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Vresk L, Flanagan M, Daniel AI, Potani I, Bourdon C, Spiegel-Feld C, Thind MK, Farooqui A, Ling C, Miraglia E, Hu G, Wen B, Zlotkin S, James P, McGrath M, Bandsma RHJ. Micronutrient status in children aged 6-59 months with severe wasting and/or nutritional edema: implications for nutritional rehabilitation formulations. Nutr Rev 2024:nuad165. [PMID: 38350491 DOI: 10.1093/nutrit/nuad165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2024] Open
Abstract
Undernutrition remains a global struggle and is associated with almost 45% of deaths in children younger than 5 years. Despite advances in management of severe wasting (though less so for nutritional edema), full and sustained recovery remains elusive. Children with severe wasting and/or nutritional edema (also commonly referred to as severe acute malnutrition and part of the umbrella term "severe malnutrition") continue to have a high mortality rate. This suggests a likely multifactorial etiology that may include micronutrient deficiency. Micronutrients are currently provided in therapeutic foods at levels based on expert opinion, with few supportive studies of high quality having been conducted. This narrative review looks at the knowledge base on micronutrient deficiencies in children aged 6-59 months who have severe wasting and/or nutritional edema, in addition to highlighting areas where further research is warranted (See "Future Directions" section).
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Affiliation(s)
- Laura Vresk
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Mary Flanagan
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Allison I Daniel
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Isabel Potani
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Celine Bourdon
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Carolyn Spiegel-Feld
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Mehakpreet K Thind
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Amber Farooqui
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Catriona Ling
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Emiliano Miraglia
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Guanlan Hu
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Bijun Wen
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Stanley Zlotkin
- Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Philip James
- Emergency Nutrition Network, Oxford, United Kingdom
| | | | - Robert H J Bandsma
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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Iijima Y, Mizoguchi T, Ishikawa M, Iwai S, Motono N, Uramoto H. Impacts of perioperative hyponatremia relevant to outcomes and prognosis of non-small cell lung cancer in octogenarians. Surgery 2023; 173:1476-1483. [PMID: 37045621 DOI: 10.1016/j.surg.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 01/28/2023] [Accepted: 03/08/2023] [Indexed: 04/14/2023]
Abstract
BACKGROUND A recent study reported the effect of preoperative hyponatremia on postoperative outcomes of patients with non-small cell lung cancer. However, the influence of postoperative hyponatremia on postoperative outcomes has not been completely investigated. METHODS We retrospectively studied 75 octogenarians who underwent pulmonary surgery for non-small cell lung cancer between 2009 and 2018. We divided them into hyponatremic and non-hyponatremic groups, depending on preoperative and immediate postoperative serum sodium levels, and investigated their clinicopathological characteristics and outcomes. Disease-specific survival and cumulative incidence of relapse rates between the two groups were calculated and compared using the stratified Kaplan-Meier method. Univariable and multivariable analyses were performed to identify prognostic factors. RESULTS Preoperative hyponatremia was associated with 66.7% of postoperative respiratory and 88.9% of non-cardiovascular complications. The long-term prognosis of the postoperative hyponatremic group was significantly worse than that of their counterpart. The 3-year disease-specific survival and 3-year cumulative incidence of relapse rate were 55.9% and 46.2%, respectively, and the median observation period after surgery was 37.4 (interquartile range, 23.7-51.0) months for the entire cohort. Kaplan-Meier curves showed that hyponatremia was associated with worse disease-specific survival and cumulative incidence of relapse. Multivariable analysis identified hyponatremia as a factor that predicted unfavorable disease-specific survival and cumulative incidence of relapse. CONCLUSIONS Immediate postoperative hyponatremia is an independent predictor of non-small cell lung cancer outcomes among octogenarians. Preoperative hyponatremia was associated with a high frequency of postoperative respiratory and non-cardiovascular complications. Surgical indications in older patients with hyponatremia should be carefully considered with follow-up.
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Affiliation(s)
- Yoshihito Iijima
- Department of Thoracic Surgery, Kanazawa Medical University, Ishikawa, Japan.
| | - Takaki Mizoguchi
- Department of Thoracic Surgery, Kanazawa Medical University, Ishikawa, Japan
| | - Masahito Ishikawa
- Department of Thoracic Surgery, Kanazawa Medical University, Ishikawa, Japan
| | - Shun Iwai
- Department of Thoracic Surgery, Kanazawa Medical University, Ishikawa, Japan
| | - Nozomu Motono
- Department of Thoracic Surgery, Kanazawa Medical University, Ishikawa, Japan
| | - Hidetaka Uramoto
- Department of Thoracic Surgery, Kanazawa Medical University, Ishikawa, Japan
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Teo CB, Gan MY, Tay RYK, Loh WJ, Loh NHW. Association of preoperative hyponatremia with surgical outcomes: a systematic review and meta-analysis of 32 observational studies. J Clin Endocrinol Metab 2022; 108:1254-1271. [PMID: 36472931 PMCID: PMC10099166 DOI: 10.1210/clinem/dgac685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 11/08/2022] [Accepted: 11/28/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Preoperative hyponatremia is prevalent in patients undergoing surgical procedures, but it is uncertain if hyponatremia will lead to increased risk of surgical mortality and morbidity. METHODS A systematic search of Medline (PubMed), Embase and Cochrane Library from inception till 2 July 2021 was performed. Full length articles that reported on the association between surgical outcomes among adults ≥18 years with documented preoperative hyponatremia were included. FINDINGS We identified 32 observational studies comprising 1,301,346 participants. All studies had low risk of bias. When adjusted for covariates, patients with hyponatremia had significantly higher odds of developing major complications (defined as a composite measure of 9 major complications) compared to patients with normal sodium concentrations (aOR = 1.37, 95%CI = 1.23-1.53, I2 = 78%. N = 10). Additionally, patients with preoperative hyponatremia also significantly higher hazards of early mortality (<90 days) compared to patients with normonatremia (aHR = 1.27, 95%CI = 1.13-1.43, I2 = 97%. N = 10) after adjustment for covariates. Preoperative hyponatremia also had significant associations with respiratory, renal and septic complications. In terms of prognostic performance, preoperative hyponatremia performed adequately in predicting major complications in surgical patients (AUC = 0.70, LR- 0.90) with a specificity of 88% and a sensitivity of 25%. INTERPRETATION Our meta-analysis suggests that preoperative hyponatremia is associated with poorer early mortality and major morbidity outcomes in surgical patients. Hyponatremia is also a specific prognosticator for major complications in surgical patients, reiterating its potential use as a clinical indicator of poor outcomes.
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Affiliation(s)
- Chong Boon Teo
- Ministry of Health Holdings, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Ryan Yong Kiat Tay
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Wann Jia Loh
- Department of Endocrinology, Changi General Hospital, Singapore
| | - Ne-Hooi Will Loh
- Department of Anaesthesia, National University Hospital, Singapore
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Baeg SI, Jeon J, Kang D, Na SJ, Cho J, Kim K, Yang JH, Chung CR, Lee JE, Huh W, Suh GY, Kim YG, Kim DJ, Jang HR. Impact of protocolized fluid management on electrolyte stability in patients undergoing continuous renal replacement therapy. Front Med (Lausanne) 2022; 9:915072. [PMID: 36117982 PMCID: PMC9471083 DOI: 10.3389/fmed.2022.915072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 08/02/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveContinuous renal replacement therapy (CRRT) is the standard treatment for critically ill patients with acute kidney injury (AKI). Electrolyte disturbance such as hypokalemia or hypophosphatemia occurs paradoxically in patients undergoing CRRT due to high clearance. We developed a fluid management protocol for dialysate and replacement fluid that depends on serum electrolytes and focuses on potassium and phosphate levels to prevent electrolyte disturbance during CRRT. The impact of our new fluid protocol on electrolyte stability was evaluated.MethodsAdult patients who received CRRT between 2013 and 2017 were included. Patients treated 2 years before (2013–2014; pre-protocol group) and 2 years following development of the fluid protocol (2016–2017; protocol group) were compared. The primary outcomes were individual coefficient of variation (CV) and abnormal event rates of serum phosphate and potassium. Secondary outcomes were frequency of electrolyte replacement and incidence of cardiac arrhythmias. Individual CV and abnormal event rates for each electrolyte were analyzed using the Wilcoxon rank-sum test and Chi-square test with Yates’ continuity correction.ResultsA total of 1,448 patients was included. Both serum phosphate and potassium were higher in the protocol group. The CVs of serum phosphate (pre-protocol vs. protocol, 0.275 [0.207–0.358] vs. 0.229 [0.169–0.304], p < 0.01) and potassium (0.104 [0.081–0.135] vs. 0.085 [0.064–0.110], p < 0.01) were significantly lower in the protocol group. The abnormal event rates of serum phosphate (rate [95% CI], 0.410 [0.400–0.415] vs. 0.280 [0.273–0.286], p < 0.01) and potassium (0.205 [0.199–0.211] vs. 0.083 [0.079–0.087], p < 0.01) were also significantly lower in the protocol group.ConclusionThe protocolized management of fluid in CRRT effectively prevented hypophosphatemia and hypokalemia by inducing excellent stability of serum phosphate and potassium levels.
