1
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Ryuge A, Nagamine S, Saito M, Matsumoto N, Asano M. Hypernatremic chloride-depletion metabolic alkalosis successfully treated with high cation-gap amino acids: a case report. CEN Case Rep 2024; 13:229-232. [PMID: 37991678 PMCID: PMC11294285 DOI: 10.1007/s13730-023-00837-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 10/29/2023] [Indexed: 11/23/2023] Open
Abstract
Normal saline (NS) is recommended for the treatment of chloride-depletion alkalosis (CDA). However, its use in patients with drinking water restrictions or fluid volume deficiencies may lead to hypernatremia. We report the case of a 42-year-old Japanese man with ileus due to sigmoidal volvulus, who presented with CDA. After endoscopic decompression, NS was administered to treat the CDA. Despite the administration of NS, CDA persisted and hypernatremia developed. The infusion was then changed to high cation-gap amino acids (HCG-AA), which improved both metabolic alkalosis and hypernatremia. Thus, HCG-AA may be useful for the treatment of hypernatremia in patients with CDA.
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Affiliation(s)
- Akihiro Ryuge
- Department of Nephrology, National Hospital Organization Nagoya Medical Center, 1-1 Sannomaru, Naka-ku, Nagoya, Aichi, 460-0001, Japan.
| | - Shogo Nagamine
- Department of Nephrology, National Hospital Organization Nagoya Medical Center, 1-1 Sannomaru, Naka-ku, Nagoya, Aichi, 460-0001, Japan
| | - Masashi Saito
- Department of Gastroenterology, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Naoki Matsumoto
- Department of Nephrology, National Hospital Organization Nagoya Medical Center, 1-1 Sannomaru, Naka-ku, Nagoya, Aichi, 460-0001, Japan
| | - Marina Asano
- Department of Nephrology, National Hospital Organization Nagoya Medical Center, 1-1 Sannomaru, Naka-ku, Nagoya, Aichi, 460-0001, Japan
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2
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Yun G, Baek SH, Kim S. Evaluation and management of hypernatremia in adults: clinical perspectives. Korean J Intern Med 2022; 38:290-302. [PMID: 36578134 PMCID: PMC10175862 DOI: 10.3904/kjim.2022.346] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 11/29/2022] [Indexed: 12/30/2022] Open
Abstract
Hypernatremia is an occasionally encountered electrolyte disorder, which may lead to fatal consequences under improper management. Hypernatremia is a disorder of the homeostatic status regarding body water and sodium contents. This imbalance is the basis for the diagnostic approach to hypernatremia. We summarize the eight diagnostic steps of the traditional approach and introduce new biomarkers: exclude pseudohypernatremia, confirm glucose-corrected sodium concentrations, determine the extracellular volume status, measure urine sodium levels, measure urine volume and osmolality, check ongoing urinary electrolyte free water clearance, determine arginine vasopressin/copeptin levels, and assess other electrolyte disorders. Moreover, we suggest six steps to manage hypernatremia by replacing water deficits, ongoing water losses, and insensible water losses: identify underlying causes, distinguish between acute and chronic hypernatremia, determine the amount and rate of water administration, select the type of replacement solution, adjust the treatment schedule, and consider additional therapy for diabetes insipidus. Physicians may apply some of these steps to all patients with hypernatremia, and can also adapt the regimens for specific causes or situations.
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Affiliation(s)
- Giae Yun
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Seon Ha Baek
- Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Korea
| | - Sejoong Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
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3
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Kang WH, Kamaruddin NA, Sukor N. Case Report: Severe Hypernatremia From Ingestion of One's Own Urine. Front Med (Lausanne) 2022; 9:929180. [PMID: 35783646 PMCID: PMC9240661 DOI: 10.3389/fmed.2022.929180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 05/19/2022] [Indexed: 12/02/2022] Open
Abstract
An often unrecognized cause of hypernatremia is the ingestion of fluids or substances with high osmolality. We hereby report a case of severe hypernatremia with acute kidney injury in a severely debilitated patient with acute gouty arthritis who resorted to ingesting his own urine. Hypernatremia induced by drinking urine could be attributed to many underlying mechanisms, one of the important possible causes is the resultant high serum urea that leads to significant osmotic diuresis and a further increase in free water clearance. To the best of our knowledge this is the first case report that describes this unique cause of hypernatremia.
