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Yadav CP, Dhakal S, Bhattarai HB, Bhattarai M, Lamichhane S, Singh I, Subedi P. Traumatic retroclival hematoma complicated with hyponatremia and delayed traumatic intracranial hematoma in an adult: A case report. SAGE Open Med Case Rep 2023; 11:2050313X231178400. [PMID: 37325171 PMCID: PMC10265364 DOI: 10.1177/2050313x231178400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Accepted: 05/10/2023] [Indexed: 06/17/2023] Open
Abstract
Intracranial hematoma is a common variety of brain insults in trauma. However, posterior fossa hematoma in the retroclival location is quite unusual. There are limited numbers of case reports regarding traumatic retroclival hematoma. Some are managed with surgery in this condition. We present a traumatic retroclival hematoma in a 34-year-old gentleman who sustained brain trauma in a motor vehicle accident. His condition was further complicated by hyponatremia and delayed traumatic intracerebral hematoma in a distant location. The only symptom he had later was severe headache which could be attributed to delayed traumatic intracerebral hematoma and hyponatremia. He was managed conservatively and discharged on the 12th day from the hospital.
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Affiliation(s)
| | - Sudan Dhakal
- Department of Neurosurgery, Annapurna Neurological Institute & Allied Sciences, Kathmandu, Nepal
| | | | | | - Saral Lamichhane
- Gandaki Medical College Teaching Hospital & Research Center, Pokhara, Nepal
| | - Ishani Singh
- Kathmandu Medical College, Teaching Hospital and Research Center, Kathmandu, Nepal
| | - Prativa Subedi
- KIST Medical College & Teaching Hospital, Lalitpur, Nepal
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2
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Picetti E, Catena F, Abu-Zidan F, Ansaloni L, Armonda RA, Bala M, Balogh ZJ, Bertuccio A, Biffl WL, Bouzat P, Buki A, Cerasti D, Chesnut RM, Citerio G, Coccolini F, Coimbra R, Coniglio C, Fainardi E, Gupta D, Gurney JM, Hawrylux GWJ, Helbok R, Hutchinson PJA, Iaccarino C, Kolias A, Maier RW, Martin MJ, Meyfroidt G, Okonkwo DO, Rasulo F, Rizoli S, Rubiano A, Sahuquillo J, Sams VG, Servadei F, Sharma D, Shutter L, Stahel PF, Taccone FS, Udy A, Zoerle T, Agnoletti V, Bravi F, De Simone B, Kluger Y, Martino C, Moore EE, Sartelli M, Weber D, Robba C. Early management of isolated severe traumatic brain injury patients in a hospital without neurosurgical capabilities: a consensus and clinical recommendations of the World Society of Emergency Surgery (WSES). World J Emerg Surg 2023; 18:5. [PMID: 36624517 PMCID: PMC9830860 DOI: 10.1186/s13017-022-00468-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 12/01/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Severe traumatic brain-injured (TBI) patients should be primarily admitted to a hub trauma center (hospital with neurosurgical capabilities) to allow immediate delivery of appropriate care in a specialized environment. Sometimes, severe TBI patients are admitted to a spoke hospital (hospital without neurosurgical capabilities), and scarce data are available regarding the optimal management of severe isolated TBI patients who do not have immediate access to neurosurgical care. METHODS A multidisciplinary consensus panel composed of 41 physicians selected for their established clinical and scientific expertise in the acute management of TBI patients with different specializations (anesthesia/intensive care, neurocritical care, acute care surgery, neurosurgery and neuroradiology) was established. The consensus was endorsed by the World Society of Emergency Surgery, and a modified Delphi approach was adopted. RESULTS A total of 28 statements were proposed and discussed. Consensus was reached on 22 strong recommendations and 3 weak recommendations. In three cases, where consensus was not reached, no recommendation was provided. CONCLUSIONS This consensus provides practical recommendations to support clinician's decision making in the management of isolated severe TBI patients in centers without neurosurgical capabilities and during transfer to a hub center.
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Affiliation(s)
- Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy.
| | - Fausto Catena
- grid.414682.d0000 0004 1758 8744Department of General and Emergency Surgery, Bufalini Hospital, Cesena, Italy
| | - Fikri Abu-Zidan
- grid.43519.3a0000 0001 2193 6666The Research Office, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Luca Ansaloni
- grid.8982.b0000 0004 1762 5736Unit of General Surgery, San Matteo Hospital Pavia, University of Pavia, Pavia, Italy
| | - Rocco A. Armonda
- grid.411663.70000 0000 8937 0972Department of Neurosurgery, 71541MedStar Georgetown University Hospital, Washington, DC USA ,grid.415235.40000 0000 8585 5745Department of Neurosurgery, 8405MedStar Washington Hospital Center, Washington, DC USA
| | - Miklosh Bala
- grid.9619.70000 0004 1937 0538Acute Care Surgery and Trauma Unit, Department of General Surgery, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem Kiriat Hadassah, Jerusalem, Israel
| | - Zsolt J. Balogh
- grid.413648.cDepartment of Traumatology, John Hunter Hospital, Hunter Medical Research Institute and University of Newcastle, Newcastle, NSW Australia
| | - Alessandro Bertuccio
- Department of Neurosurgery, SS Antonio E Biagio E Cesare Arrigo Alessandria Hospital, Alessandria, Italy
| | - Walt L. Biffl
- grid.415401.5Scripps Clinic Medical Group, La Jolla, CA USA
| | - Pierre Bouzat
- grid.450308.a0000 0004 0369 268XInserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences, Université Grenoble Alpes, Grenoble, France
| | - Andras Buki
- grid.15895.300000 0001 0738 8966Department of Neurosurgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Davide Cerasti
- grid.411482.aNeuroradiology Unit, Azienda Ospedaliero-Universitaria of Parma, Parma, Italy
| | - Randall M. Chesnut
- grid.34477.330000000122986657Department of Neurological Surgery, University of Washington, Seattle, WA USA ,grid.34477.330000000122986657Department of Orthopedics and Sports Medicine, University of Washington, Seattle, WA USA ,grid.34477.330000000122986657Department of Global Health, University of Washington, Seattle, WA USA
| | - Giuseppe Citerio
- grid.7563.70000 0001 2174 1754School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy ,grid.415025.70000 0004 1756 8604Neuroscience Department, NeuroIntensive Care Unit, Hospital San Gerardo, ASST Monza, Monza, Italy
| | - Federico Coccolini
- grid.144189.10000 0004 1756 8209Department of Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Raul Coimbra
- grid.43582.380000 0000 9852 649XRiverside University Health System Medical Center, Loma Linda University School of Medicine, Riverside, CA USA
| | - Carlo Coniglio
- grid.416290.80000 0004 1759 7093Department of Anesthesia, Intensive Care and Prehospital Emergency, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy
| | - Enrico Fainardi
- grid.8404.80000 0004 1757 2304Neuroradiology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Deepak Gupta
- grid.413618.90000 0004 1767 6103Department of Neurosurgery, Neurosciences Centre and JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Jennifer M. Gurney
- grid.420328.f0000 0001 2110 0308Department of Trauma, San Antonio Military Medical Center and the U.S. Army Institute of Surgical Research, San Antonio, TX 78234 USA ,grid.461685.80000 0004 0467 8038The Department of Defense Center of Excellence for Trauma, Joint Trauma System (JTS), JBSA Fort Sam Houston, San Antonio, TX 78234 USA
| | - Gregory W. J. Hawrylux
- grid.239578.20000 0001 0675 4725Cleveland Clinic, 762 S. Cleveland-Massillon Rd, Akron, OH 44333 USA
| | - Raimund Helbok
- grid.5361.10000 0000 8853 2677Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Peter J. A. Hutchinson
- grid.5335.00000000121885934Department of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Corrado Iaccarino
- grid.413363.00000 0004 1769 5275Neurosurgery Unit, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
| | - Angelos Kolias
- grid.5335.00000000121885934National Institute for Health Research Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK ,grid.5335.00000000121885934Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital,, University of Cambridge, Cambridge, UK