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Affiliation(s)
- Song In Baeg
- Division of Nephrology, Department of Internal Medicine, Myongji Hospital, Hanyang University Medical Center, Goyang, South Korea
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Samsung Biomedical Research Institute, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Junseok Jeon
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Samsung Biomedical Research Institute, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Danbee Kang
- Department of Clinical Research Design and Evaluation, Samsung Advanced Institute for Health Sciences and Technology, Sungkyunkwan University, Seoul, South Korea
- Center of Clinical Epidemiology, Samsung Medical Center, Seoul, South Korea
| | - Soo Jin Na
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Juhee Cho
- Department of Clinical Research Design and Evaluation, Samsung Advanced Institute for Health Sciences and Technology, Sungkyunkwan University, Seoul, South Korea
- Center of Clinical Epidemiology, Samsung Medical Center, Seoul, South Korea
| | - Kyunga Kim
- Statistics and Data Center, Samsung Medical Center, Seoul, South Korea
| | - Jeong Hoon Yang
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Chi Ryang Chung
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jung Eun Lee
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Samsung Biomedical Research Institute, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Wooseong Huh
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Samsung Biomedical Research Institute, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Gee Young Suh
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Yoon-Goo Kim
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Samsung Biomedical Research Institute, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Dae Joong Kim
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Samsung Biomedical Research Institute, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Hye Ryoun Jang
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Samsung Biomedical Research Institute, Sungkyunkwan University School of Medicine, Seoul, South Korea
- *Correspondence: Hye Ryoun Jang,
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Ferdaus MZ, Terker AS, Koumangoye R, Delpire E. KCC3a, a Strong Candidate Pathway for K+ Loss in Alkalemia. Front Cell Dev Biol 2022; 10:931326. [PMID: 35874803 PMCID: PMC9301082 DOI: 10.3389/fcell.2022.931326] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 05/24/2022] [Indexed: 11/13/2022] Open
Abstract
Loss-of-function mutations in the human potassium chloride cotransporter-3 (KCC3) cause a hereditary motor sensory neuropathy associated with agenesis of the corpus callosum. While recapitulating the neuropathy, KCC3-knockout mice also exhibit high blood pressure. This phenotype is believed to have neurogenic and/or vascular origins. The role of KCC3 in the kidney is poorly understood. KCC3 is encoded by two major isoforms originating from alternative promoters: KCC3a and KCC3b, with KCC3b being the predominant transcript in the kidney. Although the transporter has previously been localized to the proximal tubule, we show here the unique expression of the KCC3a isoform in the connecting tubule. Using a KCC3a-specific polyclonal antibody validated for both immunofluorescence and immunoblotting, we showed an intense KCC3a signal restricted to cortical intercalated cells. No overlap is detected between KCC3a and sodium chloride cotransporter (NCC), a distal convoluted tubule (DCT) marker; or between KCC3a and ENaC or calbindin, which are both principal cell markers. KCC3a signal was observed in cells expressing the apical V-ATPase and pendrin, establishing a unique expression pattern characteristic of intercalated cells of type-B or type-nonA/nonB. We further show that treatment of wild-type mice with hydrochlorothiazide, amiloride, or fed a K+-deficient diet up-regulates KCC3a level, suggesting that volume depletion increases KCC3a abundance. This hypothesis was confirmed by showing a higher abundance of KCC3a protein after 23-h water restriction or after placing the mice on a low-salt diet. More importantly, abundance of the Cl−/HCO3− exchanger, pendrin, which is known to secrete bicarbonate in alkalotic conditions, was significantly diminished in KCC3-knockout mice. In addition, KCC3a abundance increased significantly alongside pendrin abundance in bicarbonate-treated alkalotic mice, providing a credible mechanism for K+ loss in metabolic alkalosis.
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Affiliation(s)
- Mohammed Zubaerul Ferdaus
- Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, TN, United States
| | - Andrew Scott Terker
- Division of Nephrology, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, United States
| | - Rainelli Koumangoye
- Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, TN, United States
| | - Eric Delpire
- Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, TN, United States
- *Correspondence: Eric Delpire,
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Cihoric M, Kehlet H, Lauritsen ML, Højlund J, Foss NB. Electrolyte and Acid-Base Disturbances in Emergency High-Risk Abdominal Surgery, a Retrospective Study. World J Surg 2022; 46:1325-1335. [PMID: 35262790 DOI: 10.1007/s00268-022-06499-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Patients undergoing emergency high-risk abdominal surgery potentially suffer from both systemic dehydration and hypovolaemia. Data on the prevalence and clinical impact of electrolyte disturbances in this patient group, specifically the differences in patients with intestinal obstruction (IO) versus perforated viscus (PV) are lacking. METHODS Adult patients undergoing emergency high-risk abdominal surgery in a standardized perioperative pathway were included in this retrospective single-center cohort study. Electrolytes and arterial blood gas analysis were measured during the early perioperative period. Prevalence and clinical impact of electrolyte disturbances were assessed. RESULTS A total of 354 patients were included in the study. Preoperative alkalemia dominated preoperatively, significantly more prevalent in IO (45 vs. 32%, p < .001), while acidosis was most pronounced postoperatively in PV (49 vs. 28%, p < .0001). Preoperative hypochloraemia and hypokalemia were more frequent in the IO (34 vs. 20% and 37 vs. 25%, respectively). Hyponatremia was highly prevalent in both IO and PV. Pre- and postoperative hypochloremia were independently associated with 30-day postoperative morbidity and mortality in patients with IO (OR 2.87 (1.35, 6.23) p = 0.006, OR 6.86 (1.71, 32.2) p = 0.009, respectively). Hypochloremic patients presented with reduced long-term survival as compared with the normo- and hyperchloremic patients (p < 0.05). Neither plasma sodium nor potassium showed a significant association with outcome. CONCLUSION These observations suggest that acute high-risk abdominal patients have frequent preoperative alkalosis shifting to postoperative acidosis. Both pre- and postoperative hypochloremia were independently associated with both impaired short- and long-term outcome in patients with intestinal obstruction, with potential implications for the choice of resuscitations fluids.
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Affiliation(s)
- Mirjana Cihoric
- Department of Anesthesiology and Intensive Care Medicine, Hvidovre University Hospital, Kettegaard allé 30, Hvidovre, 2650, Copenhagen, Denmark.
| | - Henrik Kehlet
- Surgical Pathophysiology Unit, Rigshospitalet, Copenhagen, Denmark
| | | | - Jakob Højlund
- Department of Anesthesiology and Intensive Care Medicine, Hvidovre University Hospital, Kettegaard allé 30, Hvidovre, 2650, Copenhagen, Denmark
| | - Nicolai Bang Foss
- Department of Anesthesiology and Intensive Care Medicine, Hvidovre University Hospital, Kettegaard allé 30, Hvidovre, 2650, Copenhagen, Denmark
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Sugar, Sodium, and Water: A Recipe for Disaster. Ann Am Thorac Soc 2021; 17:1016-1020. [PMID: 32735168 DOI: 10.1513/annalsats.202004-360cc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Berni A, Malandrino D, Corona G, Maggi M, Parenti G, Fibbi B, Poggesi L, Bartoloni A, Lavorini F, Fanelli A, Scocchera G, Nozzoli C, Peris A, Pieralli F, Pini R, Ungar A, Peri A. Serum sodium alterations in SARS CoV-2 (COVID-19) infection: impact on patient outcome. Eur J Endocrinol 2021; 185:137-144. [PMID: 33950864 PMCID: PMC9494309 DOI: 10.1530/eje-20-1447] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 05/05/2021] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Hyponatremia is the most common electrolyte disorder in hospitalized patients and occurs in about 30% of patients with pneumonia. Hyponatremia has been associated with a worse outcome in several pathologic conditions The main objective of this study was to determine whether serum sodium alterations may be independent predictors of the outcome of hospitalized COVID-19 patients. DESIGN AND METHODS In this observational study, data from 441 laboratory-confirmed COVID-19 patients admitted to a University Hospital were collected. After excluding 61 patients (no serum sodium at admission available, saline solution infusion before sodium assessment, transfer from another hospital), data from 380 patients were analyzed. RESULTS 274 (72.1%) patients had normonatremia at admission, 87 (22.9%) patients had hyponatremia and 19 (5%) patients had hypernatremia. We found an inverse correlation between serum sodium and IL-6, whereas a direct correlation between serum sodium and PaO2/FiO2 ratio was observed. Patients with hyponatremia had a higher prevalence of non-invasive ventilation and ICU transfer than those with normonatremia or hypernatremia. Hyponatremia was an independent predictor of in-hospital mortality (2.7-fold increase vs normonatremia) and each mEq/L of serum sodium reduction was associated with a 14.4% increased risk of death. CONCLUSIONS These results suggest that serum sodium at admission may be considered as an early prognostic marker of disease severity in hospitalized COVID-19 patients.
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Affiliation(s)
- Andrea Berni
- Internal Medicine Unit 3, Careggi University Hospital, Florence, Italy
| | - Danilo Malandrino
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Giovanni Corona
- Endocrinology Unit, Medical Department, Azienda Usl Bologna Maggiore-Bellaria Hospital, Bologna, Italy
| | - Mario Maggi
- Endocrinology Unit, Careggi University Hospital, Florence, Italy
- Department of Experimental and Clinical Biomedical Sciences ‘Mario Serio’, University of Florence, Florence, Italy
| | - Gabriele Parenti
- Endocrinology Unit, Careggi University Hospital, Florence, Italy
- Pituitary Diseases and Sodium Alterations Unit, Careggi University Hospital, Florence, Italy
| | - Benedetta Fibbi
- Endocrinology Unit, Careggi University Hospital, Florence, Italy
- Pituitary Diseases and Sodium Alterations Unit, Careggi University Hospital, Florence, Italy
| | - Loredana Poggesi
- Internal Medicine Unit 3, Careggi University Hospital, Florence, Italy
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Alessandro Bartoloni
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Infectious and Tropical Diseases Unit, Careggi University Hospital, Florence, Italy
| | - Federico Lavorini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Pneumology and Thoraco Pulmonary Pathophysiology Unit, Careggi University Hospital, Florence, Italy
| | - Andrea Fanelli
- Internal Medicine Unit 2, Careggi University Hospital, Florence, Italy
| | - Giulia Scocchera
- Internal Medicine Unit 2, Careggi University Hospital, Florence, Italy
| | - Carlo Nozzoli
- Internal Medicine Unit 1, Careggi University Hospital, Florence, Italy
| | - Adriano Peris
- Intensive Care Unit and Regional ECMO Referral Center, Careggi University Hospital, Florence, Italy
| | - Filippo Pieralli
- High Intensity Internal Medicine Unit, Careggi University Hospital, Florence, Italy
| | - Riccardo Pini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Department of Internal and Emergency Medicine, Careggi Hospital, Florence, Italy
| | - Andrea Ungar
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Geriatric-UTIG Unit, Careggi University Hospital, Florence, Italy
| | - Alessandro Peri
- Endocrinology Unit, Careggi University Hospital, Florence, Italy
- Department of Experimental and Clinical Biomedical Sciences ‘Mario Serio’, University of Florence, Florence, Italy
- Pituitary Diseases and Sodium Alterations Unit, Careggi University Hospital, Florence, Italy
- Correspondence should be addressed to A Peri Email
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Trecarichi EM, Mazzitelli M, Serapide F, Pelle MC, Tassone B, Arrighi E, Perri G, Fusco P, Scaglione V, Davoli C, Lionello R, La Gamba V, Marrazzo G, Busceti MT, Giudice A, Ricchio M, Cancelliere A, Lio E, Procopio G, Costanzo FS, Foti DP, Matera G, Torti C. Clinical characteristics and predictors of mortality associated with COVID-19 in elderly patients from a long-term care facility. Sci Rep 2020; 10:20834. [PMID: 33257703 PMCID: PMC7705720 DOI: 10.1038/s41598-020-77641-7] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 11/13/2020] [Indexed: 01/08/2023] Open
Abstract
Since December 2019, coronavirus disease 2019 (COVID-19) pandemic has spread from China all over the world and many COVID-19 outbreaks have been reported in long-term care facilities (LCTF). However, data on clinical characteristics and prognostic factors in such settings are scarce. We conducted a retrospective, observational cohort study to assess clinical characteristics and baseline predictors of mortality of COVID-19 patients hospitalized after an outbreak of SARS-CoV-2 infection in a LTCF. A total of 50 patients were included. Mean age was 80 years (SD, 12 years), and 24/50 (57.1%) patients were males. The overall in-hospital mortality rate was 32%. At Cox regression analysis, significant predictors of in-hospital mortality were: hypernatremia (HR 9.12), lymphocyte count < 1000 cells/µL (HR 7.45), cardiovascular diseases other than hypertension (HR 6.41), and higher levels of serum interleukin-6 (IL-6, pg/mL) (HR 1.005). Our study shows a high in-hospital mortality rate in a cohort of elderly patients with COVID-19 and hypernatremia, lymphopenia, CVD other than hypertension, and higher IL-6 serum levels were identified as independent predictors of in-hospital mortality. Given the small population size as major limitation of our study, further investigations are necessary to better understand and confirm our findings in elderly patients.
