Severe Hypernatremia Correction RateMortality in Hospitalized Patients

Hypernatremia and Its Rate of Correction: The Evidence So Far

Hypernatremia or high serum sodium levels can have many different causes, including insufficient free water intake, or excess free water losses. The management of hypernatremia focuses on resolving the underlying cause, replenishing free water deficit, and preventing further losses while closely monitoring serum sodium concentration. This systematic review was carried out using medical databases such as PubMed, PubMed Central, and Google Scholar for relevant medical literature. The identified articles were reviewed, eligibility criteria were applied, and seven research articles were identified. The effect of the rate of hypernatremia correction on both short- and long-term outcomes in volume-resuscitated patients was the focus of our search for randomized or observational studies. Based on our analysis of the clinical evidence, we concluded that the present recommendations for treating acute and chronic hypernatremia in resuscitated patients do not stem from high-quality research.

Association of postoperative hypernatremia with outcomes after elective craniotomy

STUDY OBJECTIVE

Hypernatremia is a treatable biochemical disorder associated with significant morbidity and mortality in patients undergoing surgery. However, its impact on patients who undergo elective craniotomy is not well understood. This study aimed to investigate the prognostic implications of postoperative hypernatremia on the 30-day mortality of patients undergoing elective craniotomy.

DESIGN

Retrospective cohort study.

SETTING

The Department of Neurosurgery of a high-volume center.

PATIENTS

Adult patients undergoing elective craniotomy except those with pituitary tumors, intracerebral hemorrhage, subarachnoid hemorrhage, or traumatic brain injury.

INTERVENTIONS

None.

MEASUREMENTS

Perioperative laboratory data were collected for all study participants, including sodium levels, neutrophil count, serum albumin, lymphocyte count, and blood glucose. These measurements were obtained as part of routine clinical care and provided valuable information for data analysis.

MAIN RESULTS

Of the 10,223 identified elective craniotomy patients who met our inclusion and exclusion criteria, 14.9% (1519) developed postoperative hypernatremia. This population's overall postoperative 30-day mortality rate was 1.7% (175). After performing an adjusted logistic regression analysis, we found that the odds of 30-day mortality increased gradually with increasing severity of hypernatremia: 2.9 deaths (OR, 3.79; 95% CI, 2.46-5.85) in patients with mild hypernatremia, 13.9 deaths (OR, 17.73; 95% CI, 11.17-28.12) in those with moderate hypernatremia, and 38.3 deaths (OR, 67.00; 95% CI, 40.44-111.00) in those with severe hypernatremia.

CONCLUSIONS

Hypernatremia is common after elective craniotomy, and its presence is associated with increased mortality and complications, particularly in cases of severe hypernatremia. These results emphasize the significance of risk evaluation in neurosurgical patients and propose the advantages of closely monitoring serum sodium levels in high-risk individuals. Future randomized controlled trials could provide more insight into the effect of treating postoperative hypernatremia in these patients.

Risk factors for mortality in brain injury patients who have severe hypernatremia and received continuous venovenous hemofiltration

Background and objectives

The mortality rate for people with brain injuries is increased when hypernatremia is present. Patients with severe hypernatremia, who have a significant short-term mortality rate, were shown to benefit from continuous venovenous hemofiltration (CVVH), which has been indicated to be successful. Exploring the risk factors for short-term mortality in brain injury patients who underwent CVVH and had severe hypernatremia was the aim of the current study.

Materials and methods

Retrospective screening was performed on patients with brain injuries who underwent CVVH at Xijing Hospital between 1 December 2010 and 31 December 2021 and who have a diagnosis of severe hypernatremia. The outcomes included 28-day patient mortality and hospital stay duration. The patient survival rate was examined using the Kaplan-Meier survival curve. To determine the risk factors for short-term death for patients, univariate and multivariate Cox regression analysis models were used.

Results

Our current study included a total of 83 individuals. The included patients had a median age of 49 (IQR 35-59) years. Of the included patients, 58 patients (69.9 %) died within 28 days. The median length of hospital stay for the patient was 13 (IQR 7-21) days. The APACHE II score, SOFA score, GCS, PLT count, INR, stroke, mechanical ventilation, and vasopressor reliance were related to 28-day mortality according to the univariate Cox analysis. INR (HR = 1.004, 95 % Cl: 1.001-1.006, P = 0.008), stroke (HR = 1.971, 95 % Cl: 1.031-3.768, P = 0.04), mechanical ventilation (HR = 3.948, 95 % Cl: 1.090-14.294, P = 0.036), and vasopressor dependency (HR = 2.262, 95 % Cl: 1.099-4.655, P = 0.027) were independently associated with the risk of 28-day death rates, according to multivariate Cox regression analysis.

Conclusions

Brain injuries who have severe hypernatremia requires CVVH, which has high short-term patient mortality. Mechanical ventilation, INR increase, stroke, and vasopressor dependence are independently associated with increased patient mortality risk.

Rate of Correction and All-Cause Mortality in Patients With Severe Hypernatremia

Importance

Hypernatremia is common among hospitalized patients and is associated with high mortality rates. Current guidelines suggest avoiding fast correction rates but are not supported by robust data.

Objective

To investigate whether there is an association between hypernatremia correction rate and patient survival.

Design, Setting, and Participants

This retrospective cohort study examined data from all patients admitted to the Tel Aviv Medical Center between 2007 and 2021 who were diagnosed with severe hypernatremia (serum sodium ≥155 mmol/L) at admission or during hospitalization. Statistical analysis was performed from April 2022 to August 2023.

Exposure

Patients were grouped as having fast correction rates (>0.5 mmol/L/h) and slow correction rates (≤0.5 mmol/L/h) in accordance with current guidelines.

Main Outcomes and Measures

All-cause 30-day mortality.

Results

A total of 4265 patients were included in this cohort, of which 2621 (61.5%) were men and 343 (8.0%) had fast correction rates; the median (IQR) age at diagnosis was 78 (64-87) years. Slow correction was associated with higher 30-day mortality compared with fast correction (50.7% [1990 of 3922] vs 31.8% [109 of 343]; P < .001). These results remained significant after adjusting for demographics (age, gender), Charlson comorbidity index, initial sodium, potassium, and creatinine levels, hospitalization in an ICU, and severe hyperglycemia (adjusted odds ratio [aOR], 2.02 [95% CI, 1.55-2.62]), regardless of whether hypernatremia was hospital acquired (aOR, 2.19 [95% CI, 1.57-3.05]) or documented on admission (aOR, 1.64 [95% CI, 1.06-2.55]). There was a strong negative correlation between absolute sodium correction during the first 24 hours following the initial documentation of severe hypernatremia and 30-day mortality (Pearson correlation coefficient, -0.80 [95% CI, -0.93 to -0.50]; P < .001). Median (IQR) hospitalization length was shorter for fast correction vs slow correction rates (5.0 [2.1-14.9] days vs 7.2 [3.5-16.1] days; P < .001). Prevalence of neurological complications was comparable for both groups, and none were attributed to fast correction rates of hypernatremia.