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Affiliation(s)
- Waye Hann Kang
- Department of Medicine, Faculty of Medicine and Health Sciences, University Tunku Abdul Rahman, Kuala Lumpur, Malaysia
- Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - N. A. Kamaruddin
- Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Norlela Sukor
- Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
- *Correspondence: Norlela Sukor
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Ryu JY, Yoon S, Lee J, Baek S, Jo YH, Ko KP, Sim JA, Han J, Kim S, Baek SH. Efficacy and safety of rapid intermittent bolus compared with slow continuous infusion in patients with severe hypernatremia (SALSA II trial): a study protocol for a randomized controlled trial. Kidney Res Clin Pract 2022; 41:508-520. [PMID: 35545225 PMCID: PMC9346395 DOI: 10.23876/j.krcp.21.193] [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: 09/01/2021] [Accepted: 11/22/2021] [Indexed: 11/04/2022] Open
Abstract
Background Methods Conclusion
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Affiliation(s)
- Ji Young Ryu
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Songuk Yoon
- Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Republic of Korea
| | - Jeonghwan Lee
- Department of Internal Medicine, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea
| | - Sumin Baek
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - You Hwan Jo
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Kwang-Pil Ko
- Clinical Preventive Medicine Center, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Jin-ah Sim
- School of AI Convergence, Hallym University, Chuncheon, Republic of Korea
| | - Junhee Han
- Department of Statistics and Institute of Statistics, Hallym University, Chuncheon, Republic of Korea
| | - Sejoong Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Center for Artificial Intelligence in Healthcare, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
- Correspondence: Sejoong Kim Department of Internal Medicine, Seoul National University Bundang Hospital, 82 Gumi-ro 173beon-gil, Bundang-gu, Seongnam 13620, Republic of Korea. E-mail:
| | - Seon Ha Baek
- Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Republic of Korea
- Seon Ha Baek Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, 7 Keunjaebong-gil, Hwaseong 18450, Republic of Korea. E-mail:
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5
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Leong XF, Cheng M, Jong B, Hwang NC, Roscoe A. Sodium Abnormalities in Cardiac Surgery With Cardiopulmonary Bypass in Adults: A Narrative Review. J Cardiothorac Vasc Anesth 2020; 35:3374-3384. [PMID: 32888797 DOI: 10.1053/j.jvca.2020.07.047] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 07/07/2020] [Accepted: 07/13/2020] [Indexed: 11/11/2022]
Abstract
Perioperative sodium abnormalities or dysnatremia is not uncommon in patients presenting for cardiac surgery and is associated with increased morbidity and mortality. Both the disease process of heart failure and its treatment may contribute to abnormalities in serum sodium concentration. Serum sodium is the main determinant of serum osmolality, which in turn affects cell volume. Brain cells are particularly vulnerable to changes in serum osmolality because of the nondistensible cranium. The potentially catastrophic neurologic sequelae of rapidly correcting chronic dysnatremia and the time-sensitive nature of cardiac surgery can make the management of these patients challenging. The use of cardiopulmonary bypass to facilitate surgery adds another layer of complexity in the intraoperative management of sodium and water balance. This narrative review examines the definition and classification of dysnatremia. It also covers the etiology and pathophysiology of dysnatremia, implications during cardiac surgery requiring cardiopulmonary bypass, and the perioperative management of dysnatremia.
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Affiliation(s)
- Xin Fang Leong
- Department of Anaesthesiology, Singapore General Hospital, Singapore; Department of Cardiothoracic Anaesthesia, National Heart Centre, Singapore
| | - Maureen Cheng
- Department of Anaesthesiology, Singapore General Hospital, Singapore; Department of Cardiothoracic Anaesthesia, National Heart Centre, Singapore
| | - Bronte Jong
- Department of Anaesthesiology, Singapore General Hospital, Singapore
| | - Nian Chih Hwang
- Department of Anaesthesiology, Singapore General Hospital, Singapore; Department of Cardiothoracic Anaesthesia, National Heart Centre, Singapore
| | - Andrew Roscoe
- Department of Anaesthesiology, Singapore General Hospital, Singapore; Department of Cardiothoracic Anaesthesia, National Heart Centre, Singapore.