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Affiliation(s)
- Enrico Maria Trecarichi
- Infectious and Tropical Disease Unit, Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro, Viale Europa, 88100, Catanzaro, Italy.
| | - Maria Mazzitelli
- Infectious and Tropical Disease Unit, Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro, Viale Europa, 88100, Catanzaro, Italy
| | - Francesca Serapide
- Infectious and Tropical Disease Unit, Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro, Viale Europa, 88100, Catanzaro, Italy
| | - Maria Chiara Pelle
- Infectious and Tropical Disease Unit, Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro, Viale Europa, 88100, Catanzaro, Italy
| | - Bruno Tassone
- Infectious and Tropical Disease Unit, Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro, Viale Europa, 88100, Catanzaro, Italy
| | - Eugenio Arrighi
- Infectious and Tropical Disease Unit, Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro, Viale Europa, 88100, Catanzaro, Italy
| | - Graziella Perri
- Infectious and Tropical Disease Unit, Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro, Viale Europa, 88100, Catanzaro, Italy
| | - Paolo Fusco
- Infectious and Tropical Disease Unit, Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro, Viale Europa, 88100, Catanzaro, Italy
| | - Vincenzo Scaglione
- Infectious and Tropical Disease Unit, Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro, Viale Europa, 88100, Catanzaro, Italy
| | - Chiara Davoli
- Infectious and Tropical Disease Unit, Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro, Viale Europa, 88100, Catanzaro, Italy
| | - Rosaria Lionello
- Infectious and Tropical Disease Unit, Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro, Viale Europa, 88100, Catanzaro, Italy
| | - Valentina La Gamba
- Infectious and Tropical Disease Unit, Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro, Viale Europa, 88100, Catanzaro, Italy
| | | | | | - Amerigo Giudice
- Department of Health Sciences, "Magna Graecia" University of Catanzaro, Catanzaro, Italy
| | - Marco Ricchio
- Infectious and Tropical Disease Unit, Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro, Viale Europa, 88100, Catanzaro, Italy
| | - Anna Cancelliere
- Infectious and Tropical Disease Unit, Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro, Viale Europa, 88100, Catanzaro, Italy
| | - Elena Lio
- Infectious and Tropical Disease Unit, Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro, Viale Europa, 88100, Catanzaro, Italy
| | - Giada Procopio
- Infectious and Tropical Disease Unit, Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro, Viale Europa, 88100, Catanzaro, Italy
| | - Francesco Saverio Costanzo
- Department of Experimental and Clinical Medicine, "Magna Graecia" University of Catanzaro, Catanzaro, Italy.,Center of Interdepartmental Services (CIS), "Magna Graecia" University of Catanzaro, Catanzaro, Italy
| | - Daniela Patrizia Foti
- Clinical Pathology Unit, Department of Health Sciences, "Magna Graecia" University of Catanzaro, Catanzaro, Italy
| | - Giovanni Matera
- Department of Health Sciences, Institute of Microbiology, "Magna Graecia" University of Catanzaro, Catanzaro, Italy
| | - Carlo Torti
- Infectious and Tropical Disease Unit, Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro, Viale Europa, 88100, Catanzaro, Italy
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10
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Shima S, Niimi Y, Moteki Y, Takahashi O, Sato S, Inoue T, Okada Y. Prognostic Significance of Hyponatremia in Acute Stroke: A Systematic Review and Meta-Analysis. Cerebrovasc Dis 2020; 49:531-539. [DOI: 10.1159/000510751] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 08/04/2020] [Indexed: 11/19/2022] Open
Abstract
<b><i>Objective:</i></b> Hyponatremia is a common electrolyte disorder in patients with stroke, which leads to various fatal complications. We performed a systematic review and meta-analysis to investigate the outcomes of acute stroke patients with hyponatremia. <b><i>Methods:</i></b> We searched MEDLINE, EMBASE, and the Cochrane Library databases for relevant literature in English published up to March 2020. Two review authors independently screened and selected the studies by assessing the eligibility and validity based on the inclusion criteria. Mortality at 90 days was set as the primary end point, and in-hospital mortality and length of hospital stay were set as the secondary end points. We conducted the data synthesis and analyzed the outcomes by calculating the odds ratio (OR) and mean difference. <b><i>Results:</i></b> Of 835 studies, 15 studies met the inclusion criteria (<i>n</i> = 10,745). The prevalence rate of stroke patients with hyponatremia was 7.0–59.2%. They had significantly higher 90-day mortality (OR, 1.73; 95% confidence interval (CI), 1.24–2.42) and longer length of hospital stay (mean difference, 10.68 days; 95% CI, 7.14–14.22) than patients without hyponatremia. Patients with hyponatremia had a higher tendency of in-hospital mortality than those without hyponatremia (OR, 1.61; 95% CI, 0.97–2.69). <b><i>Conclusions:</i></b> The development of hyponatremia in the clinical course of stroke is associated with higher short-term mortality and a longer hospital stay. Although the causal relationship is unclear, hyponatremia could be a significant predictor of poor outcomes after stroke.
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Tandukar S, Kim C, Kalra K, Verma S, Palevsky PM, Puttarajappa C. Severe Hyponatremia and Continuous Renal Replacement Therapy: Safety and Effectiveness of Low-Sodium Dialysate. Kidney Med 2020; 2:437-449. [PMID: 32775984 PMCID: PMC7406832 DOI: 10.1016/j.xkme.2020.05.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
RATIONALE & OBJECTIVE In patients with severe hyponatremia in the setting of acute kidney injury or end-stage kidney disease, continuous renal replacement therapy (CRRT) using standard-sodium (140 mEq/L) fluids may lead to excessively rapid correction of plasma sodium concentration. Use of dialysate and replacement fluids with reduced sodium concentrations can provide a controlled rate of correction of plasma sodium concentration. STUDY DESIGN We performed a single-center retrospective analysis of the safety and effectiveness of this approach in patients with plasma sodium concentrations ≤ 126 mEq/L who underwent CRRT for 24 or more hours using low-sodium (119 or 126 mEq/L) dialysate and replacement fluids. Change in plasma sodium level was assessed at 24 and 48 hours after initiation of low-sodium CRRT and at the end of treatment. SETTING & PARTICIPANTS Between January 2016 and June 2018, a total of 23 hyponatremic patients underwent continuous venovenous hemodiafiltration using low-sodium dialysate and replacement fluids; 4 patients were excluded from analysis because of CRRT duration less than <24 hours. RESULTS The 19 patients included in the study had a mean age of 56 years, 11 (58%) were men, and 15 (79%) were white. The initial mean plasma sodium level was 121 mEq/L and the initial CRRT effluent dose was 27 mL/kg/h. Only 2 (11%) patients had an increase in plasma sodium concentration > 6 mEq/L at 24 hours. Mean changes in plasma sodium levels at 24 and 48 hours and at the time of CRRT discontinuation were 3, 3, and 6 mEq/L, respectively. None of the patients developed osmotic demyelination syndrome. LIMITATIONS Key limitations were small sample size and lack of a control group. CONCLUSIONS Use of low-sodium dialysate and replacement fluids is a safe strategy for the prevention of overly rapid correction of plasma sodium levels in hyponatremic patients undergoing CRRT.
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Affiliation(s)
| | - Catherine Kim
- Department of Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Kartik Kalra
- Renal-Electrolyte Division, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Siddharth Verma
- Renal-Electrolyte Division, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Paul M. Palevsky
- Renal-Electrolyte Division, University of Pittsburgh Medical Center, Pittsburgh, PA
- Renal Section, Medical Service, VA Pittsburgh Healthcare System, Pittsburgh, PA
| | - Chethan Puttarajappa
- Renal-Electrolyte Division, University of Pittsburgh Medical Center, Pittsburgh, PA
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12
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Morgan TJ, Scott PH, Anstey CM, Bowling FG. Hyperlactatemia in diabetic ketoacidosis is common and can be prolonged: lactate time-series from 25 intensive care admissions. J Clin Monit Comput 2020; 35:757-764. [PMID: 32435932 DOI: 10.1007/s10877-020-00532-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 05/14/2020] [Indexed: 01/27/2023]
Abstract
Hyperlactatemia is a documented complication of diabetic ketoacidosis (DKA). Lactate responses during DKA treatment have not been studied and were the focus of this investigation. Blood gas and electrolyte data from 25 DKA admissions to ICU were sequenced over 24 h from the first Emergency Department sample. Hyperlactatemia (> 2 mmol/L) was present in 22 of 25 DKA presentations [mean concentration = 3.2 mmol/L]. In 18 time-series (72%), all concentrations normalized in ≤ 2.6 h (aggregate decay t1/2 = 2.29 h). In the remaining 7 (28%), hyperlactatemia persisted > 12 h. These were females (P = 0.04) with relative anemia (hemoglobin concentrations 131 v 155 g/L; P = 0.004) and lower nadir glucose concentrations (5.2 v 8.0 mmol/L, P = 0.003). Their aggregate glucose decay curve commenced higher (42 mmol/L v 29 mmol/L), descending towards a lower asymptote (8 mmol/L v 11 mmol/L). Tonicity decay showed similar disparities. There was equivalent resolution of metabolic acidosis and similar lengths of stay in both groups. Hyperlactatemia is common in DKA. Resolution is often rapid, but high lactates can persist. Females with high glucose concentrations corrected aggressively are more at risk. Limiting initial hyperglycemia correction to ≥ 11 mmol/L may benefit.
