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Mezones-Holguin E, Niño-Garcia R, Herrera-Añazco P, Taype-Rondan Á, Pacheco-Mendoza J, Hernandez AV. Possible association between dysnatremias and mortality during hospitalization in patients undergoing acute hemodialysis: analysis from a Peruvian retrospective cohort. ACTA ACUST UNITED AC 2020; 41:501-508. [PMID: 31528981 PMCID: PMC6979579 DOI: 10.1590/2175-8239-jbn-2018-0243] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 05/27/2019] [Indexed: 12/28/2022]
Abstract
Objective: To evaluate the association between dysnatremias or dyschloremias and mortality during hospitalization in patients with acute kidney injury (AKI) or chronic kidney disease (CKD) undergoing acute hemodialysis. Methods: We carried out a retrospective cohort study on adult patients undergoing acute hemodialysis with AKI or CKD diagnosis at a public hospital in Lima, Peru. Dysnatremias were categorized as hyponatremia (Na < 135mmol/L) or hypernatremia (Na > 145mmol/L), and dyschloremias were defined as hypochloremia (Cl < 98 mmol/L) or hyperchloremia (Cl > 109mmol/L). The outcome of interest was mortality during hospitalization. We performed generalized lineal Poisson family models with bias-corrected and accelerated non-parametric bootstrap to estimate the risk ratios at crude (RR) and adjusted analysis (aRR) by gender, age, HCO3 (for all patients) and Liaño score (only for AKI) with CI95%. Results: We included 263 patients (mean age: 54.3 years, females: 43%): 191 with CKD and 72 with AKI. Mortality was higher in patients with AKI (59.7%) than in patients with CKD (14.1%). In overall, patients with hypernatremia had a higher mortality during hospitalization compared to those who had normal sodium values (aRR: 1.82, 95% CI: 1.17-2.83); patients with hyponatremia did not have different mortality (aRR: 0.19, 95% CI: 0.69-2.04). We also found that hyperchloremia (aRR: 1.35, 95% CI: 0.83-2.18) or hypochloremia (aRR: 0.66, 95% CI: 0.30-14.78) did not increase mortality in comparison to normal chloride values. No association between dysnatremias or dyschloremias and mortality during hospitalization was found in CKD and AKI subgroups. Conclusions: In our exploratory analysis, only hypernatremia was associated with mortality during hospitalization among patients with AKI or CKD undergoing acute hemodialysis.
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Affiliation(s)
- Edward Mezones-Holguin
- Universidad San Ignacio de Loyola, Vicerrectorado de Investigación, Lima, Peru.,Epi-gnosis Solutions. Piura, Peru
| | - Roberto Niño-Garcia
- Epi-gnosis Solutions. Piura, Peru.,Universidad Nacional de Piura, Facultad de Ciencias de la Salud, Sociedad Científica de Estudiantes de Medicina de la Universidad Nacional de Piura (SOCIEMUNP), Piura, Peru
| | - Percy Herrera-Añazco
- Universidad San Ignacio de Loyola, Vicerrectorado de Investigación, Lima, Peru.,Hospital Nacional 2 de mayo, Department of Nephrology, Lima, Peru
| | - Álvaro Taype-Rondan
- Universidad San Ignacio de Loyola, Vicerrectorado de Investigación, Lima, Peru
| | | | - Adrian V Hernandez
- Universidad San Ignacio de Loyola, Vicerrectorado de Investigación, Lima, Peru.,University of Connecticut/Hartford Hospital Evidence-based Practice Center, Hartford, CT, USA
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Hypernatriämie. Med Klin Intensivmed Notfmed 2020; 115:263-274. [DOI: 10.1007/s00063-020-00667-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 01/20/2020] [Accepted: 02/20/2020] [Indexed: 10/24/2022]
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Abstract
The endothelial glycocalyx (EG) is the most luminal layer of the blood vessel, growing on and within the vascular wall. Shedding of the EG plays a central role in many critical illnesses. Degradation of the EG is associated with increased morbidity and mortality. Certain illnesses and iatrogenic interventions can cause degradation of the EG. It is not known whether restitution of the EG promotes the survival of the patient. First trials that focus on the reorganization and/or restitution of the EG seem promising. Nevertheless, the step "from bench to bedside" is still a big one.
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Affiliation(s)
- Jan Jedlicka
- Department of Anaesthesiology, University Hospital of Munich (LMU), Nussbaumstr. 20, Munich 80336, Germany
| | - Bernhard F Becker
- Walter-Brendel-Centre of Experimental Medicine, Ludwig-Maximilians-University, Marchioninistr. 27, Munich 81377, Germany
| | - Daniel Chappell
- Department of Anaesthesiology, University Hospital of Munich (LMU), Marchioninistr. 15, Munich 81377, Germany.
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54
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[Hyponatremia-workflow for intensive care physicians]. Med Klin Intensivmed Notfmed 2019; 115:29-36. [PMID: 31792559 DOI: 10.1007/s00063-019-00636-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 08/26/2019] [Accepted: 11/08/2019] [Indexed: 10/25/2022]
Abstract
Hyponatremia (sodium <135 mmol/l) is the most common electrolyte disorder. Despite identical serum concentrations, clinical symptomatology can vary greatly from mild to life-threatening. Accordingly, individual patients require immediate active treatment, while the majority of (mostly oligosymptomatic) patients should first undergo differentiated diagnosis. The most important element is the assessment of the clinical situation of the patient and never isolated laboratory chemical constellations: "Treat the patient, not the numbers".
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55
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Hulme OJ, Morville T, Gutkin B. Neurocomputational theories of homeostatic control. Phys Life Rev 2019; 31:214-232. [DOI: 10.1016/j.plrev.2019.07.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 06/05/2019] [Accepted: 07/06/2019] [Indexed: 01/19/2023]
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56
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Lombardi G, Ferraro P, Calvaruso L, Naticchia A, D’Alonzo S, Gambaro G. Sodium Fluctuations and Mortality in a General Hospitalized Population. Kidney Blood Press Res 2019; 44:604-614. [DOI: 10.1159/000500916] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 05/10/2019] [Indexed: 11/19/2022] Open
Abstract
Background/Aims: Aim of our study was to describe the association between natremia (Na) fluctuation and hospital mortality in a general population admitted to a tertiary medical center. Methods: We performed a retrospective observational cohort study on the patient population admitted to the Fondazione Policlinico A. Gemelli IRCCS Hospital between January 2010 and December 2014 with inclusion of adult patients with at least 2 Na values available and with a normonatremic condition at hospital admission. Patients were categorized according to all Na values recorded during hospital stay in the following groups: normonatremia, hyponatremia, hypernatremia, and mixed dysnatremia. The difference between the highest or the lowest Na value reached during hospital stay and the Na value read at hospital admission was used to identify the maximum Na fluctuation. Cox proportional hazards models were used to estimate hazard ratios (HRs) for in-hospital death in the groups with dysnatremias and across quartiles of Na fluctuation. Covariates assessed were age, sex, highest and lowest Na level, Charlson/Deyo score, cardiovascular diseases, cerebrovascular diseases, dementia, congestive heart failure, severe kidney disease, estimated glomerular filtration rate, and number of Na measurements during hospital stay. Results: 46,634 admissions matched inclusion criteria. Incident dysnatremia was independently associated with in-hospital mortality (hyponatremia: HR 3.11, 95% CI 2.53, 3.84, p < 0.001; hypernatremia: HR 5.12, 95% CI 3.94, 6.65, p < 0.001; mixed-dysnatremia: HR 4.94, 95% CI 3.08, 7.92, p < 0.001). We found a higher risk of in-hospital death by linear increase of quartile of Na fluctuation (p trend <0.001) irrespective of severity of dysnatremia (HR 2.34, 95% CI 1.55, 3.54, p < 0.001, for the highest quartile of Na fluctuation compared with the lowest). Conclusions: Incident dysnatremia is associated with higher hospital mortality. Fluctuation of Na during hospital stay is a prognostic marker for hospital death independent of dysnatremia severity.
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Management of Cerebral Salt-Wasting Syndrome and Syndrome of Inappropriate Antidiuresis in the Neurocritical Care Unit. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Reis P, Lopes AI, Leite D, Moreira J, Mendes L, Ferraz S, Amaral T, Abelha F. Predicting mortality in patients admitted to the intensive care unit after open vascular surgery. Surg Today 2019; 49:836-842. [DOI: 10.1007/s00595-019-01805-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 03/23/2019] [Indexed: 01/22/2023]
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Shakhsemampour B, Zojaji F, Amouzeshi A. Management of Persistent Hyponatremia after Off-Pump Coronary Artery Bypass Grafting: A Case Report. JOURNAL OF CLINICAL AND BASIC RESEARCH 2019. [DOI: 10.29252/jcbr.3.1.40] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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Prediction of dysnatremias in critically ill patients based on the law of conservation of mass. Comparison of existing formulae. PLoS One 2018; 13:e0207603. [PMID: 30475894 PMCID: PMC6261024 DOI: 10.1371/journal.pone.0207603] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 11/02/2018] [Indexed: 11/19/2022] Open
Abstract
Background We aimed to examine the predictive value of a novel mathematical formula based on the law of conservation of mass in calculating sodium changes in intensive care unit patients and compare its performance with previously published formulae. Methods 178 patients were enrolled from 01/2010 to 10/2013. Plasma and urine were collected in two consecutive 8-hour intervals and the sodium was measured. The predicted sodium concentration was calculated based on previous equations and our formula. The two 8-hour period (epoch 1 and 2) results were compared. Variability of predicted values among the measured range of serum sodium levels were provided by Bland-Altman plots with bias and precision statistics. Comparison of the results was performed with the statistical model of the Percentage Similarity. Results 47.19% patients had dysnatremias. The bias ± SD with 95% limits of agreement for sodium levels were -1.395±3.491 for epoch 1 and -1.623 ±11.1 for epoch 2 period. Bland-Altman analysis for the epoch 1 study period had the following results: -0.8079±3.447 for Adrogué–Madias, 0.56±9.687 for Barsoum–Levine, 0.1412±3.824 for EFWC and 0.294±4.789 for Kurtz–Nguyen formula. The mean similarity, SD and coefficient variation for the methods compared with the measured sodium are: 99.56%, 3.873, 3.89% epoch 1, 99.56%, 1.255, 1.26% for epoch 2, 99.77%, 1.245, 1.26% for Adrogue-Madias, 100.1%, 1.337, 1.34% for Barsoum-Levine, 100.1%, 1.704, 1.7% for Nguyen, 100.1%, 1.370, 1.37% for ECFW formula. Conclusions The law of conservation of mass can be successfully applied for the prediction of sodium changes in critically ill patients.
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Early Effects of Enteral Urea on Intracranial Pressure in Patients With Acute Brain Injury and Hyponatremia. J Neurosurg Anesthesiol 2018; 29:400-405. [PMID: 27438797 DOI: 10.1097/ana.0000000000000340] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Hyponatremia occurs commonly after acute brain injury and is often due to the syndrome of inappropriate antidiuretic hormone secretion (SIADH). Urea administration is 1 therapeutic option. METHODS In our Department, enteral urea is routinely administered to patients with acute brain injury who develop hyponatremia consistent with SIADH and do not respond to an initial sodium load. We reviewed the records of all patients over a 2-year period, who had acute brain injury, received enteral urea because of hyponatremia, and had intracranial pressure (ICP) monitoring using an intraventricular catheter. We recorded demographic, biological, and clinical data; mean ICP values during the 6 hours before and after the first dose of urea were also recorded. RESULTS We included 40 patients (23 subarachnoid hemorrhage, 8 traumatic brain injury, 6 intracranial hemorrhage, 2 postbrain tumor surgery, and 1 ischemic stroke); median age was 54 years (IQRs, 44 to 63 y) and median admission APACHE II score was 19 (13 to 19); 6-month survival was 63%. Median baseline sodium was 133 mEq/L (131 to 135 mEq/L). No patients received additional therapy to decrease ICP during the 6 hours following urea initiation. After the first urea dose (15 g), ICP decreased from 14 (13 to 18 mm Hg) to 11 mm Hg (8 to 13 mm Hg) (P<0.001). Changes in ICP were not correlated to changes in sodium (r=0.02). The reduction in ICP was larger in patients with ICP≥15 mm Hg (n=22) than in the others (-8 mm Hg [-14 to -3 mm Hg] vs. -2 mm Hg [-3 to 0 mm Hg], P=0.001). CONCLUSIONS Enteral urea administration in patients with acute brain injury and hyponatremia is associated with a significant reduction in ICP independent of changes in sodium levels.
