A clinical approach to the treatment of chronic hypernatremia

Hypernatremic chloride-depletion metabolic alkalosis successfully treated with high cation-gap amino acids: a case report

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.

Evaluation and management of hypernatremia in adults: clinical perspectives

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.

Case Report: Severe Hypernatremia From Ingestion of One's Own Urine

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.

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

Background

Methods

Conclusion

Sodium Abnormalities in Cardiac Surgery With Cardiopulmonary Bypass in Adults: A Narrative Review

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.

Survival Following Extreme Hypernatraemia Associated with Severe Dehydration and Undiagnosed Diabetes Mellitus

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.

Rate of Correction of Hypernatremia and Health Outcomes in Critically Ill Patients

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.

PROTRACTED ACUTE HYPERVOLEMIC HYPERNATREMIA UNMASKED AFTER VASOPRESSIN THERAPY: CASE REPORT, LITERATURE REVIEW, AND PROPOSED ALGORITHMIC APPROACH

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.

Extreme hypernatremia as a probable cause of fatal arrhythmia: a case report

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.

Evaluation and treatment of hypernatremia: a practical guide for physicians

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.

Is Admission Serum Sodium Concentration a Clinical Predictor for the Outcome of Therapy in Critically Ill Poisoned Patients?

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.

Hypernatremia in the geriatric population

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.

Characteristics, therapies, and factors influencing outcomes of hospitalized hypernatremic geriatric patients

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.

Undercorrection of hypernatremia is frequent and associated with mortality

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.