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Affiliation(s)
- Thomas J Morgan
- Mater Research, Mater Health Services and University of Queensland, Stanley Street, South Brisbane, Brisbane, QLD, 4101, Australia. .,Intensive Care Unit, Mater Health Services, Stanley Street, South Brisbane, Brisbane, QLD, 4101, Australia.
| | - Peter H Scott
- Intensive Care Unit, Mater Health Services, Stanley Street, South Brisbane, Brisbane, QLD, 4101, Australia
| | - Christopher M Anstey
- University of Queensland, Brisbane, QLD, 4072, Australia.,Griffith University, Gold Coast, Southport, QLD, 4215, Australia
| | - Francis G Bowling
- Department of Pathology, Royal Melbourne Hospital, and University of Melbourne, Parkville, VIC, 3050, Australia
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13
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Huang C, Liu Y, Li L, Liu H, Zhang P. Continuous veno-venous hemofiltration in the treatment of severely burned patients with acute hypernatremia: A retrospective study of 13 cases. Int J Artif Organs 2019; 43:416-421. [PMID: 31849258 DOI: 10.1177/0391398819893381] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES This study aimed to evaluate the clinical effects of continuous veno-venous hemofiltration in the treatment of severely burned patients with acute hypernatremia. METHODS A total of 13 severely burned patients with acute hypernatremia admitted to Xijing Hospital were included in this study. All patients received continuous veno-venous hemofiltration treatment in addition to conventional treatment. The original sodium level in the replacement fluid was set to be lower than the serum sodium level by 8 mmol/L and subsequently undergoes a reduction rate of 2.16 ± 0.18 mmol/L every 4 h. Patients' clinical features, serum laboratory tests, hemodynamic variables, changes in sodium levels in serum, and replacement fluid during continuous veno-venous hemofiltration treatment were monitored. RESULTS Patients had an average total burn surface area of 66.69% ± 20.28%. Two patients died of systematic Pseudomonas aeruginosa infections, and 11 patients survived. After continuous veno-venous hemofiltration treatment, patients showed a significant reduction in the serum sodium level (168.91 ± 4.88 mmol/L vs 144.62 ± 2.98 mmol/L, p < 0.01). Likewise, the serum levels of urea and creatinine decreased from 24.8 ± 6.5 mmol/L to 14.9 ± 8.3 mmol/L and from 278.6 ± 155.3 μmol/L to 152.6 ± 29.7 μmol/L, respectively (p < 0.05). The patients also displayed improvements in the Acute Physiology and Chronic Health Evaluation II and Glasgow scores (p < 0.05) and showed a significant reduction in hemoglobin and serum albumin levels (p < 0.05), but no obvious change in levels of platelets, alanine aminotransferase, and aspartate aminotransferase (p > 0.05). CONCLUSION Our results indicate that continuous veno-venous hemofiltration with gradient sodium replacement fluid is effective in treating hypernatremia in severely burned patients with the controllable sodium reduction rate and satisfactory clinical outcomes.
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Affiliation(s)
- Chen Huang
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Yirong Liu
- Department of Nephrology, Xining No. 1 People's Hospital, Xining, China
| | - Li Li
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Hongbao Liu
- Department of Nephrology, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Peng Zhang
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
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De Freitas G, Gudur A, Vela-Ortiz M, Jodelka J, Livert D, Krishnamurthy M. Where there is sodium there may be sepsis. J Community Hosp Intern Med Perspect 2019; 9:296-299. [PMID: 31528275 PMCID: PMC6735289 DOI: 10.1080/20009666.2019.1634407] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 06/17/2019] [Indexed: 11/14/2022] Open
Abstract
Hypernatremia affects up to 9% of critically ill patients upon hospital admission, especially in elderly patients with thirst impairment. However, hypernatremia is not entirely explained by fluid imbalance. Recent studies suggest that sodium is an important enhancer of the immune system, raising the question of whether inflammatory states such as sepsis may contribute to hypernatremia. Although sepsis patients with hypernatremia face a greater mortality rate, there is a lack of studies examining a potential association between hypernatremia and sepsis. Motivated by the frequent concurrence of hypernatremia and sepsis observed at an eastern Pennsylvanian community hospital, the current study was conducted to evaluate whether hypernatremia on admission may serve as a potential surrogate marker for sepsis. The medical records of 153 patients with hypernatremia on admission (serum sodium > 145mEq/L) were retrospectively analyzed. The mean age of patients was 81.1. Sepsis was observed in 77.1% of patients, of which 86.2% had dementia. This study demonstrated a positive correlation between hypernatremia on admission and the presence of sepsis. We suggest that the existence of hypernatremia should prompt clinicians to further investigate for sources of infection, especially in the elderly and patients with dementia.
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Affiliation(s)
| | - Anuragh Gudur
- Drexel University College of Medicine, Philadelphia, PA, USA
| | | | - Jacek Jodelka
- St. Luke's University Hospital, Fountain Hill, PA, USA
| | - David Livert
- Internal Medicine, Easton Hospital, Easton, PA, USA.,Drexel University College of Medicine, Philadelphia, PA, USA
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15
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Myles PS, McIlroy DR, Bellomo R, Wallace S. Importance of intraoperative oliguria during major abdominal surgery: findings of the Restrictive versus Liberal Fluid Therapy in Major Abdominal Surgery trial. Br J Anaesth 2019; 122:726-733. [DOI: 10.1016/j.bja.2019.01.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 12/03/2018] [Accepted: 01/02/2019] [Indexed: 01/14/2023] Open
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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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17
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Prevalence and Risk Factors of Dehydration Among Nursing Home Residents: A Systematic Review. J Am Med Dir Assoc 2018; 19:646-657. [DOI: 10.1016/j.jamda.2018.05.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 05/10/2018] [Accepted: 05/12/2018] [Indexed: 12/24/2022]
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18
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Sen S, Tran N, Chan B, Palmieri TL, Greenhalgh DG, Cho K. Sodium variability is associated with increased mortality in severe burn injury. BURNS & TRAUMA 2017; 5:34. [PMID: 29142896 PMCID: PMC5674226 DOI: 10.1186/s41038-017-0098-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 09/27/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Dysnatremias are associated with increased mortality in critically ill patients. Hypernatremia in burn patients is also associated with poor survival. Based on these findings, we hypothesized that high plasma sodium variability is a marker for increased mortality in severely burn-injured patients. METHODS We performed a retrospective review of adult burn patients with a burn injury of 15% total body surface area (TBSA) or greater from 2010 to 2014. All patients included in the study had at least three serum sodium levels checked during admission. We used multivariate logistic regression analysis to determine if hypernatremia, hyponatremia, or sodium variability independently increased the odds ratio (OR) for death. RESULTS Two hundred twelve patients met entry criteria. Mean age and %TBSA for the study was 45 ± 18 years and 32 ± 19%. Twenty-nine patients died for a mortality rate of 14%. Serum sodium was measured 10,310 times overall. The median number of serum sodium measurements per patient was 22. Non-survivors were older (59 ± 19 vs. 42 ± 16 years) and suffered from a more severe burn injury (50 ± 25% vs. 29 ± 16%TBSA). While mean sodium was significantly higher for non-survivors (138 ± 3 milliequivalents/liter (meq/l)) than for survivors (135 ± 2 meq/l), mean sodium levels remained within the laboratory reference range (135 to 145 meq/l) for both groups. Non-survivors had a significantly higher median number of hypernatremic (> 145 meq/l) measurements (2 vs. 0). Coefficient of variation (CV) was significantly higher in non-survivors (2.85 ± 1.1) than survivors (2.0 ± 0.7). Adjusting for TBSA, age, ventilator days, and intensive care unit (ICU) stay, a higher CV of sodium measurements was associated with mortality (OR 5.8 (95% confidence interval (CI) 1.5 to 22)). Additionally, large variation in sodium ranges in the first 10 days of admission may be associated with increased mortality (OR 1.35 (95% CI 1.06 to1.7)). CONCLUSIONS Increased variability in plasma sodium may be associated with death in severely burned patients.
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Affiliation(s)
- Soman Sen
- Department of Surgery, Division of Burn Surgery, University of California Davis, 2425 Stockton Blvd. Suite 718, Sacramento, CA 95817 USA
| | - Nam Tran
- Department of Surgery, Division of Burn Surgery, University of California Davis, 2425 Stockton Blvd. Suite 718, Sacramento, CA 95817 USA
| | - Brian Chan
- Department of Surgery, Division of Burn Surgery, University of California Davis, 2425 Stockton Blvd. Suite 718, Sacramento, CA 95817 USA
| | - Tina L. Palmieri
- Department of Surgery, Division of Burn Surgery, University of California Davis, 2425 Stockton Blvd. Suite 718, Sacramento, CA 95817 USA
| | - David G. Greenhalgh
- Department of Surgery, Division of Burn Surgery, University of California Davis, 2425 Stockton Blvd. Suite 718, Sacramento, CA 95817 USA
| | - Kiho Cho
- Department of Surgery, Division of Burn Surgery, University of California Davis, 2425 Stockton Blvd. Suite 718, Sacramento, CA 95817 USA
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Abstract
Purpose To describe causes, pathophysiologic mechanisms, and classifications of hyponatremia, and to describe clinical symptoms and underlying disease states associated with different levels of hyponatremia. Summary The key to comprehending hyponatremia is to understand body water content and plasma osmolality and accurately assess arterial volume. Hyponatremia results from sodium dilution because of retained water or sodium depletion because of electrolyte loss in excess of water loss. Body sodium, water, and extracellular fluid (ECF) volume are tightly regulated by mechanisms that act to maintain a closely controlled concentration of solutes in the ECF. These forces act to regulate water content and sodium excretion to maintain normal intravascular volume. The body closely defends normal plasma osmolality within a narrow range primarily by controlling the release of arginine vasopressin (AVP) and via the thirst mechanism. A number of factors can stimulate inappropriate AVP release and cause or worsen hyponatremia. Dysregulation of AVP plays an important role in heart failure and cirrhosis, common causes of hypervolemic hyponatremia. Conclusion Body water content and plasma osmolality are tightly regulated by the action of AVP. A variety of disease states are associated with hyponatremia related to inappropriate AVP release. The cause of the electrolyte disturbance must be determined, because it can have profound implications for treatment. Differential diagnosis can be guided by observation of the rapidity of onset as well as volume status changes. If untreated or treated inappropriately, hyponatremia can impact morbidity and mortality.