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Survival Following Extreme Hypernatraemia Associated with Severe Dehydration and Undiagnosed Diabetes Mellitus. Case Rep Endocrinol 2020; 2019:4174259. [PMID: 31915553 PMCID: PMC6930779 DOI: 10.1155/2019/4174259] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 11/12/2019] [Indexed: 12/02/2022] Open
Abstract
We report a case of a previously well 58-year-old man, who presented with delirium and low GCS, and was found to have extreme hypernatraemia (Na+ = 191 mmol/L) and hyperglycaemia (glucose = 31 mmol/L). This resulted in a corrected serum sodium of 202 mmol/L. He was treated with fluid and electrolyte replacement in the intensive care unit, and had returned to essentially normal function by hospital discharge. The aetiology was believed to be due to severe dehydration and a new diagnosis of diabetes mellitus. Extreme hypernatraemia (serum sodium level greater than 190 mmol/L) is rare and associated with a high mortality. The mainstay of treatment is careful fluid and electrolyte management. Most recommendations advise to reduce the serum sodium by 0.5 mmol/L/hour, due to concerns over cerebral oedema; however, there are reports that slower correction is associated with higher mortality. In this case, the initial corrected sodium of 202 mmol/L was steadily corrected to 160 mmol/L over 91 hours, at a rate of 0.46 mmol/L/hour. This demonstrates the safety of the recommended approach.
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Chauhan K, Pattharanitima P, Patel N, Duffy A, Saha A, Chaudhary K, Debnath N, Van Vleck T, Chan L, Nadkarni GN, Coca SG. Rate of Correction of Hypernatremia and Health Outcomes in Critically Ill Patients. Clin J Am Soc Nephrol 2019; 14:656-663. [PMID: 30948456 PMCID: PMC6500955 DOI: 10.2215/cjn.10640918] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 02/15/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Hypernatremia is common in hospitalized, critically ill patients. Although there are no clear guidelines on sodium correction rate for hypernatremia, some studies suggest a reduction rate not to exceed 0.5 mmol/L per hour. However, the data supporting this recommendation and the optimal rate of hypernatremia correction in hospitalized adults are unclear. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We assessed the association of hypernatremia correction rates with neurologic outcomes and mortality in critically ill patients with hypernatremia at admission and those that developed hypernatremia during hospitalization. We used data from the Medical Information Mart for Intensive Care-III and identified patients with hypernatremia (serum sodium level >155 mmol/L) on admission (n=122) and hospital-acquired (n=327). We calculated different ranges of rapid correction rates (>0.5 mmol/L per hour overall and >8, >10, and >12 mmol/L per 24 hours) and utilized logistic regression to generate adjusted odds ratios (aOR) with 95% confidence intervals (95% CIs) to examine association with outcomes. RESULTS We had complete data on 122 patients with severe hypernatremia on admission and 327 patients who developed hospital-acquired hypernatremia. The difference in in-hospital 30-day mortality proportion between rapid (>0.5 mmol/L per hour) and slower (≤0.5 mmol/L per hour) correction rates were not significant either in patients with hypernatremia at admission with rapid versus slow correction (25% versus 28%; P=0.80) or in patients with hospital-acquired hypernatremia with rapid versus slow correction (44% versus 40%; P=0.50). There was no difference in aOR of mortality for rapid versus slow correction in either admission (aOR, 1.3; 95% CI, 0.5 to 3.7) or hospital-acquired hypernatremia (aOR, 1.3; 95% CI, 0.8 to 2.3). Manual chart review of all suspected chronic hypernatremia patients, which included all 122 with hypernatremia at admission, 128 of the 327 hospital-acquired hypernatremia, and an additional 28 patients with ICD-9 codes for cerebral edema, seizures and/or alteration of consciousness, did not reveal a single case of cerebral edema attributable to rapid hyprnatremia correction. CONCLUSIONS We did not find any evidence that rapid correction of hypernatremia is associated with a higher risk for mortality, seizure, alteration of consciousness, and/or cerebral edema in critically ill adult patients with either admission or hospital-acquired hypernatremia.
