICO FORAM ENCONTRADOS SINAIS DE DESIDRATAÇÃO AGUDA. A PACIENTE PERMANECEU EM OBSERVAÇÃO NO PA E,ENQUANTO RECEBIA HIDRATAÇÃO INTRAVENOSA,FORAM COLHIDOS OS SEGUINTES EXAMES LABORATORIAIS: Na = 130 mEq/L, K = 3.2 mEq/L, GASOMETRIA COM ACIDOSE METABÓLICA, GLICEMIA = 110 mg/dL, URÉIA = 30 mg/dL E CREATININA = 0.6 mg/dL, LEUCOCITOSE DISCRETA NO HEMOGRAMA, SEM OUTRAS ALTERAÇÕES. </li></ul><ul><li>PERGUNTA-SE: </li></ul><ul><li>DIAGNÓSTICO E TRATAMENTO. </li></ul><ul><li>1º PASSO:CALCULAR A OSMOLARIDADE PLASMÁTICA </li></ul><ul><li>OSMOLARIDADE = 2 Na + GLICOSE/18 + URÉIA/ 6 </li></ul><ul><li>(2 X 30) + (110/18) + (30/6) = 271,1 DIAGNÓSTICO: HIPONATREMIA HIPOTÔNICA </li></ul><ul><li>2º PASSO: DOSAR O SÓDIO URINÁRIO PARA DIFERENCIAR PERDAS RENAIS DE EXTRARRENAIS. </li></ul><ul><li>Na Urinário = 10 mEq/L (BAIXO), CONFIRMANDO PERDA EXTRARRENAL </li></ul><ul><li>3º PASSO: DETERMINAR O ESTADO VOLÊMICO DO PACIENTE. (HIPOVOLÊMICO) </li></ul><ul><li>4º CORREÇÃO DA HIPONATREMIA. </li></ul>
  24. 25. CASO CLÍNICO(CONTINUAÇÃO) <ul><li>ESCOLHER A SOLUÇÃO: SF 0.9 % : 1L = 154 mEq / L OU SF 0.9% + 01 AMP NaCl 20%). OBS.: CADA AMP. = 34 mEq DE SÓDIO EM 10ML. TOTAL = 188 mEq </li></ul><ul><li>MUDANÇA NO SÓDIO SÉRICO= Na INF. – Na SÉRICO / ACT + 1 </li></ul><ul><li>CÁLCULO OBTIDO: 0,77 mEq (SF 0.9%) OU 1.87 (SF 0.9% + 01 AMP. DE NaCl 20%) </li></ul><ul><li>1L DA SOLUÇÃO ESCOLHIDA ___________________1.87 </li></ul><ul><li>QUANTO NECESSITO PARA_____________________8 mEq EM 24H </li></ul>

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