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Mai G, Lee JH, Caporal P, Roa G JD, González-Dambrauskas S, Zhu Y, Yock-Corrales A, Abbas Q, Kazzaz Y, Dewi DS, Chong SL. Initial dysnatremia and clinical outcomes in pediatric traumatic brain injury: a multicenter observational study. Acta Neurochir (Wien) 2024; 166:82. [PMID: 38353785 DOI: 10.1007/s00701-024-05919-0] [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: 08/29/2023] [Accepted: 11/21/2023] [Indexed: 02/16/2024]
Abstract
PURPOSE We aimed to investigate the association between initial dysnatremia (hyponatremia and hypernatremia) and in-hospital mortality, as well as between initial dysnatremia and functional outcomes, among children with traumatic brain injury (TBI). METHOD We performed a multicenter observational study among 26 pediatric intensive care units from January 2014 to August 2022. We recruited children with TBI under 18 years of age who presented to participating sites within 24 h of injury. We compared demographics and clinical characteristics between children with initial hyponatremia and eu-natremia and between those with initial hypernatremia and eu-natremia. We defined poor functional outcome as a discharge Pediatric Cerebral Performance Category (PCPC) score of moderate, severe disability, coma, and death, or an increase of at least 2 categories from baseline. We performed multivariable logistic regression for mortality and poor PCPC outcome. RESULTS Among 648 children, 84 (13.0%) and 42 (6.5%) presented with hyponatremia and hypernatremia, respectively. We observed fewer 14-day ventilation-free days between those with initial hyponatremia [7.0 (interquartile range (IQR) = 0.0-11.0)] and initial hypernatremia [0.0 (IQR = 0.0-10.0)], compared to eu-natremia [9.0 (IQR = 4.0-12.0); p = 0.006 and p < 0.001]. We observed fewer 14-day ICU-free days between those with initial hyponatremia [3.0 (IQR = 0.0-9.0)] and initial hypernatremia [0.0 (IQR = 0.0-3.0)], compared to eu-natremia [7.0 (IQR = 0.0-11.0); p = 0.006 and p < 0.001]. After adjusting for age, severity, and sex, presenting hyponatremia was associated with in-hospital mortality [adjusted odds ratio (aOR) = 2.47, 95% confidence interval (CI) = 1.31-4.66, p = 0.005] and poor outcome (aOR = 1.67, 95% CI = 1.01-2.76, p = 0.045). After adjustment, initial hypernatremia was associated with mortality (aOR = 5.91, 95% CI = 2.85-12.25, p < 0.001) and poor outcome (aOR = 3.00, 95% CI = 1.50-5.98, p = 0.002). CONCLUSION Among children with TBI, presenting dysnatremia was associated with in-hospital mortality and poor functional outcome, particularly hypernatremia. Future research should investigate longitudinal sodium measurements in pediatric TBI and their association with clinical outcomes.
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Affiliation(s)
- Gawin Mai
- Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore
| | - Jan Hau Lee
- Children's Intensive Care Unit, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
- SingHealth Paediatrics Academic Clinical Programme, Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore
| | - Paula Caporal
- Johns Hopkins International Injury Research Unit, Health Systems Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, USA
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Montevideo, Uruguay
| | - Juan D Roa G
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Montevideo, Uruguay
- Pediatric Intensive Care Unit, Los Cobos Medical Center, Universidad del Bosque, Ak. 9 #131a-40, Usaquén, Bogotá, Cundinamarca, Colombia
| | - Sebastián González-Dambrauskas
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Montevideo, Uruguay
- Departamento de Pediatría y Unidad de Cuidados Intensivos, de Niños del Centro Hospitalario Pereira Rossell, Facultad de Medicina, Universidad de la República, Bulevar Artigas 1590, Lord Ponsoby 2410, 11600, Montevideo, Uruguay
| | - Yanan Zhu
- Singapore Clinical Research Institute, Consortium for Clinical Research and Innovation, 23 Rochester Park, #06-01, Singapore, 139234, Singapore
| | - Adriana Yock-Corrales
- Emergency Department, National Children's Hospital "Dr. Carlos Saenz Herrera" CCSS, San José, Costa Rica
| | - Qalab Abbas
- Departments of Pediatrics and Child Health, National Stadium Road, Aga Khan University Hospital, Karachi, Karachi City, Sindh, 74800, Pakistan
| | - Yasser Kazzaz
- Department of Paediatrics, Ministry of National Guards Health Affairs, Prince Mutib Ibn Abdullah Ibn Abdulaziz Rd, Ar Rimayah, Riyadh, 11426, Saudi Arabia
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdul Aziz Medical City, Jeddah, 22384, Saudi Arabia
- King Abdullah International Medical Research Centre, King Abdul Aziz Medical City, Riyadh, 22384, Saudi Arabia
| | - Dianna Sri Dewi
- KK Research Centre, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Shu-Ling Chong
- Department of Emergency Medicine, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore.
- SingHealth Paediatrics Academic Clinical Programme, Emergency Medicine Academic Clinical Programme, Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore.
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Lee Y, Son D, Imaoka S, Nakai T, Kamimoto M, Hamada T, Taniguchi SI, Koda M. Late-Onset Intracranial Hemorrhage Presenting as Refractory Hyponatremia: A Case Report. Cureus 2023; 15:e38810. [PMID: 37303425 PMCID: PMC10251110 DOI: 10.7759/cureus.38810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2023] [Indexed: 06/13/2023] Open
Abstract
Here, we report a case of refractory hyponatremia and delayed intracranial hemorrhage following a head injury. A 70-year-old male patient was admitted with complaints of left chest pain and light-headedness after a fall. Hyponatremia recurred despite the correction with intravenous saline. Head computed tomography revealed a chronic subdural hematoma. The subsequent introduction of tolvaptan improved hyponatremia and disorientation. Delayed intracranial hemorrhage is a differential cause of refractory hyponatremia after head contusion. This case is clinically relevant because (i) the diagnostic delay of late-onset intracranial hemorrhage is common but fatal, and (ii) refractory hyponatremia can be a hint of late-onset intracranial hemorrhage.