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Affiliation(s)
| | | | | | - Aine Duffy
- Institute of Personalized Medicine, Department of Genetics and Genomics, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Aparna Saha
- Institute of Personalized Medicine, Department of Genetics and Genomics, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Kumardeep Chaudhary
- Institute of Personalized Medicine, Department of Genetics and Genomics, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Neha Debnath
- Division of Nephrology, Department of Medicine, and
| | - Tielman Van Vleck
- Institute of Personalized Medicine, Department of Genetics and Genomics, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Lili Chan
- Division of Nephrology, Department of Medicine, and
| | - Girish N Nadkarni
- Division of Nephrology, Department of Medicine, and .,Institute of Personalized Medicine, Department of Genetics and Genomics, Icahn School of Medicine at Mount Sinai, New York, New York
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8
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Morkos M, Fam M, Goel M, Hart P, Kazlauskaite R. PROTRACTED ACUTE HYPERVOLEMIC HYPERNATREMIA UNMASKED AFTER VASOPRESSIN THERAPY: CASE REPORT, LITERATURE REVIEW, AND PROPOSED ALGORITHMIC APPROACH. AACE Clin Case Rep 2019; 5:e95-e98. [PMID: 31967010 PMCID: PMC6873852 DOI: 10.4158/accr-2018-0363] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 09/01/2018] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Acute hypervolemic hypernatremia (HHN) is the most common form of hypernatremia in critical care settings. Previous reports implicated acute kidney injury and vasopressin withdrawal-induced central diabetes insipidus. METHODS We present the case of a 52-year-old woman who developed HHN after treatment of septic shock due to complicated bowel perforation. RESULTS After discontinuation of a 30-hour infusion of vasopressin analog, the patient manifested hypernatremia (150 to 156 mEq/L, equivalent to mmol/L) with hyponatriuria (49 mEq/L), hypoosmotic urine (163 mOsm/L), and polyuria (6.9 L/day) in a setting of cumulative positive fluid balance of 20.1 L. A trial of desmopressin yielded incomplete urinary concentration suggestive of renal resistance to desmopressin likely due to fluid overload. Despite positive water balance, her urine sodium was low at 36 to 49 mEq/L compared to serum sodium of 152 to 156 mEq/L. The hypernatremia with polyuria persisted for 16 days and resolved after treatment of the positive cumulative water balance (with controlled diuresis prioritizing natriuresis). CONCLUSION HHN may result in insufficient urine sodium clearance. We propose modifying the diagnostic/treatment algorithm by including HHN in a critical care setting, and recommending judicious administration of a loop diuretic to prioritize natriuria in hypernatremia with extreme cumulative fluid overload.
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9
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Gabriele S, Fantin F, Zivelonghi A, Zoico E, Mazzali G, Rossi AP, Zamboni M. Delirium after thiazide diuretic suspension can unmask diabetes insipidus. Geriatr Gerontol Int 2017; 17:2620-2622. [DOI: 10.1111/ggi.13159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 07/05/2017] [Indexed: 11/26/2022]
Affiliation(s)
- Sara Gabriele
- Department of Medicine, Section of Geriatrics; University of Verona; Verona Italy
| | - Francesco Fantin
- Department of Medicine, Section of Geriatrics; University of Verona; Verona Italy
| | | | - Elena Zoico
- Department of Medicine, Section of Geriatrics; University of Verona; Verona Italy
| | - Gloria Mazzali
- Department of Medicine, Section of Geriatrics; University of Verona; Verona Italy
| | - Andrea P. Rossi
- Department of Medicine, Section of Geriatrics; University of Verona; Verona Italy
| | - Mauro Zamboni
- Department of Medicine, Section of Geriatrics; University of Verona; Verona Italy
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10
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Arambewela MH, Somasundaram NP, Garusinghe C. Extreme hypernatremia as a probable cause of fatal arrhythmia: a case report. J Med Case Rep 2016; 10:272. [PMID: 27716387 PMCID: PMC5045618 DOI: 10.1186/s13256-016-1062-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 09/12/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Hypernatremia is a frequent occurrence among hospitalized patients. Severe hypernatremia is associated with mortality rates of over 60 %. Extreme hypernatremia, defined as sodium levels >190 mmol/l, is a rare occurrence. The literature on electrocardiographic changes occurring with this degree of hypernatremia is extremely scarce. We report the case of an 11-year-old Sri Lankan girl who presented with sodium levels of 226 mmol/l following infusion with 3 % hypertonic saline who developed diffuse QT prolongation leading to fatal ventricular tachycardia. CASE PRESENTATION An 11-year-old Sri Lankan girl presented with fever, headache, vomiting, and altered level of consciousness. Following admission she developed generalized tonic-clonic seizures and was intubated and ventilated. She had a recent history of polyuria and polydipsia. Magnetic resonance imaging of her brain revealed hydrocephalus due to possible craniopharyngioma. A ventriculoperitoneal shunt was inserted and she was infused with 3 % hypertonic saline in