Conclusions and Relevance

This cohort study of patients with severe hypernatremia found that rapid correction of hypernatremia was associated with shorter hospitalizations and significantly lower patient mortality without any signs of neurologic complications. These results suggest that physicians should consider the totality of evidence when considering the optimal rates of correction for patients with severe hypernatremia.

Extreme Hypernatremia due to Dehydration

Hypernatremia is defined as having a serum sodium concentration exceeding 145 mmol/L (normal range is 136 - 145 mmol/L). When the serum sodium level surpasses 160 mmol/L and 190 mmol/L, it is classified as severe and extreme hypernatremia, respectively. Extreme hypernatremia is an uncommon occurrence and is associated with significant risks of mortality and morbidity. The most frequently reported causes of extreme hypernatremia are accidental or intentional salt ingestion and diabetes insipidus, while dehydration due to poor water intake as a trigger for extreme hypernatremia is rarely documented. Here, we present a case study of an elderly patient who experienced extreme hypernatremia with a serum sodium level of 191 mmol/L due to dehydration and had altered mental status and ventriculomegaly as a complication.

Serum osmolality and hyperosmolar states

Serum osmolality is the sum of the osmolalities of every single dissolved particle in the blood such as sodium and associated anions, potassium, glucose, and urea. Under normal conditions, serum sodium concentration is the major determinant of serum osmolality. Effective blood osmolality, so-called blood tonicity, is created by the endogenous (e.g., sodium and glucose) and exogenous (e.g., mannitol) solutes that are capable of creating an osmotic gradient across the membranes. In case of change in effective blood osmolality, water shifts from the compartment with low osmolality into the compartment with high osmolarity in order to restore serum osmolality. The difference between measured osmolality and calculated osmolarity forms the osmolal gap. An increase in serum osmolal gap can stem from the presence of solutes that are not included in the osmolarity calculation, such as hypertonic treatments or toxic alcoholic ingestions. In clinical practice, determination of serum osmolality and osmolal gap is important in the diagnosis of disorders related to sodium, glucose and water balance, kidney diseases, and small molecule poisonings. As blood hypertonicity exerts its main effects on the brain cells, neurologic symptoms varying from mild neurologic signs and symptoms to life-threatening outcomes such as convulsions or even death may occur. Therefore, hypertonic states should be promptly diagnosed and cautiously managed. In this review, the causes and treatment strategies of hyperosmolar conditions including hypernatremia, diabetic ketoacidosis, hyperglycemic hyperosmolar syndrome, hypertonic treatments, or intoxications are discussed in detail to increase awareness of this important topic with significant clinical consequences.

Salt and Water: A Review of Hypernatremia

Serum sodium disorders are generally a marker of water balance in the body. Thus, hypernatremia is most often caused by an overall deficit of total body water. Other unique circumstances may lead to excess salt, without an impact on the body's total water volume. Hypernatremia is commonly acquired in both the hospital and community. As hypernatremia is associated with increased morbidity and mortality, treatment should be initiated promptly. In this review, we will discuss the pathophysiology and management of the main types of hypernatremia, which can be categorized as either a loss of water or gain of sodium that can be mediated by renal or extrarenal mechanisms.

Diagnosis and treatment of brain injury complicated by hypernatremia

Hypernatremia is a common electrolyte disorder in patients with brain injury. The mortality of brain injury patients with severe hypernatremia may be as high as 86.8%. The efficacy of conventional treatment for hypernatremia is limited. Continuous renal replacement therapy (CRRT) can slowly, controllably, and continuously reduce the blood sodium concentration and gradually become an important treatment for severe hypernatremia patients. This review aims to provide important information for clinicians and clinical researchers by describing the etiology, diagnosis, hazards, conventional treatment, and CRRT treatment of hypernatremia in patients with traumatic brain injury.

Association of Hypernatremia with Immune Profiles and Clinical Outcomes in Adult Intensive Care Unit Patients with Sepsis

Both hypernatremia and an abnormal immune response may increase hospital mortality in patients with sepsis. This study examined the association of hypernatremia with abnormal immune response and mortality in 520 adult patients with sepsis in an intensive care unit (ICU). We compared the mortality and ex vivo lipopolysaccharide (LPS)-induced inflammatory response differences among patients with hyponatremia, eunatremia, and hypernatremia, as well as between patients with acquired hypernatremia on ICU day 3 and those with sustained eunatremia over first three ICU days. Compared with eunatremia or hyponatremia, hypernatremia led to higher 7 day, 14 day, 28 day, and hospital mortality rates (p = 0.030, 0.009, 0.010, and 0.033, respectively). Compared with sustained eunatremia, acquired hypernatremia led to higher 7, 14, and 28 day mortality rates (p = 0.019, 0.042, and 0.028, respectively). The acquired hypernatremia group nonsignificantly trended toward increased hospital mortality (p = 0.056). Day 1 granulocyte colony-stimulating factor (G-CSF) and tumor necrosis factor (TNF) α levels were relatively low in patients with hypernatremia (p = 0.020 and 0.010, respectively) but relatively high in patients with acquired hypernatremia (p = 0.049 and 0.009, respectively). Thus, in ICU-admitted septic patients, hypernatremia on admission and in ICU-acquired hypernatremia were both associated with higher mortality. The higher mortality in patients with hypernatremia on admission was possibly related to the downregulation of G-CSF and TNF-α secretion after endotoxin stimulation. Compared to sustained eunatremia, acquired hypernatremia showed immunoparalysis at first and then hyperinflammation on day 3.

Treatment of hyponatremia in children with acute bacterial meningitis

Purpose

Few studies have evaluated hyponatremia management in children with bacterial meningitis (BM). Thus, we aimed to describe variations in clinical practice, the effectiveness of sodium management, and adverse outcomes in children with BM and hyponatremia.

Methods

This retrospective cross-sectional study conducted at a tertiary institution analyzed participants' demographic, clinical, and sodium-altering treatment data. The sodium trigger for treatment was defined as pretreatment sodium level, with response and overcorrection defined as increments of ≥5 and &gt;10 mmol/L after 24 h, respectively.

Results

This study enrolled 364 children with BM (age: &lt;16 years; 215 boys). Hyponatremia occurred in 62.1% of patients, among whom 25.7% received sodium-altering therapies; 91.4% of those individuals had moderate/severe hyponatremia. Monotherapy was the most common initial hyponatremia treatment. After 24 h of treatment initiation, 82.4% of the patients responded. Logistic regression analyses revealed that ΔNa24 &lt;5 mmol/L [odds ratio (OR) 15.52, 95% CI 1.71–141.06, p = 0.015] and minimum Glasgow Coma Scale (GCS) score ≤ 8 (OR 11.09, 95% CI 1.16–105.73, p = 0.036) predicted dysnatremia at 48 h after treatment initiation. Although rare, persistent moderate/severe hyponatremia or hypernatremia at 48 h after treatment initiation was associated with a high mortality rate (57.1%).

Conclusion

This study found that most cases of hyponatremia responded well to various treatments. It is important to identify and institute appropriate treatment early for moderate or severe hyponatremia or hypernatremia in children with BM. This study was limited by its non-randomized nature.