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Affiliation(s)
- Young Lee
- Department of Community-Based Family Medicine, Faculty of Medicine, Tottori University, Yonago, JPN
- Department of General Medicine, Hino Hospital, Hino-gun, JPN
| | - Daisuke Son
- Department of Community-Based Family Medicine, Faculty of Medicine, Tottori University, Yonago, JPN
- Department of General Medicine, Hino Hospital, Hino-gun, JPN
| | - Shintaro Imaoka
- Department of Community-Based Family Medicine, Faculty of Medicine, Tottori University, Yonago, JPN
- Department of General Medicine, Hino Hospital, Hino-gun, JPN
| | - Tsubasa Nakai
- Department of Community-Based Family Medicine, Faculty of Medicine, Tottori University, Yonago, JPN
- Department of General Medicine, Hino Hospital, Hino-gun, JPN
| | - Minako Kamimoto
- Tottori Medical Career Support Center, Tottori University Hospital, Yonago, JPN
| | - Toshihiro Hamada
- Department of Community-Based Family Medicine, Faculty of Medicine, Tottori University, Yonago, JPN
| | - Shin-Ichi Taniguchi
- Department of Community-Based Family Medicine, Faculty of Medicine, Tottori University, Yonago, JPN
| | - Masahiko Koda
- Department of Internal Medicine, Hino Hospital, Hino-gun, JPN
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Cerebral Salt Wasting Syndrome Caused by Severe Traumatic Brain Injury in a Pediatric Patient and Review of the Literature. Case Rep Crit Care 2021; 2021:6679279. [PMID: 34721906 PMCID: PMC8556096 DOI: 10.1155/2021/6679279] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 10/15/2021] [Indexed: 11/18/2022] Open
Abstract
Background Following acute traumatic brain injury, cerebral salt wasting (CSW) syndrome is considered as an important cause of hyponatremia apart from syndrome of inappropriate antidiuretic hormone. Differentiation between the two syndromes is crucial for the initiation of an adequate treatment. Case Presentation. We report a 15-year-old female adolescent, admitted to intensive care for acute severe traumatic brain injury. During his hospitalization, she developed a hyponatremia with an increase of urine output and hypovolemia. So, the most probable diagnosis was CSW. Initially, she was treated by hypertonic saline and volume expansion. However, his sodium level continued to fall despite infusion of hypertonic saline. That is why fludrocortisone was introduced initially at 50 μg/day then increased to 150 μg/day. Fludrocortisone was continued for the next months. Serum sodium level was 138 mmol/L after one month of treatment. Conclusion Hyponatremia may occur after severe traumatic brain injury that is why an adequate treatment initiated on time is necessary in order to reduce morbidity and mortality.
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Hoai DTP, The BL, Dieu TTM, Duyen LN, Thi MD, Minh NT. Cerebral Salt-Wasting Syndrome and Elevated Brain Natriuretic Peptide Levels caused by Minor Traumatic Brain Injury: A case report. BRAIN HEMORRHAGES 2020. [DOI: 10.1016/j.hest.2020.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Cerebral Salt Wasting Due to Bacteremia Caused by Elizabethkingia meningoseptica: A Case Report. ARCHIVES OF PEDIATRIC INFECTIOUS DISEASES 2019. [DOI: 10.5812/pedinfect.88432] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Dickerson RN. Hyponatremia in Neurosurgical Patients: Syndrome of Inappropriate Antidiuretic Hormone or Cerebral Salt Wasting Syndrome? Hosp Pharm 2017. [DOI: 10.1177/001857870203701210] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Nutritional Support Consultant features issues pertinent to the clinical aspects of pharmacy nutrition support practice. The column is edited by Dr. Roland Dickerson, Associate Professor of Pharmacy, University of Tennessee Health Sciences Center, Memphis, TN.
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Affiliation(s)
- Roland N. Dickerson
- University of Tennessee Health Sciences Center, 26, South Dunlap Street, Memphis, TN 38163
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Cerebral Salt-Wasting Syndrome Caused by Minor Head Injury. Case Rep Emerg Med 2017; 2017:8692017. [PMID: 28194285 PMCID: PMC5282430 DOI: 10.1155/2017/8692017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2016] [Accepted: 12/04/2016] [Indexed: 11/30/2022] Open
Abstract
A 34-year-old woman was admitted to hospital after sustaining a head injury in a motor vehicle accident (day 1). No signs of neurological deficit, skull fracture, brain contusion, or intracranial bleeding were evident. She was discharged without symptoms on day 4. However, headache and nausea worsened on day 8, at which time serum sodium level was noted to be 121 mEq/L. Treatment with sodium chloride was initiated, but serum sodium decreased to 116 mEq/L on day 9. Body weight decreased in proportion to the decrease in serum sodium. Cerebral salt-wasting syndrome was diagnosed. This case represents the first illustration of severe hyponatremia related to cerebral salt-wasting syndrome caused by a minor head injury.
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Rhoney DH, Parker D. Considerations in Fluids and Electrolytes After Traumatic Brain Injury. Nutr Clin Pract 2016; 21:462-78. [PMID: 16998145 DOI: 10.1177/0115426506021005462] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Appropriate fluid management of patients with traumatic brain injury (TBI) presents a challenge for many clinicians. Many of these patients may receive osmotic diuretics for the treatment of increased intracranial pressure or develop sodium disturbances, which act to alter fluid balance. However, establishment of fluid balance is extremely important for improving patient outcomes after neurologic injury. The use of hyperosmolar fluids, such as hypertonic saline, has gained significant interest because they are devoid of dehydrating properties and may have other beneficial properties for patients with TBI. Electrolyte derangements are also common after neurologic injury, with many having neurologic manifestations. In addition, the role of electrolyte abnormalities in the secondary neurologic injury cascade is being delineated and may offer a potential future therapeutic intervention.
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Affiliation(s)
- Denise H Rhoney
- Department of Pharmacy Practice, Wayne State University, Eugene Applebaum College of Pharmacy & Health Sciences, 259 Mack Avenue, Detroit, MI 48201, USA.
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Dumont AS, Nemergut EC, Jane JA, Laws ER. Postoperative Care Following Pituitary Surgery. J Intensive Care Med 2016; 20:127-40. [PMID: 15888900 DOI: 10.1177/0885066605275247] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patients undergoing surgery for pituitary tumors represent a heterogeneous population each with unique clinical, biochemical, radiologic, pathologic, neurologic, and/or ophthalmologic considerations. The postoperative management of patients following pituitary surgery often occurs in the context of a dynamic state of the hypothalamic-pituitary-end organ axis. Consequently, a significant component of the postoperative care of these patients focuses on vigilant screening and observation for neuroendocrinologic perturbations such as varying degrees of hypopituitarism and disorders of water balance (diabetes insipidus and the syndrome of inappropriate antidiuretic hormone). Additionally, one must be cognizant of other potential complications specific to the transsphenoidal approach for tumor removal including cerebrospinal fluid leakage and meningitis. This review addresses the postoperative management of patients undergoing pituitary surgery with an emphasis on careful screening and recognition of complications.