| | - Ronald W. Maier
- grid.34477.330000000122986657Harborview Medical Center, University of Washington, Seattle, WA USA
| | - Matthew J. Martin
- grid.42505.360000 0001 2156 6853Division of Trauma and Acute Care Surgery, Los Angeles County + USC Medical Center, Los Angeles, CA USA
| | - Geert Meyfroidt
- grid.410569.f0000 0004 0626 3338Department of Intensive Care, University Hospitals Leuven, Louvain, Belgium ,grid.5596.f0000 0001 0668 7884Laboratory of Intensive Care Medicine, Katholieke Universiteit Leuven, Louvain, Belgium
| | - David O. Okonkwo
- grid.412689.00000 0001 0650 7433Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA USA
| | - Frank Rasulo
- grid.412725.7Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
| | - Sandro Rizoli
- grid.413542.50000 0004 0637 437XSurgery Department, Section of Trauma Surgery, Hamad General Hospital (HGH), Doha, Qatar
| | - Andres Rubiano
- grid.412195.a0000 0004 1761 4447INUB-MEDITECH Research Group, Institute of Neurosciences, Universidad El Bosque, Bogotá, Colombia
| | - Juan Sahuquillo
- grid.7080.f0000 0001 2296 0625Department of Neurosurgery, Vall d’Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Valerie G. Sams
- grid.413561.40000 0000 9881 9161Trauma Critical Care and Acute Care Surgery, Air Force Center for Sustainment of Trauma and Readiness Skills, University of Cincinnati Medical Center, Cincinnati, OH USA
| | - Franco Servadei
- grid.452490.eDepartment of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy ,grid.417728.f0000 0004 1756 8807Department of Neurosurgery, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Deepak Sharma
- grid.34477.330000000122986657Department of Anesthesiology and Pain Medicine and Neurological Surgery, University of Washington, Seattle, WA USA
| | - Lori Shutter
- grid.21925.3d0000 0004 1936 9000Department of Critical Care Medicine, UPMC/University of Pittsburgh School of Medicine, Pittsburgh, PA USA
| | - Philip F. Stahel
- grid.461417.10000 0004 0445 646XCollege of Osteopathic Medicine, Rocky Vista University, Parker, CO USA
| | - Fabio S. Taccone
- grid.410566.00000 0004 0626 3303Department of Intensive Care, Hôpital Universitaire de Bruxelles, Brussels, Belgium
| | - Andrew Udy
- grid.1623.60000 0004 0432 511XDepartment of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC 3004 Australia
| | - Tommaso Zoerle
- grid.4708.b0000 0004 1757 2822Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy ,grid.414818.00000 0004 1757 8749Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Vanni Agnoletti
- grid.414682.d0000 0004 1758 8744Anesthesia and Intensive Care Unit, AUSL Romagna, M. Bufalini Hospital, Cesena, Italy
| | - Francesca Bravi
- grid.415207.50000 0004 1760 3756Healthcare Administration, Santa Maria Delle Croci Hospital, Ravenna, Italy
| | - Belinda De Simone
- grid.418056.e0000 0004 1765 2558Department of General, Digestive and Metabolic Minimally Invasive Surgery, Centre Hospitalier Intercommunal De Poissy/St Germain en Laye, Poissy, France
| | - Yoram Kluger
- grid.413731.30000 0000 9950 8111Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Costanza Martino
- Department of Anesthesiology and Acute Care, Umberto I Hospital of Lugo, Ausl Della Romagna, Lugo, Italy
| | - Ernest E. Moore
- grid.241116.10000000107903411Ernest E Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, CO USA
| | | | - Dieter Weber
- grid.1012.20000 0004 1936 7910Department of General Surgery, Royal Perth Hospital, The University of Western Australia, Perth, Australia
| | - Chiara Robba
- grid.410345.70000 0004 1756 7871Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy ,grid.5606.50000 0001 2151 3065Department of Surgical Sciences and Integrated Sciences, University of Genoa, Genoa, Italy
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Dey S, Kumar R, Tarat A. Evaluation of Electrolyte Imbalance in Patients With Traumatic Brain Injury Admitted in the Central ICU of a Tertiary Care Centre: A Prospective Observational Study. Cureus 2021; 13:e17517. [PMID: 34595082 PMCID: PMC8474105 DOI: 10.7759/cureus.17517] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2021] [Indexed: 11/16/2022] Open
Abstract
Introduction Electrolyte imbalance is a salient finding in traumatic brain injury which can derail their clinical course of recovery in physical and cognitive health while prolonging the hospital stay. Objective This study aims to understand the variation in electrolyte profile that occurs in traumatic brain injury patients which can help in better patient management. Materials and method 50 trauma patients with head injury (Group A) and 50 patients without head injury (Group B) admitted in Central ICU (CICU) under the Department of Anaesthesiology, Assam Medical College and Hospital (AMCH) were selected and analysed with regard to their electrolyte variability. Result All trauma patients with head injury developed an imbalance to one or more electrolytes. Then mean electrolyte level in trauma patients with a head injury and in trauma patients without head injury were 139.3±7.45 vs 143.65±8.89, p<0.05 (sodium), 3.49±0.44 vs 3.88±0.49, p<0.05 (potassium), 7.81±0.5 vs 8.9± 0.35, p<0.05 (calcium) and 2±0.33 vs 2.47±0.41, p<0.05 (magnesium) respectively. Also, patients in the head injury group had a higher incidence of hypoalbuminemia than patients without head injury 2.47±0.67 vs 2.83±0.74 (p<0.05). Conclusion We conclude that traumatic brain injury patients have a greater risk of electrolyte imbalance, viz. hyponatremia, hypokalaemia, hypocalcaemia as well as hypomagnesemia, and hypophosphatemia along with hypoalbuminemia.
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Affiliation(s)
- Sandeep Dey
- Department of Anaesthesiology, Jorhat Medical College and Hospital, Jorhat, IND
| | - Ramesh Kumar
- Department of Anaesthesiology, Assam Medical College and Hospital, Dibrugarh, IND
| | - Abhijit Tarat
- Department of Anaesthesiology, Assam Medical College and Hospital, Dibrugarh, IND
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Dysnatremia and 6-Month Functional Outcomes in Critically Ill Patients With Aneurysmal Subarachnoid Hemorrhage: A Prospective Cohort Study. Crit Care Explor 2021; 3:e0445. [PMID: 34124687 PMCID: PMC8189636 DOI: 10.1097/cce.0000000000000445] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2022] Open
Abstract
OBJECTIVES To investigate the association between plasma sodium concentrations and 6-month neurologic outcome in critically ill patients with aneurysmal subarachnoid hemorrhage. DESIGN Prospective cohort study. SETTING Eleven ICUs in Australia and New Zealand. PARTICIPANTS Three-hundred fifty-six aneurysmal subarachnoid hemorrhage patients admitted to ICU between March 2016 and June 2018. The exposure variable was daily measured plasma sodium. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Six-month neurologic outcome as measured by the modified Rankin Scale. A poor outcome was defined as a modified Rankin Scale greater than or equal to 4. The mean age was 57 years (± 12.6 yr), 68% were female, and 32% (n = 113) had a poor outcome. In multivariable analysis, including age, illness severity, and process of care measures as covariates, higher mean sodium concentrations (odds ratio, 1.17; 95% CI, 1.05-1.29), and greater overall variability-as measured by the sd (odds ratio, 1.53; 95% CI, 1.17-1.99)-were associated with a greater likelihood of a poor outcome. Multivariable generalized additive modeling demonstrated, specifically, that a high initial sodium concentration, followed by a gradual decline from day 3 onwards, was also associated with a poor outcome. Finally, greater variability in sodium concentrations was associated with a longer ICU and hospital length of stay: mean ICU length of stay ratio (1.13; 95% CI, 1.07-1.20) and mean hospital length of stay ratio (1.08; 95% CI, 1.01-1.15). CONCLUSIONS In critically ill aneurysmal subarachnoid hemorrhage patients, higher mean sodium concentrations and greater variability were associated with worse neurologic outcomes at 6 months, despite adjustment for known confounders. Interventional studies would be required to demonstrate a causal relationship.