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Affiliation(s)
- Kirkwood F. Adams
- Division of Cardiology, Department of Medicine, University of North Carolina School of Medicine, 160 Dental Circle, CB# 7075, 6034 Burnett Womack Building, Chapel Hill, NC 27599
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20
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Hundley D, Brooks A, Thomovsky E, Johnson P. Crystalloids: A Quick Reference for Challenges in Daily Practice. Top Companion Anim Med 2016; 31:46-53. [DOI: 10.1053/j.tcam.2016.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 08/04/2016] [Indexed: 11/11/2022]
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21
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Hillary SL, Hemead H, Berthoud M, Balasubramanian SP. A case report on acute severe hyponatraemia following parathyroid surgery for primary hyperparathyroidism-A rare but life threatening complication. Int J Surg Case Rep 2016; 21:136-8. [PMID: 26994458 PMCID: PMC4802297 DOI: 10.1016/j.ijscr.2016.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 03/02/2016] [Accepted: 03/03/2016] [Indexed: 10/31/2022] Open
Abstract
INTRODUCTION Parathyroidectomy is a common operation, which is well tolerated and associated with low morbidity. Patients are usually discharged within 24hours of surgery. Severe postoperative hyponatraemia is a rare complication which can cause significant morbidity including seizure, coma, respiratory arrest and even death. PRESENTATION OF CASE We present two patients with clinically significant hyponatremia resulting in seizures and collapse within 24hours after parathyroidectomy, an unreported complication following surgery for primary hyperparathyroidism. One patient required support on the High Dependency Unit and both were treated with fluid restriction which resulted in correction of their electrolyte balance. DISCUSSION We believe this was caused by the relative inability to secrete a water load after surgery and non-psychogenic polydipsia. Preoperatively, neither patient was prescribed any routine medications nor did they have any risk factors for hyponatremia. Both had normal preoperative sodium levels. It is usual practice is to advise patients to increase oral water intake when they are hypercalcaemic. The aim of parathyroidectomy is to treat hypercalcaemia by stopping excess PTH secretion from abnormal parathyroid glands. These patients continued to follow this advice after surgery when they were eucalcaemic after their operation and because they were thirsty. The patients drank several litres of water in 12-24hours after surgery. We believe that this may have contributed to this complication. CONCLUSION Healthcare professionals need to be aware of this complication and patients should be advised to restrict intake of free water after surgery.
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Affiliation(s)
- S L Hillary
- Clinical Research Fellow, Sheffield Teaching Hospitals NHS Foundation Trust c/o F25, Royal Hallamshire Hospital, Glossop Road, Sheffield S10 2JF, UK.
| | - H Hemead
- Medical Student, University of Sheffield, UK.
| | - M Berthoud
- Consultant Anaesthetist, Sheffield Teaching Hospitals NHS Foundation Trust, UK.
| | - S P Balasubramanian
- Consultant Endocrine Surgeon, Sheffield Teaching Hospitals NHS Foundation Trust, EU35, E Floor, Royal Hallamshire Hospital, Beech Hill Road, Sheffield S10 2RX, UK.
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22
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Alansari MA, Abdulmomen A, Hussein M, Zubaidi AM, Alswaiti JT. Acquired hypernatremia in a general surgical Intensive Care Unit: Incidence and prognosis. Saudi J Anaesth 2016; 10:409-413. [PMID: 27833483 PMCID: PMC5044724 DOI: 10.4103/1658-354x.177327] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Purpose: Intensive Care Unit (ICU)-acquired hypernatremia (IAH) is a serious electrolyte disturbance that recently was shown to present an independent risk factor for mortality in critically ill patients. IAH has not been widely investigated in Surgical ICU (SICU) patients. No study has specifically investigated IAH epidemiology in the Kingdome of Saudi Arabia (KSA) in general SICU. The objectives of this study are to assess the epidemiological characteristics and prognostic impact of IAH on SICU mortality and outcome in KSA and compare it with international figures. Materials and Methods: A retrospective observational study on a prospectively collected data of patients (14 years of age or older) admitted to SICU over 2 years, with normal serum sodium on admission and who developed IAH (serum sodium above 145 mmol/L) from day two of admission. Traumatic brain injury patients with therapeutic target sodium level above 145 mmol/L were excluded. Results: Over 2 years study period, 864 patients were admitted to SICU. A total of 50 (5.8%) developed IAH and were included in the study. Twenty-eight (56%) patients were male. The median age was 47 (14-84) years. The mean (± standard deviation) Acute Physiology and Chronic Health Evaluation II score was 17 ± 6.5. The incident density (the rate of occurrence of IAH per 100 days care for SICU admission for the first episode) was 0.71. Risk factors include mechanical ventilation, male sex, age ≥50 years, postgastrointestinal surgeries, weekend and night admission. SICU mortality was 40%. The SICU and hospital median (range) length of stay was 8.3 (2-53) and 28.8 (3-95), respectively. Conclusions: IAH is not uncommon in SICU patients and is associated with increased risk of SICU as well as hospital mortality.
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Affiliation(s)
- Mariam A Alansari
- Department of Adult Critical Care Medicine, College of Medicine, King Saud University, King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia
| | - Ahmed Abdulmomen
- Department of Critical Care, College of Medicine, King Saud University, King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia
| | - Mohammed Hussein
- Department of Quality Management, College of Medicine, King Saud University, King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia
| | - Ahmad Mohmmad Zubaidi
- Department of Surgical, College of Medicine, King Saud University, King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia
| | - Jalal T Alswaiti
- Department of Nursing, College of Medicine, King Saud University, King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia
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Ahamed S, Anpalahan M, Savvas S, Gibson S, Torres J, Janus E. Hyponatraemia in older medical patients: implications for falls and adverse outcomes of hospitalisation. Intern Med J 2015; 44:991-7. [PMID: 25039672 DOI: 10.1111/imj.12535] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Accepted: 07/06/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Recent evidence suggests an association between hyponatraemia and falls. AIMS To determine the association of hyponatraemia with admission-associated falls (i.e. falls as part of the presenting complaint or during admission) and predefined adverse outcomes of hospitalisation. METHODS A case-control study of patients aged ≥65 years admitted with hyponatraemia during a 6-month period was conducted. The relevant data were collected by review of medical records and analysed in univariate and multivariate models. RESULTS The prevalence of hyponatraemia was 22% and more likely to be associated with the admission diagnoses of cardiovascular (P = 0.04) and metabolic disorders (P < 0.001), use of diuretics (P = 0.037) and a higher Charlson comorbidity score (P = 0.035). Hyponatraemia was independently associated with admission-associated falls (odds ratio (OR) 3.12, confidence interval (CI) 1.84-4.38, P < 0.001). The increased odds of falling were similar for mild (OR 3.15, CI 1.75-5.66) vs moderate to severe hyponatraemia (OR 3.07, CI 1.57-6.03). Although hyponatraemia had a significant independent association with increased length of stay (LOS) (OR 1.48, CI 1.22-1.79, P < 0.001) and change in residential care status to a more dependent category at discharge (OR 4.28, CI 1.68-10.859, P = 0.002), it was not associated with mortality or time to first unplanned readmission. Hyponatraemia was significantly associated with the need for inpatient rehabilitation; however, this was no longer significant when adjusted for falls. CONCLUSION Hyponatraemia is independently associated with increased risk of admission-associated falls. The degree of falls risk is similar regardless of the severity of hyponatraemia. Hyponatraemia is also an important determinant of many adverse outcomes of hospitalisation.
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Affiliation(s)
- S Ahamed
- General Medicine Unit, Western Health, Melbourne, Victoria, Australia
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24
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Wu Y, Ren J, Wang G, Zhou B, Ding C, Chen J, Gu G, Liu S, Li J. Serum Sodium: A Reliable and Validated Predictor for Mortality in Enteric Fistula Patients Complicated with Sepsis. J INVEST SURG 2015; 28:131-9. [PMID: 25646689 DOI: 10.3109/08941939.2014.957880] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE The aim was to evaluate the predictive value of serial serum sodium determination for mortality in enteric fistula (EF) patients complicated with sepsis. METHODS Between January 1(st), 2012 to January 13(th), 2013, we performed a prospective observational study enrolling 162 patients. Patients were divided into survivors group (n = 119) and nonsurvivors group (n = 43) according to 28-day outcomes. Laboratory variables on day 0, day 3, and day 7 after admission were recorded. [Na(+)]0 was defined as serum [Na(+)] value on admission. [Na(+)]3 was defined as serum [Na(+)] value on day 3. Δ [Na(+)]3 was defined as changes from [Na(+)]3 to [Na(+)]0. The definition applied to other parameters. The results were validated in an independent cohort of 116 patients. RESULTS ROC analysis showed that [Na(+)]7>147.5 mmol/L and ΔNa7>5.2 mmol/L were reliable predictors ([Na(+)]7: 81.2% sensitivity, 87.7% specificity, (area under the curve(AUC):0.872, p < .001; Δ[Na(+)]7: 81.3% sensitivity, 83.6% specificity, AUC:0.836, p < .001) for mortality. The combination form ([Na(+)]7>147.5 mmol/L+ Δ[Na]7>5.2 mmol/L+ ΔPCT7<5.3 ng/ml) had greatest predictive value (AUC:0.899, p < .001). Their predictive values were confirmed in the validation cohort. CONCLUSIONS Serum sodium was a reliable predictor for mortality in abdominal septic patients, which should be paid close attention in the critical care.