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Affiliation(s)
- Aaron S Dumont
- Department of Neurological Surgery, University of Virginia School of Medicine, Charlottesville, 22908, USA
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Han MJ, Kim SC, Joo CU, Kim SJ. Cerebral salt-wasting syndrome in a child with Wernicke encephalopathy treated with fludrocortisone therapy: A case report. Medicine (Baltimore) 2016; 95:e4393. [PMID: 27603336 PMCID: PMC5023858 DOI: 10.1097/md.0000000000004393] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE FOR THIS CASE REPORT Cerebral Salt-Wasting Syndrome (CSWS) is characterized by hyponatremia and sodium wasting in the urine. These conditions are triggered by various neurosurgical disorders such as subarachnoid hemorrhage, brain tumor, head injury, and brain surgery. To our knowledge, CSWS caused by Wernicke encephalopathy (WE) has been rarely reported. PRESENTING CONCERNS OF THE PATIENT A 2-year-old male patient presented to our hospital due to a seizure attack. He had been neglected and refused to take food for a long time (body weight < 3rd percentile). During admission, the patient showed low serum osmolality, high urine osmolality, dehydration state, increased urine output, and negative water balance, a diagnosis of CSWS was made. DIAGNOSES, INTERVENTIONS, AND OUTCOMES Brain MRI displayed symmetrical lesions of T2WI and FLAIR high signal intensity in the peri-aqueductal and hypothalamic areas, which suggests Wernicke encephalopathy. For the early diagnosis of WE, neuroimaging studies can be an important marker. Thiamine hydrochloride was administered at a dose of 100 mg/day for 3 weeks. Cerebral salt-wasting syndrome was subsequently diagnosed due to persistent hyponatremia, dehydrated state, and high urine sodium with massive urination. MAIN LESSONS LEARNED FROM THIS CASE Wernicke encephalopathy is a very rare cause of cerebral salt-wasting syndrome in pediatrics patients. The patient had a good outcome after hypertonic solution and fludrocortisone therapy.
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Affiliation(s)
| | - Soon Chul Kim
- Department of Pediatrics
- Research Institute of Clinical Medicine, Chonbuk National University Medical School, Jeonju, Korea
| | - Chan Uhng Joo
- Department of Pediatrics
- Research Institute of Clinical Medicine, Chonbuk National University Medical School, Jeonju, Korea
| | - Sun Jun Kim
- Department of Pediatrics
- Research Institute of Clinical Medicine, Chonbuk National University Medical School, Jeonju, Korea
- Correspondence: Sun Jun Kim, Department of Pediatrics, Chonbuk National University Medical School, Geonjiro 20, Duckjinku, Jeonju, South Korea (e-mail: )
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Cerebral Salt Wasting Syndrome following Head Injury in a Child Managed Successfully with Fludrocortisone. Case Rep Pediatr 2016; 2016:6937465. [PMID: 27213068 PMCID: PMC4860235 DOI: 10.1155/2016/6937465] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Accepted: 04/10/2016] [Indexed: 11/17/2022] Open
Abstract
Cerebral salt wasting (CSW) syndrome is an important cause of hyponatremia in head injuries apart from syndrome of inappropriate antidiuretic hormone (SIADH). Proper diagnosis and differentiation between these two entities are necessary for management as the treatment is quite opposite in both conditions. Fludrocortisone can help in managing CSW where alone saline infusion does not work. We report a 17-month-old female child with head injury managed successfully with saline infusion and fludrocortisone.
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Leonard J, Garrett RE, Salottolo K, Slone DS, Mains CW, Carrick MM, Bar-Or D. Cerebral salt wasting after traumatic brain injury: a review of the literature. Scand J Trauma Resusc Emerg Med 2015; 23:98. [PMID: 26561391 PMCID: PMC4642664 DOI: 10.1186/s13049-015-0180-5] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2015] [Accepted: 11/06/2015] [Indexed: 11/10/2022] Open
Abstract
Electrolyte imbalances are common among patients with traumatic brain injury (TBI). Cerebral salt wasting (CSW) is an electrolyte imbalance characterized by hyponatremia and hypovolemia. Differentiating the syndrome of inappropriate antidiuretic hormone and CSW remains difficult and the pathophysiological mechanisms underlying CSW are unclear. Our intent was to review the literature on CSW within the TBI population, in order to report the incidence and timing of CSW after TBI, examine outcomes, and summarize the biochemical changes in patients who developed CSW. We searched MEDLINE through 2014, hand-reviewed citations, and searched abstracts from the American Association for the Surgery of Trauma (2003-2014). Publications were included if they were conducted within a TBI population, presented original data, and diagnosed CSW. Publications were excluded if they were review articles, discussed hyponatremia but did not differentiate the etiology causing hyponatremia, or presented cases with chronic disease. Fifteen of the 47 publications reviewed met the selection criteria; nine (60%) were case reports, five (33%) were prospective and 1 (7%) was a retrospective study. Incidence of CSW varied between 0.8 - 34.6%. The populations studied were heterogeneous and the criteria used to define hyponatremia and CSW varied. Though believed to play a role in the development of CSW, increased levels of natriuretic peptides in patients diagnosed with CSW were not consistently reported. These findings reinforce the elusiveness of the CSW diagnosis and the need for strict and consistent diagnostic criteria.