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Reis PV, Sousa G, Lopes AM, Costa AV, Santos A, Abelha FJ. Severity of disease scoring systems and mortality after non-cardiac surgery. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2018. [PMID: 29628154 PMCID: PMC9391813 DOI: 10.1016/j.bjane.2017.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background Mortality after surgery is frequent and severity of disease scoring systems are used for prediction. Our aim was to evaluate predictors for mortality after non-cardiac surgery. Methods Adult patients admitted at our surgical intensive care unit between January 2006 and July 2013 was included. Univariate analysis was carried using Mann–Whitney, Chi-square or Fisher's exact test. Logistic regression was performed to assess independent factors with calculation of odds ratio and 95% confidence interval (95% CI). Results 4398 patients were included. Mortality was 1.4% in surgical intensive care unit and 7.4% during hospital stay. Independent predictors of mortality in surgical intensive care unit were APACHE II (OR = 1.24); emergent surgery (OR = 4.10), serum sodium (OR = 1.06) and FiO2 at admission (OR = 14.31). Serum bicarbonate at admission (OR = 0.89) was considered a protective factor. Independent predictors of hospital mortality were age (OR = 1.02), APACHE II (OR = 1.09), emergency surgery (OR = 1.82), high-risk surgery (OR = 1.61), FiO2 at admission (OR = 1.02), postoperative acute renal failure (OR = 1.96), heart rate (OR = 1.01) and serum sodium (OR = 1.04). Dying patients had higher scores in severity of disease scoring systems and longer surgical intensive care unit stay. Conclusion Some factors influenced both surgical intensive care unit and hospital mortality.
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Affiliation(s)
- Pedro Videira Reis
- Hospital de São João, Serviço de Anestesiologia, Porto, Portugal; Universidade do Porto, Faculdade de Medicina, Porto, Portugal
| | - Gabriela Sousa
- Hospital de São João, Serviço de Anestesiologia, Porto, Portugal
| | | | - Ana Vera Costa
- Universidade do Porto, Faculdade de Medicina, Porto, Portugal
| | - Alice Santos
- Hospital de São João, Serviço de Anestesiologia, Porto, Portugal
| | - Fernando José Abelha
- Hospital de São João, Serviço de Anestesiologia, Porto, Portugal; Universidade do Porto, Faculdade de Medicina, Porto, Portugal.
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Reis PV, Sousa G, Lopes AM, Costa AV, Santos A, Abelha FJ. [Severity of disease scoring systems and mortality after non-cardiac surgery]. Rev Bras Anestesiol 2018; 68:244-253. [PMID: 29628154 DOI: 10.1016/j.bjan.2017.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 11/22/2017] [Indexed: 10/17/2022] Open
Abstract
BACKGROUND Mortality after surgery is frequent and severity of disease scoring systems are used for prediction. Our aim was to evaluate predictors for mortality after non-cardiac surgery. METHODS Adult patients admitted at our surgical intensive care unit between January 2006 and July 2013 was included. Univariate analysis was carried using Mann-Whitney, Chi-square or Fisher's exact test. Logistic regression was performed to assess independent factors with calculation of odds ratio and 95% confidence interval (95% CI). RESULTS 4398 patients were included. Mortality was 1.4% in surgical intensive care unit and 7.4% during hospital stay. Independent predictors of mortality in surgical intensive care unit were APACHE II (OR=1.24); emergent surgery (OR=4.10), serum sodium (OR=1.06) and FiO2 at admission (OR=14.31). Serum bicarbonate at admission (OR=0.89) was considered a protective factor. Independent predictors of hospital mortality were age (OR=1.02), APACHE II (OR=1.09), emergency surgery (OR=1.82), high-risk surgery (OR=1.61), FiO2 at admission (OR=1.02), postoperative acute renal failure (OR=1.96), heart rate (OR=1.01) and serum sodium (OR=1.04). Dying patients had higher scores in severity of disease scoring systems and longer surgical intensive care unit stay. CONCLUSION Some factors influenced both surgical intensive care unit and hospital mortality.
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Affiliation(s)
- Pedro Videira Reis
- Hospital de São João, Serviço de Anestesiologia, Porto, Portugal; Universidade do Porto, Faculdade de Medicina, Porto, Portugal
| | - Gabriela Sousa
- Hospital de São João, Serviço de Anestesiologia, Porto, Portugal
| | | | - Ana Vera Costa
- Universidade do Porto, Faculdade de Medicina, Porto, Portugal
| | - Alice Santos
- Hospital de São João, Serviço de Anestesiologia, Porto, Portugal
| | - Fernando José Abelha
- Hospital de São João, Serviço de Anestesiologia, Porto, Portugal; Universidade do Porto, Faculdade de Medicina, Porto, Portugal.
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Abstract
The use of fluid bolus infusion is the cornerstone for hemodynamic resuscitation of critically ill patients. Recently, the clinical use of colloids has lost strength with the publication of several trials suggesting no benefit, and possible harm of its use.On the other hand, the so-called balanced solutions, with low chloride concentrations, have emerged as an alternative with potential physiological benefits over traditional saline solution. Normal saline carries a high amount of chloride which has been associated with an increased incidence of metabolic acidosis, renal vasoconstriction, and reduced urine output. Recent observational studies associated the use of saline with acute kidney injury, which was not observed in a single prospective randomized controlled trial.The present review summarizes available literature regarding the potential clinical and laboratorial benefits of balanced solutions in septic patients.
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Affiliation(s)
- Pedro Vitale Mendes
- Intensive Care Unit , Emergency Department, Hospital das Clínicas, University of Sao Paulo Medical School, São Paulo, Brazil
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Hospital-Associated Hypernatremia Spectrum and Clinical Outcomes in an Unselected Cohort. Am J Med 2018; 131:72-82.e1. [PMID: 28860033 DOI: 10.1016/j.amjmed.2017.08.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 07/14/2017] [Accepted: 08/01/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND Although hypernatremia is associated with adverse outcomes, most studies examined selected populations. METHODS Discharge data of 19,072 unselected hospitalized adults were analyzed. The crude relationship between serum sodium [Na+] and mortality defined hypernatremia as serum [Na+] >142 mEq/L. Patients with community-acquired hypernatremia or hospital-acquired hypernatremia were compared with normonatremic patients (admission [Na+] 138-142 mEq/L) regarding in-hospital mortality, length of stay, and discharge disposition. Patients with community-acquired hypernatremia whose hypernatremia worsened during hospitalization were compared with those without aggravation. RESULTS Community-acquired hypernatremia occurred in 21% of hospitalized patients and was associated with an adjusted odds ratio (OR) of 1.67 (95% confidence interval [CI], 1.38-2.01) for in-hospital mortality and 1.44 (95% CI, 1.32-1.56) for discharge to a short-/long-term care facility and an adjusted 10% (95% CI, 7-13) increase in length of stay. Hospital-acquired hypernatremia developed in 25.9% of hospitalized patients and was associated with an adjusted OR of 3.17 (95% CI, 2.45-4.09) for in-hospital mortality and 1.45 (95% CI, 1.32-1.59) for discharge to a facility, and an adjusted 49% (95% CI, 44-53) increase in length of stay. Hospital-aggravated hypernatremia developed in 11.7% of patients with community-acquired hypernatremia and was associated with greater risk of in-hospital mortality (adjusted OR, 1.84; 95% CI, 1.32-2.56) and discharge to a facility (adjusted OR, 2.14; 95% CI, 1.71-2.69), and an adjusted 16% (95% CI, 7-27) increase in length of stay. CONCLUSIONS The hypernatremia spectrum in unselected hospitalized patients is independently associated with increased in-hospital mortality and heightened resource consumption.
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Cuesta M, Ortolá A, Garrahy A, Calle Pascual AL, Runkle I, Thompson CJ. Predictors of failure to respond to fluid restriction in SIAD in clinical practice; time to re-evaluate clinical guidelines? QJM 2017; 110:489-492. [PMID: 28186579 DOI: 10.1093/qjmed/hcx036] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Fluid restriction is recommended as first line therapy for Syndrome of Inappropriate Antidiuresis (SIAD), despite of lack of good evidence base to support its use, and poor efficacy in clinical practice and in the literature. AIM We set out to determine how many patients with well-defined SIAD had pre-treatment criteria which would predict failure to fluid restriction. DESIGN AND METHODS This was a consecutive, prospective evaluation of 183 patients with a diagnosis of SIAD in two different hospitals. Full ascertainment of the diagnostic criteria for SIAD was obtained in all patients. RESULTS About 47% of patients had a urine volume <1500 ml in 24 h, 41% had initial urine osmolality > 500 mOsm/kg, 26% a Furst-equation ratio > 1. About 59% had one criterion predicting failure to respond to fluid restriction, 37% two criteria, and 3% three criteria. CONCLUSIONS Our data suggest that up to 60% of patients with SIAD had criteria which recent clinical guidelines suggest would predict nonresponse to fluid restriction. This may explain why the recommended first line therapy for SIAD has been shown to be ineffective.
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Affiliation(s)
- M Cuesta
- Academic Endocrine Unit, Beaumont Hospital/RCSI Medical School, Dublin, Ireland
| | - A Ortolá
- Departamento de Endocrinología y Nutrición Hospital Clínico San Carlos, Universidad Complutense, Madrid, Spain
| | - A Garrahy
- Academic Endocrine Unit, Beaumont Hospital/RCSI Medical School, Dublin, Ireland
| | - A L Calle Pascual
- Departamento de Endocrinología y Nutrición Hospital Clínico San Carlos, Universidad Complutense, Madrid, Spain
| | - I Runkle
- Departamento de Endocrinología y Nutrición Hospital Clínico San Carlos, Universidad Complutense, Madrid, Spain
| | - C J Thompson
- Academic Endocrine Unit, Beaumont Hospital/RCSI Medical School, Dublin, Ireland
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Khan MI, Dellinger RP, Waguespack SG. Electrolyte Disturbances in Critically Ill Cancer Patients: An Endocrine Perspective. J Intensive Care Med 2017; 33:147-158. [PMID: 28535742 DOI: 10.1177/0885066617706650] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Electrolyte disturbances are frequently encountered in critically ill oncology patients. Hyponatremia and hypernatremia as well as hypocalcemia and hypercalcemia are among the most commonly encountered electrolyte abnormalities. In the intensive care unit, management of critical electrolyte disturbances is focused on initial evaluation and immediate treatment plan to prevent severe complications. A PubMed search was performed to identify best available evidence for evaluation and management of dysnatremias, hypocalcemia, and hypercalcemia. Current literature was reviewed regarding the management of electrolyte disturbances. The role of new therapeutic options, for example, vaptans for hyponatremia, teriparatide for hypocalcemia, and denosumab for hypercalcemia, is discussed. Early diagnosis and appropriate management are expected to reduce adverse outcomes.