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Affiliation(s)
- Yin Wu
- Department of Surgery, Jinling Hospital, Medical School of Nanjing University , Nanjing , P.R. China
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Manzanares W, Aramendi I, Langlois PL, Biestro A. Hyponatremia in the neurocritical care patient: An approach based on current evidence. Med Intensiva 2015; 39:234-43. [PMID: 25593019 DOI: 10.1016/j.medin.2014.11.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Revised: 11/06/2014] [Accepted: 11/11/2014] [Indexed: 01/20/2023]
Abstract
In the neurocritical care setting, hyponatremia is the commonest electrolyte disorder, which is associated with significant morbimortality. Cerebral salt wasting and syndrome of inappropriate antidiuretic hormone have been classically described as the 2 most frequent entities responsible of hyponatremia in neurocritical care patients. Nevertheless, to distinguish between both syndromes is usually difficult and useless as volume status is difficult to be determined, underlying pathophysiological mechanisms are still not fully understood, fluid restriction is usually contraindicated in these patients, and the first option in the therapeutic strategy is always the same: 3% hypertonic saline solution. Therefore, we definitively agree with the current concept of "cerebral salt wasting", which means that whatever is the etiology of hyponatremia, initially in neurocritical care patients the treatment will be the same: hypertonic saline solution.
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Affiliation(s)
- W Manzanares
- Cátedra de Medicina Intensiva, Centro de Tratamiento Intensivo, Hospital de Clínicas, Facultad de Medicina, Universidad de la República (UdeLaR), Montevideo, Uruguay.
| | - I Aramendi
- Cátedra de Medicina Intensiva, Centro de Tratamiento Intensivo, Hospital de Clínicas, Facultad de Medicina, Universidad de la República (UdeLaR), Montevideo, Uruguay
| | - P L Langlois
- Hôpital Fleurimont, Centre Hospitalier Universitaire de Sherbrooke, Département d'Anesthésie-Réanimation, Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Québec, Canadá
| | - A Biestro
- Cátedra de Medicina Intensiva, Centro de Tratamiento Intensivo, Hospital de Clínicas, Facultad de Medicina, Universidad de la República (UdeLaR), Montevideo, Uruguay
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Dangoisse C, Dickie H, Tovey L, Ostermann M. Correction of hyper- and hyponatraemia during continuous renal replacement therapy. Nephron Clin Pract 2015; 128:394-8. [PMID: 25592652 DOI: 10.1159/000369347] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Accepted: 10/27/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Severe hyper- and hyponatraemia is associated with significant risks, yet its correction can also have serious consequences when implemented too fast or inadequately. The safe correction of serum sodium levels is particularly challenging when renal replacement therapy (RRT) is required. METHODS Using 2 case scenarios, we aim to illustrate a simple method of correcting hyper- and hyponatraemia safely by step-wise manipulation of the dialysate/replacement fluid. RESULTS During continuous RRT, hypernatraemia can be corrected effectively and safely by adding small pre-calculated amounts of 30% NaCl to the dialysate/replacement fluid bags aiming for a [Na(+)] in the fluid that allows safe equilibration and correction of the serum [Na(+)]. To correct hyponatraemia safely, pre-calculated amounts of sterile water can be added in a step-wise manner to achieve a fluid [Na(+)] that equals the desired target serum [Na(+)]. CONCLUSION During continuous RRT, the step-wise adjustment of [Na(+)] of dialysate/replacement fluids offers a safe and reliable method to correct sodium disorders.
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Affiliation(s)
- Carole Dangoisse
- Department of Critical Care, Guy's & St. Thomas' NHS Foundation Hospital Trust, London, UK
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Rittenhouse KJ, To T, Rogers A, Wu D, Horst M, Edavettal M, Miller JA, Rogers FB. Hyponatremia as a fall predictor in a geriatric trauma population. Injury 2015; 46:119-23. [PMID: 25065652 DOI: 10.1016/j.injury.2014.06.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Revised: 05/16/2014] [Accepted: 06/13/2014] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Approximately one in three older adults fall each year, resulting in a significant proportion of geriatric traumatic injuries. In a hospital with a focus on geriatric fall prevention, we sought to characterize this population to develop targeted interventions. As mild hyponatremia, defined as a serum sodium <135meq/L, has been reported to be associated with falls, unsteadiness and attention deficits, we hypothesized that hyponatremia is associated with falls in our geriatric trauma population. METHODS Gender, age, pre-existing conditions (cardiac disease, diabetes, hematologic disorder, liver disease, malignancy, musculoskeletal disorder, neurological disorder, obesity, psychiatric disorder, pulmonary disease, renal disease, thyroid disease), mechanism of injury and admitting serum sodium level were queried for all geriatric trauma admissions from 2008 to 2011. Mechanism of injury was coded as falls admissions and non-falls admissions. Admitting serum sodium levels were coded as hyponatremic (<135mmol/L) and not hyponatremic (≥135mmol/L). RESULTS Of the 2370 geriatric trauma admissions during the study period, there were 1841 (77.7%) falls admissions and 293 (12.4%) patients who were hyponatremic. Gender, age, neurological disorder, hematologic disorder, and hyponatremia were found to be significant predictors of falls in both univariate and multivariable analyses. CONCLUSION Hyponatremic patients are significantly more likely to be admitted for a fall than non-hyponatremic patients, when adjusting for age, neurological disorder, and hematologic disorder. Consequently, hyponatremia identification and management should be an integral part of any geriatric trauma fall prevention programme. Additionally, if hyponatremia is found during a geriatric fall workup, it should be corrected prior to discharge and closely monitored by a primary care physician to prevent recurrent episodes of falls.
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Affiliation(s)
| | - Tuc To
- Lancaster General Health, Lancaster, PA, United States
| | - Amelia Rogers
- Lancaster General Health, Lancaster, PA, United States
| | - Daniel Wu
- Lancaster General Health, Lancaster, PA, United States
| | - Michael Horst
- Lancaster General Health, Lancaster, PA, United States
| | | | - Jo Ann Miller
- Lancaster General Health, Lancaster, PA, United States
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The relevance of hyponatraemia to perioperative care of surgical patients. Surgeon 2014; 13:163-9. [PMID: 25523069 DOI: 10.1016/j.surge.2014.09.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Revised: 09/16/2014] [Accepted: 09/22/2014] [Indexed: 11/21/2022]
Abstract
BACKGROUND Hyponatraemia is the most common electrolyte disturbance in hospitalized patients. There is an increasing awareness of the impact of hyponatraemia on the perioperative management of surgical patients. METHODS We performed a literature review. We have included relevant data from different surgical disciplines for analysis. In this review we discuss the differential diagnosis of hyponatraemia, and explain the specific relevance of hyponatraemia to pre-, peri- and post-operative care. RESULTS Hyponatraemia is common during the preoperative period and is associated with an increase in subsequent peri-operative complications, such as wound infection, pneumonia, higher mortality rate and higher direct and indirect costs. Furthermore, data shows poorer surgical outcomes when plasma sodium concentration drops. Careful preoperative evaluation of the hyponatraemic patient enables assessment of surgical risk and individualization of the management of hyponatraemia. CONCLUSIONS We outline a practical guide to the assessment of the cause of hyponatraemia, which dictates the correct management of hyponatraemia and the correct selection of perioperative fluids. Finally, for the therapeutic role of the new vasopressin antagonist drugs in the treatment of surgical hyponatraemia is discussed in two illustrative surgical clinical cases.
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Hypernatremia: correction rate and hemodialysis. Case Rep Med 2014; 2014:736073. [PMID: 25431600 PMCID: PMC4241301 DOI: 10.1155/2014/736073] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Revised: 10/13/2014] [Accepted: 10/18/2014] [Indexed: 11/18/2022] Open
Abstract
Severe hypernatremia is defined as serum sodium levels above 152 mEq/L, with a mortality rate ≥60%. 85-year-old gentleman was brought to the emergency room with altered level of consciousness after refusing to eat for a week at a skilled nursing facility. On admission patient was nonverbal with stable vital signs and was responsive only to painful stimuli. Laboratory evaluation was significant for serum sodium of 188 mmol/L and water deficit of 12.0 L. Patient was admitted to medicine intensive care unit and after inadequate response to suboptimal fluid repletion, hemodialysis was used to correct hypernatremia. Within the first fourteen hours, sodium concentration only changed 1 mEq/L with a fluid repletion; however, the concentration dropped greater than 20 mEq/L within two hours during hemodialysis. Despite such a drastic drop in sodium concentration, patient did not develop any neurological sequela and was at baseline mental status at the time of discharge.
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Leise MD, Yun BC, Larson JJ, Benson JT, DongYang J, Therneau TM, Rosen CB, Heimbach JK, Biggins SW, Kim WR. Effect of the pretransplant serum sodium concentration on outcomes following liver transplantation. Liver Transpl 2014; 20:687-97. [PMID: 24616214 PMCID: PMC4128788 DOI: 10.1002/lt.23860] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Revised: 02/04/2014] [Accepted: 02/18/2014] [Indexed: 12/23/2022]
Abstract
Hyponatremia is associated with an increased risk of mortality on the liver transplantation (LT) waiting list. Although the incorporation of the serum sodium (Na) level into the Model for End-Stage Liver Disease score may reduce wait-list mortality, concerns remain about a potential association between pre-LT hyponatremia and decreased post-LT survival. Furthermore, the relationship between pre-LT hypernatremia and post-LT survival remains unexplored. The purpose of this study was to investigate the impact of the entire spectrum of pre-LT serum Na levels on post-LT outcomes. We identified 19,537 patients from 2003 to 2010 for whom serum Na levels immediately before LT were available. The patients were divided into 3 groups [hyponatremic (Na ≤ 130 mEq/L), normonatremic (Na = 131-145 mEq/L), and hypernatremic (Na > 145 mEq/L)], and their post-LT outcomes were compared. There was no difference in in-hospital mortality or 90-day survival between patients with hyponatremia and patients with normonatremia. A fraction of the patients (2.4%) had hypernatremia, which was associated with increased in-hospital mortality (11.2% versus 4.2%, P < 0.001) and diminished 90-day survival (86.4% versus 94.0.%, P < 0.001). After adjustments for important clinical variables, the association of pre-LT hypernatremia with posttransplant mortality remained significant with a hazard ratio of 1.13 for each unit increase in the Na level > 145 mEq/L (P < 0.001). The duration of the hospitalization after LT was significantly longer for hypernatremic patients (P < 0.001). In conclusion, hyponatremia per se does not affect post-LT survival. Pre-LT hypernatremia is a highly significant risk factor for post-LT mortality.