an attempt to reduce intracranial pressure. The following day she became polyuric and dehydrated with tachycardia and low blood pressure. Biochemistry revealed serum sodium of 226 mmol/l, measured serum osmolality of 470 mOsm/kg, urine osmolality of 280 mOsm/kg, urine spot sodium of 116 mmol/l, blood urea of 8.1 mmol/l, and blood glucose of 8.5 mmol/l. Her serum potassium, calcium, and magnesium levels were normal. Extreme hypernatremia due to infusion of 3 % hypertonic saline in the background of cranial diabetes insipidus was considered. She was managed aggressively with 5 % dextrose infusion and clear water via nasogastric feeding to correct the fluid deficit of 7 liters over 36 hours. Her sodium levels dropped to 160 mmol/l the following day. However, she developed electrocardiographic changes with widespread gross QT prolongation with ST segment deviations followed by fatal ventricular tachycardia. CONCLUSIONS Extreme hypernatremia is rare, and the literature on electrocardiographic changes occurring at such high levels of sodium is scarce. At present there are no established guidelines on rate and mode of correction of such high sodium levels. This case highlights the electrocardiographic changes observed during extreme hypernatremia, controversies in managing increased intracranial pressure with hypertonic saline, and dilemmas encountered in managing extreme hypernatremia.
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Affiliation(s)
| | - Noel P. Somasundaram
- Department of Diabetes and Endocrinology, National Hospital of Sri Lanka, Colombo, Sri Lanka
| | - Chaminda Garusinghe
- Department of Diabetes and Endocrinology, National Hospital of Sri Lanka, Colombo, Sri Lanka
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Liamis G, Filippatos TD, Elisaf MS. Evaluation and treatment of hypernatremia: a practical guide for physicians. Postgrad Med 2016; 128:299-306. [PMID: 26813151 DOI: 10.1080/00325481.2016.1147322] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Hypernatremia (serum sodium concentration >145 mEq/L) is a common electrolyte disorder with increased morbidity and mortality especially in the elderly and critically ill patients. The review presents the main pathogenetic mechanisms of hypernatremia, provides specific directions for the evaluation of patients with increased sodium levels and describes a detailed algorithm for the proper correction of hypernatremia. Furthermore, two representative cases of hypovolemic and hypervolemic hypernatremia are presented along with practical clues for their proper evaluation and treatment. Accurate diagnosis and appropriate treatment is crucial since undercorrection or overcorrection of hypernatremia are both associated with poor patients' prognosis.
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Affiliation(s)
- George Liamis
- a Department of Internal Medicine , School of Medicine, University of Ioannina , Ioannina , Greece
| | - Theodosios D Filippatos
- a Department of Internal Medicine , School of Medicine, University of Ioannina , Ioannina , Greece
| | - Moses S Elisaf
- a Department of Internal Medicine , School of Medicine, University of Ioannina , Ioannina , Greece
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12
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Eizadi-Mood N, Sabzghabaee AM, Hosseini H, Soltaninejad F, Massoumi G, Farajzadegan Z, Yaraghi A. Is Admission Serum Sodium Concentration a Clinical Predictor for the Outcome of Therapy in Critically Ill Poisoned Patients? Med Arch 2015; 69:240-3. [PMID: 26543310 PMCID: PMC4610660 DOI: 10.5455/medarh.2015.69.240-243] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 07/19/2015] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Disorders of serum sodium concentration are some of the most electrolyte abnormalities in the intensive care unit (ICU) patients. These disorders adversely affect the function of vital organs and are associated with increased hospital mortality. PURPOSE In the present study we aimed to evaluate the effects of serum sodium concentration abnormalities at the time of hospital admission on the clinical outcome of therapy in a cohort of critically ill poisoned patients. METHODS In this cross-sectional study, 184 critically ill poisoned patients aged >18 years and in the first 8 hours of their poisoning, hospitalized in the ICU of a tertiary care university hospital (Isfahan, Iran) between 2010-2012, were evaluated at the admission time and 24 hours later for serum sodium concentration abnormalities and its relationship with age, gender, consciousness status, ingested drugs and clinical outcome of therapy. The clinical outcome was considered as recovery and mortality. Logistic Regression analysis was performed for predictive variables including serum sodium concentration abnormalities in patients' clinical outcome. FINDINGS On admission, 152 patients (82.6%) were eunatremic, 21 patients (11.4%) were hyponatremic and 11 patients (6%) were hypernatremic. In the second day eunatremia, hyponatremia and hypernatremia was observed in 84.4%, 13% and 2.2% respectively. Age (OR=1.92; CI=1.18-3.12) and severity of toxicity (OR=1.32; CI=1.12-2.41) were predicting factors of mortality in ICU poisoning patients. CONCLUSIONS Serum sodium concentration abnormalities are prevalent in critically ill poisoned patient but do not seem to have a predictive value for the clinical outcome of therapy.