Approach to the Patient: "Utility of the Copeptin Assay"

Copeptin derives from the same precursor peptide preprovasopressin as arginine vasopressin (AVP). The secretion of both peptides is stimulated by similar physiological processes, such as osmotic stimulation, hypovolemia, or stress. AVP is difficult to measure due to complex preanalytical requirements and due to technical difficulties. In the last years, copeptin was found to be a stable, sensitive, and simple to measure surrogate marker of AVP release. Different immunoassays exist to measure copeptin. The 2 assays which have most often be used in clinical studies are the original sandwich immunoluminometric assay and its automated immunofluorescent successor. In addition, various enzyme-linked immunosorbent assay have been developed. With the availability of the copeptin assay, the differential diagnosis of diabetes insipidus was recently revisited. The goal for this article is therefore to first review the physiology of copeptin, and second to describe its use as marker for the differential diagnosis of vasopressin-dependent fluid disorders, mainly diabetes insipidus but also hyper- and hyponatremia. Furthermore, we highlight the role of copeptin as prognostic marker in other acute and chronic diseases.

Increased short-term and long-term mortality in community- and hospital-acquired hypernatraemia and in patients with delayed serum sodium correction

BACKGROUND

This study examined the short-term and long-term mortality of community- and hospital-acquired hypernatraemia in a large cohort of general hospitalised patients, and the impact of delayed serum sodium correction in hypernatraemic patients.

METHODS

Adult patients admitted to Mayo Clinic Rochester from 2011 to 2013 were examined. The patients with admission serum sodium ≥138 mEq/L and at least 2 serum sodium measurements during hospitalisation were included. Hypernatraemia was defined as serum sodium ≥143 mEq/L. The patients were categorised into three groups based on serum sodium at admission and during hospitalisation: (a) normal serum sodium, (b) community-acquired hypernatraemia and (c) hospital-acquired hypernatraemia. Outcomes included hospital mortality and 1-year mortality after hospital discharge amongst hospital survivors.

RESULTS

Of 25 781 eligible patients, 45% had normal serum sodium, 20% had community-acquired hypernatraemia and 35% had hospital-acquired hypernatraemia. In adjusted analysis, odds ratios (ORs) of community- and hospital-acquired hypernatraemia for hospital mortality were 4.91 (95% CI 3.47-6.94) and 4.11 (95% CI 2.94-5.73), whereas hazard ratio (HR) for 1-year mortality was 1.76 (95% CI 1.56-1.98) and 1.61 (95% CI 1.45-1.79), respectively. Hospital-acquired hypernatraemia had a higher hospital mortality but not 1-year mortality than community-acquired hypernatraemia. In patients with community-acquired hypernatraemia, 36% remained hypernatraemic by hospital day 3. Hospital mortality (OR 3.01; 95% CI 2.71-5.83) and 1-year mortality (HR 1.51; 95% CI 1.26-1.81) were significantly increased in patients with persistent hypernatraemia, compared with those with serum sodium correction into optimal range of 138-142 mEq/L.

CONCLUSION

Hypernatraemia, regardless of acquisition origin, is associated with elevated short-term and long-term mortality. Hospital-acquired hypernatraemia was more common and had a higher short-term mortality than community-acquired hypernatraemia. Failure to correct hypernatraemia by hospital day 3 is associated with increased mortality.

Intravenous Infusion of Sterile Water for the Treatment of Hypernatraemia

Little research has been carried out into the infusion of intravenous sterile water for the treatment of hypernatraemia, and it remains a contentious issue. We conducted a review of the literature and extract results following an extensive search of Medline 1946, Embase 1974, ProQuest, evidence-based practice resources, national and international guideline sites and the publications of various professional bodies. The review is presented on the infusion of sterile water (hypotonic fluid) to lower serum sodium level in those circumstances when enteral supplementation of water is not possible, such as in postoperative patients or when other isotonic fluids (such as 5% dextrose in water infusion) are less than ideal—for example, hyperglycaemic patients on an insulin infusion. Absence of guidelines has limited the use of sterile water, even as an off-label drug when it can be administered relatively safely via a central line.

A non-linear ensemble model-based surgical risk calculator for mixed data from multiple surgical fields

BACKGROUND

The misestimation of surgical risk is a serious threat to the lives of patients when implementing surgical risk calculator. Improving the accuracy of postoperative risk prediction has received much attention and many methods have been proposed to cope with this problem in the past decades. However, those linear approaches are inable to capture the non-linear interactions between risk factors, which have been proved to play an important role in the complex physiology of the human body, and thus may attenuate the performance of surgical risk calculators.

METHODS

In this paper, we presented a new surgical risk calculator based on a non-linear ensemble algorithm named Gradient Boosting Decision Tree (GBDT) model, and explored the corresponding pipeline to support it. In order to improve the practicability of our approach, we designed three different modes to deal with different data situations. Meanwhile, considering that one of the obstacles to clinical acceptance of surgical risk calculators was that the model was too complex to be used in practice, we reduced the number of input risk factors according to the importance of them in GBDT. In addition, we also built some baseline models and similar models to compare with our approach.

RESULTS

The data we used was three-year clinical data from Surgical Outcome Monitoring and Improvement Program (SOMIP) launched by the Hospital Authority of Hong Kong. In all experiments our approach shows excellent performance, among which the best result of area under curve (AUC), Hosmer-Lemeshow test ([Formula: see text]) and brier score (BS) can reach 0.902, 7.398 and 0.047 respectively. After feature reduction, the best result of AUC, [Formula: see text] and BS of our approach can still be maintained at 0.894, 7.638 and 0.060, respectively. In addition, we also performed multiple groups of comparative experiments. The results show that our approach has a stable advantage in each evaluation indicator.

CONCLUSIONS

The experimental results demonstrate that NL-SRC can not only improve the accuracy of predicting the surgical risk of patients, but also effectively capture important risk factors and their interactions. Meanwhile, it also has excellent performance on the mixed data from multiple surgical fields.

Prevalence and outcome of dysnatremia in patients with COVID-19 compared to controls

OBJECTIVE

The pandemic of coronavirus disease (COVID-19) has rapidly spread globally and infected millions of people. The prevalence and prognostic impact of dysnatremia in COVID-19 is inconclusive. Therefore, we investigated the prevalence and outcome of dysnatremia in COVID-19.

DESIGN

The prospective, observational, cohort study included consecutive patients with clinical suspicion of COVID-19 triaged to a Swiss Emergency Department between March and July 2020.

METHODS

Collected data included clinical, laboratory and disease severity scoring parameters on admission. COVID-19 cases were identified based on a positive nasopharyngeal swab test for SARS-CoV-2, patients with a negative swab test served as controls. The primary analysis was to assess the prognostic impact of dysnatremia on 30-day mortality using a cox proportional hazard model.