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Affiliation(s)
- Jan Leonard
- Department of Trauma Research, Swedish Medical Center, 501 E. Hampden Ave, Englewood, CO, 80113, USA. .,Department of Trauma Research, St. Anthony Hospital, 11600 W. 2nd Place, Lakewood, CO, 80228, USA. .,Department of Trauma Research, The Medical Center of Plano, 3901 West 15th St, Plano, TX, 75075, USA.
| | - Raymond E Garrett
- Department of Trauma Research, Swedish Medical Center, 501 E. Hampden Ave, Englewood, CO, 80113, USA. .,Craig Hospital, 3425 S. Clarkson St, Englewood, CO, 80113, USA.
| | - Kristin Salottolo
- Department of Trauma Research, Swedish Medical Center, 501 E. Hampden Ave, Englewood, CO, 80113, USA. .,Department of Trauma Research, St. Anthony Hospital, 11600 W. 2nd Place, Lakewood, CO, 80228, USA. .,Department of Trauma Research, The Medical Center of Plano, 3901 West 15th St, Plano, TX, 75075, USA.
| | - Denetta S Slone
- Trauma Services Department, Swedish Medical Center, 501 E. Hampden Ave, Englewood, CO, 80113, USA.
| | - Charles W Mains
- Trauma Services Department, St. Anthony Hospital, 11600 W. 2nd Place, Lakewood, CO, 80228, USA.
| | - Matthew M Carrick
- Trauma Services Department, The Medical Center of Plano, 3901 West 15th St, Plano, TX, 75075, USA.
| | - David Bar-Or
- Department of Trauma Research, Swedish Medical Center, 501 E. Hampden Ave, Englewood, CO, 80113, USA. .,Department of Trauma Research, St. Anthony Hospital, 11600 W. 2nd Place, Lakewood, CO, 80228, USA. .,Department of Trauma Research, The Medical Center of Plano, 3901 West 15th St, Plano, TX, 75075, USA.
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Incidence, Etiology and Outcomes of Hyponatremia after Transsphenoidal Surgery: Experience with 344 Consecutive Patients at a Single Tertiary Center. J Clin Med 2014; 3:1199-219. [PMID: 26237599 PMCID: PMC4470178 DOI: 10.3390/jcm3041199] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Revised: 09/23/2014] [Accepted: 09/27/2014] [Indexed: 12/18/2022] Open
Abstract
Hyponatremia is often seen after transsphenoidal surgery and is a source of considerable economic burden and patient-related morbidity and mortality. We performed a retrospective review of 344 patients who underwent transsphenoidal surgery at our institution between 2006 and 2012. Postoperative hyponatremia was seen in 18.0% of patients at a mean of 3.9 days postoperatively. Hyponatremia was most commonly mild (51.6%) and clinically asymptomatic (93.8%). SIADH was the primary cause of hyponatremia in the majority of cases (n = 44, 71.0%), followed by cerebral salt wasting (n = 15, 24.2%) and desmopressin over-administration (n = 3, 4.8%). The incidence of postoperative hyponatremia was significantly higher in patients with cardiac, renal and/or thyroid disease (p = 0.0034, Objective Risk (OR) = 2.60) and in female patients (p = 0.011, OR = 2.18) or patients undergoing post-operative cerebrospinal fluid drainage (p = 0.0006). Treatment with hypertonic saline (OR = −2.4, p = 0.10) and sodium chloride tablets (OR = −1.57, p = 0.45) was associated with a non-significant trend toward faster resolution of hyponatremia. The use of fluid restriction and diuretics should be de-emphasized in the treatment of post-transsphenoidal hyponatremia, as they have not been shown to significantly alter the time-course to the restoration of sodium balance.
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Karaca P, Desailloud R. [Hormonal dysnatremia]. ANNALES D'ENDOCRINOLOGIE 2013; 74 Suppl 1:S42-S51. [PMID: 24356291 DOI: 10.1016/s0003-4266(13)70020-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Because of antidiuretic hormone (ADH) disorder on production or function we can observe dysnatremia. In the absence of production by posterior pituitary, central diabetes insipidus (DI) occurs with hypernatremia. There are hereditary autosomal dominant, autosomal recessive or X- linked forms. When ADH is secreted but there is an alteration on his receptor AVPR2, it is a nephrogenic diabetes insipidus in acquired or hereditary form. We can make difference on AVP levels and/or on desmopressine response which is negative in nephrogenic forms. Hyponatremia occurs when there is an excess of ADH production: it is a euvolemic hypoosmolar hyponatremia. The most frequent etiology is SIADH (syndrome of inappropriate secretion of ADH), a diagnostic of exclusion which is made after eliminating corticotropin deficiency and hypothyroidism. In case of brain injury the differential diagnosis of cerebral salt wasting (CSW) syndrome has to be discussed, because its treatment is perfusion of isotonic saline whereas in SIADH, the treatment consists in administration of hypertonic saline if hyponatremia is acute and/or severe. If not, fluid restriction demeclocycline or vaptans (antagonists of V2 receptors) can be used in some European countries. Four types of SIADH exist; 10 % of cases represent not SIADH but SIAD (syndrome of inappropriate antidiuresis) due to a constitutive activation of vasopressin receptor that produces water excess. c 2013 Published by Elsevier Masson SAS.
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Affiliation(s)
- P Karaca
- Service d'endocrinologie, Maladies métaboliques et nutrition, CHU d'Amiens, place Victor-Pauchet, 80054 Amiens, France.
| | - R Desailloud
- Service d'endocrinologie, Maladies métaboliques et nutrition, CHU d'Amiens, place Victor-Pauchet, 80054 Amiens, France
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Renal salt-wasting syndrome in children with intracranial disorders. Pediatr Nephrol 2012; 27:733-9. [PMID: 22237777 DOI: 10.1007/s00467-011-2093-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2011] [Revised: 11/23/2011] [Accepted: 12/07/2011] [Indexed: 01/05/2023]
Abstract
Hypotonic hyponatremia, a serious and recognized complication of any intracranial disorder, results from extra-cellular fluid volume depletion, inappropriate anti-diuresis or renal salt-wasting. The putative mechanisms by which intracranial disorders might lead to renal salt-wasting are either a disrupted neural input to the kidney or the elaboration of a circulating natriuretic factor. The key to diagnosis of renal salt-wasting lies in the assessment of extra-cellular volume status: the central venous pressure is currently considered the yardstick for measuring fluid volume status in subjects with intracranial disorders and hyponatremia. Approximately 110 cases have been reported so far in subjects ≤18 years of age (male: 63%; female: 37%): intracranial surgery, meningo-encephalitis (most frequently tuberculous) or head injury were the most common underlying disorders. Volume and sodium repletion are the goals of treatment, and this can be performed using some combination of isotonic saline, hypertonic saline, and mineralocorticoids (fludrocortisone). It is worthy of a mention, however, that some authorities contend that cerebral salt wasting syndrome does not exist, since this diagnosis requires evidence of a reduced arterial blood volume, a concept but not a measurable variable.