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Impact of donor sodium levels on clinical outcomes in liver transplant recipients: a systematic review. Eur J Gastroenterol Hepatol 2020; 32:1489-1496. [PMID: 32804851 DOI: 10.1097/meg.0000000000001776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
We performed a systematic review of the literature to examine the effects of donor sodium levels on liver graft function and recipient survival, as well as to identify the optimal serum sodium target in donors. We searched MEDLINE, Cochrane, and trial registries from 1946 to May 2019 for studies that evaluated the effect of serum sodium levels in neurologically deceased liver donors on transplant outcomes. We used a two-step review process with four independent reviewers to identify relevant articles based on inclusion/exclusion criteria. We summarize the results narratively, assess the risk of bias, and apply the Grading of Recommendations Assessment, Development, and Evaluation methods to evaluate the certainty in the evidence. We included 25 cohort studies were in our final analysis (total n = 19 389). Twenty-two reported on graft function and survival. Summary data suggest an association between donor serum sodium and recipient liver graft dysfunction, with very low certainty in evidence due to serious concerns with risk of bias, inconsistency, indirectness, and imprecision. Seven studies reported on recipient mortality, with results suggesting no association between donor sodium and recipient survival. The certainty in evidence for this outcome was also very low due to serious concerns with imprecision, indirectness, and risk of bias. Donor sodium dysregulation is associated with liver graft dysfunction, but not recipient mortality. Further research is needed to determine the effects of correcting donor sodium levels on transplant outcomes, quantify the dose-response curve, and identify liver recipients most vulnerable to sodium dysregulation.
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Kleindienst A, Georgiev S, Schlaffer SM, Buchfelder M. Tolvaptan Versus Fluid Restriction in the Treatment of Hyponatremia Resulting from SIADH Following Pituitary Surgery. J Endocr Soc 2020; 4:bvaa068. [PMID: 32666012 PMCID: PMC7326480 DOI: 10.1210/jendso/bvaa068] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 06/08/2020] [Indexed: 12/21/2022] Open
Abstract
Context The relevance of hyponatremia has been acknowledged by guidelines from the United States (2013) and Europe (2014). However, treatment recommendations differ due to limited evidence. Objective In hyponatremia following pituitary surgery-caused by the syndrome of inappropriate antidiuretic hormone (SIADH) secretion-we compared fluid restriction with the pharmacological increase of water excretion by blocking the vasopressin 2 receptors with tolvaptan at a low and a moderate dose. Design Prospective observational study. Setting Neurosurgical Department of a University hospital with more than 200 surgical pituitary procedures per year. Patients Patients undergoing pituitary surgery and developing serum sodium below 136 mmol/L. The diagnosis of SIADH was established by euvolemia (daily measurement of body weight and fluid balance), inappropriately concentrated urine (specific gravity), and exclusion of adrenocorticotropic and thyroid-stimulating hormone deficiency. Intervention Patients were treated with fluid restriction (n = 40) or tolvaptan at 3.75 (n = 38) or 7.5 mg (n = 48). Main Outcome Measures Treatment efficacy was assessed by the duration of hyponatremia, sodium nadir, and length of hospitalization. Safety was established by a sodium increment below 10 mmol/L per day and exclusion of side effects. Results Treatment with 7.5 mg of tolvaptan resulted in a significant attenuation of hyponatremia and in a significant overcorrection of serum sodium in 30% of patients. The duration of hospitalization did not differ between treatment groups. Conclusions Tolvaptan at a moderate dose is more effective than fluid restriction in the treatment of SIADH. Overcorrection of serum sodium may be a side effect of tolvaptan even at low doses.
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Affiliation(s)
- Andrea Kleindienst
- Department of Neurosurgery, Friedrich-Alexander-University Nürnberg-Erlangen, Erlangen, Germany
| | - Simeon Georgiev
- Department of Neurosurgery, Friedrich-Alexander-University Nürnberg-Erlangen, Erlangen, Germany
| | - Sven Martin Schlaffer
- Department of Neurosurgery, Friedrich-Alexander-University Nürnberg-Erlangen, Erlangen, Germany
| | - Michael Buchfelder
- Department of Neurosurgery, Friedrich-Alexander-University Nürnberg-Erlangen, Erlangen, Germany
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Abstract
PURPOSE OF REVIEW This article provides an overview of the major electrolyte disorders and discusses in detail the homeostasis, etiologies, neurologic manifestations, and treatment of these disorders. RECENT FINDINGS The diagnosis and management of hyponatremia continue to evolve. Diagnostic accuracy is improved by assessing serum and urine osmolality as well as urinary sodium. Avoiding overcorrection of hyponatremia is crucial to avoid osmotic demyelination syndrome, although even careful correction can cause osmotic demyelination syndrome in patients who have other risk factors. The clinical presentation of osmotic demyelination syndrome has expanded, with many patients presenting with extrapontine myelinolysis in addition to central pontine myelinolysis. SUMMARY Electrolyte disorders often present with neurologic manifestations. Whereas disorders of some electrolytes, such as sodium, preferentially affect the central nervous system, disorders of others, such as potassium and calcium, have significant neuromuscular manifestations. An understanding of the pathophysiology of these disorders and recognition of these manifestations are crucial for the practicing neurologist as the symptoms are reversible with correct management.
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Lerner DP, Shepherd SA, Batra A. Hyponatremia in the Neurologically Ill Patient: A Review. Neurohospitalist 2020; 10:208-216. [PMID: 32549945 DOI: 10.1177/1941874419895124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Hyponatremia is a well-known disorder commonly faced by clinicians managing neurologically ill patients. Neurological disorders are often associated with hyponatremia during their acute presentation and can be associated with specific neurologic etiologies and symptoms. Patients may present with hyponatremia with traumatic brain injury, develop hyponatremia subacutely following aneurysmal subarachnoid hemorrhage, or may manifest with seizures due to hyponatremia itself. Clinicians caring for the neurologically ill patient should be well versed in identifying these early signs, symptoms, and etiologies of hyponatremia. Early diagnosis and treatment can potentially avoid neurologic and systemic complications in these patients and improve outcomes. This review focuses on the causes and findings of hyponatremia in the neurologically ill patient and discusses the pathophysiology, diagnoses, and treatment strategies for commonly encountered etiologies.
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Affiliation(s)
- David P Lerner
- Department of Neurology, Lahey Hospital and Medical Center, Burlington, MA, USA
| | - Starane A Shepherd
- Department of Neurology, Rush University Medical Center, Chicago, IL, USA
| | - Ayush Batra
- Ken & Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Utagawa A. Fluid Management for Neurocritical Care. Neurocrit Care 2019. [DOI: 10.1007/978-981-13-7272-8_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Hyponatremia in Traumatic Brain Injury: A Practical Management Protocol. World Neurosurg 2017; 108:529-533. [PMID: 28899834 DOI: 10.1016/j.wneu.2017.09.013] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 09/01/2017] [Accepted: 09/02/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND Hyponatremia (defined as serum sodium <135 mEq/L) is the most common electrolyte abnormality in traumatic brain injury (TBI) and is also an independent predictor of poor neurologic outcome. The reported incidence of hyponatremia varies widely in literature reports, and there is continuing difficulty in clearly differentiating between the 2 common causes of hyponatremia with natriuresis: the syndrome of inappropriate antidiuretic hormone secretion (SIADH) and cerebral salt wasting (CSW). We encounter hyponatremia frequently in our practice, and we therefore decided to review data from our center to estimate the incidence of hyponatremia and the results of our management strategies, and attempt to formulate simple guidelines for the correction of hyponatremia in TBI. METHODS A retrospective analysis of 1500 consecutively admitted patients with TBI was performed by the use of electronic records and radiographic review. Hyponatremia was defined as serum sodium <135 mEq/L, and natriuresis as a urine spot sodium of more than >40 mEq/L. The incidence of TBI, its management, and the effect of fludrocortisone were evaluated. RESULTS The incidence of hyponatremia was 13.2%. Early therapy with fludrocortisone significantly reduced the duration of hospital stay (P < 0.05). Traumatic subarachnoid hemorrhage was the most common abnormality on the admission computed tomographic scan in patients who experienced hyponatremia. CONCLUSION Early initiation of fludrocortisone in the setting of hyponatremia with natriuresis decreases the hospital stay. This protocol is probably safer in a tropical country where fluid restriction might be harmful. It also eliminates the need to differentiate between SIADH and CSW.
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Shchekochikhin DY, Kozlovskaya NL, Kopylov FY, Syrkin AL, Shilov EM. Hyponatremia: A clinical approach. TERAPEVT ARKH 2017; 89:134-140. [DOI: 10.17116/terarkh2017898134-140] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Hyponatremia is the most common electrolyte metabolic abnormality in clinical practice. The unfavorable course of many diseases is associated with hyponatremia. Acute severe hyponatremia is life-threatening because cerebral edema may develop. Less obvious chronic hyponatremia increases the risk of balance problems, falls and fractures, especially in elderly patients. In any occasion, hyponatremia should not be now regarded only as a laboratory phenomenon in critically ill patients, but it necessitates a thorough clinical analysis of each individual case and appropriate therapy. The paper presents approaches to diagnosing and treating hyponatremia in various clinical situations.