RESULTS

172 (17%) cases with COVID-19 and 849 (83%) controls were included. Patients with COVID-19 showed a higher prevalence of hyponatremia compared to controls (28.1% vs 17.5%, P < 0.001); while comparable for hypernatremia (2.9% vs 2.1%, P = 0.34). In COVID-19 but not in controls, hyponatremia was associated with a higher 30-day mortality (HR: 1.4, 95% CI: 1.10-16.62, P = 0.05). In both groups, hypernatremia on admission was associated with higher 30-day mortality (COVID-19 - HR: 11.5, 95% CI: 5.00-26.43, P < 0.001; controls - HR: 5.3, 95% CI: 1.60-17.64, P = 0.006). In both groups, hyponatremia and hypernatremia were significantly associated with adverse outcome, for example, intensive care unit admission, longer hospitalization and mechanical ventilation.

CONCLUSION

Our results underline the importance of dysnatremia as predictive marker in COVID-19. Treating physicians should be aware of appropriate treatment measures to be taken for patients with COVID-19 and dysnatremia.

Increased mortality risk associated with serum sodium variations and borderline hypo- and hypernatremia in hospitalized adults

Background

This study aimed to evaluate short-term and long-term mortalities in a cohort of unselected hospitalized patients with serum sodium concentration ([Na⁺]) variations within and outside of reference range.

Methods

All adult patients admitted to the Mayo Clinic, Rochester, MN, USA from January 2011 to December 2013 (n = 147358) were retrospectively screened. Unique patients admitted during the study period were examined. The main exposure was serum [Na⁺] variation. Outcome measures were hospital and 1-year all-cause mortalities.

Results

A total of 60944 patients, mean age 63 ± 17 years, were studied. On admission, 17% (n = 10066) and 1.4% (n = 852) had hypo- and hypernatremia, respectively. During the hospital stay, 11044 and 4128 developed hypo- and hypernatremia, respectively, accounting for 52.3 and 82.9% of the total hypo- and hypernatremic patients. Serum [Na⁺] variations of ≥6 mEq/L occurred in 40.6% (n = 24 740) of the 60 944 patients and were significantly associated with hospital and 1-year mortalities after adjusting potential confounders (including demographics, comorbidities, estimated glomerular filtration rate, admission serum [Na⁺], number of [Na⁺] measurements and length of hospital stay). Adjusted odds ratios for hospital and 1-year mortalities increased with increasing [Na⁺] variations in a dose-dependent manner, from 1.47 to 5.48 (all 95% confidence intervals >1.0). Moreover, in fully adjusted models, [Na⁺] variations (≥6 mEq/L) within the reference range (135–145 mEq/L) or borderline hypo- or hypernatremia (133–137 and 143–147 mEq/L, respectively) compared with 138–142 mEq/L were associated with increased hospital and 1-year mortalities.

Conclusion

In hospitalized adults, [Na⁺] fluctuation (≥6 mEq/L) irrespective of admission [Na⁺] and borderline hypo- or hypernatremia are independent predictors of progressively increasing short- and long-term mortality burdens.

Hyponatraemia and hypernatraemia: Disorders of Water Balance in Neurosurgery

Disorders of tonicity, hyponatraemia and hypernatraemia, are common in neurosurgical patients. Tonicity is sensed by the circumventricular organs while the volume state is sensed by the kidney and peripheral baroreceptors; these two signals are integrated in the hypothalamus. Volume is maintained through the renin-angiotensin-aldosterone axis, while tonicity is defended by arginine vasopressin (antidiuretic hormone) and the thirst response. Edelman found that plasma sodium is dependent on the exchangeable sodium, potassium and free-water in the body. Thus, changes in tonicity must be due to disproportionate flux of these species in and out of the body. Sodium concentration may be measured by flame photometry and indirect, or direct, ion-sensitive electrodes. Only the latter method is not affected by changes in plasma composition. Classification of hyponatraemia by the volume state is imprecise. We compare the tonicity of the urine, given by the sodium potassium sum, to that of the plasma to determine the renal response to the dysnatraemia. We may then assess the activity of the renin-angiotensin-aldosterone axis using urinary sodium and fractional excretion of sodium, urate or urea. Together, with clinical context, these help us determine the aetiology of the dysnatraemia. Symptomatic individuals and those with intracranial catastrophes require prompt treatment and vigilant monitoring. Otherwise, in the absence of hypovolaemia, free-water restriction and correction of any reversible causes should be the mainstay of treatment for hyponatraemia. Hypernatraemia should be corrected with free-water, and concurrent disorders of volume should be addressed. Monitoring for overcorrection of hyponatraemia is necessary to avoid osmotic demyelination.

Approach to the Management of Hypernatraemia in Older Hospitalised Patients

Hypernatraemia is associated with high morbidity and mortality and is more common in patients of older age, nursing home residents and those with cognitive impairment and restricted mobility. The most common cause in hospital settings is water dehydration due to reduced intake although other causes should be identified. Once identified, prompt management is necessary to avoid delayed correction as prolonged hypernatremia is associated with increased hospital stay and mortality. Comprehensive history-taking and physical examination, basic investigations and medication review are essential to identify causative and remediable factors in those admitted with hypernatraemia. Accurate calculation of fluid deficit and ongoing losses is essential in order to ensure adequate fluid replacement, The administration of appropriate, usually hypotonic, fluids is also essential to the timely restoration of eunatraemia. Although evidence of definite harm resulting from rapid correction is lacking, a serum sodium reduction rate of <12 mmol/l day is advised with the caveat that close monitoring of electrolytes is required to ensure the desired correction rate is being achieved. Medical and nursing professionals should have access to a local hospital protocol to guide management of patients with hypernatraemia to improve patient outcomes and mitigate the risk of harm, particularly from under-recognition and slow correction.

Association Between ICU-Acquired Hypernatremia and In-Hospital Mortality: Data From the Medical Information Mart for Intensive Care III and the Electronic ICU Collaborative Research Database

Objectives

Describe the relationship between ICU-acquired hypernatremia and in-hospital mortality and investigate the optimal hypernatremia correction rate.

Design Setting Participants and Measurements

Observational study including two individual ICU cohorts. We used the Medical Information Mart for Intensive Care III v. 1.4 database consists of all ICU patients admitted to the Beth Israel Deaconess Medical Center in Boston from 2001 to 2012 (n = 46,476). The electronic ICU v. 2.0 database consists of all ICU patients admitted to 208 distinct hospitals across the United States from 2014 to 2015 (n = 200,859). We included all adult patients admitted to an ICU with two consecutive sodium samples within normal range (135-145 mmol/L) and without two consecutive hyponatremic samples (< 135 mmol/L) during the ICU stay.

Results

Of 23,445 patients identified in Medical Information Mart for Intensive Care III, 9% (n = 2,172) developed hypernatremia during their ICU stay. In electronic ICU, 88,160 patients were identified and 7% (n = 5,790) developed hypernatremia. In both cohorts, patients with hypernatremia had a higher mortality (Medical Information Mart for Intensive Care III: 20% vs 42%; p < 0.01 and electronic ICU: 6% vs 22%; p < 0.01), with hypernatremia increasing the risk of in-hospital mortality (Medical Information Mart for Intensive Care III: odds ratio, 1.15; 95% CI, 1.13-1.17 and electronic ICU: odds ratio, 1.11; 95% CI, 1.10-1.12) and over time using a Cox regression. Rapid sodium correction rate (> 0.5 mmol/L/hr) was associated with an increased in-hospital mortality in both cohorts (Medical Information Mart for Intensive Care III: odds ratio, 1.08; 95% CI, 1.03-1.13 and electronic ICU: odds ratio, 1.10; 95% CI, 1.06-1.13). In the electronic ICU cohort, rapid correction rates were associated with a significant difference in in-hospital mortality, but there was no statistically significant association in the Medical Information Mart for Intensive Care III cohort.