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Paiva WS, Bezerra DAF, Amorim RLO, Figueiredo EG, Tavares WM, De Andrade AF, Teixeira MJ. Serum sodium disorders in patients with traumatic brain injury. Ther Clin Risk Manag 2011; 7:345-9. [PMID: 21941440 PMCID: PMC3176167 DOI: 10.2147/tcrm.s17692] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Sodium disorders are the most common and most poorly understood electrolyte disorders in neurological patients. The aim of this study was to determine the incidence of sodium disorders and its association with different traumatic brain injuries. This prospective study was conducted in 80 patients diagnosed with moderate and severe traumatic brain injuries. All patients underwent cerebral computed tomography. Incidence of sodium disorders, presence of injuries in the first computed tomography after traumatic brain injury, and level of consciousness were analyzed. Patients that presented other potential causes of sodium disorders and systemic trauma were excluded from the study. The incidence of sodium disturbances was 45%: 20 patients presented hypernatremia and 16 hyponatremia. Refers to all patients with sodium disturbances 53% were detected in the first sample. We recorded at least one measurement <125 mEq/L in 50% of the patients with hyponatremia. A greater incidence of sodium disorders was found in patients with subdural, intracerebral hematoma and with diffuse axonal injury. The incidence of sodium disorders among the patients with diffuse lesions was greater than in the group of patients with brain contusion (P = 0.022). The incidence of sodium disorders is higher in patients with diffuse traumatic brain injuries. No association was found between focal lesions and proportion of sodium disorders.
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Affiliation(s)
- Wellingson Silva Paiva
- Intensive Care Unit, Division of Neurosurgery, Hospital Das Clinicas, University of São Paulo School of Medicine, São Paulo, Brazil
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Costa KN, Nakamura HM, Cruz LRD, Miranda LSVFD, Santos-Neto RCD, Cosme SDL, Casulari LA. Hyponatremia and brain injury: absence of alterations of serum brain natriuretic peptide and vasopressin. ARQUIVOS DE NEURO-PSIQUIATRIA 2010; 67:1037-44. [PMID: 20069215 DOI: 10.1590/s0004-282x2009000600014] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2009] [Accepted: 08/05/2009] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To study any possible relation between hyponatremia following brain injury and the presence of cerebral salt-wasting syndrome (CSWS) or the syndrome of inappropriate secretion of antidiuretic hormone (SIADH), and if vasopressin, brain natriuretic peptide (BNP) and aldosterone have a role in its mechanism. METHOD Patients with brain injury admitted to the intensive care unit were included and had their BNP, aldosterone and vasopressin levels dosed on day 7. RESULTS Twenty six adult patients were included in the study. Nine (34.6%) had hyponatremia and presented with a negative water balance and higher values of urinary sodium, serum potassium and diuresis than patients with normonatremia. The serum levels of BNP, aldosterone, and vasopressin were normal and no relation was observed between plasma sodium and BNP, aldosterone or vasopressin. CONCLUSION The most likely cause of hyponatremia was CSWS and there was no correlation between BNP, aldosterone and vasopressin with serum sodium level.
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Yee AH, Burns JD, Wijdicks EFM. Cerebral salt wasting: pathophysiology, diagnosis, and treatment. Neurosurg Clin N Am 2010; 21:339-52. [PMID: 20380974 DOI: 10.1016/j.nec.2009.10.011] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Cerebral salt wasting (CSW) is a syndrome of hypovolemic hyponatremia caused by natriuresis and diuresis. The mechanisms underlying CSW have not been precisely delineated, although existing evidence strongly implicates abnormal elevations in circulating natriuretic peptides. The key in diagnosis of CSW lies in distinguishing it from the more common syndrome of inappropriate secretion of antidiuretic hormone. Volume status, but not serum and urine electrolytes and osmolality, is crucial for making this distinction. Volume and sodium repletion are the goals of treatment of patients with CSW, and this can be performed using some combination of isotonic saline, hypertonic saline, and mineralocorticoids.
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Affiliation(s)
- Alan H Yee
- Department of Neurology, Mayo Clinic, 200 1st Street SW, Rochester, MN 55905, USA.
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Yeh YW, Kuo SC, Chen CY, Shiah IS, Chen YC, Huang SY. Mimicking catatonic symptoms: a head injury induced acute hyponatremia complicated by rhabdomyolysis in a patient with schizophrenia. Prog Neuropsychopharmacol Biol Psychiatry 2009; 33:731-2. [PMID: 19296911 DOI: 10.1016/j.pnpbp.2009.03.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2009] [Revised: 03/08/2009] [Accepted: 03/09/2009] [Indexed: 11/16/2022]
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Differentiating appropriate antidiuretic hormone secretion, inappropriate antidiuretic hormone secretion and cerebral salt wasting: the common, uncommon, and misnamed. Curr Opin Pediatr 2008; 20:448-52. [PMID: 18622203 DOI: 10.1097/mop.0b013e328305e403] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Causes of hyponatremia in children include the syndrome of appropriate antidiuretic hormone secretion, the syndrome of inappropriate antidiuretic hormone secretion and cerebral salt wasting. The purpose of this review is to distinguish these possibilities, focusing on cerebral salt wasting. RECENT FINDINGS Most cases of hyponatremia in children are due to the syndrome of appropriate antidiuretic hormone secretion. The syndrome of inappropriate antidiuretic hormone secretion can be seen with neurological injury, pain and medication use. Recent studies suggest that cerebral salt wasting is a rare cause of hyponatremia. When cerebral salt wasting is diagnosed, it is often difficult to make a direct link with the central nervous system insult. SUMMARY The clinical condition, assessment of extracellular fluid space volume status, measurement of urinary electrolytes and responses to infusion of saline solutions can distinguish between syndrome of appropriate antidiuretic hormone secretion, syndrome of inappropriate antidiuretic hormone secretion and cerebral salt wasting. The word 'cerebral' in 'cerebral salt wasting syndrome' can thus be inappropriate, conveying inaccurate causation.