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Affiliation(s)
- Maryam I Khan
- 1 Division of Endocrinology, Diabetes and Metabolism, Cooper University Health Care, Camden, NJ, USA
| | - R Phillip Dellinger
- 2 Division of Critical Care Medicine, Cooper University Health Care, Camden, NJ, USA
| | - Steven G Waguespack
- 3 Department of Endocrine Neoplasia and Hormonal Disorders, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Hu J, Wang Y, Geng X, Chen R, Zhang P, Lin J, Teng J, Zhang X, Ding X. Dysnatremia is an Independent Indicator of Mortality in Hospitalized Patients. Med Sci Monit 2017; 23:2408-2425. [PMID: 28528344 PMCID: PMC5447666 DOI: 10.12659/msm.902032] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background Dysnatremia is a risk factor for poor outcomes. We aimed to describe the prevalence and outcomes of various dysnatremia in hospitalized patients. High-risk patients must be identified to improve the prognosis of dysnatremia. Material/Methods This prospective study included all adult patients admitted consecutively to a university hospital between October 1, 2014 and September 30, 2015. Result All 90 889 patients were included in this study. According to the serum sodium levels during hospitalization, the incidence of hyponatremia and hypernatremia was 16.8% and 1.9%, respectively. Mixed dysnatremia, which was defined when both hyponatremia and hypernatremia happened in the same patient during hospitalization, took place in 0.3% of patients. The incidence of dysnatremia was different in various underlying diseases. Multiple logistic regression analyses showed that all kinds of dysnatremia were independently associated with hospital mortality. The following dysnatremias were strong predictors of hospital mortality: mixed dysnatremia (OR 22.344, 95% CI 15.709–31.783, P=0.000), hypernatremia (OR 13.387, 95% CI 10.642–16.840, P=0.000), and especially hospital-acquired (OR 16.216, 95% CI 12.588–20.888, P=0.000) and persistent (OR 22.983, 95% CI 17.554–30.092, P=0.000) hypernatremia. Hyponatremia was also a risk factor for hospital mortality (OR 2.225, 95% CI 1.857–2.667). However, the OR increased to 56.884 (95% CI 35.098–92.193) if hyponatremia was over-corrected to hypernatremia. Conclusions Dysnatremia was independently associated with poor outcomes. Hospital-acquired and persistent hypernatremia were strong risk factors for hospital mortality. Effective prevention and proper correction of dysnatremia in high-risk patients may reduce the hospital mortality.
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Affiliation(s)
- Jiachang Hu
- Division of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, China (mainland).,Shanghai Institute of Kidney and Dialysis, Shanghai, China (mainland).,Shanghai Key Laboratory for Kidney and Blood Purification, Shanghai, China (mainland)
| | - Yimei Wang
- Division of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, China (mainland).,Shanghai Institute of Kidney and Dialysis, Shanghai, China (mainland).,Shanghai Key Laboratory for Kidney and Blood Purification, Shanghai, China (mainland)
| | - Xuemei Geng
- Division of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, China (mainland).,Shanghai Institute of Kidney and Dialysis, Shanghai, China (mainland).,Shanghai Key Laboratory for Kidney and Blood Purification, Shanghai, China (mainland)
| | - Rongyi Chen
- Division of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, China (mainland).,Shanghai Institute of Kidney and Dialysis, Shanghai, China (mainland).,Shanghai Key Laboratory for Kidney and Blood Purification, Shanghai, China (mainland)
| | - Pan Zhang
- Division of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, China (mainland).,Shanghai Institute of Kidney and Dialysis, Shanghai, China (mainland).,Shanghai Key Laboratory for Kidney and Blood Purification, Shanghai, China (mainland)
| | - Jing Lin
- Division of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, China (mainland).,Shanghai Institute of Kidney and Dialysis, Shanghai, China (mainland).,Shanghai Key Laboratory for Kidney and Blood Purification, Shanghai, China (mainland)
| | - Jie Teng
- Division of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, China (mainland).,Shanghai Institute of Kidney and Dialysis, Shanghai, China (mainland).,Shanghai Key Laboratory for Kidney and Blood Purification, Shanghai, China (mainland)
| | - Xiaoyan Zhang
- Division of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, China (mainland).,Shanghai Institute of Kidney and Dialysis, Shanghai, China (mainland).,Shanghai Key Laboratory for Kidney and Blood Purification, Shanghai, China (mainland)
| | - Xiaoqiang Ding
- Division of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, China (mainland).,Shanghai Institute of Kidney and Dialysis, Shanghai, China (mainland).,Shanghai Key Laboratory for Kidney and Blood Purification, Shanghai, China (mainland)
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Bihari S, Prakash S, Peake SL, Bailey M, Pilcher D, Bersten A. ICU mortality is increased with high admission serum osmolarity in all patients other than those admitted with pulmonary diseases and hypoxia. Respirology 2017; 22:1165-1170. [PMID: 28417586 DOI: 10.1111/resp.13055] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 02/02/2017] [Accepted: 02/20/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND OBJECTIVE High serum osmolarity has been shown to be lung protective. There is lack of clinical studies evaluating the impact on outcomes such as mortality. We aimed to examine the effect of serum osmolarity on intensive care unit (ICU) mortality in critically ill patients METHODS: Data from January 2000 to December 2012 was accessed using the Australian and New Zealand Intensive Care Society (ANZICS) Clinical Outcomes and Resource Evaluation (CORE) database. A total of 509 180 patients were included. Serum osmolarity was calculated from data during the first 24 h of ICU admission. Predefined subgroups (Acute Physiology and Chronic Health Evaluation (APACHE) III diagnostic codes), including patients with acute pulmonary diagnoses, were examined. The effect of serum osmolarity on ICU mortality was assessed with analysis adjusted for illness severity (serum sodium, glucose and urea component removed) and year of admission. Results are presented as OR (95% CI) referenced against a serum osmolarity of 290-295 mmol/L. RESULTS The ICU mortality was elevated at each extremes of serum osmolarity (U-shaped relationship). A similar relationship was found in various subgroups, with the exception of patients with pulmonary diagnoses in whom ICU mortality was not influenced by high serum osmolarity and was different from other non-pulmonary subgroups (P < 0.01). Any adverse associations with high serum osmolarity in pulmonary patients were confined to patients with a PaO2 /FiO2 ratio > 200. CONCLUSION High admission serum osmolarity was not associated with increased odds for ICU death in pulmonary patients, unlike other subgroup of patients, and could be a potential area for future interventional therapy.
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Affiliation(s)
- Shailesh Bihari
- Department of Critical Care Medicine, Flinders University, Adelaide, South Australia, Australia.,Department of Intensive Care Medicine, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Shivesh Prakash
- Department of Critical Care Medicine, Flinders University, Adelaide, South Australia, Australia.,Department of Intensive Care Medicine, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Sandra L Peake
- School of Medicine, University of Adelaide, Adelaide, South Australia, Australia.,ANZIC Research Centre, Monash University, Melbourne, Victoria, Australia.,Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive medicine, Monash University, Melbourne, Victoria, Australia
| | - David Pilcher
- ANZIC Research Centre, Monash University, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive medicine, Monash University, Melbourne, Victoria, Australia.,Department of Intensive Care Medicine, The Alfred Hospital, Melbourne, Victoria, Australia.,Australia New Zealand Intensive Care Society (ANZICS) Clinical Outcomes and Resource Evaluation (CORE) Centre, Melbourne, Victoria, Australia
| | - Andrew Bersten
- Department of Critical Care Medicine, Flinders University, Adelaide, South Australia, Australia.,Department of Intensive Care Medicine, Flinders Medical Centre, Adelaide, South Australia, Australia
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71
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van IJzendoorn MMCO, Buter H, Kingma WP, Koopmans M, Navis G, Boerma EC. Hydrochlorothiazide in intensive care unit-acquired hypernatremia: A randomized controlled trial. J Crit Care 2016; 38:225-230. [PMID: 27984823 DOI: 10.1016/j.jcrc.2016.11.035] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 11/17/2016] [Accepted: 11/23/2016] [Indexed: 12/31/2022]
Abstract
PURPOSE Thiazides are suggested as a treatment for intensive care unit (ICU)-acquired hypernatremia (IAH). The primary aim of the study was reducing serum sodium concentration (sNa) in patients with IAH with hydrochlorothiazide (HCT) in comparison to placebo. Secondary end points were a difference in urine sodium concentration (uNa) and duration of severe IAH. MATERIALS A monocentric, double-blind, placebo-controlled trial was conducted in 50 patients with IAH and urine potassium + uNa less than sNa in a spot urine sample. Patients were randomized to HCT 25 mg or placebo 1 qd for maximal 7 days. Patients on renal replacement therapy, on medication inducing diabetes insipidus, or with recent use of diuretics were excluded. IAH was defined as sNa of at least 143 mmol/L. RESULTS At baseline, sNa and uNa were comparable between groups. During the study period, sNa decreased significantly with median 4 mmol/L in both groups, with no significant difference between groups (P=.32). Median uNa increased significantly in both groups (46 [16-86] mmol/L in the HCT-group; 20 [10-66]mmol/L in the placebo group), with no difference between groups (P=.34). Median duration of sNa of at least 145 mmol/L was 3 days in both groups (P=.91). CONCLUSION HCT 25 mg 1 qd did not significantly affect sNa or uNa in patients with IAH.
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Affiliation(s)
- Marjolein M C O van IJzendoorn
- Department of Intensive Care, Medical Centre Leeuwarden, PO Box 888, 8901 BK Leeuwarden, the Netherlands; Department of Internal Medicine, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, the Netherlands.
| | - Hanneke Buter
- Department of Intensive Care, Medical Centre Leeuwarden, PO Box 888, 8901 BK Leeuwarden, the Netherlands.
| | - W Peter Kingma
- Department of Intensive Care, Medical Centre Leeuwarden, PO Box 888, 8901 BK Leeuwarden, the Netherlands.
| | - Matty Koopmans
- Department of Intensive Care, Medical Centre Leeuwarden, PO Box 888, 8901 BK Leeuwarden, the Netherlands.
| | - Gerjan Navis
- Department of Internal Medicine, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, the Netherlands.
| | - E Christiaan Boerma
- Department of Intensive Care, Medical Centre Leeuwarden, PO Box 888, 8901 BK Leeuwarden, the Netherlands.
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72
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Hessels L, Oude Lansink A, Renes MH, van der Horst ICC, Hoekstra M, Touw DJ, Nijsten MW. Postoperative fluid retention after heart surgery is accompanied by a strongly positive sodium balance and a negative potassium balance. Physiol Rep 2016; 4:4/10/e12807. [PMID: 27225629 PMCID: PMC4886173 DOI: 10.14814/phy2.12807] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Accepted: 04/25/2016] [Indexed: 01/09/2023] Open
Abstract
The conventional model on the distribution of electrolyte infusions states that water will distribute proportionally over both the intracellular (ICV) and extracellular (ECV) volumes, while potassium homes to the ICV and sodium to the ECV. Therefore, total body potassium is the most accurate measure of ICV and thus potassium balances can be used to quantify changes in ICV. In cardiothoracic patients admitted to the ICU we performed complementary balance studies to measure changes in ICV and ECV. In 39 patients, fluid, sodium, potassium, and electrolyte‐free water (EFW) balances were determined to detect changes in ICV and ECV. Cumulatively over 4 days, these patients received a mean ± SE infusion of 14.0 ± 0.6 L containing 1465 ± 79 mmol sodium, 196 ± 11 mmol potassium and 2.1 ± 0.1 L EFW. This resulted in strongly positive fluid (4.0 ± 0.6 L) and sodium (814 ± 75 mmol) balances but in negative potassium (−101 ± 14 mmol) and EFW (−1.1 ± 0.2 L) balances. We subsequently compared potassium balances (528 patients) and fluid balances (117 patients) between patients who were assigned to either a 4.0 or 4.5 mmol/L blood potassium target. Although fluid balances were similar in both groups, the additionally administered potassium (76 ± 23 mmol) in the higher target group was fully excreted by the kidneys (70 ± 23 mmol). These findings indicate that even in the context of rapid and profound volume expansion neither water nor potassium moves into the ICV.