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Abstract
Purpose To describe causes, pathophysiologic mechanisms, and classifications of hyponatremia, and to describe clinical symptoms and underlying disease states associated with different levels of hyponatremia. Summary The key to comprehending hyponatremia is to understand body water content and plasma osmolality and accurately assess arterial volume. Hyponatremia results from sodium dilution because of retained water or sodium depletion because of electrolyte loss in excess of water loss. Body sodium, water, and extracellular fluid (ECF) volume are tightly regulated by mechanisms that act to maintain a closely controlled concentration of solutes in the ECF. These forces act to regulate water content and sodium excretion to maintain normal intravascular volume. The body closely defends normal plasma osmolality within a narrow range primarily by controlling the release of arginine vasopressin (AVP) and via the thirst mechanism. A number of factors can stimulate inappropriate AVP release and cause or worsen hyponatremia. Dysregulation of AVP plays an important role in heart failure and cirrhosis, common causes of hypervolemic hyponatremia. Conclusion Body water content and plasma osmolality are tightly regulated by the action of AVP. A variety of disease states are associated with hyponatremia related to inappropriate AVP release. The cause of the electrolyte disturbance must be determined, because it can have profound implications for treatment. Differential diagnosis can be guided by observation of the rapidity of onset as well as volume status changes. If untreated or treated inappropriately, hyponatremia can impact morbidity and mortality.
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Affiliation(s)
- Kirkwood F. Adams
- Division of Cardiology, Department of Medicine, University of North Carolina School of Medicine, 160 Dental Circle, CB# 7075, 6034 Burnett Womack Building, Chapel Hill, NC 27599
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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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Howard R, Eriksson S, Hirsch N, Kitchen N, Kullmann D, Taylor C, Walker M. Disorders of Consciousness, Intensive Care Neurology and Sleep. Neurology 2016. [DOI: 10.1002/9781118486160.ch20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Palmer BF, Rock AD, Woodward EJ. Dose comparison of conivaptan (Vaprisol®) in patients with euvolemic or hypervolemic hyponatremia--efficacy, safety, and pharmacokinetics. Drug Des Devel Ther 2016; 10:339-51. [PMID: 26848258 PMCID: PMC4723016 DOI: 10.2147/dddt.s95326] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
PURPOSE This study aimed to evaluate the efficacy, safety, and pharmacokinetics of 20 and 40 mg/day conivaptan (Vaprisol®) in patients with hypervolemic or euvolemic hyponatremia. METHODS Hyponatremic patients - serum sodium (sNa) ≤130 mEq/L - received either 20 or 40 mg/day of conivaptan for 4 days, following an initial 20 mg loading dose. Efficacy was evaluated by the magnitude and extent of change in sNa. Safety was evaluated by the incidence of adverse events, changes in vital signs and laboratory parameters, rate of sNa correction, and frequency of infusion-site reactions. Pharmacokinetic parameters were also measured. RESULTS A total of 37 patients received 20 mg/day and 214 patients received 40 mg/day conivaptan. Baseline-adjusted sNa-area under the concentration-time curve increased by an average of 753.8±499.9 mEq·hr/L (20 mg/day) and 689.2±417.3 mEq·hr/L (40 mg/day) over the course of the 4-day treatment period. The majority of patients in both treatment groups achieved a 4 mEq/L increase in sNa over baseline in ~24 hours (82.5%). Average increase in sNa after 4 days was ~10 mEq/L, varying with dosage level and baseline volume status. Treatment success (normal sNa or increase of ≥6 mEq/L) was attained by 70.3% of patients in the 20 mg/day group and 72.0% in the 40 mg/day group. CONCLUSION Both 20 and 40 mg/day doses of conivaptan are efficacious in increasing sNa over 4 days of treatment with no observed increase in the frequency of adverse events or specific infusion-site reactions using the higher dose. The pharmacokinetic parameters of both doses were similar to what has been reported previously, exhibiting greater-than-dose-proportional plasma concentrations.
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Affiliation(s)
- Biff F Palmer
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, USA
| | - Amy D Rock
- Department of Research and Development, Cumberland Pharmaceuticals Inc., Nashville, TN, USA
| | - Emily J Woodward
- Department of Research and Development, Cumberland Pharmaceuticals Inc., Nashville, TN, USA
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Kleindienst A, Hannon MJ, Buchfelder M, Verbalis JG. Hyponatremia in Neurotrauma: The Role of Vasopressin. J Neurotrauma 2015; 33:615-24. [PMID: 26472056 DOI: 10.1089/neu.2015.3981] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Hyponatremia is frequent in patients suffering from traumatic brain injury, subarachnoid hemorrhage, or following intracranial procedures, with approximately 20% having a decreased serum sodium concentration to <125 mmol/L. The pathophysiology of hyponatremia in neurotrauma is not completely understood, but in large part is explained by the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). The abnormal water and/or sodium handling creates an osmotic gradient promoting the shift of water into brain cells, thereby worsening cerebral edema and precipitating neurological deterioration. Unless hyponatremia is corrected promptly and effectively, morbidity and mortality increases through seizures, elevations in intracranial pressure, and/or herniation. The excess mortality in patients with severe hyponatremia (<125 mmol/L) extends beyond the time frame of hospital admission, with a reported mortality of 20% in hospital and 45% within 6 months of follow-up. Current options for the management of hyponatremia include fluid restriction, hypertonic saline, mineralocorticoids, and osmotic diuretics. However, the recent development of vasopressin receptor antagonists provides a more physiological tool for the management of excess water retention and consequent hyponatremia, such as occurs in SIADH. This review summarizes the existing literature on the pathophysiology, clinical features, and management of hyponatremia in the setting of neurotrauma.
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Affiliation(s)
- Andrea Kleindienst
- 1 Department of Neurosurgery, Friedrich-Alexander-University Erlangen-Nürenberg , Erlangen, Germany .,2 Department of Neurosurgery, Klinikum Amberg, Amberg, Germany
| | | | - Michael Buchfelder
- 1 Department of Neurosurgery, Friedrich-Alexander-University Erlangen-Nürenberg , Erlangen, Germany
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Mahanna E, McGrade H, Afshinnik A, Iwuchukwu I, Sherma AK, Sabharwal V. Management of Sodium Abnormalities in the Neurosurgical Intensive Care Unit. CURRENT ANESTHESIOLOGY REPORTS 2015. [DOI: 10.1007/s40140-015-0126-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Gray JR, Morbitzer KA, Liu-DeRyke X, Parker D, Zimmerman LH, Rhoney DH. Hyponatremia in Patients with Spontaneous Intracerebral Hemorrhage. J Clin Med 2014; 3:1322-32. [PMID: 26237605 PMCID: PMC4470185 DOI: 10.3390/jcm3041322] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Revised: 10/28/2014] [Accepted: 10/31/2014] [Indexed: 12/04/2022] Open
Abstract
Hyponatremia is the most frequently encountered electrolyte abnormality in critically ill patients. Hyponatremia on admission has been identified as an independent predictor of in-hospital mortality in patients with spontaneous intracerebral hemorrhage (sICH). However, the incidence and etiology of hyponatremia (HN) during hospitalization in a neurointensive care unit following spontaneous intracerebral hemorrhage (sICH) remains unknown. This was a retrospective analysis of consecutive patients admitted to Detroit Receiving Hospital for sICH between January 2006 and July 2009. All serum Na levels were recorded for patients during the ICU stay. HN was defined as Na <135 mmol/L. A total of 99 patients were analyzed with HN developing in 24% of sICH patients. Patients with HN had an average sodium nadir of 130 ± 3 mmol/L and an average time from admission to sodium <135 mmol/L of 3.9 ± 5.7 days. The most common cause of hyponatremia was syndrome of inappropriate antidiuretic hormone (90% of HN patients). Patients with HN were more likely to have fever (50% vs. 23%; p = 0.01), infection (58% vs. 28%; p = 0.007) as well as a longer hospital length of stay (14 (8–25) vs. 6 (3–9) days; p < 0.001). Of the patients who developed HN, fifteen (62.5%) patients developed HN in the first week following sICH. This shows HN has a fairly high incidence following sICH. The presence of HN is associated with longer hospital length of stays and higher rates of patient complications, which may result in worse patient outcomes. Further study is necessary to characterize the clinical relevance and treatment of HN in this population.