Conclusions

ICU-acquired hypernatremia is associated with increased in-hospital mortality. Furthermore, a rapid sodium correction rates may be harmful. This suggests it is important to both prevent ICU-acquired hypernatremia and to avoid rapid correction rates if a patient becomes hypernatremic.

Correction of hypernatremic dehydration in neonates with supervised breast-feeding: A cross-sectional observational study

BACKGROUND

Hypernatremic dehydration is an uncommon but a serious cause of readmission in neonates especially in the ones on exclusive breast-feeding. The management of such neonates is challenging as serious complications can occur both because of hypernatremic dehydration and its rapid correction. The aim was to study the clinical profile of neonates with hypernatremic dehydration and determine the outcome of these neonates after appropriate management.

METHODS

This is a prospective cross-sectional observational study of neonates readmitted with hypernatremic dehydration in a tertiary care hospital in a 12-month period from March 2017 to February 2018. The inclusion criterion was as follows: all neonates with serum sodium >145 mEq/l. The exclusion criteria were as follows: neonates with hypoglycemia, positive sepsis screen and any other congenital diseases. Neonates with serum sodium between 145 and 160 mEq/l were treated with supervised quantified oral feeds at 150 ml/kg/day, unless they had features of shock. Neonates who had serum sodium ≥160 mEq/l were given intravenous (IV) fluids initially.

RESULTS

A total of 2412 deliveries took place during the study period. Hypernatremic dehydration was reported in 46 (1.9%) of them, which required admission. We found that all these neonates were exclusively breast-fed, with 81.3% neonates born to primigravidae. One neonate presented with seizures, and one, with metabolic acidosis. More than 50% neonates had acute kidney injury (AKI) on admission. No neonates in our study developed central nervous system (CNS) complications such as cerebral venous thrombosis, convulsions or intracranial haemorrhage, and complete recovery from AKI was documented in all neonates.

CONCLUSION

Hypernatremic dehydration can be a serious problem even in term healthy neonates especially in exclusively breast-fed neonates born to primiparous women. Our study shows that quantified oral feeding is effective in successful management of hypernatremic dehydration and not associated with the dreaded CNS complications due to rapid correction.

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

Perioperative sodium abnormalities or dysnatremia is not uncommon in patients presenting for cardiac surgery and is associated with increased morbidity and mortality. Both the disease process of heart failure and its treatment may contribute to abnormalities in serum sodium concentration. Serum sodium is the main determinant of serum osmolality, which in turn affects cell volume. Brain cells are particularly vulnerable to changes in serum osmolality because of the nondistensible cranium. The potentially catastrophic neurologic sequelae of rapidly correcting chronic dysnatremia and the time-sensitive nature of cardiac surgery can make the management of these patients challenging. The use of cardiopulmonary bypass to facilitate surgery adds another layer of complexity in the intraoperative management of sodium and water balance. This narrative review examines the definition and classification of dysnatremia. It also covers the etiology and pathophysiology of dysnatremia, implications during cardiac surgery requiring cardiopulmonary bypass, and the perioperative management of dysnatremia.

Prolonged Brackish Water Exposure: A Case Report

Exposure to and consumption of brackish water are associated with an elevated risk of infection, hypernatremia, and hypothermia. Minimal data exist to support the diagnosis and treatment of patients with long-term brackish water exposure. We present a case of a patient who spent 5 to 10 d semisubmerged in the Elizabeth River in coastal Virginia. A 55-y-old male presented via ambulance after 5 to 10 d of being "stuck in the mud." He was hypernatremic, with a sodium of 176 mEq·L^-1, hypothermic to 34.5°C (94.1°F), and hypotensive at 88/50 mm Hg, with a sodium concentration of 176 mEq·L^-1 and an osmolality of 412 mosm·kg^-1. He developed pneumonia, with respiratory cultures growing Vibrio parahemolyticus, Klebsiella oxytoca, and Shewanella algae. He had pustules, which grew Aeromonas hydrophilia and Aeromonas caviae. A nasogastric tube was placed. Using suction, 500 mL of coarse sand and gravel was removed from his stomach. Antibiotics and intravenous fluids were given. The patient fully recovered after 3 wk and was discharged to rehabilitation. Exposure to brackish water can present a unique set of infectious and metabolic complications. Initial care should include treatment of metabolic derangements, such as hypovolemia, hypernatremia, and hypothermia, and treatment of infections with antibiotics based on knowledge of the most likely causative organisms.

Extremely Severe Hypernatremia Caused by Wrong Belief in a Patient with Cervical Cancer

A 56-year old female patient who was undergoing follow-up for cervical cancer in our oncology center was presented to the emergency center with anxiety and excessive thirst. The initial serum sodium level of the patient exceeded 200mEq/L, rising up to 238mEq/L during hospitalization. The extremely severe hypernatremia was caused by patient's wrong belief that bay salt would cure the cancer. The patient was treated with hypotonic solution and finally with appropriate hydration, she was fully recovered without any neurological complications.

Pharmacotherapy of sodium disorders in neurocritical care

PURPOSE OF REVIEW

To describe the pathophysiology and pharmacotherapy of dysnatremia in neurocritical care patients.

RECENT FINDINGS

Sodium disorders may affect approximately half of the neurocritical care patients and are associated with worse neurological outcome and increased risk of death. Pharmacotherapy of sodium disorders in neurocritical care patients may be challenging and is guided by a careful investigation of water and sodium balance.

SUMMARY

In case of hyponatremia, because of excessive loss of sodium, fluid challenge with isotonic solution, associated with salt intake is the first-line therapy, completed with mineralocorticoids if needed. In case of hyponatremia because of SIADH, fluid restriction is the first-line therapy followed by urea if necessary. Hypernatremia should always be treated with hypotonic solutions according to the free water deficit, associated in case of DI with desmopressin. The correction speed should take into consideration the symptoms associated with dysnatremia and the rapidity of the onset.

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

We report a case of a previously well 58-year-old man, who presented with delirium and low GCS, and was found to have extreme hypernatraemia (Na⁺ = 191 mmol/L) and hyperglycaemia (glucose = 31 mmol/L). This resulted in a corrected serum sodium of 202 mmol/L. He was treated with fluid and electrolyte replacement in the intensive care unit, and had returned to essentially normal function by hospital discharge. The aetiology was believed to be due to severe dehydration and a new diagnosis of diabetes mellitus. Extreme hypernatraemia (serum sodium level greater than 190 mmol/L) is rare and associated with a high mortality. The mainstay of treatment is careful fluid and electrolyte management. Most recommendations advise to reduce the serum sodium by 0.5 mmol/L/hour, due to concerns over cerebral oedema; however, there are reports that slower correction is associated with higher mortality. In this case, the initial corrected sodium of 202 mmol/L was steadily corrected to 160 mmol/L over 91 hours, at a rate of 0.46 mmol/L/hour. This demonstrates the safety of the recommended approach.