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Affiliation(s)
- Lara Hessels
- Department of Critical Care, University of Groningen University Medical Center Groningen, Groningen, The Netherlands
| | - Annemieke Oude Lansink
- Department of Critical Care, University of Groningen University Medical Center Groningen, Groningen, The Netherlands
| | - Maurits H Renes
- Department of Critical Care, University of Groningen University Medical Center Groningen, Groningen, The Netherlands
| | - Iwan C C van der Horst
- Department of Critical Care, University of Groningen University Medical Center Groningen, Groningen, The Netherlands
| | - Miriam Hoekstra
- Department of Critical Care, University of Groningen University Medical Center Groningen, Groningen, The Netherlands Department of Anesthesiology, University of Groningen University Medical Center Groningen, Groningen, The Netherlands
| | - Daan J Touw
- Department of Clinical Pharmacy and Pharmacology, University of Groningen University Medical Center Groningen, Groningen, The Netherlands
| | - Maarten W Nijsten
- Department of Critical Care, University of Groningen University Medical Center Groningen, Groningen, The Netherlands
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73
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Ma F, Liu Y, Bai M, Li Y, Yu Y, Zhou M, Wang P, He L, Huang C, Wang H, Sun S. The Reduction Rate of Serum Sodium and Mortality in Patients Undergoing Continuous Venovenous Hemofiltration for Acute Severe Hypernatremia. Am J Med Sci 2016; 352:272-9. [PMID: 27650232 DOI: 10.1016/j.amjms.2016.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Revised: 06/02/2016] [Accepted: 06/03/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND The excessive correction of acute hypernatremia is not known to be harmful. This study aimed to evaluate whether a reduction rate of serum sodium (RRSeNa) > 1mEq/L/hour in acute severe hypernatremia is an independent risk factor for mortality in critically ill patients undergoing continuous venovenous hemofiltration (CVVH) treatment. MATERIALS AND METHODS For this retrospective study, we reviewed records of 75 critically ill patients undergoing CVVH treatment for acute severe hypernatremia between March 2011 and March 2015. RESULTS The 28-day mortality rate of all patients was 61.3%. In multivariate Cox regression analyses, a reduction rate of serum sodium (RRSeNa) > 1mEq/L/hour (hazard ratio = 1.89; 95% CI: 1.03-3.47; P = 0.04), Acute Physiology and Chronic Health Evaluation II score and vasopressor dependency (yes or no) had a statistically significantly effect on mortality. Once we excluded patients with an RRSeNa ≤ 0.5mEq/L/hour, only RRSeNa > 1mEq/L/hour (hazard ratio = 2.611; 95% CI: 1.228-5.550; P = 0.013) and vasopressor dependency had a statistically significant influence on mortality in multivariate regression. CONCLUSIONS In addition to the Acute Physiology and Chronic Health Evaluation II score and vasopressor dependency, the excessive correction of acute severe hypernatremia was possibly associated with mortality in critically ill patients undergoing CVVH treatment. The optimal reduction rate of acute hypernatremia should be extensively studied in critically ill patients.
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Affiliation(s)
- Feng Ma
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi׳an, Shaanxi, China
| | - Yirong Liu
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi׳an, Shaanxi, China; Department of Nephrology, Xining No. 1 People׳s Hospital, Xining, Qinghai, China
| | - Ming Bai
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi׳an, Shaanxi, China
| | - Yangping Li
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi׳an, Shaanxi, China
| | - Yan Yu
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi׳an, Shaanxi, China
| | - Meilan Zhou
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi׳an, Shaanxi, China
| | - Pengbo Wang
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi׳an, Shaanxi, China
| | - Lijie He
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi׳an, Shaanxi, China
| | - Chen Huang
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi׳an, Shaanxi, China
| | - Hanmin Wang
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi׳an, Shaanxi, China
| | - Shiren Sun
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi׳an, Shaanxi, China.
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74
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The Development of Intensive Care Unit Acquired Hypernatremia Is Not Explained by Sodium Overload or Water Deficit: A Retrospective Cohort Study on Water Balance and Sodium Handling. Crit Care Res Pract 2016; 2016:9571583. [PMID: 27703807 PMCID: PMC5040124 DOI: 10.1155/2016/9571583] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 07/27/2016] [Accepted: 08/15/2016] [Indexed: 01/27/2023] Open
Abstract
Background. ICU acquired hypernatremia (IAH, serum sodium concentration (sNa) ≥ 143 mmol/L) is mainly considered iatrogenic, induced by sodium overload and water deficit. Main goal of the current paper was to answer the following questions: Can the development of IAH indeed be explained by sodium intake and water balance? Or can it be explained by renal cation excretion? Methods. Two retrospective studies were conducted: a balance study in 97 ICU patients with and without IAH and a survey on renal cation excretion in 115 patients with IAH. Results. Sodium intake within the first 48 hours of ICU admission was 12.5 [9.3-17.5] g in patients without IAH (n = 50) and 15.8 [9-21.9] g in patients with IAH (n = 47), p = 0.13. Fluid balance was 2.3 [1-3.7] L and 2.5 [0.8-4.2] L, respectively, p = 0.77. Urine cation excretion (urine Na + K) was < sNa in 99 out of 115 patients with IAH. Severity of illness was the only independent variable predicting development of IAH and low cation excretion, respectively. Conclusion. IAH is not explained by sodium intake or fluid balance. Patients with IAH are characterized by low urine cation excretion, despite positive fluid balances. The current paradigm does not seem to explain IAH to the full extent and warrants further studies on sodium handling in ICU patients.
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Cuesta M, Garrahy A, Thompson CJ. SIAD: practical recommendations for diagnosis and management. J Endocrinol Invest 2016; 39:991-1001. [PMID: 27094044 DOI: 10.1007/s40618-016-0463-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 03/23/2016] [Indexed: 12/26/2022]
Abstract
Hyponatremia is the commonest electrolyte disturbance encountered in hospitalized patients, and the syndrome of inappropriate antidiuresis (SIAD) is the most frequent underlying disorder. There is a well-recognized relationship between hyponatremia and increased morbidity and mortality. Therefore, to provide appropriate treatment is critical to improve the clinical outcome related to SIAD-hyponatremia. There have been important advances in the treatment of SIAD over the last decade, leading to the publication of several clinical guidelines. In particular, the introduction of the vasopressin-2 receptor antagonists provides a potent pharmacological tool to target the underlying pathophysiology of SIAD. The evidence base recommendations of the available therapies for SIAD are discussed in this study. Fluid restriction is considered the first-line therapy by the recent published guidelines, but it is certainly ineffective or unfeasible in many patients with SIAD. We discuss a number of relevant points to the use of fluid restriction in this study, including the lack of good evidence-based recommendations to support its use. Conversely, the clinical efficacy of oral tolvaptan in SIAD supported by good quality randomized, placebo controlled, clinical trials. However, the cost of the therapy and the need for long-term safety data may limit its widespread use. Finally, new recommendations for the management of acute hyponatremia with a focus on the use of bolus therapy with 3 % hypertonic sodium chloride are described in this study.
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Affiliation(s)
- M Cuesta
- Academic Department of Endocrinology, Beaumont Hospital/RCSI Medical School, Dublin 9, Ireland
| | - A Garrahy
- Academic Department of Endocrinology, Beaumont Hospital/RCSI Medical School, Dublin 9, Ireland
| | - C J Thompson
- Academic Department of Endocrinology, Beaumont Hospital/RCSI Medical School, Dublin 9, Ireland.
- Beaumont Private Clinic, Beaumont Hospital, Dublin 9, Ireland.
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76
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Shao M, Li G, Sarvottam K, Wang S, Thongprayoon C, Dong Y, Gajic O, Kashani K. Dyschloremia Is a Risk Factor for the Development of Acute Kidney Injury in Critically Ill Patients. PLoS One 2016; 11:e0160322. [PMID: 27490461 PMCID: PMC4974002 DOI: 10.1371/journal.pone.0160322] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Accepted: 07/18/2016] [Indexed: 01/29/2023] Open
Abstract
Introduction Dyschloremia is common in critically ill patients, although its impact has not been well studied. We investigated the epidemiology of dyschloremia and its associations with the incidence of acute kidney injury and other intensive care unit outcomes. Material and Methods This is a single-center, retrospective cohort study at Mayo Clinic Hospital—Rochester. All adult patients admitted to intensive care units from January 1st, 2006, through December 30th, 2012 were included. Patients with known acute kidney injury and chronic kidney disease stage 5 before intensive care unit admission were excluded. We evaluated the association of dyschloremia with ICU outcomes, after adjustments for the effect of age, gender, Charlson comorbidity index and severity of illness score. Results A total of 6,025 patients were enrolled in the final analysis following the implementation of eligibility criteria. From the cohort, 1,970 patients (33%) developed acute kidney injury. Of the total patients enrolled, 4,174 had a baseline serum chloride. In this group, 1,530 (37%) had hypochloremia, and 257 (6%) were hyperchloremic. The incidence of acute kidney injury was higher in hypochloremic and hyperchloremic patients compared to those with a normal serum chloride level (43% vs.30% and 34% vs. 30%, respectively; P < .001). Baseline serum chloride was lower in the acute kidney injury group vs. the non-acute kidney injury group [100 mmol/L (96–104) vs. 102 mmol/L (98–105), P < .0001]. In a multivariable logistic regression model, baseline serum chloride of ≤94 mmol/L found to be independently associated with the risk of acute kidney injury (OR 1.7, 95% CI 1.1–2.6; P = .01). Discussion Dyschloremia is common in critically ill patients, and severe hypochloremia is independently associated with an increased risk of development of acute kidney injury.
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Affiliation(s)
- Min Shao
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, United States of America
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC) Research Group, Mayo Clinic, Rochester, MN, United States of America
- Department of Critical Care Medicine, Anhui Provincial hospital Affiliated to Anhui Medical University, Hefei, Anhui, China
| | - Guangxi Li
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC) Research Group, Mayo Clinic, Rochester, MN, United States of America
- Department of Pulmonary Medicine, Guang’Anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Kumar Sarvottam
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, United States of America
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC) Research Group, Mayo Clinic, Rochester, MN, United States of America
| | - Shengyu Wang
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC) Research Group, Mayo Clinic, Rochester, MN, United States of America
- Department of Pulmonary Medicine, The First Affiliated Hospital of Xi’an Medical University, Shaanxi, China
| | - Charat Thongprayoon
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC) Research Group, Mayo Clinic, Rochester, MN, United States of America
| | - Yue Dong
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC) Research Group, Mayo Clinic, Rochester, MN, United States of America
| | - Ognjen Gajic
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC) Research Group, Mayo Clinic, Rochester, MN, United States of America
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, United States of America
| | - Kianoush Kashani
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, United States of America
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC) Research Group, Mayo Clinic, Rochester, MN, United States of America
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, United States of America
- * E-mail:
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Hu B, Han Q, Mengke N, He K, Zhang Y, Nie Z, Zeng H. Prognostic value of ICU-acquired hypernatremia in patients with neurological dysfunction. Medicine (Baltimore) 2016; 95:e3840. [PMID: 27583842 PMCID: PMC5008526 DOI: 10.1097/md.0000000000003840] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Many studies have indicated that hypernatremia is associated with increased mortality. In this study, we aimed to explore the relationship between intensive care unit (ICU)-acquired hypernatremia and the prognosis of critically neurological patients.Based on serum sodium level in the ICU, 450 patients were divided into 3 groups: 222 had normal serum sodium, 142 had mild hypernatremia, and 86 had severe hypernatremia. Kaplan-Meier and multivariable binary logistic regression analyses were performed to evaluate the prognostic value of hypernatremia in critically neurological patients. Receiver operating characteristic (ROC) curve was constructed for serum sodium levels to determine their roles in predicting ICU mortality.Hypernatremia was significantly related with age, Glasgow Coma Scale (GCS) score, serum sodium, APACHE II score, and serum creatinine. Moreover, the different treatment outcome including mechanical ventilation, the days of stayed in ICU, and Glasgow Outcome Scale score had correlation with serum sodium levels. Old ages, GCS score, therapeutic intervention scoring system (TISS) score, APACHE II score, serum sodium peak, and so on were all associated with the mortality. In addition, hypernatremia was an independent prognostic factor for critically neurological patients by logistic regression analysis (odds ratio = 1.192, 95% confidence interval = 1.135-1.252, P = 0.000). Moreover, we got the sensitivity of 79.4% and specificity of 74.5% in the ROC analysis between peak serum sodium and the mortality. The area under the ROC curve was 0.844, and the optimal cutoff value was 147.55.Our results showed that ICU-acquired hypernatremia may be a potential prognosis marker for critically neurological patients.