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Affiliation(s)
- Jaime Robenolt Gray
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA.
| | - Kathryn A Morbitzer
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA.
| | - Xi Liu-DeRyke
- Department of Pharmacy, Detroit Receiving Hospital, Detroit, MI 48201, USA.
| | - Dennis Parker
- Department of Pharmacy, Detroit Receiving Hospital, Detroit, MI 48201, USA.
- Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI 48201, USA.
| | - Lisa Hall Zimmerman
- Department of Pharmacy, New Hanover Regional Medical Center, Wilmington, NC 28401, USA.
| | - Denise H Rhoney
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA.
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Zhang YZ, Qie JY, Zhang QH. Incidence and mortality prognosis of dysnatremias in neurologic critically ill patients. Eur Neurol 2014; 73:29-36. [PMID: 25377050 DOI: 10.1159/000368353] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Accepted: 09/14/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND Dysnatremia, which is associated with increased mortality in general intensive care units (ICU), has not been thoroughly studied in neurologic ICU (NICU). METHODS Prevalence of dysnatremia was retrospectively assessed. The multivariable binary logistic regression model was used to determine the influence of dysnatremia on mortality. RESULTS Of 519 patients, 106 (20.4%) were admitted with hyponatremia and 177 (34.10%) with hypernatremia. Hypernatremia was detected in 69 (13.29%) patients on admission to NICU and in 108 patients (20.81%) during the ICU stay. However, the incidence of dysnatremia did not differ across the neurological categories (p = 0.4690). ICU stay in patients with acquired hypernatremia (22.3 ± 25.35 days) was longer than those with admission hypernatremia (13.5 ± 12.8 days) or with consistent normonatremia (16.16 ± 20.06 days). The other indicators such as Acute Physiology and Chronic Health Evaluation II, Glasgow Coma Scale score, urinary catheterization, and incidence of pneumonia were also associated with the serum sodium concentrations. Hypernatremia both on admission and acquired in NICU could significantly differentiate between survivors and nonsurvivors (p = 0.002 and <0.0001). However, only NICU-acquired hypernatremia was the independent risk factor for mortality with high sensitivity (p = 0.000). CONCLUSIONS Dysnatremia is more common in NICU, whereas only acquired-hypernatremia was independently associated with outcome.
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Affiliation(s)
- Yun-Zhou Zhang
- Neurocritical Care Unit, Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, PR China
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Bajwa SJS, Haldar R. Endocrinological disorders affecting neurosurgical patients: An intensivists perspective. Indian J Endocrinol Metab 2014; 18:778-783. [PMID: 25364671 PMCID: PMC4192981 DOI: 10.4103/2230-8210.140240] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Management of critically ill neurosurgical patients is often complicated by the presence or development of endocrinological ailments which complicate the clinical scenario and adversely affect the prognosis of these patients. The anatomical proximity to the vital centers regulating the endocrinological physiology and alteration in the neurotransmitter release causes disturbances in the hormonal homeostasis. This paves the way for development of diverse disorders where single or multiple hormones may be involved which can have deleterious effect on the different organ system. Understanding and awareness of these disorders is important for the treating intensivist to recognize these changes early in their course, so that appropriate and timely therapeutic measures can be initiated along with the treatment of the primary malady.
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Affiliation(s)
- Sukhminder Jit Singh Bajwa
- Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Banur, Punjab, India
| | - Rudrashish Haldar
- Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Banur, Punjab, India
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Ryan JM, Gorman SL. How Clinical Reasoning Can and Should Impact Interprofessional Communication to Address Behaviors That Hinder Acute Care Practice. JOURNAL OF ACUTE CARE PHYSICAL THERAPY 2014. [DOI: 10.1097/01.jat.0000446089.28525.f2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Gritti P, Lanterna LA, Rotasperti L, Filippini M, Cazzaniga S, Brembilla C, Sarnecki T, Lorini FL. Clinical evaluation of hyponatremia and hypovolemia in critically ill adult neurologic patients: contribution of the use of cumulative balance of sodium. J Anesth 2014; 28:687-95. [PMID: 24652158 DOI: 10.1007/s00540-014-1814-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Accepted: 02/25/2014] [Indexed: 11/27/2022]
Abstract
PURPOSE Knowledge of the cumulative balance of sodium (CBS) is important for the diagnosis of salt disorders and water homeostasis and has the potential to predict hypovolemic status in acute neurological patients. However, an extensive application of the use of CBS is still lacking in the intensive care setting, where salt and water homeostasis represents a priority. METHODS Records of consecutive series of acute neurological patients admitted to a neurointensive care unit over a 6-month period were retrospectively reviewed. CBS was calculated at the admission to the Emergency Department. Discrimination between cerebral salt-wasting syndrome (CSWS) and the syndrome of inappropriate antidiuretic hormone secretion (SIADH) was performed on the basis of the classical criteria. Additionally, we used the findings of a negative CBS exceeding 2 mEq/kg for the diagnosis of CSWS. Two independent clinicians who were blinded to the CBS results performed diagnosis of the causes of hyponatremia and estimated the daily volemic status of the patients on the basis of clinical parameters. Logistic regression analysis was used to determine the independent prognostic factors of hypovolemia. RESULTS Thirty-five patients were studied for a total of 418 days. Four patients (11.4%) fitted the criteria of CSWS and three patients (8.5%) had SIADH. The unavailability of the CBS led to a wrong diagnosis in three of the eight hyponatremic patients (37.5%). The risk of developing hypovolemia in patients with negative CBS was 7.1 times higher (CI 3.86-13.06; p < 0.001). Multivariate analysis revealed that negative cumulative fluid balance, negative CBS >2 mEq/kg, and CVP ≤5 cmH2O were independent prognostic factors for hypovolemia. CONCLUSIONS CBS is likely to be a useful parameter in the diagnosis of CSWS and a surrogate parameter for estimating hypovolemia in acute neurological patients.
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Affiliation(s)
- Paolo Gritti
- Department of Anesthesia and Intensive Care, Ospedale Papa Giovanni XXIII°, Bergamo, Italy,
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Neurologic complications of electrolyte disturbances and acid-base balance. HANDBOOK OF CLINICAL NEUROLOGY 2014; 119:365-82. [PMID: 24365306 DOI: 10.1016/b978-0-7020-4086-3.00023-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Electrolyte and acid-base disturbances are common occurrences in daily clinical practice. Although these abnormalities can be readily ascertained from routine laboratory findings, only specific clinical correlates may attest as to their significance. Among a wide phenotypic spectrum, acute electrolyte and acid-base disturbances may affect the peripheral nervous system as arreflexic weakness (hypermagnesemia, hyperkalemia, and hypophosphatemia), the central nervous system as epileptic encephalopathies (hypomagnesemia, dysnatremias, and hypocalcemia), or both as a mixture of encephalopathy and weakness or paresthesias (hypocalcemia, alkalosis). Disabling complications may develop not only when these derangements are overlooked and left untreated (e.g., visual loss from intracranial hypertension in respiratory or metabolic acidosis; quadriplegia with respiratory insufficiency in hypermagnesemia) but also when they are inappropriately managed (e.g., central pontine myelinolisis when rapidly correcting hyponatremia; cardiac arrhythmias when aggressively correcting hypo- or hyperkalemia). Therefore prompt identification of the specific neurometabolic syndromes is critical to correct the causative electrolyte or acid-base disturbances and prevent permanent central or peripheral nervous system injury. This chapter reviews the pathophysiology, clinical investigations, clinical phenotypes, and current management strategies in disorders resulting from alterations in the plasma concentration of sodium, potassium, calcium, magnesium, and phosphorus as well as from acidemia and alkalemia.