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Affiliation(s)
- Nastaran Eizadi-Mood
- Isfahan Clinical Toxicology Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ali Mohammad Sabzghabaee
- Isfahan Clinical Toxicology Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Hossein Hosseini
- Department of Clinical Toxicology, Noor and Ali-Asghar [PBUH] university hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Forough Soltaninejad
- Department of Pulmonary, Faculty of Medicine, Shahrekord University of Medical Sciences, Shahrekord, Iran
| | - Gholamreza Massoumi
- Department of Clinical Toxicology, Noor and Ali-Asghar [PBUH] university hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ziba Farajzadegan
- Departments of Health and Social Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ahmad Yaraghi
- Department of Clinical Toxicology, Noor and Ali-Asghar [PBUH] university hospital, Isfahan University of Medical Sciences, Isfahan, Iran
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13
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Abstract
Hypernatremia in the geriatric population is a common disorder associated with significant morbidity and mortality. Older people are predisposed to developing hypernatremia because of age-related physiologic changes such as decreased thirst drive, impaired urinary concentrating ability, and reduced total body water. Medications may exacerbate this predisposition. Hypernatremia and dehydration occurring in nursing homes are considered indicators of neglect that warrant reporting, but there are other nonavoidable causes of hypernatremia, and consideration at time of presentation is essential to prevent delay in diagnosis and management. We describe a case illustrating the importance of the consideration of alternate explanations for hypernatremia in a nursing home resident, followed by a review of hypernatremia in the elderly population, to underscore that neglect is the etiology of exclusion after alternatives have been considered.
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Affiliation(s)
- Maulin K Shah
- Department of Internal Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Biruh Workeneh
- Department of Internal Medicine, Baylor College of Medicine, Houston, TX, USA ; Department of Nephrology, Baylor College of Medicine, Houston, TX, USA
| | - George E Taffet
- Department of Internal Medicine, Baylor College of Medicine, Houston, TX, USA ; Huffington Center on Aging, Baylor College of Medicine, Houston, TX, USA
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14
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Toor MR, Singla A, DeVita MV, Rosenstock JL, Michelis MF. Characteristics, therapies, and factors influencing outcomes of hospitalized hypernatremic geriatric patients. Int Urol Nephrol 2014; 46:1589-94. [PMID: 24817519 DOI: 10.1007/s11255-014-0721-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Accepted: 04/21/2014] [Indexed: 12/20/2022]
Abstract
PURPOSE Hypernatremia is a common electrolyte disorder associated with adverse outcomes such as increased length of stay and mortality due to a variety of factors. Our aim was to investigate known factors as well as other variables which we had identified in hospitalized hypernatremic geriatric patients and their relationship to patient outcomes. METHODS A retrospective chart review of all adult hospitalized patients in a 4-month period with a serum sodium level >150 mmol/L was performed. Factors evaluated included use of a nephrology consultation, certain urine laboratory measures, fluids employed, rate of correction, and patient's level of care setting. Outcome measures included length of stay and mortality. RESULTS The patient mortality rate was 52 %. Mean age was 79.6 years (n = 33), and mean initial sodium level was 152.6 mmol/L. Plasma and urine osmolality, and urine sodium concentration were checked in less than 25 % of patients. Fifteen of 18 patients in the ICU expired, whereas only 2 of 15 patients not in the ICU expired (p < 0.0004, OR 32.50, CI 95 % (4.68-225.54)). Of the 23 patients (70 %) who had their serum sodium level corrected, 11 were corrected in ≤3 days and 12 in >3 days, but this difference did not affect mortality rate (45 vs. 50 %, p = 0.99). The mortality rate was similar (60 %, p = 0.52) for those whose serum sodium level never corrected suggesting that correction did not influence outcomes. The fluids chosen for therapy of the hypernatremia were appropriate to the patients volume status. Five of 15 patients who received a nephrology consultation survived, while 11 of 18 patients without a nephrology consultation survived (p = 0.12). The mean length of stay was 25.0 ± 23.9 days and no different for those who expired versus those who survived (25.2 ± 21.2 vs. 24.8 ± 25.9 days, p = 0.96). CONCLUSIONS Hypernatremia is associated with a poor prognosis, and outcomes are still disappointing despite appropriate rates of correction, intensive monitoring, and the involvement of a nephrologist. Strategies directed at avoidance of the development of hypernatremia and attention to concomitant disease may provide significant patient benefit.