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Affiliation(s)
- Bei Hu
- Southern Medical University, Guangzhou
- Department of Emergency and Critical Care Medicine, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou
| | - Qianpeng Han
- Southern Medical University, Guangzhou
- Department of Emergency and Critical Care Medicine, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou
| | - Nashun Mengke
- Southern Medical University, Guangzhou
- Department of Emergency and Critical Care Medicine, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou
| | - Kairan He
- Department of Emergency and Critical Care Medicine, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou
| | - Yiqin Zhang
- Southern Medical University, Guangzhou
- Department of Emergency and Critical Care Medicine, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou
| | - Zhiqiang Nie
- Department of Cardiovascular Epidemiology, Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Hongke Zeng
- Southern Medical University, Guangzhou
- Department of Emergency and Critical Care Medicine, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou
- Correspondence: Hongke Zeng, Department of Emergency and Critical Care Medicine, Guangdong General Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, Guangdong 510080, China; Southern Medical University, 1063 Shatai Nan road, Guangzhou 510515, China (e-mail: )
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78
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Zhang R, Wang S, Zhang M, Cui L. Hyponatremia in patients with chronic kidney disease. Hemodial Int 2016; 21:3-10. [PMID: 27350025 DOI: 10.1111/hdi.12447] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Rui Zhang
- Department of Nephrology; Jilin Province People's Hospital; Changchun China
| | - Songyan Wang
- Department of Nephrology; Jilin Province People's Hospital; Changchun China
| | - Mian Zhang
- Department of Nephrology; Jilin Province People's Hospital; Changchun China
| | - Lijuan Cui
- Department of Nephrology; Jilin Province People's Hospital; Changchun China
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79
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Chisti MJ, Ahmed T, Ahmed AMS, Sarker SA, Faruque ASG, Islam MM, Huq S, Shahrin L, Bardhan PK, Salam MA. Hypernatremia in Children With Diarrhea: Presenting Features, Management, Outcome, and Risk Factors for Death. Clin Pediatr (Phila) 2016; 55:654-63. [PMID: 26810623 DOI: 10.1177/0009922815627346] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We sought to investigate the magnitude, clinical features, treatment, and outcome of children suffering from hypernatremic diarrhea and to identify risk factors for fatal outcome among them. We reviewed 2 data sets of children <15 years admitted to the in-patient ward of the Dhaka Hospital of International Centre for Diarrhoeal Disease Research, Bangladesh (icddr, b) with diarrhea and hypernatremia (serum sodium ≥150 mmol/L): (a) March 2001 to March 2002 (n = 371) and (b) March 2009 to August 2011 (n = 360). We reviewed their records and collected relevant information for analyses. The prevalence of hypernatremia was 5.1% (371/7212) and 2.4% (360/15 219), case fatality rate was 15% and 19%, respectively. In logistic regression analysis, the risk for death significantly increased in association with serum sodium ≥170 mmol/L, nutritional edema, hypoglycemia, respiratory distress, and absent peripheral pulses and reduced with the sole use of oral rehydration salts (ORS) or ORS following intravenous fluid, if indicated (for all, P < .05). Thus, managing children with hypernatremia using only ORS or ORS following intravenous fluid may help reduce the number of deaths.
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Affiliation(s)
- Mohammad Jobayer Chisti
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Tahmeed Ahmed
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - A M Shamshir Ahmed
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Shafiqul Alam Sarker
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Abu Syed Golam Faruque
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Md Munirul Islam
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Sayeeda Huq
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Lubaba Shahrin
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Pradip Kumar Bardhan
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Mohammed Abdus Salam
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
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Ueda Y, Hopper K, Epstein SE. Incidence, severity and prognosis associated with hypernatremia in dogs and cats. J Vet Intern Med 2016; 29:794-800. [PMID: 25996661 PMCID: PMC4895431 DOI: 10.1111/jvim.12582] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Revised: 11/24/2014] [Accepted: 03/02/2015] [Indexed: 11/28/2022] Open
Abstract
Background Hypernatremia has been associated with substantial morbidity and death in human patients. The incidence and importance of hypernatremia in dogs and cats has not been determined. Hypothesis/Objectives To describe the incidence of and prognosis associated with hypernatremia in dogs and cats at a university teaching hospital. Animals A total of 16,691 dogs and 4,211 cats with measured blood or serum sodium concentration. Methods Retrospective study. Medical records of animals with a blood or serum sodium concentration measured during a 60‐month period were reviewed to determine the severity of hypernatremia and its associated case fatality rate. Cases with moderate (11–15 mmol/L above the reference range) or severe hypernatremia (≥16 mmol/L above the reference range) were further reviewed. Results A total of 957 dogs (5.7%) and 338 cats (8.0%) were diagnosed with hypernatremia. Case fatality rates of dogs and cats with hypernatremia was 20.6 and 28.1%, respectively compared to 4.4 and 4.5% with a normal blood or serum sodium concentration (P < .0001). The magnitude of hypernatremia was linearly associated with a higher case fatality rate (P < .0001). Hypernatremia was associated with a higher case fatality rate than hyponatremia. Among the animals with moderate or severe hypernatremia, 50% of dogs and 38.5% of cats presented with community‐acquired hypernatremia, and 50% of dogs and 61.5% of cats developed hospital‐acquired hypernatremia. Conclusions and clinical importance Hypernatremia was found infrequently in this population but was associated with increased case fatality rates in dogs and cats. Presence and severity of hypernatremia might be useful as a prognostic indicator.
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Affiliation(s)
- Y Ueda
- William R. Pritchard Veterinary Medical Teaching Hospital, University of California, Davis, Davis, CA
| | - K Hopper
- Department of Veterinary Surgical and Radiological Sciences, University of California, Davis, Davis, CA
| | - S E Epstein
- Department of Veterinary Surgical and Radiological Sciences, University of California, Davis, Davis, CA
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Risk Factors and Outcomes in Patients With Hypernatremia and Sepsis. Am J Med Sci 2016; 351:601-5. [PMID: 27238923 DOI: 10.1016/j.amjms.2016.01.027] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Revised: 11/16/2015] [Accepted: 01/06/2016] [Indexed: 11/22/2022]
Abstract
BACKGROUND Hypernatremia is an uncommon but important electrolyte abnormality in intensive care unit patients. Sepsis is one of the most common causes of intensive care unit admission, but few studies about the role of hypernatremia in sepsis has been published yet. In this study, we aimed to explore the risk factors for developing hypernatremia in patients with sepsis, and the prognosis of patients with sepsis with or without hypernatremia was also assessed. MATERIALS AND METHODS In this retrospective cohort study of 51 septic intensive care unit patients at a single center, we examined the risk factors for the development of hypernatremia and the association of hypernatremia with clinical outcomes using univariate and multivariable analyses. Clinical outcomes such as mortality and hospital duration of patients with or without hypernatremia were also compared. RESULTS Acute Physiology and Chronic Health Evaluation II score (odds ratio = 1.15; 95% CI: 1.022-1.294) was found to be the only independent risk factor for hypernatremia in patients with sepsis. Moreover, patients developing hypernatremia during hospitalization showed significantly higher morbidity and mortality. CONCLUSIONS Acute Physiology and Chronic Health Evaluation II score may be an independent risk factor for hypernatremia in patients with sepsis. Moreover, hypernatremia is strongly associated with worse outcome in sepsis.
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The effect of continuous hypertonic saline infusion and hypernatremia on mortality in patients with severe traumatic brain injury: a retrospective cohort study. Can J Anaesth 2016; 63:664-73. [PMID: 27030131 DOI: 10.1007/s12630-016-0633-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 10/30/2015] [Accepted: 03/14/2016] [Indexed: 10/22/2022] Open
Abstract
PURPOSE Hypertonic saline (HTS) is used to control intracranial pressure (ICP) in patients with traumatic brain injury (TBI); however, in prior studies, the resultant hypernatremia has been associated with increased mortality. We aimed to study the effect of HTS on ICP and mortality in patients with severe TBI. METHODS We performed a retrospective cohort study of 231 patients with severe TBI (Glasgow Coma Scale [GCS] ≤ 8) admitted to two neurotrauma units from 2006-2012. We recorded daily HTS, ICP, and serum sodium (Na) concentration. We used Cox proportional regression modelling for hospital mortality and incorporated the following time-dependent variables: use of HTS, hypernatremia, and desmopressin administration. RESULTS The mean [standard deviation (SD)] age of patients was 34 (17) and the median (interquartile range [IQR]) GCS was 6 [3-8]. Hypertonic saline was administered as a continuous infusion in 124 of 231 (54%) patients over 788 of 2,968 (27%) patient-days. Hypernatremia (Na > 145 mmol·L(-1)) developed in 151 of 231 (65%) patients over 717 of 2,968 (24%) patients-days. In patients who developed hypernatremia, the median [IQR] Na was 146 [142-147] mmol·L(-1). Overall hospital mortality was 26% (59 of 231 patients). After adjusting for baseline covariates, neither HTS (hazard ratio [HR], 1.07; 95% confidence interval [CI], 0.56 to 2.05; P = 0.84) nor hypernatremia (HR, 1.31; 95% CI, 0.68 to 2.55; P = 0.42) was associated with hospital mortality. There was no effect modification by either HTS or hypernatremia on each another. Patients who received HTS observed a significant decrease in ICP during their ICU stay compared with those who did not receive HTS (4 mmHg; 95% CI, 2 to 6; P < 0.001 vs 2 mmHg; 95% CI, -1 to 5; P = 0.14). CONCLUSIONS Hypertonic saline and hypernatremia are not associated with hospital mortality in patients with severe TBI.
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Oude Lansink-Hartgring A, Hessels L, Weigel J, de Smet AMGA, Gommers D, Panday PVN, Hoorn EJ, Nijsten MW. Long-term changes in dysnatremia incidence in the ICU: a shift from hyponatremia to hypernatremia. Ann Intensive Care 2016; 6:22. [PMID: 26983857 PMCID: PMC4794471 DOI: 10.1186/s13613-016-0124-x] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 03/02/2016] [Indexed: 12/18/2022] Open
Abstract
Background Dysnatremia is associated with adverse outcome in critically ill patients. Changes in patients or treatment strategies may have affected the incidence of dysnatremia over time. We investigated long-term changes in the incidence of dysnatremia and analyzed its association with mortality. Methods Over a 21-year period (1992–2012), all serum sodium measurements were analyzed retrospectively in two university hospital ICUs, up to day 28 of ICU admission for the presence of dysnatremia. The study period was divided into five periods. All serum sodium measurements were collected from the electronic databases of both ICUs. Serum sodium was measured at the clinical chemistry departments using standard methods. All sodium measurements were categorized in the following categories: <120, 120–124, 125–129, 130–134, 135–139, 140–145, 146–150, 151–155, 156–160, >160 mmol/L. Mortality was determined at 90 days after ICU admission. Results In 80,571 ICU patients, 913,272 serum sodium measurements were analyzed. A striking shift in the pattern of ICU-acquired dysnatremias was observed: The incidence of hyponatremia almost halved (47–25 %, p < 0.001), whereas the incidence of hypernatremia nearly doubled (13–24 %, p < 0.001). Most hypernatremias developed after ICU admission, and the incidence of severe hypernatremia (sodium > 155 mmol/L) increased dramatically over the years. On ICU day 10 this incidence was 0.7 % in the 1992–1996 period, compared to 6.3 % in the 2009–2012 period (p < 0.001). More severe dysnatremia was associated with significantly higher mortality throughout the 21-year study period (p < 0.001). Conclusions In two large Dutch cohorts, we observed a marked shift in the incidence of dysnatremia from hyponatremia to hypernatremia over two decades. As hypernatremia was mostly ICU acquired, this strongly suggests changes in treatment as underlying causes. This shift may be related to the increased use of sodium-containing infusions, diuretics, and hydrocortisone. As ICU-acquired hypernatremia is largely iatrogenic, it should be—to an important extent—preventable, and its incidence may be considered as an indicator of quality of care. Strategies to prevent hypernatremia deserve more emphasis; therefore, we recommend that further study should be focused on interventions to prevent the occurrence of dysnatremias during ICU stay. Electronic supplementary material The online version of this article (doi:10.1186/s13613-016-0124-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Annemieke Oude Lansink-Hartgring
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands.
| | - Lara Hessels
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Joachim Weigel
- Department of Intensive Care Adults, Erasmus MC, Rotterdam, The Netherlands
| | - Anne Marie G A de Smet
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Diederik Gommers
- Department of Intensive Care Adults, Erasmus MC, Rotterdam, The Netherlands
| | - Prashant V Nannan Panday
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Ewout J Hoorn
- Department of Internal Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Maarten W Nijsten
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
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Cuesta M, Hannon MJ, Thompson CJ. Diagnosis and treatment of hyponatraemia in neurosurgical patients. ACTA ACUST UNITED AC 2016; 63:230-8. [PMID: 26965574 DOI: 10.1016/j.endonu.2015.12.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Revised: 12/01/2015] [Accepted: 12/17/2015] [Indexed: 12/15/2022]
Abstract
Hyponatraemia is the most common electrolyte imbalance in neurosurgical patients. Acute hyponatraemia is particularly common in neurosurgical patients after any type of brain insult, including brain tumours and their treatment, pituitary surgery, subarachnoid haemorrhage or traumatic brain injury. Acute hyponatraemia is an emergency condition, as it leads to cerebral oedema due to passive osmotic movement of water from the hypotonic plasma to the relatively hypertonic brain which ultimately is the cause of the symptoms associated with hyponatraemia. These include decreased level of consciousness, seizures, non-cardiogenic pulmonary oedema or transtentorial brain herniation. Prompt treatment is mandatory to prevent such complications, minimize permanent brain damage and therefore permit rapid recovery after brain insult. The infusion of 3% hypertonic saline is the treatment of choice with different rates of administration based on the severity of symptoms and the rate of drop in plasma sodium concentration. The pathophysiology of hyponatraemia in neurotrauma is multifactorial; although the syndrome of inappropriate antidiuresis (SIADH) and central adrenal insufficiency are the commonest causes encountered. Fluid restriction has historically been the classical treatment for SIADH, although it is relatively contraindicated in some neurosurgical patients such as those with subarachnoid haemorrhage. Furthermore, many cases admitted have acute onset hyponatraemia, who require hypertonic saline infusion. The recently developed vasopressin receptor 2 antagonist class of drug is a promising and effective tool but more evidence is needed in neurosurgical patients. Central adrenal insufficiency may also cause acute hyponatraemia in neurosurgical patients; this responds clinically and biochemically to hydrocortisone. The rare cerebral salt wasting syndrome is treated with large volume normal saline infusion. In this review, we summarize the current evidence based on the clinical presentation, causes and treatment of different types of hyponatraemia in neurosurgical patients.