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Outcome and frequency of sodium disturbances in neurocritically ill patients. Acta Neurol Belg 2013; 113:139-45. [PMID: 23055112 DOI: 10.1007/s13760-012-0137-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2012] [Accepted: 09/13/2012] [Indexed: 10/27/2022]
Abstract
Sodium disturbances are frequent and serious complications in neurocritically ill patients. Hyponatremia is more common than hypernatremia, which is, however, prognostically worse. The aim of this study was to analyse outcome and frequency of sodium disturbances in relation to measured serum osmolality in neurologic-neurosurgical critically ill patients. A 5-year retrospective collection of patients (pts) and laboratory data were made from the Laboratory Information System database in the Clinical Biochemistry Department. The criteria for patients' inclusion was acute brain disease and serum sodium (SNa(+)) <135 mmol/l (hyponatremia) or SNa(+) >150 mmol/l (hypernatremia). Hypoosmolality was defined as measured serum osmolality (SOsm) <275 mmol/kg, hyperosmolality as SOsm >295 mmol/kg. We performed analysis of differences between hyponatremia and hypernatremia and subanalysis of differences between hypoosmolal hyponatremia and hypernatremia. From 1,440 pts with acute brain diseases there were 251 (17 %) pts with hyponatremia (mean SNa(+) 131.78 ± 2.89 mmol/l, SOsm 279.46 ± 11.84 mmol/kg) and 75 (5 %) pts with hypernatremia (mean SNa(+) 154.38 ± 3.76 mmol/l, SOsm 326.07 ± 15.93 mmol/kg). Hypoosmolal hyponatremia occurred in 50 (20 % of hyponatremic patients) pts (mean SNa(+) 129.62 ± 4.15 mmol/l; mean SOsm 267.35 ± 6.28 mmol/kg). Multiple logistic regression analysis showed that hypernatremia is a significant predictor of mortality during neurologic-neurosurgical intensive care unit (NNICU) stay (OR 5.3, p = 0.002) but not a predictor of bad outcome upon discharge from NNICU, defined as Glasgow Coma Scale 1-3. These results showed that hypernatremia occurred less frequently than all hyponatremias, but more often than hypoosmolal hyponatremia. Hypernatremia was shown to be a significant predictor of NNICU mortality compared to hyponatremia.
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Abstract
The pituitary gland has a role in puberty, reproduction, stress-adaptive responses, sodium and water balance, uterine contractions, lactation, thyroid function, growth, body composition and skin pigmentation. Ageing is marked by initially subtle erosion of physiological signalling mechanisms, resulting in lower incremental secretory-burst amplitude, more disorderly patterns of pituitary hormone release and blunted 24 h rhythmic secretion. Almost all pituitary hormones are altered by ageing in humans, often in a manner dependent on sex, body composition, stress, comorbidity, intercurrent illness, medication use, physical frailty, caloric intake, immune status, level of exercise, and neurocognitive decline. The aim of this article is to critically discuss the mechanisms mediating clinical facets of changes in the hypothalamic-pituitary axis during ageing, and the extent to which confounding factors operate to obscure ageing-related effects.
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Affiliation(s)
- Johannes D Veldhuis
- Endocrine Research Unit, Mayo School of Graduate Medical Education, Center for Translational Science Activities, Mayo Clinic, Rochester, MN 55905, USA.
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Response to a bolus of conivaptan in patients with acute hyponatremia after brain injury. J Crit Care 2012; 27:745.e1-5. [DOI: 10.1016/j.jcrc.2012.03.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Revised: 03/05/2012] [Accepted: 03/11/2012] [Indexed: 11/19/2022]
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Abstract
Hyponatraemia--the most common serum electrolyte disorder--has also emerged as an important marker of the severity and prognosis of important diseases such as heart failure and cirrhosis. Acute hyponatraemia can cause severe encephalopathy, but the rapid correction of chronic hyponatraemia can also profoundly impair brain function and even cause death. With the expanding elderly population and the increased prevalence of hyponatraemia in this segment of society, prospective studies are needed to examine whether correcting hyponatraemia in the elderly will diminish cognitive impairment, improve balance and reduce the incidence of falls and fractures. Given that polypharmacy is also common in the elderly population, the various medications that may stimulate arginine vasopressin release and/or enhance the hormone's action to increase water absorption must also be taken into consideration. Whether hyponatraemia in a patient with cancer is merely a marker of poor prognosis or whether its presence may alter the patient's quality of life remains to be examined. In any case, hyponatraemia can no longer be considered as just a biochemical bystander in the ill patient. A systematic diagnostic approach is necessary to determine the specific aetiology of a patient's hyponatraemia. Therapy must then be dictated not only by recognized reversible causes such as advanced hypothyroidism, adrenal insufficiency, diuretics or other medicines, but also by whether the hyponatraemia occurred acutely or chronically. Information is emerging that the vast majority of cases of hyponatraemia are caused by the nonosmotic release of arginine vasopressin. Now that vasopressin V2-receptor blockers are available, a new era of clinical investigation is necessary to examine whether hyponatraemia is just a marker of severe disease or whether correction of hyponatraemia could improve a patient's quality of life. Such an approach must involve prospective randomized studies in different groups of patients with hyponatraemia, including those with advanced heart failure, those with cirrhosis, patients with cancer, and the elderly.
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Ryan CG, Ajam KS, Thompson RE. Neurosurgery. Perioper Med (Lond) 2012. [DOI: 10.1002/9781118375372.ch24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Abstract
Cerebral edema is a common finding in a variety of neurological conditions, including ischemic stroke, traumatic brain injury, ruptured cerebral aneurysm, and neoplasia. With the possible exception of neoplasia, most pathological processes leading to edema seem to share similar molecular mechanisms of edema formation. Challenges to brain-cell volume homeostasis can have dramatic consequences, given the fixed volume of the rigid skull and the effect of swelling on secondary neuronal injury. With even small changes in cellular and extracellular volume, cerebral edema can compromise regional or global cerebral blood flow and metabolism or result in compression of vital brain structures. Osmotherapy has been the mainstay of pharmacologic therapy and is typically administered as part of an escalating medical treatment algorithm that can include corticosteroids, diuretics, and pharmacological cerebral metabolic suppression. Novel treatment targets for cerebral edema include the Na(+)-K(+)-2Cl(-) co-transporter (NKCC1) and the SUR1-regulated NC(Ca-ATP) (SUR1/TRPM4) channel. These two ion channels have been demonstrated to be critical mediators of edema formation in brain-injured states. Their specific inhibitors, bumetanide and glibenclamide, respectively, are well-characterized Food and Drug Administration-approved drugs with excellent safety profiles. Directed inhibition of these ion transporters has the potential to reduce the development of cerebral edema and is currently being investigated in human clinical trials. Another class of treatment agents for cerebral edema is vasopressin receptor antagonists. Euvolemic hyponatremia is present in a myriad of neurological conditions resulting in cerebral edema. A specific antagonist of the vasopressin V1A- and V2-receptor, conivaptan, promotes water excretion while sparing electrolytes through a process known as aquaresis.
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Affiliation(s)
- Brian P. Walcott
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114 USA
| | - Kristopher T. Kahle
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114 USA
| | - J. Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201 USA
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Patterson JH, Adams KF, Human T, Rhoney DH. Case Studies in Hypervolemic Hyponatremia. Hosp Pharm 2011. [DOI: 10.1310/hpj4612-s39] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Brain Natriuretic Peptide Concentrations After Aneurysmal Subarachnoid Hemorrhage: Relationship with Hypovolemia and Hyponatremia. Neurocrit Care 2011; 14:176-81. [DOI: 10.1007/s12028-011-9504-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Murphy-Human T, Diringer MN. Sodium Disturbances Commonly Encountered in the Neurologic Intensive Care Unit. J Pharm Pract 2010; 23:470-82. [DOI: 10.1177/0897190010372323] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Disorders of sodium and water balance are common in patients with central nervous system (CNS) disease. These disorders frequently complicate the treatment course by precipitating or worsening neurological symptoms. These patients are not only at risk for symptoms secondary to dysnatremia but also at risk from the consequences of treatment. If not treated properly, this electrolyte disturbance can vastly increase morbidity and can even lead to death. Appropriate diagnosis and intervention requires an understanding of the physiologic and pathophysiologic mechanisms involved in sodium and water homeostasis.