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Segura Matute S, Balaguer Gargallo M, Cambra Lasaosa FJ, Zambudio Sert S, Martín Rodrigo JM, Palomeque Rico A. [Fluid and electrolyte disorders following surgery for brain tumors]. An Pediatr (Barc) 2008; 67:225-30. [PMID: 17785159 DOI: 10.1016/s1695-4033(07)70611-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
INTRODUCTION Fluid and electrolyte disorders such as diabetes insipidus, salt wasting syndrome (SWS) and syndrome of inappropriate antidiuretic hormone secretion (SIADH) can appear in the immediate postoperative period after surgery for brain tumors. Early diagnosis and treatment are important to prevent the potential adverse effects of these disorders on the central nervous system (CNS). OBJECTIVES To determine the incidence and characteristics of fluid and electrolyte disorders in the immediate postoperative period after surgery for CNS tumors in children treated in our hospital. MATERIAL AND METHODS We retrospectively analyzed clinical and laboratory data in all infants and children who underwent surgery for CNS tumors in our hospital from January 1998 to June 2005 and who met the laboratory criteria for diabetes insipidus, SWS or SIADH. RESULTS Twenty-three electrolyte disorders were identified in 149 surgical patients (an incidence of 15.4%). The median age was 5 years and 3 months (from 6 months to 17 years) and 48.7% of the patients were male. The most frequent electrolyte disturbance was diabetes insipidus (65.2% of all electrolyte disorders). On average, onset of diabetes insipidus occurred 19 hours after surgery. Treatment with desmopressin was administrated in all patients. On average, diabetes insipidus was resolved 73 hours after diagnosis, except in one patient with permanent diabetes insipidus due to a surgical lesion of the hypothalamic-pituitary axis. The second most frequent electrolyte disturbance was SWS (26.1%) with a mean time of onset of 50.4 hours after surgery. On average, SWS was resolved 57.6 hours after administration of saline solutions. Only two patients developed SIADH, which was treated with water restriction and adequate sodium supply. Both cases of SIADH resolved spontaneously in the first 36 hours after diagnosis. At discharge, none of the patients showed neurological disturbances due to an electrolytic disorder. CONCLUSIONS In our series, the most frequent electrolyte disorder after surgery for CNS tumors was diabetes insipidus. Early treatment with desmopressin almost always prevents hypernatremia. Unless there is a surgical lesion of the hypothalamic-pituitary axis, spontaneous resolution will take place in 3 days on average. The management of SWS and SIADH requires close monitoring of plasma sodium due to the risk of hyponatremia.
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Affiliation(s)
- S Segura Matute
- Unidad de Cuidados Intensivos Pediátricos, Servicio de Pediatría, Hospital Sant Joan de Déu-Clínic, Universitat de Barcelona, España.
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Carpenter J, Weinstein S, Myseros J, Vezina G, Bell MJ. Inadvertent hyponatremia leading to acute cerebral edema and early evidence of herniation. Neurocrit Care 2007; 6:195-9. [PMID: 17572863 DOI: 10.1007/s12028-007-0032-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION For years, the maintenance of normal or supranormal serum sodium (Na) concentrations has been believed to be beneficial in brain injuries. Recently published guidelines for cerebral trauma recommend the use of hypertonic saline to achieve hypernatremia for the management of increased intracranial pressure and these standards are generally practiced across most diseases in neurocritical care including stroke, hemorrhage and tumors. Severe hyponatremia has long been known to be detrimental, but objective evidence for the harm of mild hyponatremia as a secondary injury has been scarce. DESCRIPTION OF CASE In this case report, we describe a child with aneurysmal subarachnoid hemorrhage who had a sudden, inadvertent decrease in serum Na (128 meq/l) that was associated with a deterioration of her neurological examination and evidence of early transtentorial herniation on emergent brain CT scan. These findings were quickly reversed after the serum Na was corrected. DISCUSSION This report emphasizes that close monitoring of serum Na and osmolarity in acute head injured children is important, and provides evidence that alterations of these parameters is a substantial risk for cerebral edema in children with evolving brain injuries and briefly reviews the literature regarding the risks of hyponatremia in children.
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Affiliation(s)
- Jessica Carpenter
- Department of Neurology, Children's Research Institute, Children's National Medical Center, Washington, DC, USA.
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Moro N, Katayama Y, Igarashi T, Mori T, Kawamata T, Kojima J. Hyponatremia in patients with traumatic brain injury: incidence, mechanism, and response to sodium supplementation or retention therapy with hydrocortisone. ACTA ACUST UNITED AC 2007; 68:387-93. [PMID: 17905062 DOI: 10.1016/j.surneu.2006.11.052] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2006] [Accepted: 11/21/2006] [Indexed: 10/22/2022]
Abstract
BACKGROUND Hyponatremia is a frequently observed electrolyte abnormality in patients with central nervous system disease. Several mechanisms, such as SIADH, hypopituitarism, and CSWS, have been proposed with varied incidences among several studies. We attempted to clarify the incidence and mechanism of hyponatremia for each type of TBI. We also assessed the efficacy of sodium supplementation and retention therapy. For sodium retention therapy, hydrocortisone was administered, expecting its mineralocorticoid effect, when the hyponatremia was associated with excess natriuresis. METHODS Retrospective analysis of 298 patients with TBI between January 2003 and December 2004 was performed. The incidence, background, clinical data, and outcome were evaluated. RESULTS Of the 298 patients, 50 (16.8%) presented hyponatremia during the time course. Hyponatremia was associated with longer hospital stay (P < .001) and bad outcome (P = .02). Among these 50 patients, 37 recovered from the hyponatremia with simple sodium supplementation. The remaining 13 patients presented massive natriuresis and required additional sodium retention therapy. Hydrocortisone statistically reduced the amount of sodium excretion (P = .002) and returned the serum sodium level to a normal value. CONCLUSIONS A high rate of hyponatremia after TBI was observed. Further studies are required to establish the precise mechanism of hyponatremia after TBI. Clear definition of CSWS is required to avoid confusion of the pathophysiology that causes hyponatremia. Hydrocortisone was useful to prevent excess natriuresis.
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Affiliation(s)
- Nobuhiro Moro
- Department of Neurological Surgery, Nihon University School of Medicine, Itabashi-ku, Tokyo 173-8610, Japan.