Continuous veno-venous hemofiltration in the treatment of severely burned patients with acute hypernatremia: A retrospective study of 13 cases

OBJECTIVES

This study aimed to evaluate the clinical effects of continuous veno-venous hemofiltration in the treatment of severely burned patients with acute hypernatremia.

METHODS

A total of 13 severely burned patients with acute hypernatremia admitted to Xijing Hospital were included in this study. All patients received continuous veno-venous hemofiltration treatment in addition to conventional treatment. The original sodium level in the replacement fluid was set to be lower than the serum sodium level by 8 mmol/L and subsequently undergoes a reduction rate of 2.16 ± 0.18 mmol/L every 4 h. Patients' clinical features, serum laboratory tests, hemodynamic variables, changes in sodium levels in serum, and replacement fluid during continuous veno-venous hemofiltration treatment were monitored.

RESULTS

Patients had an average total burn surface area of 66.69% ± 20.28%. Two patients died of systematic Pseudomonas aeruginosa infections, and 11 patients survived. After continuous veno-venous hemofiltration treatment, patients showed a significant reduction in the serum sodium level (168.91 ± 4.88 mmol/L vs 144.62 ± 2.98 mmol/L, p < 0.01). Likewise, the serum levels of urea and creatinine decreased from 24.8 ± 6.5 mmol/L to 14.9 ± 8.3 mmol/L and from 278.6 ± 155.3 μmol/L to 152.6 ± 29.7 μmol/L, respectively (p < 0.05). The patients also displayed improvements in the Acute Physiology and Chronic Health Evaluation II and Glasgow scores (p < 0.05) and showed a significant reduction in hemoglobin and serum albumin levels (p < 0.05), but no obvious change in levels of platelets, alanine aminotransferase, and aspartate aminotransferase (p > 0.05).

CONCLUSION

Our results indicate that continuous veno-venous hemofiltration with gradient sodium replacement fluid is effective in treating hypernatremia in severely burned patients with the controllable sodium reduction rate and satisfactory clinical outcomes.

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

BACKGROUND AND OBJECTIVES

Hypernatremia is common in hospitalized, critically ill patients. Although there are no clear guidelines on sodium correction rate for hypernatremia, some studies suggest a reduction rate not to exceed 0.5 mmol/L per hour. However, the data supporting this recommendation and the optimal rate of hypernatremia correction in hospitalized adults are unclear.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We assessed the association of hypernatremia correction rates with neurologic outcomes and mortality in critically ill patients with hypernatremia at admission and those that developed hypernatremia during hospitalization. We used data from the Medical Information Mart for Intensive Care-III and identified patients with hypernatremia (serum sodium level >155 mmol/L) on admission (n=122) and hospital-acquired (n=327). We calculated different ranges of rapid correction rates (>0.5 mmol/L per hour overall and >8, >10, and >12 mmol/L per 24 hours) and utilized logistic regression to generate adjusted odds ratios (aOR) with 95% confidence intervals (95% CIs) to examine association with outcomes.

RESULTS

We had complete data on 122 patients with severe hypernatremia on admission and 327 patients who developed hospital-acquired hypernatremia. The difference in in-hospital 30-day mortality proportion between rapid (>0.5 mmol/L per hour) and slower (≤0.5 mmol/L per hour) correction rates were not significant either in patients with hypernatremia at admission with rapid versus slow correction (25% versus 28%; P=0.80) or in patients with hospital-acquired hypernatremia with rapid versus slow correction (44% versus 40%; P=0.50). There was no difference in aOR of mortality for rapid versus slow correction in either admission (aOR, 1.3; 95% CI, 0.5 to 3.7) or hospital-acquired hypernatremia (aOR, 1.3; 95% CI, 0.8 to 2.3). Manual chart review of all suspected chronic hypernatremia patients, which included all 122 with hypernatremia at admission, 128 of the 327 hospital-acquired hypernatremia, and an additional 28 patients with ICD-9 codes for cerebral edema, seizures and/or alteration of consciousness, did not reveal a single case of cerebral edema attributable to rapid hyprnatremia correction.

CONCLUSIONS

We did not find any evidence that rapid correction of hypernatremia is associated with a higher risk for mortality, seizure, alteration of consciousness, and/or cerebral edema in critically ill adult patients with either admission or hospital-acquired hypernatremia.

A novel scoring system for assessing the severity of electrolyte and acid-base disorders and predicting outcomes in hospitalized patients

Electrolyte and acid-base disorders are commonly seen in critically ill and other hospitalized patients. A scoring system is needed to assess the severity of electrolyte and acid-base disorders and to predict outcome in hospital patients. Herein, we prospectively enrolled a total of 322,046 patients, including 84,700 patients in the derivation cohort and 237,346 in the validation cohort, in a large, tertiary hospital in East China from 2014 to 2017. A points-scoring system of general electrolyte and acid-base disorders with a sum of 20.8 points was generated by multiple logistic regression analysis of the derivation cohort. Receiver operating characteristic curve analysis showed that the optimal cut-off value of 2.0 was associated with 65.4% sensitivity and 88.4% specificity (area under the curve: 0.818 (95% CI 0.809 to 0.827)) to predict hospital mortality in the validation cohort. On Kaplan-Meier survival analysis, the five intervals of risk score (Q1: 0 to 2.0; Q2: 2.1 to 2.5; Q3: 2.6 to 3.3; Q4: 3.4 to 4.5; and Q5: >4.5 points) showed differences in hospital survival (p<0.001). Elevated (delta) risk score >2 during hospitalization increased the risk of hospital death, while those with a delta risk score <0 and <−2 points had higher survival rates. This novel scoring system could be used to evaluate and to dynamically monitor the severity of electrolyte and acid-base disorders in hospitalized patients.

Hypernatraemia in 39 hospitalised foals: clinical findings, primary diagnosis and outcome

OBJECTIVE

To evaluate hypernatraemia in foals presenting as medical emergencies to an intensive care unit (ICU) to determine the prevalence, clinical findings, primary diagnosis and outcome.

METHODS

Retrospective case study of records from Thoroughbred foals aged less than 3 months that presented to an ICU as medical emergencies in 2002-12. Data retrieved included signalment, clinical findings, laboratory results, primary diagnosis and outcome. Foals with hypernatraemia (serum sodium > 145 mmol/L) on admission laboratory data were identified and further evaluated.

RESULTS

A total of 39 of 1718 foals (2.3%) were diagnosed with hypernatraemia; all foals were less than 7 days of age. The most common primary diagnoses in the foals with hypernatraemia were neonatal syndrome (19/39, 48.7%) and sepsis (15/39, 38.5%). Foals with hypernatraemia at presentation were more likely to die or be euthanased during their hospitalisation than foals with a normal serum sodium concentration on ICU admission (33.3% vs 16.1%; odds ratio, 2.3; 95% confidence interval, 1.2-4.6; P = 0.02).

CONCLUSION

Admission hypernatraemia was an uncommon but important electrolyte abnormality in this population of hospitalised foals. Although the short-term outcome in survivors was most likely dependent on the underlying disease process, hypernatraemia was negatively associated with outcome in hospitalised foals.