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Affiliation(s)
- Theresa Murphy-Human
- Department of Pharmacy, Barnes-Jewish Hospital, Washington University School of Medicine, St Louis, MO, USA
| | - Michael N. Diringer
- Neurological Surgery and Anesthesiology, Neurology/Neurosurgery Intensive Care Unit, Washington University School of Medicine, St Louis, MO, USA
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Orbak Z, Kara IS. Unusual complication in a child with lightning strike: cerebral salt wasting. Childs Nerv Syst 2010; 26:1125-7. [PMID: 20490508 DOI: 10.1007/s00381-010-1175-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2010] [Accepted: 05/06/2010] [Indexed: 11/27/2022]
Abstract
Several case reports have presented various neurological complications caused by lightning. However, there was no report related to cerebral salt wasting caused by lightning injury. We described a patient with lightning strike, who was subsequently diagnosed with cerebral salt wasting.
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Affiliation(s)
- Zerrin Orbak
- Department of Pediatric Endocrinology and Metabolism, Medical Faculty, Ataturk University, 25240 Erzurum, Turkey.
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Assessment und Management medizinischer Komplikationen. NeuroRehabilitation 2010. [DOI: 10.1007/978-3-642-12915-5_34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Rahman M, Friedman WA. Hyponatremia in neurosurgical patients: clinical guidelines development. Neurosurgery 2009; 65:925-35; discussion 935-6. [PMID: 19834406 DOI: 10.1227/01.neu.0000358954.62182.b3] [Citation(s) in RCA: 101] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Neurosurgical patients have a high risk of hyponatremia and associated complications. We critically evaluated the existing literature to identify the determinants for the development of hyponatremia and which management strategies provided the best outcomes. METHODS A multidisciplinary panel in the areas of neurosurgery, nephrology, critical care medicine, endocrinology, pharmacy, and nursing summarized and classified hyponatremia literature scientific studies published in English from 1950 through 2008. The panel's recommendations were used to create an evaluation and treatment protocol for hyponatremia in neurosurgical patients at the University of Florida. RESULTS Hyponatremia should be further investigated and treated when the serum sodium level is less than 131 mmol/L (class II). Evaluation of hyponatremia should include a combination of physical examination findings, basic laboratory studies, and invasive monitoring when available (class III). Obtaining levels of hormones such as antidiuretic hormone and natriuretic peptides is not supported by the literature (class III). Treatment of hyponatremia should be based on severity of symptoms (class III). The serum sodium level should not be corrected by more than 10 mmol/L/d (class III). Cerebral salt wasting should be treated with replacement of serum sodium and intravenous fluids (class III). Fludrocortisone may be considered in the treatment of hyponatremia in subarachnoid hemorrhage patients at risk of vasospasm (class I). Hydrocortisone may be used to prevent natriuresis in subarachnoid hemorrhage patients (class I). Hyponatremia in subarachnoid hemorrhage patients at risk of vasospasm should not be treated with fluid restriction (class II). Syndrome of inappropriate antidiuretic hormone may be treated with urea, diuretics, lithium, demeclocycline, and/or fluid restriction (class III). CONCLUSION The summarized literature on the evaluation and treatment of hyponatremia was used to develop practice management recommendations for hyponatremia in the neurosurgical population. However, the practice management recommendations relied heavily on expert opinion because of a paucity of class I evidence literature on hyponatremia.
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Affiliation(s)
- Maryam Rahman
- Department of Neurosurgery, University of Florida, Gainesville, Florida 32610-0265, USA.
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Hoefer D, Ruttmann-Ulmer E, Smits JM, DeVries E, Antretter H, Laufer G. Donor hypo- and hypernatremia are predictors for increased 1-year mortality after cardiac transplantation. Transpl Int 2009; 23:589-93. [DOI: 10.1111/j.1432-2277.2009.01024.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Monitoring of cerebrovascular autoregulation: facts, myths, and missing links. Neurocrit Care 2009; 10:373-86. [PMID: 19127448 DOI: 10.1007/s12028-008-9175-7] [Citation(s) in RCA: 227] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2008] [Accepted: 12/02/2008] [Indexed: 12/16/2022]
Abstract
UNLABELLED The methods for continuous assessment of cerebral autoregulation using correlation, phase shift, or transmission (either in time- or frequency-domain) were introduced a decade ago. They express dynamic relationships between slow waves of transcranial Doppler (TCD), blood flow velocity (FV) and cerebral perfusion pressure (CPP), or arterial pressure (ABP). We review a methodology and clinical application of indices useful for monitoring cerebral autoregulation and pressure-reactivity in various scenarios of neuro-critical care. FACTS Poor autoregulation and loss of pressure-reactivity are independent predictors of fatal outcome following head injury. Autoregulation is impaired by too low or too high CPP when compared to autoregulation with normal CPP (usually between 60 and 85 mmHg; and these limits are highly individual). Hemispheric asymmetry of the bi-laterally assessed autoregulation has been associated with asymmetry of CT scan findings: autoregulation was found to be worse ipsilateral to contusion or lateralized edema causing midline shift. The pressure-reactivity (PRx index) correlated with a state of low CBF and CMRO2 revealed using PET studies. The PRx is easier to monitor over prolonged periods of time than the TCD-based indices as it does not require fixation of external probes. Continuous monitoring with the PRx can be used to direct CPP-oriented therapy by determining the optimal CPP for pressure-reactivity. Autoregulation indices are able to reflect transient changes of autoregulation, as seen during plateau waves of ICP. However, minute-to-minute assessment of autoregulation has a poor signal-to-noise ratio. Averaging across time (30 min) or by combining with other relevant parameters improves the accuracy. MYTHS: It is debatable whether the TCD-based indices in head injured patients can be calculated using ABP instead of CPP. Thresholds for functional and disturbed autoregulation dramatically depends on arterial tension of CO2--therefore, comparison between patients cannot be performed without comparing their PaCO2. The TCD pulsatility index cannot accurately detect the lower limit of autoregulation. MISSING LINKS: We still do not know whether autoregulation-oriented therapy can be understood as a consensus between CPP-directed protocols and the Lund-concept. What are the links between endothelial function and autoregulation indices? Can autoregulation after head injury be improved with statins or EPO, as in subarachnoid hemorrhage? In conclusion, monitoring cerebral autoregulation can be used in a variety of clinical scenarios and may be helpful in delineating optimal therapeutic strategies.
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Murphy T, Dhar R, Diringer M. Conivaptan bolus dosing for the correction of hyponatremia in the neurointensive care unit. Neurocrit Care 2009; 11:14-9. [PMID: 19123060 DOI: 10.1007/s12028-008-9179-3] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2008] [Accepted: 12/10/2008] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Hyponatremia frequently complicates acute brain injury and may precipitate neurological worsening by promoting cerebral edema. An increase in brain water may be better managed through water excretion than with fluid restriction or hypertonic fluids. Vasopressin-receptor antagonists such as conivaptan, which promote free water excretion, may be ideal agents to treat this common and potentially serious disorder. METHODS The efficacy of intermittent bolus doses of conivaptan to correct hyponatremia was examined in a consecutive series of patients treated in our neurointensive care unit. Patients were excluded if baseline sodium was over 135 mEq/l or if another conivaptan dose was given within 12 h. We assessed the proportion responding with a 4 or 6 mEq/l rise in sodium by 12 h, the change in sodium from baseline, and, in those not receiving another dose for at least 72 h, the long-term ability of a single dose to maintain sodium at least 4 mEq/l above baseline. We also recorded the effects of conivaptan on urine output and specific gravity, and noted any adverse events. RESULTS A total of 25 doses given to 19 patients were included (out of 44 total doses administered in the study period). Sodium rose by 5.8 +/- 3.2 mEq/l within 12 h, with 71% rising by at least 4 mEq/l and 52% manifesting at least a 6 mEq/l increase. In those receiving only a single dose, 69% maintained at least a 4 mEq/l rise up to 72 h. Conivaptan also consistently led to increased urine output and a significant drop in urine specific gravity (i.e., aquaresis). No cases of phlebitis were observed despite administration of conivaptan through peripheral IVs. CONCLUSION Intermittent dosing of conivaptan was effective in increasing free water excretion and correcting hyponatremia in neurologically ill patients. This supports its further evaluation for managing hyponatremia in this population.
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Affiliation(s)
- Theresa Murphy
- Department of Pharmacy, Neurology/Neurosurgery Intensive Care Unit, Barnes-Jewish Hospital, Washington University School of Medicine, 216 S. Kingshighway Blvd, Saint Louis, MO 63110, USA.