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von Bismarck P, Ankermann T, Eggert P, Claviez A, Fritsch MJ, Krause MF. Diagnosis and management of cerebral salt wasting (CSW) in children: the role of atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP). Childs Nerv Syst 2006; 22:1275-81. [PMID: 16607534 DOI: 10.1007/s00381-006-0091-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2005] [Indexed: 12/26/2022]
Abstract
OBJECTIVE The aim of this study is to report our experience with diagnosis and management of cerebral salt wasting (CSW) in children and to evaluate the role of atrial natriuretic peptide/brain natriuretic peptide (ANP/BNP) in pediatric patients. MATERIALS AND METHODS We present nine children suffering from prevalent cerebral disease--seven of whom underwent anesthesia and surgical procedures--with features of CSW, seen within a 22-month period. The symptoms, patient characteristics (including hormone status), monitoring, treatment protocol, and outcome are described. RESULTS Natriuresis (urine Na+ concentrations 131 to >250 mmol/l) and polyuria (5.5+/-1.5 ml/kg/h) with increased Na+ turnover (maximum Na+ loss: median 1.50 mmol Na+/kg/h, range 0.47 to >3.50) vanished within 2 weeks in 6/9 patients (increase in serum Na+ from 127+/-2 mmol/l to 136+/-1). K+ excretion was also high (maximum K+ loss: median 0.18 mmol K+/kg/h, range 0.09-0.53). ANP/BNP as suspected causes of salt wasting were elevated only in 1/6 and 2/7 patients, respectively. Plasma renin activities and aldosterone levels were either suppressed or in the low normal range. CONCLUSION Natriuresis and polyuria are the main diagnostic criteria for CSW. The fluid balance in CSW is negative, in contrast to a positive fluid balance in SIADH. The length of the disease is self-limited and generally ceases within 2 weeks, while Na+, K+, and fluid turnover should be monitored carefully. Only a minority of our children showed elevated ANP/BNP levels. A dose/effect relationship for natriuretic peptide levels and increased Na+ turnover could not be established.
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Affiliation(s)
- Philipp von Bismarck
- Department of General Pediatrics, Children's Hospital, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Schwanenweg 20, 24105, Kiel, Germany
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Sviri GE, Soustiel JF, Zaaroor M. Alteration in brain natriuretic peptide (BNP) plasma concentration following severe traumatic brain injury. Acta Neurochir (Wien) 2006; 148:529-33; discussion 533. [PMID: 16322908 DOI: 10.1007/s00701-005-0666-4] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2005] [Accepted: 10/06/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND Brain natriuretic peptide (BNP) is a potent natriuretic and vasodilator factor which, by its systemic effects, can decrease cerebral blood flow (CBF). In aneurysmal subarchnoid hemorrhage (aSAH), BNP plasma concentrations were found to be associated with hyponatremia and were progressively elevated in patients who eventually developed delayed ischemic deficit secondary to vasospasm. The purpose of the present study was to evaluate trends in BNP plasma concentrations during the acute phase following severe (traumatic brain injury) TBI. METHODS BNP plasma concentration was evaluated in 30 patients with severe isolated head injury (GCS<8 on admission) in four time periods after the injury (period 1: days 1-2; period 2: days 4-5; period 3: days 7-8; period 4: days 10-11). All patients were monitored for ICP during the first week after the injury. FINDINGS The initial BNP plasma concentrations (42+/-36.9 pg/ml) were 7.3 fold (p<0.01) higher in TBI patients as compared to the control group (5.78+/-1.90 pg/ml). BNP plasma concentrations were progressively elevated through days 7-8 after the injury in patients with diffused SAH as compared to patients with mild or no SAH (p<0.001) and in patients with elevated ICP as compared to patients without elevated ICP (p<0.001). Furthermore, trends in BNP plasma concentrations were significantly and positively associated with poor outcome. INTERPRETATION BNP plasma concentrations are elevated shortly after head injury and are continuously elevated during the acute phase in patients with more extensive SAH and in those with elevated ICP, and correlate with poor outcomes. Further studies should be undertaken to evaluate the role of BNP in TBI pathophysiology.
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Affiliation(s)
- G E Sviri
- Department of Neurosurgery, Rambam (Maimonides) Medical Center, Technion-Israel Institute of Technology, Haifa, Israel
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Steelman R, Corbitt B, Pate MFD. Early onset of cerebral salt wasting in a patient with head and facial injuries. J Oral Maxillofac Surg 2006; 64:746-7. [PMID: 16546664 DOI: 10.1016/j.joms.2005.12.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2005] [Indexed: 11/23/2022]
Affiliation(s)
- Robert Steelman
- Pediatric Critical Care Medicine, Doernbecher Children's Hospital, Oregon Health & Science University, Portland, OR 97239, USA.
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Cole CD, Gottfried ON, Liu JK, Couldwell WT. Hyponatremia in the neurosurgical patient: diagnosis and management. Neurosurg Focus 2004; 16:E9. [PMID: 15191338 DOI: 10.3171/foc.2004.16.4.10] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Hyponatremia is frequently encountered in patients who have undergone neurosurgery for intracranial processes. Making an accurate diagnosis between the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) and cerebral salt wasting (CSW) in patients in whom hyponatremia develops is important because treatment differs greatly between the conditions. The SIADH is a volume-expanded condition, whereas CSW is a volume-contracted state that involves renal loss of sodium. Treatment for patients with SIADH is fluid restriction and treatment for patients with CSW is generally salt and water replacement. In this review, the authors discuss the differential diagnosis of hyponatremia, distinguish SIADH from CSW, and highlight the diagnosis and management of hyponatremia, which is commonly encountered in patients who have undergone neurosurgery, specifically those with traumatic brain injury, aneurysmal subarachnoid hemorrhage, recent transsphenoidal surgery for pituitary tumors, and postoperative cranial vault reconstruction for craniosynostosis.
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Affiliation(s)
- Chad D Cole
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah 84132, USA
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Brouh Y, Paut O, Tsimaratos M, Camboulives J. [Postoperative hyponatremia in children: pathophysiology, diagnosis and treatment]. ACTA ACUST UNITED AC 2004; 23:39-49. [PMID: 15022629 DOI: 10.1016/j.annfar.2003.09.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To review the current data on pathophysiology, causes and management of postoperative hyponatremia in children. DATA SOURCES AND EXTRACTION The Pubmed database was searched for articles, combined with references analysis of major articles on the field. DATA SYNTHESIS The incidence of postoperative hyponatremia has been evaluated at 0.34% and its mortality significant. Postoperative hyponatremia is triggered by the diminished renal ability to excrete free water, due to antidiuretic hormone release. Inappropriate secretion of antidiuretic hormone is frequently seen after spine, cardiac and neurosurgery but can occur even after minor surgery. In this context, the infusion of hypotonic fluids represents a strong risk factor for developing hyponatremia. Other causes of hyponatremia are represented by extrarenal fluid losses, cerebral salt wasting syndrome, desalination phenomenon, adrenal insufficiency or some medications. Preventive treatment is essential and based on prohibition of hypotonic fluids infusion and the use of isotonic fluids infusions, maintenance of a normal total blood volume, the observance of the good practice recommendations for fluid infusion in children, and frequent blood and urine sodium concentration determinations in patients at risk for developing hyponatremia. Hyponatremic encephalopathy requires an emergent management, consisting in respiratory care and hypertonic sodium chloride infusion. Chronic hyponatremia is most often asymptomatic and the main neurological risk factor is represented by a too rapid correction of plasma sodium, which may lead to centropontine myelinolysis.