Could sodium imbalances predispose to postoperative venous thromboembolism? An analysis of the NSQIP database

Background

Hyponatremia is common among patients with pulmonary embolism, while hypernatremia increases the risk of venous thromboembolism (VTE). Our objective was to evaluate the association between sodium imbalances and the incidence of VTE and other selected perioperative outcomes.

Methods

We conducted a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) and identified 1,108,704 patients undergoing major surgery from 2008 to 2012. We evaluated 30-day perioperative outcomes, including mortality and cardiac, respiratory, neurological, urinary, wound, and VTE outcomes. Multivariate logistic regressions were used to estimate the odds of 30-day perioperative outcomes.

Results

Compared with the normal sodium group, in which VTE occurred in 1.0% of patients, 1.8% of patients in the hyponatremia group (unadjusted odds ratio (OR) 1.84) and 2.4% of patients in the hypernatremia group (unadjusted OR 2.49) experienced VTE. Crude mortality was 1.3% in the normal sodium group, 4.9% in the hyponatremia group (unadjusted OR 3.93) and 8.4% in the hypernatremia group (unadjusted OR 7.01). Crude composite morbidity was 7.1% for the normal sodium group, 16.7% for the hyponatremia group (unadjusted OR 2.63) and 20.6% for the hypernatremia group (unadjusted OR 3.43). After adjusting for potential confounders, hyponatremia and hypernatremia remained significantly and independently associated with an increased risk of VTE (adjusted OR 1.43 and 1.56, respectively), mortality (adjusted OR 1.39 and 1.39, respectively) and composite morbidity (adjusted OR 2.15 and 3.34, respectively).

Conclusions

Pre-operative hyponatremia and hypernatremia are potential prognostic markers for perioperative 30-day morbidity, mortality and VTE.

Intensive care management of severe hypernatraemia in the context of group A streptococcal septicaemia

This case describes a 54-year-old woman with exudative eczema, who was admitted to the intensive care unit with a serum sodium concentration of 191 mmol/L, secondary to profound dehydration in the context of group A streptococcal septicaemia. Successful rehydration and electrolyte normalisation was achieved with continuous venovenous haemodiafiltration (CVVHDF), the replacement fluid of which was infused with hypertonic saline to limit the rate of sodium reduction. This case report comments on three areas of interest. First, hypernatraemia of this level is unusual. Second, the infusion of hypertonic saline into the replacement fluid of the CVVHDF filter is not common practice but successfully ensured a controlled reduction in serum sodium concentration while aggressively replacing a 9 L water deficit. Third, the notable physiological reserve demonstrated by the patient: despite an extraordinary serum sodium concentration in the context of overwhelming streptococcal septicaemia, she has made a full cognitive recovery.

Copeptin levels and commonly used laboratory parameters in hospitalised patients with severe hypernatraemia - the "Co-MED study"

Background

Hypernatraemia is common in inpatients and is associated with substantial morbidity. Its differential diagnosis is challenging, and delayed treatment may have devastating consequences. The most important hormone for the regulation of water homeostasis is arginine vasopressin, and copeptin, the C-terminal portion of the precursor peptide of arginine vasopressin, might be a reliable new parameter with which to assess the underlying cause of hypernatraemia.

Methods

In this prospective, multicentre, observational study conducted in two tertiary referral centres in Switzerland, 92 patients with severe hyperosmolar hypernatraemia (Na⁺ > 155 mmol/L) were included. After a standardised diagnostic evaluation, the underlying cause of hypernatraemia was identified and copeptin levels were measured.

Results

The most common aetiology of hypernatraemia was dehydration (DH) (n = 65 [71%]), followed by salt overload (SO) (n = 20 [22%]), central diabetes insipidus (CDI) (n = 5 [5%]) and nephrogenic diabetes insipidus (NDI) (n = 2 [2%]). Low urine osmolality was indicative for patients with CDI and NDI (P < 0.01). Patients with CDI had lower copeptin levels than patients with DH or SO (both P < 0.01) or those with NDI. Copeptin identified CDI with an AUC of 0.99 (95% CI 0.97–1.00), and a cut-off value ≤ 4.4pmol/L showed a sensitivity of 100% and a specificity of 99% to predict CDI. Similarly, urea values were lower in CDI than in DH or SO (P < 0.05 and P < 0.01, respectively) or NDI. The AUC for diagnosing CDI was 0.98 (95% CI 0.96–1.00), and a cut-off value < 5.05 mmol/L showed high specificity and sensitivity for the diagnosis of CDI (98% and 100%, respectively). Copeptin and urea could not differentiate hypernatraemia induced by DH from that induced by SO (P = 0.66 and P = 0.30, respectively).

Conclusions

Copeptin and urea reliably identify patients with CDI and are therefore helpful tools for therapeutic management in patients with severe hypernatraemia.

Trials registration

ClinicalTrials.gov, NCT01456533. Registered on 20 October 2011.

Electronic supplementary material

The online version of this article (10.1186/s13054-018-1955-7) contains supplementary material, which is available to authorized users.

Severity of community acquired hypernatremia is an independent predictor of mortality

Hypernatremia develops commonly in critically ill patients during hospitalization, and is associated with adverse outcomes. However, community acquired hypernatremia (CAH) has been rarely studied. We conducted a study in patients who presented to an urban referral hospital, and were admitted with CAH. We retrospectively analyzed patients admitted to an urban tertiary care hospital from January 1, 2012 to December 31, 2014. CAH is defined as more than 147 mEq/L at admission in patients not transferred from other hospitals. Severity of hypernatremia is categorized as mild (148-150 mEq/L), moderate (151-154 mEq/L) or severe (≥155 mEq/L). All data were extracted from electronic medical records and the major outcome is hospital mortality. During the study period, 79,998 patients were admitted to the hospital. Of them, 178 patients (0.2%) had hypernatremia at the time of admission. 121 (68.0%) had mild hypernatremia, 33 (18.5%) had moderate hypernatremia, and 24 (13.5%) had severe hypernatremia at admission. During the hospital stay, 91 (51.1%) developed mild hypernatremia, 31 (17.4%) developed moderate hypernatremia and 56 (31.5%) developed severe hypernatremia. Mean duration of hypernatremia was 2.3 ± 2.0 days. The length of hospital stay was 7 (interquartile range 3-23) days and hospital mortality was 24.3%. Multivariate analysis shows that a peak sodium level that qualified as moderate [OR = 11.50, 95% CI (2.67-49.42)] or severe hypernatremia [OR = 5.18, 95% CI (1.43-18.79)] is an independent risk factor for hospital mortality compared to mild hypernatremia. Admission from the emergency department (ED), oral intake restriction, mean arterial pressure (MAP) and respiratory rate (RR) at admission time are also independently associated with hospital mortality. Maximum sodium level in CAH is independently associated with hospital mortality.