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Kao L, Al-Lawati Z, Vavao J, Steinberg GK, Katznelson L. Prevalence and clinical demographics of cerebral salt wasting in patients with aneurysmal subarachnoid hemorrhage. Pituitary 2009; 12:347-51. [PMID: 19462244 DOI: 10.1007/s11102-009-0188-9] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2008] [Accepted: 05/11/2009] [Indexed: 10/20/2022]
Abstract
Hyponatremia is a frequent complication following subarachnoid hemorrhage (SAH), and is commonly attributed either to the syndrome of inappropriate antidiuretic hormone secretion (SIADH) or cerebral salt wasting syndrome (CSW). The object of this study is to elucidate the clinical demographics and sequelae of hyponatremia due to CSW in subjects with aneurysmal SAH. Retrospective chart review of patients >18 years with aneurysmal SAH admitted between January 2004 and July 2007 was performed. Subjects with moderate to severe hyponatremia (serum sodium <130 mmol l(-1)) were divided into groups consistent with CSW and SIADH based on urine output, fluid balance, natriuresis, and response to saline infusion. Clinical demographics were compared. Of 316 subjects identified, hyponatremia (serum sodium <135 mmol l(-1)) was detected in 187 (59.2%) subjects and moderate to severe hyponatremia in 48 (15.2%). Of the latter group, 35.4% were categorized with SIADH and 22.9% with CSW. Compared to eunatremic subjects, hyponatremia was associated with significantly longer hospital stay (15.7 +/- 1.9 vs. 9.6 +/- 1.1 days, p < 0.001). Subjects with CSW had similar mortality and duration of hospital stay vs. those with SIADH. Though less common than SIADH, CSW was detected in approximately 23% of patients with history of aneurysmal SAH and was not clearly associated with enhanced morbidity and mortality compared to subjects with SIADH. Further studies regarding the pathogenesis and management, along with the medical consequences, of CSW are important.
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Affiliation(s)
- Lily Kao
- Department of Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA
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Conivaptan for hyponatremia in the neurocritical care unit. Neurocrit Care 2008; 11:6-13. [PMID: 19003543 DOI: 10.1007/s12028-008-9152-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2008] [Accepted: 09/11/2008] [Indexed: 01/27/2023]
Abstract
INTRODUCTION Conivaptan is the first arginine vasopressin antagonist to be FDA-approved for the treatment of euvolemic hyponatremia, a common complication in neurointensive care patients. Due to risks for cerebral edema and seizures, sodium levels are generally aggressively maintained within normal levels (135-145 meq/l) in this patient population. OBJECTIVE To assess the safety and efficacy of conivaptan for the treatment of euvolemic hyponatremia in the neurocritical care unit. METHODS Data were obtained retrospectively on 22 patients treated with conivaptan for euvolemic hyponatremia. End points evaluated included time to [Na] increase of >or=6 meq/l; incidences of rapid overcorrection of [Na] (defined as an increase of >12 meq/l in a 24-h period while on conivaptan), infusion site reactions, or other adverse events; and whether sodium levels decreased after discontinuation of conivaptan. RESULTS A [Na] increase of >or=6 meq/l was reached in 19/22 (86%) patients, with an average time to goal of 13.1 h. No patients experienced a rapid overcorrection of [Na]. Five patients had an infusion site reaction necessitating an IV change. One patient experienced hypotension and another complained of thirst during infusion. Conivaptan was initiated in 11/22 patients (50%) who were hyponatremic despite already being on conventional therapies. CONCLUSION Conivaptan was safe and effective in this small series of neurointensive care patients, including many patients who were hyponatremic despite traditional treatments to maintain normal sodium levels. Further studies are needed to clarify the role of conivaptan as an adjunctive and/or alternative therapy for hyponatremia in this patient population.
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Cerdà-Esteve M, Cuadrado-Godia E, Chillaron JJ, Pont-Sunyer C, Cucurella G, Fernández M, Goday A, Cano-Pérez JF, Rodríguez-Campello A, Roquer J. Cerebral salt wasting syndrome: review. Eur J Intern Med 2008; 19:249-54. [PMID: 18471672 DOI: 10.1016/j.ejim.2007.06.019] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2007] [Revised: 06/04/2007] [Accepted: 06/29/2007] [Indexed: 10/22/2022]
Abstract
Hyponatremia is the most frequent electrolyte disorder in critically neurological patients. Cerebral salt wasting syndrome (CSW) is defined as a renal loss of sodium during intracranial disease leading to hyponatremia and a decrease in extracellular fluid volume. The pathogenesis of this disorder is still not completely understood. Sympathetic responses as well as some natriuretic factors play a role in this syndrome. Distinction between SIADH and CSW might be difficult. The essential point is the volemic state. It is necessary to rule out other intermediate causes. Treatment requires volume replacement and maintenance of a positive salt balance. Mineral corticoids may be useful in complicated cases.
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Affiliation(s)
- M Cerdà-Esteve
- Endocrinology Department, Hospital Universitari del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain.
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Changes in osmolality modulate voltage-gated calcium channels in trigeminal ganglion neurons. Brain Res 2008; 1208:56-66. [PMID: 18378217 DOI: 10.1016/j.brainres.2008.02.048] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2007] [Revised: 02/09/2008] [Accepted: 02/17/2008] [Indexed: 12/27/2022]
Abstract
Voltage-gated calcium channels (VGCCs) participate in many important physiological functions. However whether VGCCs are modulated by changes of osmolarity and involved in anisotonicity-induced nociception is still unknown. For this reason by using whole-cell patch clamp techniques in rat and mouse trigeminal ganglion (TG) neurons we tested the effects of hypo- and hypertonicity on VGCCs. We found that high-voltage-gated calcium current (I(HVA)) was inhibited by both hypo- and hypertonicity. In rat TG neurons, the inhibition by hypotonicity was mimicked by Transient Receptor Potential Vanilloid 4 receptor (TRPV4) activator but hypotonicity did not exhibit inhibition in TRPV4(-/-) mice TG neurons. Concerning the downstream signaling pathways, antagonism of PKG pathway selectively reduced the hypotonicity-induced inhibition, whereas inhibition of PLC- and PI3K-mediated pathways selectively reduced the inhibition produced by hypertonicity. In summary, although the effects of hypo- and hypertonicity show similar phenotype, receptor and intracellular signaling pathways were selective for hypo- versus hypertonicity-induced inhibition of I(HVA).
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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: 54] [Impact Index Per Article: 3.2] [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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Affiliation(s)
- David H Ellison
- Division of Nephrology and Hypertension and the Department of Physiology and Pharmacology, Oregon Health and Science University and Veterans Affairs Medical Center, Portland, OR 97239, USA.
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Diringer MN, Axelrod Y. Hemodynamic manipulation in the neuro-intensive care unit: cerebral perfusion pressure therapy in head injury and hemodynamic augmentation for cerebral vasospasm. Curr Opin Crit Care 2007; 13:156-62. [PMID: 17327736 DOI: 10.1097/mcc.0b013e32807f2aa5] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The intent of this manuscript is to summarize the pathophysiologic basis for hemodynamic manipulation in subarachnoid hemorrhage and traumatic brain injury, highlight the most recent literature and present expert opinion on indications and use. RECENT FINDINGS Hemodynamic augmentation with vasopressors and inotropes along with hypervolemia are the mainstay of treatment of vasospasm due to subarachnoid hemorrhage. Considerable variation continues to exist regarding fluid management and the use of vasopressors and inotropes. Blood pressure augmentation, volume expansion and cardiac contractility enhancement improve cerebral blood flow in ischemic areas, ameliorate vasospasm and improve clinical condition. In patients suffering from severe traumatic brain injury, while every attempt is made to control intracranial hypertension, cerebral perfusion-directed therapy with fluids and vasopressors is also used to keep cerebral perfusion pressure above 60-70 mmHg. Yet, recent observations suggest that posttraumatic mitochondrial dysfunction has been proposed as an alternative explanation for lower cerebral blood flow after acute trauma. SUMMARY Hemodynamic manipulation is routinely used in the management of patients with acute vasospasm following subarachnoid hemorrhage and severe head injury. The rationale is to improve blood flow to the injured brain and prevent secondary ischemia.
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Affiliation(s)
- Michael N Diringer
- Neurology/Neurosurgery Intensive Care Unit, Barnes-Jewish Hospital, Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110, USA.
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