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Affiliation(s)
- Martín Cuesta
- Academic Department of Endocrinology, Beaumont Hospital/RCSI Medical School, Dublin, Ireland
| | - Mark J Hannon
- Academic Department of Endocrinology, Beaumont Hospital/RCSI Medical School, Dublin, Ireland
| | - Christopher J Thompson
- Academic Department of Endocrinology, Beaumont Hospital/RCSI Medical School, Dublin, Ireland.
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Tolvaptan for hyponatremia with preserved sodium pool in critically ill patients. Ann Intensive Care 2016; 6:1. [PMID: 26728593 PMCID: PMC4700037 DOI: 10.1186/s13613-015-0096-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 12/07/2015] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Hyponatremia is the most common electrolyte disturbance in hospitalized patients, and it represents a well-established risk factor for ICU/hospital mortality. The majority of hyponatremic states are associated with elevated arginine vasopressin levels and a preserved sodium pool. Conventional treatment is either not pathophysiologically oriented or of limited effectiveness. The aim of the present study is to investigate the use of enteral Tolvaptan in critically ill hyponatremic patients. METHODS This is a retrospective observational study in a general ICU. Patients with preserved sodium pool hyponatremia refractory to conventional therapy were enrolled. The hemodynamic, renal, and hepatic functions, together with sodium and water balance as close as possible to the drug administration and up to 72 h thereafter, were analyzed. The main outcome was a serum sodium increase of ≥ 4 mmol/L in 24 h; secondary endpoints were the ability to maintain serum sodium at 24 and 72 h, a decrease in urine sodium concentration and an increase in sodium-free diuresis. RESULTS 38 patients were enrolled. The average dose of enteral Tolvaptan was 7.5 mg. 31 patients (81.6 %) increased their serum sodium >4 mmol/l/24 h; the average increase was 6.7 ± 3.4 mmol/l during the first 24 h (p < 0.001 vs baseline), and this was sustained at 72 h. No adverse effects were reported. Plasma sodium (R = -0.622, p < 0.001), urine sodium (R = -0.345, p < 0.001), central venous oxygen saturation (R = 0.401, p = 0.013), and BUN (R = -0.416, p = 0.031) before Tolvaptan were all significantly correlated with the absolute increase in serum sodium after the administration. CONCLUSIONS Enteral administration of Tolvaptan seems effective in the treatment of hyponatremia with preserved sodium pool in critically ill patients. Even if the study was underpowered to detect significant side effects or complications of unwarranted fast corrections of hyponatremia, we report no complications.
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Basile-Filho A, Menegueti MG, Nicolini EA, Lago AF, Martinez EZ, Auxiliadora-Martins M. Are the Dysnatremias a Permanent Threat to the Critically Ill Patients? J Clin Med Res 2015; 8:141-6. [PMID: 26767083 PMCID: PMC4701070 DOI: 10.14740/jocmr2425w] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2015] [Indexed: 12/25/2022] Open
Abstract
Backgroud The dysnatremias (hyponatremia and hypernatremia) are relatively common findings on admission of intensive care unit (ICU) patients and may represent a major risk. The aim of the study was to assess the ability of serum sodium levels and the Acute Physiology and Chronic Health Evaluation II (APACHE II) to predict mortality of surgical critically ill patients. Methods One hundred and ninety-five surgical patients (62% males and 38% females; mean age of 51.8 ± 17.3 years) admitted to the ICU in the postoperative phase were retrospectively studied. The patients were divided into survivors (n = 152) and non-survivors (n = 43). APACHE II, and serum sodium levels at admission, 48 h and discharge were analyzed by generation of receiver operating characteristic (ROC) curves. Results The mean APACHE II was 16.3 ± 8.3 (13.6 ± 6.1 for survivors and 25.5 ± 8.5 for non-survivors). The area under the ROC curve for APACHE II was 0.841 (0.782 - 0.889) and 0.721 (0.653 - 0.783), 0.754 (0.653 - 0.783) and 0.720 (0.687 - 0.812) for serum sodium level at admission, 48 h and discharge, respectively. Conclusion Even though APACHE II scoring system was the most effective index to predict mortality in the surgical critically ill patients, the serum sodium levels on admission may also be used as an independent predictor of outcome.
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Affiliation(s)
- Anibal Basile-Filho
- Division of Intensive Care, Department of Surgery and Anatomy, Ribeirao Preto Medical School, University of Sao Paulo, SP 14049-900 Ribeirao Preto, Brazil
| | - Mayra Goncalves Menegueti
- Division of Intensive Care, Department of Surgery and Anatomy, Ribeirao Preto Medical School, University of Sao Paulo, SP 14049-900 Ribeirao Preto, Brazil
| | - Edson Antonio Nicolini
- Division of Intensive Care, Department of Surgery and Anatomy, Ribeirao Preto Medical School, University of Sao Paulo, SP 14049-900 Ribeirao Preto, Brazil
| | - Alessandra Fabiane Lago
- Division of Intensive Care, Department of Surgery and Anatomy, Ribeirao Preto Medical School, University of Sao Paulo, SP 14049-900 Ribeirao Preto, Brazil
| | - Edson Zangiacomi Martinez
- Department of Social Medicine (Statistics), Ribeirao Preto Medical School, University of Sao Paulo, SP 14049-900 Ribeirao Preto, Brazil
| | - Maria Auxiliadora-Martins
- Division of Intensive Care, Department of Surgery and Anatomy, Ribeirao Preto Medical School, University of Sao Paulo, SP 14049-900 Ribeirao Preto, Brazil
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Kleindienst A, Hannon MJ, Buchfelder M, Verbalis JG. Hyponatremia in Neurotrauma: The Role of Vasopressin. J Neurotrauma 2015; 33:615-24. [PMID: 26472056 DOI: 10.1089/neu.2015.3981] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Hyponatremia is frequent in patients suffering from traumatic brain injury, subarachnoid hemorrhage, or following intracranial procedures, with approximately 20% having a decreased serum sodium concentration to <125 mmol/L. The pathophysiology of hyponatremia in neurotrauma is not completely understood, but in large part is explained by the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). The abnormal water and/or sodium handling creates an osmotic gradient promoting the shift of water into brain cells, thereby worsening cerebral edema and precipitating neurological deterioration. Unless hyponatremia is corrected promptly and effectively, morbidity and mortality increases through seizures, elevations in intracranial pressure, and/or herniation. The excess mortality in patients with severe hyponatremia (<125 mmol/L) extends beyond the time frame of hospital admission, with a reported mortality of 20% in hospital and 45% within 6 months of follow-up. Current options for the management of hyponatremia include fluid restriction, hypertonic saline, mineralocorticoids, and osmotic diuretics. However, the recent development of vasopressin receptor antagonists provides a more physiological tool for the management of excess water retention and consequent hyponatremia, such as occurs in SIADH. This review summarizes the existing literature on the pathophysiology, clinical features, and management of hyponatremia in the setting of neurotrauma.
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Affiliation(s)
- Andrea Kleindienst
- 1 Department of Neurosurgery, Friedrich-Alexander-University Erlangen-Nürenberg , Erlangen, Germany .,2 Department of Neurosurgery, Klinikum Amberg, Amberg, Germany
| | | | - Michael Buchfelder
- 1 Department of Neurosurgery, Friedrich-Alexander-University Erlangen-Nürenberg , Erlangen, Germany
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Miell J, Dhanjal P, Jamookeeah C. Evidence for the use of demeclocycline in the treatment of hyponatraemia secondary to SIADH: a systematic review. Int J Clin Pract 2015; 69:1396-417. [PMID: 26289137 PMCID: PMC5042094 DOI: 10.1111/ijcp.12713] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
AIMS Hyponatraemia (HN) is the most common electrolyte balance disorder in clinical practice. Since the 1970s, demeclocycline has been used in some countries to treat chronic HN secondary to syndrome of inappropriate antidiuretic hormone secretion (SIADH). The precise mechanism of action of demeclocycline is unclear, but has been linked to the induction of nephrogenic diabetes insipidus. Furthermore, the safety profile of demeclocycline is variable with an inconsistent time to onset, and a potential for complications. There has been no systematic evaluation of the use of demeclocycline for the treatment of HN secondary to SIADH to date. A systematic literature review was performed to obtain an insight into the clinical safety and efficacy of demeclocycline for this condition. METHODS Embase(™) , MEDLINE(®) , MEDLINE(®) In-Process, and The Cochrane Library were searched on two occasions using MeSH terms combined with free-text terms. References were screened by two independent reviewers. Relevant publications were then extracted by two independent reviewers, with a third reviewer collating and finalising extractions. RESULTS The searches returned a total of 705 hits. 632 abstracts were screened after the removal of duplicates. Following screening, 35 full-length publications were reviewed. Of these, 17 were excluded, resulting in 18 studies deemed relevant for data extraction. Two were randomised controlled trials (RCTs), 16 were non-RCTs, and 10 were case reports. DISCUSSION Although most reports suggest that demeclocycline can address serum sodium levels in specific patients with HN, efficacy is variable, and may depend upon the underlying aetiology. Demeclocycline dose adjustments can be complex, and as its use in clinical practice is not well defined, it can differ between healthcare professionals. CONCLUSION There is a lack of clinical and economic evidence supporting the use of demeclocycline for HN secondary to SIADH. Patients receiving demeclocycline for HN secondary to SIADH must be closely monitored.
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Affiliation(s)
- J Miell
- Department of Endocrinology, University Hospital Lewisham, London, UK
| | - P Dhanjal
- Otsuka Pharmaceutical UK Limited, Wexham, UK
| | - C Jamookeeah
- Otsuka Pharmaceutical Europe Limited, Wexham, UK
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Rafat C, Flamant M, Gaudry S, Vidal-Petiot E, Ricard JD, Dreyfuss D. Hyponatremia in the intensive care unit: How to avoid a Zugzwang situation? Ann Intensive Care 2015; 5:39. [PMID: 26553121 PMCID: PMC4639545 DOI: 10.1186/s13613-015-0066-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 09/02/2015] [Indexed: 12/11/2022] Open
Abstract
Hyponatremia is a common
electrolyte derangement in the setting of the intensive care unit. Life-threatening neurological complications may arise not only in case of a severe (<120 mmol/L) and acute fall of plasma sodium levels, but may also stem from overly rapid correction of hyponatremia. Additionally, even mild hyponatremia carries a poor short-term and long-term prognosis across a wide range of conditions. Its multifaceted and intricate physiopathology may seem deterring at first glance, yet a careful multi-step diagnostic approach may easily unravel the underlying mechanisms and enable physicians to adopt the adequate measures at the patient’s bedside. Unless hyponatremia is associated with obvious extracellular fluid volume increase such as in heart failure or cirrhosis, hypertonic saline therapy is the cornerstone of the therapeutic of profound or severely symptomatic hyponatremia. When overcorrection of hyponatremia occurs, recent data indicate that re-lowering of plasma sodium levels through the infusion of hypotonic fluids and the cautious use of desmopressin acetate represent a reasonable strategy. New therapeutic options have recently emerged, foremost among these being vaptans, but their use in the setting of the intensive care unit remains to be clarified.
