Survival with extreme hypernatremia at 209 mmol/l

Case Report : Severe Hypernatremia following treatment for Hyperosmolar Hyperglycaemic State : A pragmatic approach used to manage hypernatremia

The Hyperosmolar Hyperglycaemia State (HHS) is an endocrine emergency with a mortality rate between 10 and 50%. The mainstay for the treatment of this condition is vigorous IV fluid replacement with close monitoring of blood glucose, serum osmolality, and electrolytes. However, after initial resuscitation, patients can develop hypernatremia and raised serum osmolality, which have deleterious consequences. While hypernatremia in HHS can be treated with infusions of 0.45% saline or 5% dextrose, alternate measures such as intravenous (IV) hypotonic fluid infusion [e.g. 0.18% sodium chloride (NaCl) containing 4% dextrose and 0.15% potassium chloride (KCl)], or free water administration through a nasogastric (NG) tube can be used. We report the case of a 70-year-old man, who was initially admitted to a medical high care ward (MHC) with HHS, and was transferred to the ICU 72 hours later with an altered level of consciousness and severe hypernatremia. His treatment consisted in an IV hypotonic 0.18% NaCl infusion containing 4% dextrose and 0.15% KCl. He also received free water through a NG tube at a rate that was calculated to correct natremia at an average rate of 0.55 meq L-1 hr-1 over 72 hours. A multipronged approach was instituted to manage this patient, including, in addition to natremia correction, blood glucose control with insulin, appropriate IV antibiotics to treat infected foot ulcers, adequate analgesic medications, low-molecular-weight- heparin (LMWH) for thromboprophylaxis, proton- pump inhibitors, and continuation of patient’s ongoing antidepressant drugs at the time of his Glasgow Coma Score improvement. This case report demonstrates the feasibility and success of IV hypotonic fluid (0.18% NaCl - 4% dextrose - 0.15% KCl), alongside NG free water for correcting sodium levels with lower fluid volumes than would have been otherwise required if corrected with 0.45% saline. This treatment seems to be a reasonable choice for correcting sodium levels and osmolality in HHS patients who present with hypernatremia after an initial resuscitation, insofar as it avoids fluid overload and provides dextrose as an energy substrate, in addition to potassium ions. However, while correcting natremia with hypotonic fluid, other aspects of management should not be ignored.

Full recovery from extreme hypernatremia in an elderly woman with hyperosmolar hyperglycemic syndrome and abnormal electroencephalogram

Background:

Hyperosmolar hyperglycemic state is a life-threatening endocrine disorder that most commonly affects adults with type 2 diabetes mellitus. The condition results from an osmotic diuresis-induced loss of water exceeding that of sodium. Altered mental status, hypernatremia and hyperglycemia are characteristic features at presentation. Abnormal electroencephalogram findings have been reported. Successful therapy requires judicious fluid replacement and close monitoring.

Case:

A 78-year-old Hispanic female with a significant past medical history of type 2 diabetes mellitus was admitted with altered mental status, severe hypernatremia and hyperglycemia. She was diagnosed with hyperosmolar hyperglycemic state, and fluid therapy was started. A continuous electroencephalogram revealed left frontocentral and temporal periodic lateralized epileptiform discharges that resolved as her hypernatremia and dehydration were treated. She survived and was discharged after 1 week of treatment.

Conclusion:

Abnormal electroencephalogram findings consistent with nonconvulsive seizure activity may be temporary and reversible and do not suggest a poor prognosis in an elderly patient suffering from hyperosmolar hyperglycemic state and altered mental status.

[Successful treatment of extreme hypernatremia by continuous veno-venous hemodiafiltration]

Extreme hypernatremia in intensive care unit are frequently associated with a poor prognosis and their treatment, when associated with acute renal failure, is not consensual. We report the case of a 39-year-old man admitted in our intensive care unit for coma who presented extreme hyperosmolar hypernatremia (sodium 180 mmol/L, osmolarity 507 mOsm/L) associated with acute renal failure (urea 139.3 mmol/L, creatinine 748 μmol/L) and many other metabolic abnormalities. He was treated with hypotonic fluid administration and continuous renal replacement therapy (veno-venous hemodiafiltration) using an industrial dialysate fluid. Natremia was controlled by modulating intravenous water and sodium intake according to biological data. After 10 days, continuous renal replacement therapy was stopped and neurological exam was normal. Continuous veno-venous hemodiafiltration may be useful for treatment of extreme hypernatremia by allowing gradual correction of fluid and electrolyte disorders.

Preoperative hypernatremia predicts increased perioperative morbidity and mortality

BACKGROUND

The prognostic implications of preoperative hypernatremia are unknown. We sought to determine whether preoperative hypernatremia is a predictor of 30-day perioperative morbidity and mortality.