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Affiliation(s)
| | - Byung Cheol Yun
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | | | | | - Ju DongYang
- William J. von Leibig Transplant Center, Mayo Clinic, Rochester
| | | | | | | | - Scott W. Biggins
- Division of Gastroenterology and Hepatology, University of Colorado Denver Anschutz Medical Campus, Aurora Colorado
| | - W. Ray Kim
- William J. von Leibig Transplant Center, Mayo Clinic, Rochester
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Abstract
PURPOSE OF REVIEW This review explores the contemporary definition of the term 'balanced crystalloid' and outlines optimal design features and their underlying rationale. RECENT FINDINGS Crystalloid interstitial expansion is unavoidable, but also occurs with colloids when there is endothelial glycocalyx dysfunction. Reduced chloride exposure may lessen kidney dysfunction and injury with a possible mortality benefit. Exact balance from an acid-base perspective is achieved with a crystalloid strong ion difference of 24 mEq/l. This can be done simply by replacing 24 mEq/l of chloride in 0.9% sodium chloride with bicarbonate or organic anion bicarbonate substitutes. Potassium, calcium and magnesium additives are probably unnecessary. Large volumes of mildly hypotonic crystalloids such as lactated Ringer's solution reduce extracellular tonicity in volunteers and increase intracranial pressure in nonbrain-injured experimental animals. A total cation concentration of 154 mmol/l with accompanying anions provides isotonicity. Of the commercial crystalloids, Ringer's acetate solution is close to balanced from both acid-base and tonicity perspectives, and there is little current evidence of acetate toxicity in the context of volume loading, in contrast to renal replacement. SUMMARY The case for balanced crystalloids is growing but unproven. A large randomized controlled trial of balanced crystalloids versus 0.9% sodium chloride is the next step.
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Choo WP, Groeneveld ABJ, Driessen RH, Swart EL. Normal saline to dilute parenteral drugs and to keep catheters open is a major and preventable source of hypernatremia acquired in the intensive care unit. J Crit Care 2014; 29:390-4. [PMID: 24603000 DOI: 10.1016/j.jcrc.2014.01.025] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2013] [Revised: 01/12/2014] [Accepted: 01/27/2014] [Indexed: 02/08/2023]
Abstract
PURPOSE We wanted to identify modifiable risk factors for intensive care unit (ICU)-acquired hypernatremia. MATERIALS AND METHODS We retrospectively studied sodium and fluid loads and balances up to 7 days prior to the development of hypernatremia (first serum sodium concentration, [Na+], >150 mmol/L; H) vs control (maximum [Na+] ≤150 mmol/L; N), in consecutive patients admitted into the ICU with a normal serum sodium (<145 mmol/L) and without cerebral disease, within a period of 8 months. RESULTS There were 57 H and 150 N patients. Severity of disease and organ failure was greater, and length of stay and mechanical ventilation in the ICU were longer in H (P<.001), with a mortality rate of 28% vs 16% in N (P=.002). Sodium input was higher in H than in N, particularly from 0.9% saline to dissolve drugs for infusion and to keep catheters open during the week prior to the first day of hypernatremia (P<.001). Fluid balances were positive and did not differ from N on most days in the presence of slightly higher plasma creatinine and more frequent administration of furosemide, at higher doses, in H than in N. CONCLUSIONS High sodium input by 0.9% saline used to dilute drugs and keep catheters open is a modifiable risk factor for ICU-acquired H. Dissolving drugs in dextrose 5% may partially prevent potentially harmful sodium overloading and H.
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Affiliation(s)
- Wai-Ping Choo
- Department of Clinical Pharmacology and Pharmacy, VU University Medical Center, Amsterdam, The Netherlands.
| | - A B Johan Groeneveld
- Department of Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Ronald H Driessen
- Department of Intensive care, VU University Medical Center, Amsterdam, The Netherlands
| | - Eleonora L Swart
- Department of Clinical Pharmacology and Pharmacy, VU University Medical Center, Amsterdam, The Netherlands
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SUAN C, YERGA POZO G. Post-operative hyponatraemic encephalopathy: a successful outcome despite hypoxia. Acta Anaesthesiol Scand 2014; 58:254-7. [PMID: 24563921 DOI: 10.1111/aas.12248] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Hyponatraemia is the most common electrolyte disorder encountered in clinical practice. Symptomatic hyponatraemia reflects brain damage because of cerebral swelling. Some coexisting factors such as extreme ages, hypoxia and female sex are associated with poor prognosis. In this report, we describe the case of a 75-year-old patient who suffered from hyponatraemic encephalopathy after elective vaginal hysterectomy under spinal anaesthesia. After being transferred to the ward, she developed nausea, vomiting, hypertensive crisis and intense anxiety. These symptoms were followed by grand mal seizure. Serum sodium level was 108 mmol/l. She also presented hypoxia, considered an aggravating factor, which was probably caused by the combination of benzodiazepine intake and cerebral oedema. However, fast raise of serum sodium level was achieved by immediate treatment with hypertonic saline, and she was discharged home without any sequelae.
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Affiliation(s)
- C. SUAN
- Department of Anaesthesia; Hospital for Women Virgen del Rocío; Seville Spain
| | - G. YERGA POZO
- Department of Anaesthesia; Hospital for Women Virgen del Rocío; Seville Spain
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McClure V, Dvir E. Adipsia and hypernatraemia in a 6-month-old Staffordshire bull terrier. J S Afr Vet Assoc 2013. [DOI: 10.4102/jsava.v84i1.953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
A 6-month-old female Staffordshire bull terrier cross presented to the Onderstepoort Veterinary Academic Hospital with lethargy, weakness, decreased appetite, abnormal vocalisation, twitching of the facial muscles and ears, circling, alopecia, pruritus, seborrhoea sicca and erythema. Serum biochemistry revealed severe hypernatraemia (200.4 mmol/L; Reference Interval 140 mmol/L – 155 mmol/L). Treatment required careful administration of intravenous fluids. The electrolytes were monitored to ensure slow and controlled sodium normalisation (the target reduction of Na concentration was by 0.5 mmol/L/h –1 mmol/L/h or 12 mmol/L/24 h – 24 mmol/L/24 h). Despite the careful fluid calculations and close monitoring, the serum sodium levels dropped more than the recommended 0.5 mmol/L/h – 1 mmol/L/h in the first 4 h and the fluids had to be adjusted. The patient’s habitus improved and the central nervous system signs started to resolve after 1 day of fluid treatment. The puppy started eating food mixed with water, but made no attempt to drink water. The pruritus and erythema resolved once the sodium levels normalised and the seborrhoea sicca began to resolve. At a follow up visit 20 days post discharge the skin was normal. A diagnosis of hypernatraemia as a result of pure water loss due to hypodipsia or adipsia was made, as the puppy made no attempt to drink water when her serum sodium levels increased (a strong thirst stimulus). Hypernatraemia recurred if she was not forced to take in adequate amounts of water mixed with her food. Dermatological changes such as seborrhoea, hyperkeratosis and alopecia have been reported in a few other cases of hypernatraemia in dogs and sodium levels should be investigated in dermatological patients when no other cause can be established. This study, supported by another retrospective study done in 2008, suggests that the Staffordshire bull terrier may be a breed that is predisposed to hypernatraemia.
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Turgutalp K, Özhan O, Gök Oğuz E, Yılmaz A, Horoz M, Helvacı I, Kiykim A. Community-acquired hypernatremia in elderly and very elderly patients admitted to the hospital: clinical characteristics and outcomes. Med Sci Monit 2013. [PMID: 23197235 PMCID: PMC3560803 DOI: 10.12659/msm.883600] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background The clinical features, outcome and cost burden of community-acquired hypernatremia (CAH) in elderly and very elderly patients are not well known. Our aim was to investigate the etiologies, reasons for admission, clinical courses, outcomes, complications, and cost assessments of the elderly patients with CAH. Material/Methods We conducted a retrospective study in our tertiary hospital. Elderly and very elderly patients evaluated in the emergency department (ED) from January 1, 2010 to December 31, 2010 (n=4960) were included. Totally, 102 patients older than 65 years and diagnosed with CAH were evaluated. The patients were divided into 2 main groups according to their age: elderly (65–74 years old) (group 1) (n=38), and very elderly (>74 years) (group 2) (n=64). Results Our overall observed prevalence of CAH was 2.0% (n=102, 102/4960). In particular, the prevalences of CAH in group 1 and group 2 were 1.0% (38/3651) and 4.8% (64/1309), respectively (p<0.001). Totally, 62 patients had been treated by renin-angiotensin system (RAS) blockers (ie, ACE-inhibitors). Alzheimer’s disease had been diagnosed in 46.1% of the subjects. The mean Katz scores at the time of admission were 2.4±1.9 and 1.1±1.0 in group 1 and 2, respectively (p<0.001). The mean cost was higher in group 2 than in group 1 (2407.13±734.54 USD, and 2141.12±1387.14 USD, respectively) (p<0.01). The need for intensive care was significantly greater in group 2 as compared to group 1. Conclusions The important determinants of “CAH” in elderly subjects are accompanying Alzheimer’s disease, oral intake impairment, and concomitant treatment with RAS blockers.
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Affiliation(s)
- Kenan Turgutalp
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Mersin University, Mersin, Turkey.
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Ollivett TL, McGuirk SM. Salt poisoning as a cause of morbidity and mortality in neonatal dairy calves. J Vet Intern Med 2013; 27:592-5. [PMID: 23551171 PMCID: PMC7166516 DOI: 10.1111/jvim.12078] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2012] [Revised: 01/17/2013] [Accepted: 02/11/2013] [Indexed: 11/26/2022] Open
Affiliation(s)
- T L Ollivett
- Department of Clinical Sciences, Cornell University, Ithaca, NY, USA
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Principles in the Selection of Intravenous Solutions Replacement. JOURNAL OF INFUSION NURSING 2013; 36:126-30. [DOI: 10.1097/nan.0b013e318283440d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Fluctuations in Serum Sodium Level Are Associated With an Increased Risk of Death in Surgical ICU Patients*. Crit Care Med 2013; 41:133-42. [DOI: 10.1097/ccm.0b013e318265f576] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Preoperative hyponatremia predicts outcomes after cardiac surgery. J Surg Res 2012; 181:60-6. [PMID: 22748596 DOI: 10.1016/j.jss.2012.06.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2012] [Revised: 05/22/2012] [Accepted: 06/01/2012] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To study the effect of preoperative hyponatremia (Na <135 mEq/L) on outcomes after cardiac surgery. METHODS From 2002 to 2008, 4370 patients had cardiac surgery at our institution (CABG in 2238, valve in 597, CABG valve in 537, other in 998). The institution electronic medical records, STS database, and Social Security death index data were analyzed. The association of hyponatremia with mortality, hospital length of stay (LOS), and complications was analyzed using regression analysis. RESULTS Prevalence of hyponatremia was 21%. Patients with preoperative hyponatremia had lower left ventricular ejection fraction (39% ± 17% versus 46% ± 14%, P < 0.001) and glomerular filtration rate (69 ± 32 mg/min/1.73 m(2)versus 74 ± 27 mg/min/1.73 m(2), P < 0.001) and higher median EuroSCORE (19% versus 9%, P < 0.001), NYHA class 3-4 (77% versus 65%, P < 0.001), prevalence of chronic obstructive pulmonary disease (25% versus 18%, P < 0.001), and arteriopathy (20% versus 13%, P < 0.001). Hyponatremia was associated with increased early mortality (9% versus 4%, P < 0.001), late mortality (24% versus 16%, P < 0.001), and LOS (13 versus 8 d, P < 0.001). Mortality increased with the severity of hyponatremia. After adjusting for baseline and operative variables, hyponatremia was associated with increased hazard of mortality (hazard ratio [HR] 1.31, 95% confidence interval [CI] 1.14-1.52, P < 0.001), risk of early mortality (odds ratio [OR] 1.52, 95% CI 1.09-2.12, P < 0.001), late mortality (HR 1.37, 95% CI 1.16-1.62, P < 0.001), LOS (multiplier 1.26, 95% CI 1.15-1.39, P < 0.001), operative complications (OR 1.30, 95% CI 1.00-1.69, P = 0.051), and dialysis (OR 1.64, 95% CI 1.11-2.44, P = 0.013). CONCLUSIONS Preoperative hyponatremia is common, especially in high-risk patients. It is an independent risk factor for mortality, prolonged hospitalization, and complications after cardiac surgery.