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Affiliation(s)
- Cédric Rafat
- AP-HP, Service de Réanimation Médico-Chirurgicale, Hôpital Louis Mourier, Colombes, France. .,AP-HP, Urgences Néphrologiques et Transplantation Rénale, Hôpital Tenon, Paris, France.
| | - Martin Flamant
- AP-HP, Service de Physiologie Rénale, Hôpital Bichat, Paris, France. .,Université Paris Diderot, Sorbonne Paris Cité, Paris, France. .,INSERM, U1149, Centre de Recherche sur l'Inflammation, Paris, France.
| | - Stéphane Gaudry
- AP-HP, Service de Réanimation Médico-Chirurgicale, Hôpital Louis Mourier, Colombes, France. .,Université Paris Diderot, Sorbonne Paris Cité, Paris, France. .,ECEVE UMR 1123, ECEVE, Paris, France.
| | - Emmanuelle Vidal-Petiot
- AP-HP, Service de Physiologie Rénale, Hôpital Bichat, Paris, France. .,Université Paris Diderot, Sorbonne Paris Cité, Paris, France. .,INSERM, U1149, Centre de Recherche sur l'Inflammation, Paris, France.
| | - Jean-Damien Ricard
- AP-HP, Service de Réanimation Médico-Chirurgicale, Hôpital Louis Mourier, Colombes, France. .,Université Paris Diderot, Sorbonne Paris Cité, Paris, France. .,INSERM UMR 1137, IAME, Paris, France.
| | - Didier Dreyfuss
- AP-HP, Service de Réanimation Médico-Chirurgicale, Hôpital Louis Mourier, Colombes, France. .,Université Paris Diderot, Sorbonne Paris Cité, Paris, France. .,INSERM UMR 1137, IAME, Paris, France.
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Lee JJ, Kim YS, Jung HH. Acute serum sodium concentration changes in pediatric patients undergoing cardiopulmonary bypass and the association with postoperative outcomes. SPRINGERPLUS 2015; 4:641. [PMID: 26543775 PMCID: PMC4628041 DOI: 10.1186/s40064-015-1436-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 10/14/2015] [Indexed: 12/01/2022]
Abstract
The objective of this study is to investigate the degree of serum sodium changes and its association with patient outcomes in pediatrics undergoing heart surgery with cardiopulmonary bypass (CPB). We reviewed the medical records of 275 pediatric patients who underwent heart surgery with CPB. Prior to CPB, hyponatremia (≤135 mmol/L) was observed in 21 of 275 patients. After initiation of CPB, serum sodium decreased significantly and severe hyponatermia (≤130 mmol/L) subsequently developed in 32 patients. At the end of CPB, however, hypernatremia (≥145 mmol/L) developed in 86 patients. The degree of acute serum sodium change during CPB was not associated with patient outcomes. However, the patients with preoperative hyponatremia and those with hypernatremia at the conclusion of CPB had longer hospital stays and higher postoperative complication rates. Lower serum sodium prior to CPB and higher serum sodium at the end of CPB, along with age and duration of the operation, were independently associated with worse in-hospital outcomes. Acute and transient hyponatremia occurred frequently after initiation of CPB, and then serum sodium immediately increased above preoperative levels at the end of CPB. Caution is required to avoid serum sodium overcorrection on the conclusion of CPB.
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Affiliation(s)
- Jeong Jin Lee
- Department of Anaesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Young-Soon Kim
- Department of Anaesthesiology and Pain Medicine, Seoul Woman's Hospital, Gyeonggi-do, Bucheon, South Korea
| | - Hae Hyuk Jung
- Department of Medicine, Kangwon National University Hospital, Kangwon National University School of Medicine, 156 Baekryung-ro Gangwon-do, Chuncheon, 200-722 South Korea
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92
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Mendes RS, Soares M, Valente C, Suassuna JH, Rocha E, Maccariello ER. Predialysis hypernatremia is a prognostic marker in acute kidney injury in need of renal replacement therapy. J Crit Care 2015. [DOI: 10.1016/j.jcrc.2015.05.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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93
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Godoy DA, Piñero GR, Koller P, Masotti L, Napoli MD. Steps to consider in the approach and management of critically ill patient with spontaneous intracerebral hemorrhage. World J Crit Care Med 2015; 4:213-229. [PMID: 26261773 PMCID: PMC4524818 DOI: 10.5492/wjccm.v4.i3.213] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Revised: 03/03/2015] [Accepted: 06/08/2015] [Indexed: 02/06/2023] Open
Abstract
Spontaneous intracerebral hemorrhage is a type of stroke associated with poor outcomes. Mortality is elevated, especially in the acute phase. From a pathophysiological point of view the bleeding must traverse different stages dominated by the possibility of re-bleeding, edema, intracranial hypertension, inflammation and neurotoxicity due to blood degradation products, mainly hemoglobin and thrombin. Neurological deterioration and death are common in early hours, so it is a true neurological-neurosurgical emergency. Time is brain so that action should be taken fast and accurately. The most significant prognostic factors are level of consciousness, location, volume and ventricular extension of the bleeding. Nihilism and early withdrawal of active therapy undoubtedly influence the final result. Although there are no proven therapeutic measures, treatment should be individualized and guided preferably by pathophysiology. The multidisciplinary teamwork is essential. Results of recently completed studies have birth to promising new strategies. For correct management it’s important to establish an orderly and systematic strategy based on clinical stabilization, evaluation and establishment of prognosis, avoiding secondary insults and adoption of specific individualized therapies, including hemostatic therapy and intensive control of elevated blood pressure. Uncertainty continues regarding the role of surgery.
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94
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Eizadi-Mood N, Sabzghabaee AM, Hosseini H, Soltaninejad F, Massoumi G, Farajzadegan Z, Yaraghi A. Is Admission Serum Sodium Concentration a Clinical Predictor for the Outcome of Therapy in Critically Ill Poisoned Patients? Med Arch 2015; 69:240-3. [PMID: 26543310 PMCID: PMC4610660 DOI: 10.5455/medarh.2015.69.240-243] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 07/19/2015] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Disorders of serum sodium concentration are some of the most electrolyte abnormalities in the intensive care unit (ICU) patients. These disorders adversely affect the function of vital organs and are associated with increased hospital mortality. PURPOSE In the present study we aimed to evaluate the effects of serum sodium concentration abnormalities at the time of hospital admission on the clinical outcome of therapy in a cohort of critically ill poisoned patients. METHODS In this cross-sectional study, 184 critically ill poisoned patients aged >18 years and in the first 8 hours of their poisoning, hospitalized in the ICU of a tertiary care university hospital (Isfahan, Iran) between 2010-2012, were evaluated at the admission time and 24 hours later for serum sodium concentration abnormalities and its relationship with age, gender, consciousness status, ingested drugs and clinical outcome of therapy. The clinical outcome was considered as recovery and mortality. Logistic Regression analysis was performed for predictive variables including serum sodium concentration abnormalities in patients' clinical outcome. FINDINGS On admission, 152 patients (82.6%) were eunatremic, 21 patients (11.4%) were hyponatremic and 11 patients (6%) were hypernatremic. In the second day eunatremia, hyponatremia and hypernatremia was observed in 84.4%, 13% and 2.2% respectively. Age (OR=1.92; CI=1.18-3.12) and severity of toxicity (OR=1.32; CI=1.12-2.41) were predicting factors of mortality in ICU poisoning patients. CONCLUSIONS Serum sodium concentration abnormalities are prevalent in critically ill poisoned patient but do not seem to have a predictive value for the clinical outcome of therapy.
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Affiliation(s)
- Nastaran Eizadi-Mood
- Isfahan Clinical Toxicology Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ali Mohammad Sabzghabaee
- Isfahan Clinical Toxicology Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Hossein Hosseini
- Department of Clinical Toxicology, Noor and Ali-Asghar [PBUH] university hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Forough Soltaninejad
- Department of Pulmonary, Faculty of Medicine, Shahrekord University of Medical Sciences, Shahrekord, Iran
| | - Gholamreza Massoumi
- Department of Clinical Toxicology, Noor and Ali-Asghar [PBUH] university hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ziba Farajzadegan
- Departments of Health and Social Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ahmad Yaraghi
- Department of Clinical Toxicology, Noor and Ali-Asghar [PBUH] university hospital, Isfahan University of Medical Sciences, Isfahan, Iran
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95
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Ueda Y, Hopper K, Epstein S. Incidence, Severity and Prognosis Associated with Hyponatremia in Dogs and Cats. J Vet Intern Med 2015. [PMCID: PMC4895419 DOI: 10.1111/jvim.12581] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background Hyponatremia is a common electrolyte abnormality in human patients and is associated with substantial morbidity and death. The incidence and importance of hyponatremia in dogs and cats has not been determined. Hypothesis/Objectives To describe the incidence of and prognosis associated with hyponatremia in dogs and cats at a university teaching hospital. Animals Of 16,691 dogs and 4,211 cats with measured blood or serum sodium concentration. Methods Retrospective study. Medical records of animals with a blood or serum sodium concentration measured during a 60‐month period were reviewed to determine the severity of hyponatremia and its associated fatality rate. Cases with moderate (11–15 mmol/L below the reference range) or severe hyponatremia (≥16 mmol/L below the reference range) were further reviewed. Results Of 4,254 dogs (25.5%) and 2,081 cats (49.4%) were diagnosed with hyponatremia. Case fatality rates of dogs and cats with hyponatremia were 13.7% and 11.9%, respectively, compared to 4.4% and 4.5% with a normal blood or serum sodium concentration (P < 0.0001). The magnitude of hyponatremia was linearly associated with a higher case fatality rate (P < 0.0001). Hyponatremia was associated with a lower case fatality rate than hypernatremia in the same population. Among the animals with moderate or severe hyponatremia, 92.1% of dogs and 90.6% of cats presented with community‐acquired hyponatremia, and 7.9% of dogs and 9.4% of cats developed hospital‐acquired hyponatremia. Conclusions and clinical importance Hyponatremia was found commonly in this population and was associated with increased case fatality rate. Presence and severity of hyponatremia might be useful as a prognostic indicator.
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Affiliation(s)
- Y. Ueda
- William R. Pritchard Veterinary Medical Teaching Hospital; University of California; Davis CA
| | - K. Hopper
- Department of Veterinary Surgical and Radiological Sciences; University of California; Davis CA
| | - S.E. Epstein
- Department of Veterinary Surgical and Radiological Sciences; University of California; Davis CA
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96
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Besen BAMP, Gobatto ALN, Melro LMG, Maciel AT, Park M. Fluid and electrolyte overload in critically ill patients: An overview. World J Crit Care Med 2015; 4:116-129. [PMID: 25938027 PMCID: PMC4411563 DOI: 10.5492/wjccm.v4.i2.116] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Revised: 12/24/2014] [Accepted: 03/05/2015] [Indexed: 02/06/2023] Open
Abstract
Fluids are considered the cornerstone of therapy for many shock states, particularly states that are associated with relative or absolute hypovolemia. Fluids are also commonly used for many other purposes, such as renal protection from endogenous and exogenous substances, for the safe dilution of medications and as “maintenance” fluids. However, a large amount of evidence from the last decade has shown that fluids can have deleterious effects on several organ functions, both from excessive amounts of fluids and from their non-physiological electrolyte composition. Additionally, fluid prescription is more common in patients with systemic inflammatory response syndrome whose kidneys may have impaired mechanisms of electrolyte and free water excretion. These processes have been studied as separate entities (hypernatremia, hyperchloremic acidosis and progressive fluid accumulation) leading to worse outcomes in many clinical scenarios, including but not limited to acute kidney injury, worsening respiratory function, higher mortality and higher hospital and intensive care unit length-of-stays. In this review, we synthesize this evidence and describe this phenomenon as fluid and electrolyte overload with potentially deleterious effects. Finally, we propose a strategy to safely use fluids and thereafter wean patients from fluids, along with other caveats to be considered when dealing with fluids in the intensive care unit.