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Affiliation(s)
- Muhammad R Toor
- Nephrology, Lenox Hill Hospital, 100 East 77th Street, New York, NY, 10075, USA,
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Bataille S, Baralla C, Torro D, Buffat C, Berland Y, Alazia M, Loundou A, Michelet P, Vacher-Coponat H. Undercorrection of hypernatremia is frequent and associated with mortality. BMC Nephrol 2014; 15:37. [PMID: 24559470 PMCID: PMC3939641 DOI: 10.1186/1471-2369-15-37] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Accepted: 02/10/2014] [Indexed: 11/10/2022] Open
Abstract
Background About 1% of patients admitted to the Emergency Department (ED) have hypernatremia, a condition associated with a mortality rate of 20 to 60%. Management recommendations originate from intensive care unit studies, in which patients and medical diseases differ from those in ED. Methods We retrospectively studied clinical characteristics, treatments, and outcomes of severely hypernatremic patients in the ED and risk factors associated with death occurrence during hospitalization. Results During 2010, 85 cases of severe hypernatremia ≥150 mmol/l were admitted to ED. Hypernatremia occurred in frail patients: mean age 79.7 years, 55% institutionalized, 28% with dementia. Twenty four percent of patients died during hospitalization. Male gender and low mean blood pressure (MBP) were independently associated with death, as well as slow natremia correction speed, but not the severity of hyperosmolarity at admission. Infusion solute was inappropriate for 45% of patients with MBP <70 mmHg who received hypotonic solutes and 22% of patients with MBP ≥70 mmHg who received isotonic solutes or were not perfused. Conclusions This is the first study assessing outcome of hypernatremic patients in the ED according to the treatment provided. It appears that not only a too quick, but also a too slow correction speed is associated with an increased risk of death regardless of initial natremia. Medical management of hypernatremic patients must be improved regarding evaluation and treatment.
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Affiliation(s)
- Stanislas Bataille
- Aix-Marseille University, APHM, Hôpital de la Conception, Centre de néphrologie et transplantation rénale, Marseille 13005, France.
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Disnatremias como consecuencia del Morbus diureticus en 2 pacientes ancianos. HIPERTENSION Y RIESGO VASCULAR 2014. [DOI: 10.1016/j.hipert.2013.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Wall BM, Gosmanova EO. In Reply to ‘Understanding Hypernatremia’ and ‘Thiazides for Hypervolemic Hypernatremia: A Valid Therapeutic Strategy?’. Am J Kidney Dis 2013; 61:1041-2. [DOI: 10.1053/j.ajkd.2013.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Accepted: 03/08/2013] [Indexed: 11/11/2022]
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Menon MC. Thiazides for Hypervolemic Hypernatremia: A Valid Therapeutic Strategy? Am J Kidney Dis 2013; 61:1041. [DOI: 10.1053/j.ajkd.2013.01.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Accepted: 01/03/2013] [Indexed: 11/11/2022]
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Kahn T. Understanding Hypernatremia. Am J Kidney Dis 2013; 61:1041. [DOI: 10.1053/j.ajkd.2012.10.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Accepted: 10/01/2012] [Indexed: 11/11/2022]
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