METHODS

We conducted a cohort study using the American College of Surgeons-National Surgical Quality Improvement Program and identified 908,869 adult patients undergoing major surgery from approximately 300 hospitals from the years 2005 to 2010. We followed the patients for 30-day perioperative outcomes, which included death, major coronary events, wound infections, pneumonia, and venous thromboembolism. Multivariable logistic regression was used to estimate the odds of 30-day perioperative outcomes.

RESULTS

The 20,029 patients (2.2%) with preoperative hypernatremia (>144 mmol/L) were compared with the 888,840 patients with a normal baseline sodium (135-144 mmol/L). Hypernatremia was associated with a higher odds for 30-day mortality (5.2% vs 1.3%; adjusted odds ratio [aOR], 1.44; 95% confidence interval [CI], 1.33-1.56), and this finding was consistent in all subgroups. The odds increased according to the severity of hypernatremia (P < .001 for pairwise comparison for mild [145-148 mmol/L] vs severe [>148 mmol/L] categories). Furthermore, hypernatremia was associated with a greater odds for perioperative major coronary events (1.6% vs 0.7%; aOR, 1.16; 95% CI, 1.03-1.32), pneumonia (3.4% vs 1.5%; aOR, 1.23; 95% CI, 1.13-1.34), and venous thromboembolism (1.8% vs 0.9%; OR, 1.28; 95% CI, 1.14-1.42).

CONCLUSION

Preoperative hypernatremia is associated with increased perioperative 30-day morbidity and mortality.

[Severe hypernatremia. Case report, pathophysiology and therapy]

The case of a female patient with a suprasellar optic glioma is reported, who was admitted to the intensive care unit due to decompensated diabetes insipidus with hypernatremia of 194 mmol/l. The sodium concentration was reduced slowly over 4 days and the patient recovered without sequelae. Based on this case the article deals with the pathophysiology and therapy of hypernatremia. An increase in extracellular osmolarity leads to augmented production of intracellular osmolytes in order to maintain the cell volume constant. Due to this counterregulation correction of the sodium concentration must be done with caution.

Disorders of sodium and water balance in hospitalized patients

PURPOSE

To review and discuss the epidemiology, contributing factors, and approach to clinical management of disorders of sodium and water balance in hospitalized patients.

SOURCE

An electronic search of the MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases and a search of the bibliographies of all relevant studies and review articles for recent reports on hyponatremia and hypernatremia with a focus on critically ill patients.

PRINCIPAL FINDINGS

Disorders of sodium and water balance are exceedingly common in hospitalized patients, particularly those with critical illness and are often iatrogenic. These disorders are broadly categorized as hypo-osmolar or hyper-osmolar, depending on the balance (i.e., excess or deficit) of total body water relative to total body sodium content and are classically recognized as either hyponatremia or hypernatremia. These disorders may represent a surrogate for increased neurohormonal activation, organ dysfunction, worsening severity of illness, or progression of underlying chronic disease. Hyponatremic disorders may be caused by appropriately elevated (volume depletion) or inappropriately elevated (SIADH) arginine vasopressin levels, appropriately suppressed arginine vasopressin levels (kidney dysfunction), or alterations in plasma osmolality (drugs or body cavity irrigation with hypotonic solutions). Hypernatremia is most commonly due to unreplaced hypotonic water depletion (impaired mental status and/or access to free water), but it may also be caused by transient water shift into cells (from convulsive seizures) and iatrogenic sodium loading (from salt intake or administration of hypertonic solutions).

CONCLUSION

In hospitalized patients, hyponatremia and hypernatremia are often iatrogenic and may contribute to serious morbidity and increased risk of death. These disorders require timely recognition and can often be reversed with appropriate intervention and treatment of underlying predisposing factors.

[Severe hypernatremia: survival without neurologic sequelae]

Hypernatremia is an electrolyte disturbance most frequently caused by excess water loss and less frequently by increased sodium intake. The few reported cases of severe hypernatremia (> 190 mEq/l) had an adverse outcome with high mortality and/or severe neurologic sequelae. The first case was a 7-year-old girl with renal failure undergoing continuous venovenous hemodiafiltration therapy who presented hypernatremia (216 mEq/l) after incorrect preparation of dialysis fluid. The patient was treated with hemodiafiltration and hypernatremia was resolved in 48 hours. She had a convulsive crisis without subsequent neurologic impairment. The second patient, a 3-year-old girl with pseudohypoaldosteronism type I and encephalopathy, had hypernatremia (203 mEq/l) due to erroneous sodium administration, which was corrected in 36 hours with intravenous fluid therapy. Her neurologic status was unchanged by treatment. We conclude that children with extreme hypernatremia survive without neurologic sequelae if treatment achieves a progressive decrease of natremia.