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97
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Behan LA, Sherlock M, Moyles P, Renshaw O, Thompson CJT, Orr C, Holte K, Salehmohamed MR, Glynn N, Tormey W, Thompson CJ. Abnormal plasma sodium concentrations in patients treated with desmopressin for cranial diabetes insipidus: results of a long-term retrospective study. Eur J Endocrinol 2015; 172:243-50. [PMID: 25430399 DOI: 10.1530/eje-14-0719] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
CONTEXT AND OBJECTIVE Patients with cranial diabetes insipidus (CDI) are at risk of developing both hypernatraemia and hyponatraemia, due to the condition itself or secondary to treatment with vasopressin-analogues or during administration of i.v. fluids. We aimed to assess the frequency and impact of dysnatraemias in the inpatient (INPT) and outpatient (OPT) setting in desmopressin-treated CDI, comparing those with normal thirst with those with abnormal thirst. DESIGN The study included 192 patients with cranial diabetes, who were identified from the Beaumont Pituitary Database, a tertiary referral centre. Retrospective case note audit was performed and the clinical and biochemical information of 147 patients with CDI were available for analysis. RESULTS A total of 4142 plasma sodium measurements for 137 patients with normal thirst, and 385 plasma sodium measurements for ten patients with abnormal thirst were analysed. In those with normal thirst, the most common OPT abnormality was mild hyponatraemia (pNa(+) 131-134 mmol/l) in 27%, while 14.6% had more significant hyponatraemia (pNa(+) ≤130 mmol/l). Of those patients with normal thirst, 5.8% were admitted due to complications directly related to hyponatraemia. Compared with patients with normal thirst, those with abnormal thirst were more likely to develop significant OPT hypernatraemia (20% vs 1.4%, P=0.02) and significant INPT hyponatraemia (50% vs 11.1%, P 0.02). CONCLUSION OPT management of CDI is complicated by a significant incidence of hyponatraemia. In contrast, OPT hypernatraemia is almost exclusively a complication seen in adipsic CDI, who also had more frequent INPT hyponatraemia. CDI associated with thirst disorder requires increased physician attention and patient awareness of potential complications.
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Affiliation(s)
- L A Behan
- Academic Department of EndocrinologyRCSI Medical School, Beaumont Hospital, Beaumont Road, Dublin 9, IrelandDepartment of EndocrinologyTrinity College, Adelaide and Meath Hospitals, Dublin, Incorporating the National Children's Hospital, Dublin, IrelandAcademic Department of Chemical PathologyRCSI Medical School, Beaumont Hospital, Beaumont Road, Dublin 9, Ireland
| | - M Sherlock
- Academic Department of EndocrinologyRCSI Medical School, Beaumont Hospital, Beaumont Road, Dublin 9, IrelandDepartment of EndocrinologyTrinity College, Adelaide and Meath Hospitals, Dublin, Incorporating the National Children's Hospital, Dublin, IrelandAcademic Department of Chemical PathologyRCSI Medical School, Beaumont Hospital, Beaumont Road, Dublin 9, Ireland
| | - P Moyles
- Academic Department of EndocrinologyRCSI Medical School, Beaumont Hospital, Beaumont Road, Dublin 9, IrelandDepartment of EndocrinologyTrinity College, Adelaide and Meath Hospitals, Dublin, Incorporating the National Children's Hospital, Dublin, IrelandAcademic Department of Chemical PathologyRCSI Medical School, Beaumont Hospital, Beaumont Road, Dublin 9, Ireland
| | - O Renshaw
- Academic Department of EndocrinologyRCSI Medical School, Beaumont Hospital, Beaumont Road, Dublin 9, IrelandDepartment of EndocrinologyTrinity College, Adelaide and Meath Hospitals, Dublin, Incorporating the National Children's Hospital, Dublin, IrelandAcademic Department of Chemical PathologyRCSI Medical School, Beaumont Hospital, Beaumont Road, Dublin 9, Ireland
| | - C J T Thompson
- Academic Department of EndocrinologyRCSI Medical School, Beaumont Hospital, Beaumont Road, Dublin 9, IrelandDepartment of EndocrinologyTrinity College, Adelaide and Meath Hospitals, Dublin, Incorporating the National Children's Hospital, Dublin, IrelandAcademic Department of Chemical PathologyRCSI Medical School, Beaumont Hospital, Beaumont Road, Dublin 9, Ireland
| | - C Orr
- Academic Department of EndocrinologyRCSI Medical School, Beaumont Hospital, Beaumont Road, Dublin 9, IrelandDepartment of EndocrinologyTrinity College, Adelaide and Meath Hospitals, Dublin, Incorporating the National Children's Hospital, Dublin, IrelandAcademic Department of Chemical PathologyRCSI Medical School, Beaumont Hospital, Beaumont Road, Dublin 9, Ireland
| | - K Holte
- Academic Department of EndocrinologyRCSI Medical School, Beaumont Hospital, Beaumont Road, Dublin 9, IrelandDepartment of EndocrinologyTrinity College, Adelaide and Meath Hospitals, Dublin, Incorporating the National Children's Hospital, Dublin, IrelandAcademic Department of Chemical PathologyRCSI Medical School, Beaumont Hospital, Beaumont Road, Dublin 9, Ireland
| | - M R Salehmohamed
- Academic Department of EndocrinologyRCSI Medical School, Beaumont Hospital, Beaumont Road, Dublin 9, IrelandDepartment of EndocrinologyTrinity College, Adelaide and Meath Hospitals, Dublin, Incorporating the National Children's Hospital, Dublin, IrelandAcademic Department of Chemical PathologyRCSI Medical School, Beaumont Hospital, Beaumont Road, Dublin 9, Ireland
| | - N Glynn
- Academic Department of EndocrinologyRCSI Medical School, Beaumont Hospital, Beaumont Road, Dublin 9, IrelandDepartment of EndocrinologyTrinity College, Adelaide and Meath Hospitals, Dublin, Incorporating the National Children's Hospital, Dublin, IrelandAcademic Department of Chemical PathologyRCSI Medical School, Beaumont Hospital, Beaumont Road, Dublin 9, Ireland
| | - W Tormey
- Academic Department of EndocrinologyRCSI Medical School, Beaumont Hospital, Beaumont Road, Dublin 9, IrelandDepartment of EndocrinologyTrinity College, Adelaide and Meath Hospitals, Dublin, Incorporating the National Children's Hospital, Dublin, IrelandAcademic Department of Chemical PathologyRCSI Medical School, Beaumont Hospital, Beaumont Road, Dublin 9, Ireland
| | - C J Thompson
- Academic Department of EndocrinologyRCSI Medical School, Beaumont Hospital, Beaumont Road, Dublin 9, IrelandDepartment of EndocrinologyTrinity College, Adelaide and Meath Hospitals, Dublin, Incorporating the National Children's Hospital, Dublin, IrelandAcademic Department of Chemical PathologyRCSI Medical School, Beaumont Hospital, Beaumont Road, Dublin 9, Ireland
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Eltawansy S, Gomez J, Liss K, Nivera N, Babyatsky M. Syndrome of inappropriate anti-diuretic hormone secondary to non-cirrhotic primary hepatocellular carcinoma. AMERICAN JOURNAL OF CASE REPORTS 2015; 16:31-6. [PMID: 25612883 PMCID: PMC4315651 DOI: 10.12659/ajcr.892370] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Patient: Male, 71 Final Diagnosis: SIADH Symptoms: Cachexia • confusion Medication: — Clinical Procedure: Percutaneous liver biopsy Specialty: Oncology
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Affiliation(s)
- Sherif Eltawansy
- Department of Internal Medicine, Monmouth Medical Center, Long Branch, NJ, USA
| | - Johnson Gomez
- Department of Internal Medicine, Monmouth Medical Center, Long Branch, NJ, USA
| | - Kenneth Liss
- Department of Internal Medicine, Monmouth Medical Center, Long Branch, NJ, USA
| | - Noel Nivera
- Department of Internal Medicine, Monmouth Medical Center, Long Branch, NJ, USA
| | - Mark Babyatsky
- Department of Internal Medicine, Monmouth Medical Center, Long Branch, NJ, USA
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99
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Wolff A, Stuckler D, McKee M. Are patients admitted to hospitals from care homes dehydrated? A retrospective analysis of hypernatraemia and in-hospital mortality. J R Soc Med 2015; 108:259-65. [PMID: 25592963 DOI: 10.1177/0141076814566260] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES To compare risks of hypernatraemia on admission to hospital in persons who were with those who were not identified as care home residents and evaluate the association of hypernatraemia with in-hospital mortality. DESIGN Retrospective observational study. SETTING A National Health Service Trust in London. PARTICIPANTS A total of 21,610 patients aged over 65 years whose first admission to the Trust was between 1 January 2011 and 31 December 2013. MAIN OUTCOME MEASURES Hypernatraemia on admission (plasma Na > 145 mmol/L) and in-hospital death. RESULTS Patients admitted from care homes had 10-fold higher prevalence of hypernatraemia than those from their own homes (12.0% versus 1.3%, respectively; odds ratio [OR]: 10.5, 95% confidence interval [CI]: 8.43-13.0). Of those with hypernatraemia, nine in 10 cases were associated with nursing home ECOHOST residency (attributable fraction exposure: 90.5%), and the population attributable fraction of hypernatraemia on admission associated with care homes was 36.0%. After correcting for age, gender, mode of admission and dementia, care home residents were significantly more likely to be admitted with hypernatraemia than were own-home residents (adjusted odds ratio [AOR]: 5.32, 95% CI: 3.85-7.37). Compared with own-home residents, care home residents were also at about a two-fold higher risk of in-hospital mortality compared with non-care home residents (AOR: 1.97, 95% CI: 1.59-2.45). Consistent with evidence that hypernatraemia is implicated in higher mortality, the association of nursing homes with in-hospital mortality was attenuated after adjustment for it (AOR: 1.61, 95% CI: 1.26-2.06). CONCLUSIONS Patients admitted to hospital from care homes are commonly dehydrated on admission and, as a result, appear to experience significantly greater risks of in-hospital mortality.
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Affiliation(s)
| | - David Stuckler
- Department of Sociology, Christchurch College, University of Oxford, Oxford OX1 3UQ, UK
| | - Martin McKee
- ECOHOST, London School of Hygiene and Tropical Medicine, London WC1H 9SH, UK
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100
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Buffington MA, Abreo K. Hyponatremia: A Review. J Intensive Care Med 2015; 31:223-36. [PMID: 25592330 DOI: 10.1177/0885066614566794] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 10/24/2014] [Indexed: 01/03/2023]
Abstract
Hyponatremia is the most frequently occurring electrolyte abnormality and can lead to life-threatening complications. This disorder may be present on admission to the intensive care setting or develop during hospitalization as a result of treatment or multiple comorbidities. Patients with acute hyponatremia or symptomatic chronic hyponatremia will likely require treatment in the intensive care unit (ICU). Immediate treatment with hypertonic saline is needed to reduce the risk of permanent neurologic injury. Chronic hyponatremia should be corrected at a rate sufficient to reduce symptoms but not at an excessive rate that would create a risk of osmotic injury. Determination of the etiology of chronic hyponatremia requires analysis of serum osmolality, volume status, and urine osmolality and sodium level. Correct diagnosis points to the appropriate treatment and helps identify risk factors for accelerated correction of the serum sodium level. Management in the ICU facilitates frequent laboratory draws and allows close monitoring of the patient's mentation as well as quantification of urine output. Overly aggressive correction of serum sodium levels can result in neurological injury caused by osmotic demyelination. Therapeutic measures to lower the serum sodium level should be undertaken if the rate increases too rapidly.
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Affiliation(s)
- Mary Ansley Buffington
- LSU Health Shreveport School of Medicine, Nephrology Section of Department of Internal Medicine, Shreveport, LA, USA.
| | - Kenneth Abreo
- LSU Health Shreveport School of Medicine, Nephrology Section of Department of Internal Medicine, Shreveport, LA, USA
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