Life Threatening Severe Hypernatraemic Dehydration in Neonates: A Report of Two Cases

Hypernatraemic dehydration in neonates may lead to potentially lethal consequences like cerebral oedema, intracranial haemorrhage, hydrocephalus and gangrene. In the light of increase in the infants presenting with hypernatraemic dehydration, there is a definitive need to heighten the awareness and have a high degree of suspicion in diagnosis for this potentially lethal condition. We report two neonates of severe hypernatraemia with dehydration highlighting its diagnosis and management. Treatment of hypernatraemic dehydration involves correction of electrolyte imbalance by careful restoration of fluids and ensuring appropriate intake of calories. Promoting, protecting and supporting breastfeeding by careful breastfeeding assessment and including an early post partum follow up in the hospital protocol to detect any unusual weight loss in the newborn period plays a significant role in preventing this condition.

The association between sodium fluctuations and mortality in surgical patients requiring intensive care

PURPOSE

Serum sodium derangement is the most common electrolyte disturbance among patients admitted to intensive care. This study aims to validate the association between dysnatremia and serum sodium fluctuation with mortality in surgical intensive care patients.

METHOD

We performed a retrospective analysis of the Medical Information Mart for Intensive Care II database. Dysnatremia was defined as a sodium concentration outside physiologic range (135-145mmol/L) and subjects were categorized by severity of dysnatremia and sodium fluctuation. Univariate and multivariable logistic regressions were used to test for associations between sodium fluctuations and mortality.

RESULTS

We identified 8600 subjects, 39% of whom were female, with a median age of 66years for analysis. Subjects with dysnatremia were more likely to be dead at 28 days (17% vs 7%; P<.001). There was a significant association between sodium fluctuation and mortality at 28 days (adjusted odds ratio per 1mmol/L change, 1.10 [95% confidence interval, 1.08-1.12; P<.001]), even in patients who remained normotremic during their intensive care unit stay (1.12 [95% confidence interval, 1.09-1.16; P<.001]) CONCLUSIONS: This observational study validates previous findings of an association between serum sodium fluctuations and mortality in surgical intensive care patients. This association was also present in subjects who remained normonatremic throughout their intensive care unit admission.

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

BACKGROUND

Hypernatremia is a frequent occurrence among hospitalized patients. Severe hypernatremia is associated with mortality rates of over 60 %. Extreme hypernatremia, defined as sodium levels >190 mmol/l, is a rare occurrence. The literature on electrocardiographic changes occurring with this degree of hypernatremia is extremely scarce. We report the case of an 11-year-old Sri Lankan girl who presented with sodium levels of 226 mmol/l following infusion with 3 % hypertonic saline who developed diffuse QT prolongation leading to fatal ventricular tachycardia.

CASE PRESENTATION

An 11-year-old Sri Lankan girl presented with fever, headache, vomiting, and altered level of consciousness. Following admission she developed generalized tonic-clonic seizures and was intubated and ventilated. She had a recent history of polyuria and polydipsia. Magnetic resonance imaging of her brain revealed hydrocephalus due to possible craniopharyngioma. A ventriculoperitoneal shunt was inserted and she was infused with 3 % hypertonic saline in an attempt to reduce intracranial pressure. The following day she became polyuric and dehydrated with tachycardia and low blood pressure. Biochemistry revealed serum sodium of 226 mmol/l, measured serum osmolality of 470 mOsm/kg, urine osmolality of 280 mOsm/kg, urine spot sodium of 116 mmol/l, blood urea of 8.1 mmol/l, and blood glucose of 8.5 mmol/l. Her serum potassium, calcium, and magnesium levels were normal. Extreme hypernatremia due to infusion of 3 % hypertonic saline in the background of cranial diabetes insipidus was considered. She was managed aggressively with 5 % dextrose infusion and clear water via nasogastric feeding to correct the fluid deficit of 7 liters over 36 hours. Her sodium levels dropped to 160 mmol/l the following day. However, she developed electrocardiographic changes with widespread gross QT prolongation with ST segment deviations followed by fatal ventricular tachycardia.

CONCLUSIONS

Extreme hypernatremia is rare, and the literature on electrocardiographic changes occurring at such high levels of sodium is scarce. At present there are no established guidelines on rate and mode of correction of such high sodium levels. This case highlights the electrocardiographic changes observed during extreme hypernatremia, controversies in managing increased intracranial pressure with hypertonic saline, and dilemmas encountered in managing extreme hypernatremia.

The Reduction Rate of Serum Sodium and Mortality in Patients Undergoing Continuous Venovenous Hemofiltration for Acute Severe Hypernatremia

BACKGROUND

The excessive correction of acute hypernatremia is not known to be harmful. This study aimed to evaluate whether a reduction rate of serum sodium (RRSeNa) > 1mEq/L/hour in acute severe hypernatremia is an independent risk factor for mortality in critically ill patients undergoing continuous venovenous hemofiltration (CVVH) treatment.

MATERIALS AND METHODS

For this retrospective study, we reviewed records of 75 critically ill patients undergoing CVVH treatment for acute severe hypernatremia between March 2011 and March 2015.

RESULTS

The 28-day mortality rate of all patients was 61.3%. In multivariate Cox regression analyses, a reduction rate of serum sodium (RRSeNa) > 1mEq/L/hour (hazard ratio = 1.89; 95% CI: 1.03-3.47; P = 0.04), Acute Physiology and Chronic Health Evaluation II score and vasopressor dependency (yes or no) had a statistically significantly effect on mortality. Once we excluded patients with an RRSeNa ≤ 0.5mEq/L/hour, only RRSeNa > 1mEq/L/hour (hazard ratio = 2.611; 95% CI: 1.228-5.550; P = 0.013) and vasopressor dependency had a statistically significant influence on mortality in multivariate regression.

CONCLUSIONS

In addition to the Acute Physiology and Chronic Health Evaluation II score and vasopressor dependency, the excessive correction of acute severe hypernatremia was possibly associated with mortality in critically ill patients undergoing CVVH treatment. The optimal reduction rate of acute hypernatremia should be extensively studied in critically ill patients.

Hemorrhagic Encephalopathy From Acute Baking Soda Ingestion

Baking soda is a readily available household product composed of sodium bicarbonate. It can be used as a home remedy to treat dyspepsia. If used in excessive amounts, baking soda has the potential to cause a variety of serious metabolic abnormalities. We believe this is the first reported case of hemorrhagic encephalopathy induced by baking soda ingestion. Healthcare providers should be aware of the dangers of baking soda misuse and the associated adverse effects.

Severe hypernatremia associated catheter malposition in an intensive care patient

We present a catheter related severe hypernatremia in a 2-month-old baby who was admitted to the pediatric intensive care. Imbalance of plasma sodium is commonly seen in pediatric intensive care patients. The water and sodium balance is a complex process. Especially, brain and kidneys are the most important organs that affect the water and sodium balance. Other mechanisms of the cellular structure include osmoreceptors, Na-K ATPase systems, and vasopressin. Hypernatremia is usually an iatrogenic condition in hospitalized patients due to mismanagement of water electrolyte imbalance. Central venous catheterization is frequently used in pediatric intensive care patients. Complications of central venous catheter placement still continue despite the usage of ultrasound guidance. Malposition of central venous catheter in the brain veins should be kept in mind as a rare cause of iatrogenic hypernatremia.