This document provides an overview of sodium disorders, including definitions, classifications, approaches, etiologies, and treatments. It discusses hyponatremia and hypernatremia. Hyponatremia is classified based on sodium level, onset, volume status, and osmolality. Treatment depends on factors like underlying cause, symptoms, and chronicity. Rapid correction of sodium levels can cause osmotic demyelination syndrome. Hypernatremia treatment involves slow correction based on calculated water deficit to avoid neurological issues. The document also presents three case studies and guidelines for evaluating and managing different sodium disorder presentations.

1. Sodium Disorders
Abdalmohsen ababtain

2. Outlines
 Definitions of sodium disorders
 Classifications
 Approach
 To know the etiologies
 Treatment

3. Case 1
 80 y/o gentle man presented with
pneumonia

4. Categorizations
 Based on the level
 Onset
 Volume status
 Osmolality

5. Profound Hyponatremia !
 mild 130-135 mmol/l
 moderate 125-129 mmol/l
 profound <125 mmol/l
 results from increase intake of water
or increase sodium Loss
 the most common disorder of body
fluid and electrolyte balance
encountered in clinical practice

6. Based on Time
 Acute hyponatraemia < 48 h.
 Chronic hyponatraemia > 48 h.
 If hyponatraemia cannot be classified,
we consider it chronic, unless there is
clinical or anamnestic evidence of the
contrary

9.  Effective blood volume depletion
 Diuretic-induced hyponatremia
 Hypothyroidism
 Adrenal insufficiency
 Exercise-associated hyponatremia
 Advanced renal failure
 Primary polydipsia
 SIADH

10. SIADH
 CNS disturbances
 Drugs carbamazepine,
cyclophosphamide and SSRI
 Malignancies
 Surgery (pain)
 Pulmonary disease
 Hormone deficiency
 HIV infection

11. Or Symptoms

12. Water and Sodium Regulation
 ADH:
 Osmoreceptors: In the ant. pituitary
 Baroreceptors: In the Left Atrium,
Aortic Arch and Carotid sinus
 Renal Regulation
 Aldosterone and atrial natriuretic
peptide

14. High triglycerides
Multiple myeloma Azotemia
Alcohol intoxication

17. Case 1
 80 y/o gentle man presented with
pneumonia

18. Hx and Exam
 Hx: fluid loss (vomiting, diarrhea,
diuretic therapy)
 Hx of SIADH
 Hx or signs adrenal insufficiency or
hypothyroidism
 PE: Signs of peripheral
edema and/or ascites
 Or signs of dehydration

20. Labs
 Serum osmolality
 Urine osmolality
 Urine sodium, potassium, and chloride
concentrations
 uric acid
 cortisol
 TSH

21. urine osmolality
 urine osmolality can be used to
distinguish between impaired water
excretion and primary polydipsia .
 > 100 mosmol/kg high ADH
 < 100 mosmol/kg appropriate
suppression of ADH may be due to
primary polydipsia or Malnutrition or
Reset osmostat

22. Urine sodium and chloride
concentration
 In Hypovolemia urine Na is <
25 meq/L
 In SIADH urine Na >40 meq/L
 In hypovolemic hyponatremic patients
who have metabolic alkalosis caused
by vomiting urine Na > 25 meq/L, but
the urine Cl < 25 meq/L

23. How to Assess for
Extracellular fluid volume ?

24. Assessment of extracellular fluid
volume in hyponatremia
 Clinical assessment correctly
identified only 47% of hypovolemic
patients and 48% of normovolemic
patients !
 Concentration of sodium clearly
separated hypovolemic (mean UNa =
18 meq/L) from normovolemic (mean
UNa = 72 meq/L)
Am J Med. 1987 Nov;83(5):905-8

25.  accuracy of clinical evaluation for
predicting the state of extracellular
fluid volume in hyponatremia is low.
 The combination of low fractional
sodium excretion (< 0.5%) and low
fractional urea excretion (< 55%) is
the best biochemical way to predict
saline response, whereas high
fractional potassium excretion (> 20%)
indicates diuretic intake.
Am J Med. 1995 Oct;99(4):348-55

26. FENa
 FENa < 1 % suggests effective
volume depletion, while a value about
2 percent suggests acute tubular
necrosis

27. Hyperglycemia
 a correction factor of a 2.4 meq/L
decrease in sodium concentration per
100 mg/dL increase in glucose
concentration is a better overall
estimate of this association than the
usual correction factor of 1.6
 Shall we change it !!
Am J Med. 1999 Apr;106(4):399-403

28. Case 2
 66 yo lady called from home PHx
hypertension, hyperlipidaemia
 1/52 ago dx with UTI, given Bactrim
 4/7 vomiting, diarrhoea, anorexia,
increasing confusion 2/7
 Na 110, asked to present to ED
Presented to ED with confusion,
lethargy, anorexia. No seizures.