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Errors in fluid therapy in medical wards. Int J Clin Pharm 2012; 34:374-81. [DOI: 10.1007/s11096-012-9620-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2011] [Accepted: 02/15/2012] [Indexed: 10/28/2022]
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Fofi L, Dall'armi V, Durastanti L, Valenza A, Lorenzano S, Prencipe M, Toni D. An observational study on electrolyte disorders in the acute phase of ischemic stroke and their prognostic value. J Clin Neurosci 2012; 19:513-6. [PMID: 22321365 DOI: 10.1016/j.jocn.2011.07.041] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2011] [Revised: 06/20/2011] [Accepted: 07/03/2011] [Indexed: 11/28/2022]
Abstract
Data on electrolyte disorders in neurological conditions and in acute stroke are somewhat scanty and not easily compared. In our Stroke Unit we studied patients hospitalized within six hours of the onset of an acute ischemic stroke and recorded their demographic and clinical data. Blood test results were recorded before any pharmacological therapy. A total of 475 individuals (256 M, 219 F; range: 14-96 years) treated over a period of 18 consecutive months, were selected. According to multiple logistic regression analysis, the baseline National Institute of Health Stroke Scale (NIHSS) score (odds ratio [OR]=1.33; 95% confidence interval [CI]: 1.22-1.44) and natremia alterations (OR=6.89; 95% CI=1.94-24.40) were associated with higher odds of death. Based on the ordinal logistic regression analysis, the baseline NIHSS score (OR=1.07; 95% CI=1.03-1.10) and baseline hypernatremia (OR=9.69; 95% CI=1.55-60.69) were related to early neurological worsening. Our work suggests an association between serum sodium alterations and mortality, and between high sodium levels and neurological clinical impairment, in the acute phase of an ischemic stroke.
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Affiliation(s)
- Luisa Fofi
- Clinical Trial Center, IRCCS San Raffaele Pisana, Via della Pisana 235, Rome, Italy.
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Patterson JH, Adams KF, Human T, Rhoney DH. Case Studies in Hypervolemic Hyponatremia. Hosp Pharm 2011. [DOI: 10.1310/hpj4612-s39] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Ekpebegh CO, Longo-Mbenza B, Nge-Okwe A, Ogbera AO, Tonjeni NT. Advanced age, altered level of consciousness and a new diagnosis of diabetes are independently associated with hypernatreamia in hyperglycaemic crisis. BMC Endocr Disord 2011; 11:8. [PMID: 21501465 PMCID: PMC3103444 DOI: 10.1186/1472-6823-11-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2011] [Accepted: 04/18/2011] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND There is limited literature on hypernatreamia in the setting of hyperglycaemic crisis. This is despite the fact that the presence of hypernatreamia may impact on the classification of hyperglycaemic crisis and its management particularly with regards to the nature of fluid therapy. We determined the prevalence of hypernatreamia and its associated factors at presentation for hyperglycaemic crisis. METHODS This was a retrospective review of data for hyperglycaemic crisis admissions in Nelson Mandela Academic Hospital, Mthatha, South Africa. The prevalence of hypernatreamia (uncorrected Serum Sodium at presentation >145 mmol/L) was determined. Hyperosmolality was defined by calculated effective osmolality >320 mosmols/Kg. Multivariate logistic regression was undertaken using variables that were statistically significant in univariate analysis to ascertain those that were independently associated (Odds Ratio (OR) with 95% Confidence Interval (CI)) with hypernatreamia. RESULTS The prevalence of hypernatreamia in our admissions for hyperglycaemic crisis was 11.7% (n = 32/273 including 171 females and 102 males). All admissions with hypernatreamia met the criteria for hyperosmolality. Age ≥ 60 years (OR = 3.9 95% CI 1.3-12.3; P = 0.018), Altered level of consciousness (OR = 8.8 95% CI 2.3-32.8; P < 0.001) and a new diagnosis of diabetes (OR = 3.7 95%CI 1.2-11.5; P = 0.025) were independently associated with hypernatreamia. CONCLUSION The prevalence rate of hypernatreamia in hyperglycaemic admissions was high with all hypernatreamic admissions meeting the criteria for hyperosmolality. Advanced age, altered conscious level and a new diagnosis of diabetes were independently associated with hypernatreamia.
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Affiliation(s)
- Chukwuma O Ekpebegh
- Department of Internal Medicine, Faculty of Health Sciences, Walter Sisulu University/Nelson Mandela Academic Hospital, Mthatha, Eastern Cape Province, South Africa
| | - Benjamin Longo-Mbenza
- Department of Internal Medicine, Faculty of Health Sciences, Walter Sisulu University/Nelson Mandela Academic Hospital, Mthatha, Eastern Cape Province, South Africa
| | - Augustin Nge-Okwe
- Biostatistics Unit, Lomo Medical Center and Heart of Africa Centre of Cardiology, Kinshasa, Democratic Republic of Congo
| | - Anthonia O Ogbera
- Department of Internal Medicine, Lagos State University Teaching Hospital, Ikeja, Lagos State, Nigeria
| | - Nomawethu T Tonjeni
- Department of Internal Medicine, Faculty of Health Sciences, Walter Sisulu University/Nelson Mandela Academic Hospital, Mthatha, Eastern Cape Province, South Africa
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Vacuolar pathology in the median eminence of the hypothalamus after hyponatremia. J Neuropathol Exp Neurol 2011; 70:151-6. [PMID: 21343884 DOI: 10.1097/nen.0b013e318208fc5d] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
The median eminence of the hypothalamus is an important conduit by which neurosecretory hormones from hypothalamic nuclei are delivered to the pars nervosa (neural lobe) of the pituitary en route to the bloodstream. Dilutional hyponatremia was produced in adult rats to determine the effect on the morphology of the median eminence of the hypothalamus. Hyponatremia was caused by reducing electrolyte and organic osmolyte reserves to block the excretion of water through delivery of the nephrotoxin mercuric chloride (HgCl2). Histological examination of the brain 1 day after a hyponatremic insult revealed vacuolation within the median eminence of the hypothalamus. No other lesions were found in other parts of the brain after hyponatremia. The hyponatremic lesion consisted of a band of closely packed vacuoles that crossed the floor of the third ventricle. Vacuoles associated with hyponatremia were predominantly in the subependymal, fiber, reticular, and palisade layers of the median eminence. Vacuolation was not observed in the tanycyte layer of the median eminence. This study indicates that the median eminence is a potentially vulnerable site in human hyponatremic conditions that should be evaluated further in relevant animal models.
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Garg R, Punj J, Pandey R, Darlong V. Delayed recovery due to exaggerated acid, base and electrolyte imbalance in prolonged laparoscopic repair of diaphragmatic hernia. Saudi J Anaesth 2011; 5:79-81. [PMID: 21655023 PMCID: PMC3101760 DOI: 10.4103/1658-354x.76477] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
The acid, base and electrolyte changes are usually observed in the perioperative settings. We report a case of prolonged laparoscopic repair of left-sided diaphragmatic hernia which involved a lot of tissue handling and fluid replacement leading to acid, base and electrolyte imbalance. A 42-year-old male underwent prolonged laparoscopic repair under general anesthesia. Intraoperatively, surgeon reported that contents of hernia includes bowel along with mesentery, spleen and lot of fatty tissue The blood loss was about 2 L which was replaced with 1 L of colloid and 7.5 L of lactated ringer. Near the end of surgery arterial blood gas analysis revealed metabolic acidosis, hyperkalemia, and hypocalcemia leading to delayed recovery. We conclude prolonged laparoscopic surgery involving lot of tissue handling including gut and fat should be monitored for acid, base, electrolyte imbalance and corrected timely to have uneventful rapid recovery.
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Affiliation(s)
- Rakesh Garg
- Department of Anaesthesiology and Intensive Care, All India Institute of Medical Sciences, New Delhi, India
- Address for correspondence: Dr. Rakesh Garg, 58-E, Kavita Colony, Nangloi, Delhi-110041, India. E-mail:
| | - Jyotsna Punj
- Department of Anaesthesiology and Intensive Care, All India Institute of Medical Sciences, New Delhi, India
| | - Ravindra Pandey
- Department of Anaesthesiology and Intensive Care, All India Institute of Medical Sciences, New Delhi, India
| | - Vanlal Darlong
- Department of Anaesthesiology and Intensive Care, All India Institute of Medical Sciences, New Delhi, India
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Abstract
The development of hyponatremia represents an ominous event in the progression of cirrhosis to end-stage liver disease. It usually develops in those with refractory ascites and is a manifestation of the non-osmotic release of arginine vasopressin (AVP). In the hospitalized cirrhotic patient, hyponatremia is associated with increased disease severity and mortality. In this article, we review the pathophysiology of hyponatremia, its clinical implications, evaluation, and treatment.
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Affiliation(s)
- Elizabeth Ross
- Division of Gastroenterology, Department of Medicine, New York University School of Medicine, New York, New York
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