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Affiliation(s)
- Y Brouh
- Département d'anesthésie et de réanimation pédiatrique, faculté de médecine, université de la Méditerranée, CHU Timone-enfants, Marseille, France
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Abstract
BACKGROUND Hyponatremia is the most common and important electrolyte disorder encountered in the neurologic intensive care unit (NICU). Advances in our knowledge of the pathophysiological mechanisms at play in patients with acute neurologic disease have improved our understanding of this derangement. REVIEW SUMMARY Evaluation of hyponatremia requires a structured approach beginning with the measurement of serum and urine osmolalities. Most cases of hyponatremia in the NICU are associated with serum hypotonicity. Iatrogenic causes, most conspicuously inadequate tonicity of intravenous fluids, should be promptly identified and removed when possible. Two main mechanisms are responsible for most non-iatrogenic cases of hyponatremia in patients with neurologic or neurosurgical disease: inappropriate secretion of antidiuretic hormone (SIADH) and cerebral salt wasting syndrome (CSW). Distinction between these two syndromes may be difficult and must be based on an accurate assessment of the patient's volume status. SIADH is associated with normal or slightly expanded volume status and should be treated with fluid restriction. Patients with CSW are hypovolemic and require adequate fluid and sodium replacement. Correction of hyponatremia should not exceed 8 to 10 mmol/L over any 24-hour period to avoid the risk of osmotic demyelination. CONCLUSIONS Hyponatremia may complicate the clinical course of many acute neurologic and neurosurgical disorders. It is most often iatrogenic causes, CSW, or SIADH. Physicians working with critically ill neurologic patients should be familiar with management strategies addressing these underlying pathophysiological mechanisms.
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Affiliation(s)
- Alejandro A Rabinstein
- Neurological Neurosurgical Intensive Care Unit, Saint Mary's Hospital, Rochester, MN 55905, USA
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Dass R, Nagaraj R, Murlidharan J, Singhi S. Hyponatraemia and hypovolemic shock with tuberculous meningitis. Indian J Pediatr 2003; 70:995-7. [PMID: 14719791 DOI: 10.1007/bf02723828] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
A 12-year-old boy with tuberculous meningitis and hydrocephalous, after undergoing revision of ventriculo-peritoneal shunt had persistent impairment of sensorium and episodes of hyponatremia (serum sodium 104 to 125 mmol/l), accompanied by polyuria, signs of poor peripheral, perfusion hypotension and low CVP, and high urinary sodium excretion (114-60 mmol/l). A diagnosis of cerebral salt wasting syndrome (CSWS) was made and was treated with saline replacement and fludrocortisone (10 microg/kg/day). Within next 3 days the sensorium, signs of shock, urine output and serum and urinary sodium returned to normal. The case illustrates that life-threatening hyponatremia in a child with neurological illness could be caused by CSWS, which must be differentiated from Syndrome of inappropriate antidiuretic hormone secretion (SIADH), as CSWS requires rigorous salt and volume replacement in contrast to fluid restriction in SIADH.
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Affiliation(s)
- Rashna Dass
- Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Abstract
Pituitary tumors are common and are often associated with endocrine abnormalities. Furthermore, pituitary surgery itself may result in additional hormonal changes, including impairment of anterior pituitary hormone secretion and, more commonly, abnormalities of ADH regulation. Endocrine management of patients with pituitary or other sellar lesions involves acute hospital-based and longer term office-based evaluation and treatment. In the immediate postoperative period, careful attention must be directed toward sodium and water balance as well as toward recognition of changes in endocrine function. Postoperative measurement of serum hormone levels also helps to determine if resection of a hypersecreting tumor has been successful. To minimize postoperative morbidity, perioperative endocrine assessment and management of patients undergoing pituitary surgery should consist of a team approach, involving both the neurosurgeon and the endocrinologist.
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Affiliation(s)
- Peter A Singer
- Division of Endocrinology and Metabolism, Keck School of Medicine, University of Southern California, 1355 San Pablo Street, Room 118, Los Angeles, CA 90033, USA.
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Abstract
Pediatric trauma performance improvement programs may share some of the criteria tracked by their counterparts in the adult trauma world. However, some of the criteria must be specific to the unique diagnostic and therapeutic needs of children. Nine criteria are defined in terms of the critical issues, what information is required to evaluate the appropriateness of the care provided in regards to those issues, and acceptable thresholds for review. In addition, practical aspects of multi-disciplinary peer review in the performance improvement process is presented.
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Affiliation(s)
- Pam Pieper
- University of Florida College of Nursing, Jacksonville 32209, USA
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Berkenbosch JW, Lentz CW, Jimenez DF, Tobias JD. Cerebral salt wasting syndrome following brain injury in three pediatric patients: suggestions for rapid diagnosis and therapy. Pediatr Neurosurg 2002; 36:75-9. [PMID: 11893888 DOI: 10.1159/000048356] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The association between hyponatremia and intracranial pathology has been well described. When accompanied by natriuresis, hyponatremia has most commonly been attributed to inappropriate secretion of antidiuretic hormone. However, there is growing evidence to suggest that many of these patients may actually have cerebral mediated salt losses, a disorder referred to as the cerebral salt wasting syndrome (CSWS). While this syndrome has been reasonably well described in adults, data regarding CSWS in pediatric-aged patients remains sparse. Since fluid management of these disorders is different, it is important that the clinician be able to rapidly differentiate between them. We report three cases of CSWS in acutely brain-injured children and comment on the role that early quantitation of urine volume and urine sodium concentration had in rapidly establishing the correct diagnosis.
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Affiliation(s)
- John W Berkenbosch
- Department of Child Health, The University of Missouri-Columbia, Columbia, MO 65212, USA.
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