30.  O/E: Confused Not oriented to time,
place or person. GCS 14.
 Very dry mucous membranes,
clinically volume deplete, Pink,
perfused
 Abdo: Soft, tender palpable bladder
 Neuro: Normal

31.  VBG: Na 98 , K 3.7, Gluc 10.5 pH
7.50, pCO2 25, HCO3 20
 Serum Osmolality: 211
 Urine Osmolality: 263
 Urine Na: 51
 Urine K: 28
 CXR: NAD

33. Hyponatremia Treatment
 Treat the underlying disease, if
possible.
 Fluid restriction.
 intravenous sodium chloride in
patients with true volume depletion
 Glucocorticoids to patients with
adrenal insufficiency

34. Severe Symptoms
 150 ml (2ml/kg) 3% hypertonic over 20
min can be repeated.
 until a target of 5 mmol/l increase in
serum sodium concentration is
achieved
 If no improvement continue 3%NS till
pt is stabilized

35. If not improving
 If symptoms do not improve after a 10
mmol/l increase in serum sodium
concentration,Think of something else
!

36. After resolution of symptoms
 keeping the i.v. line open by infusing
the smallest feasible volume of 0.9%
saline until cause-specific treatment is
started
 limiting the increase in serum sodium
concentration to a total of 10 mmol/l
during the first 24h
 an additional 8 mmol/l during every 24
h thereafter until the serum sodium
concentration reaches 130 mmol/l

37.  Keep in mind that if hypokalaemia is
present, correction of the
hypokalaemia will contribute to an
increase in serum sodium
concentration

38. Studies supporting use of hypertonic
saline in severe symptomatic
hyponatremia
 October 2009, Volume II, Issue 2, pp
228-234
 Clin J Am Soc Nephrol. 2007
Nov;2(6):1110-7
 Acta Med Scand. 1980;207(4):279-81
 Am J Med. 1982 Jan;72(1):43-8
 Br Med J (Clin Res Ed). 1986 Jan
18;292(6514)

39.  250–750 ml 3% NaCl, presenting
symptoms of seizures and delirium
resolved, although averaged initial
increases in serum sodium
concentration were limited to 6-12
mmol/l/h

40. Acute Hyponatraemia with
moderately severe symptoms
 ‘acute’ hyponatraemia as hyponatraemia
that is documented to exist <48 h
 Stop, if possible, medications and other
factors that can contribute to or provoke
hyponatraemia
 Start Diagnostic assessment
 Single i.v. infusion of 150 ml 3%
hypertonic saline over 20 min can be
started aiming for a 5 mmol/l per 24-h
increase in Na concentration

41.  After 1 h, the serum sodium
concentration was 4.3 mmol/l higher
for the participants receiving i.v. fluids
than for the patients receiving oral
rehydration

43. Acute hyponatraemia without
symptoms
 stop fluids, medications and other
factors that can contribute to or
provoke hyponatraemia
 starting prompt diagnostic assessment
 If the acute decrease in serum sodium
concentration exceeds 10 mmol/l, we
suggest a single i.v. infusion of 150 ml
3% hypertonic saline or equivalent
over 20 min

44. Chronic hyponatraemia without
symptoms
 mild hyponatraemia, we suggest
against treatment with the sole aim of
increasing the serum sodium
concentration
 Aim for increase in serum sodium
concentration of <10 mmol/l during the
first 24 h and <8 mmol/l during every
24 h thereafter

45. American Journal of Kidney Diseases, Vol 56, No 4 (October), 2010: pp 774-779

46. Dehydrated patients
 Restoring extracellular volume with i.v.
infusion of 0.9% saline or a balanced
crystalloid solution at 0.5–1.0 ml/kg/h

47. If overcorrected
 Re-lowering the serum sodium
concentration if it increases > 10
mmol/l during the first 24 h or >8
mmol/l in any 24 h thereafter
 discontinue the ongoing active
treatment
 Consult nephrology

48.  Start an infusion of 10 ml/kg D5%
over1 h under strict monitoring of urine
output and fluid balance
 Or Desmopressin IV 2 micrograms
q8hrs

49. Your Goal
 Decreasing Serum Na at a rate of
1 meq/L /hour
 Aiming for a net Change of
<10meq/L/day

50. Osmotic demyelination
syndrome
 Systematic review of the cases of
osmotic demyelination syndrome
published during the past 15 years
supports restricting increases in serum
sodium concentration <10 mmol/l in
the first 24 h and <18 mmol/l in the
first 48 h.
 rare but dramatic complication that
occurs in chronic hyponatraemia when
the serum sodium concentration
increases too rapidly

51. Risk of osmotic demyelination
syndrome
 Liver disease
 Use of thiazides
 Antidepressant medications
 Original biochemical degree
 Duration of hyponatraemia
 Chronic hyponatremia
 Serum sodium concentration <105
mEq/L
 Hypokalemia
 Alcoholism
 Malnutrition

52. Symptoms
 Irreversible or only partially reversible
 Delayed for 2-6 days
 dysarthria
 dysphagia
 quadriparesis
 behavioral disturbances
 lethargy
 Confusion, disorientation or
obtundation

53.  54 cases of osmotic demyelination
syndrome published since 1997
 In 96%, the Dx of osmotic demyelination
syndrome was based on MRI
 In 96% the initial serum Na concentration
was <120 mmol/l
 In 87%, the Na concentration increased >12
mmol/l during the first 24 h or >20 mmol/l
during the first 48 h

54. Case 3
 90 yo bedridden presented with
lethargy, weakness, and irritability for
2 days
 Vitally stable
 Looks dehydrated
 Na 160

55.  Values above 180 meq/L are
associated with a high mortality rate,
particularly in adults
Mayo Clin Proc. 1990;65(12):1587

56. HYPERNATREMIA
 Water loss
 Potassium intake
 Sodium intake (salt poisoning)
 Iatrogenic
 Impaired thirst mechanism
 diabetes insipidus
 Osmotic diuresis

58.  The cause of the hypernatremia is
usually evident from the history
 If not, send for serum osmolality
 Urine osmolality which should be >600
mosmol/kg, if not think of central or
nephrogenic diabetes insipidus.

59. Symptoms
 lethargy
 weakness
 Irritability
 twitching
 seizures
 coma

60. Signs manifest changes in serum
osmolality
 Brain shrinkage secondary to free
water loss
 >350 Excessive thirst
 >375 Weakness and lethargy.
Irritability
 >400 Ataxia, tremor
 >420 Focal neurological deficit;
Hyperreflexia and Spasticity
 >430 Coma and seizures

61. Treatment
 Calculate the Water Deficit = Total
body water x (serum Na-140)/ (140)
 Rate of correction !

62. Fast or slow correction in
elderlies with acute symptoms !
 Correction of less than 6 meq/L per
day [<0.25 meq/L/hr] should be
avoided
 slow rate of hypernatremia correction
during the first 24 hours were found to
be significant predictor of 30-day
patient mortality
Am J Med Sci. 2011 May;341(5):356-60

63. Chronic Hypernatremia
 5% DW, intravenously, at a rate of
(1.35 mL/hour x patient's weight in kg)
 Aiming for lowering the serum sodium
by a maximum of 10 meq/L in a 24-
hour period (0.4 meq/L/hr)
 Sodium level should be checked Q 4-6
hrs

64. Acute Hypernatremia
 5% DW at a rate of 3-6 mL/kg/hr
lowering Na level 1-2 meq/l/hr
 Once you reach Na level 145 meq/l
Reduce the rate to 1 ml/kg/hr till you
reach 140 meq/l
 The serum sodium and blood glucose
should be monitored every 1-2 hours
until the serum sodium is lowered
below 145 meq/L within 24 hours

65. Acute Hypernatremia
 should be lowered to normal within 24
hours to prevent osmotic
demyelination
J Child Neurol. 1999;14(7):428
Rev Neurol. 2000;31(11):1033.

66. If you suspect DI
 Consult Nephrology to start
desmopressin may be necessary in
patients with diabetes insipidus

67. Thank You