1
|
Wang X, Li X, Sun J, Wang M, Lang W, Xu X. Relationship between sodium level and in-hospital mortality in traumatic brain injury patients of MIMIC IV database. Front Neurol 2024; 15:1349710. [PMID: 38562424 PMCID: PMC10982354 DOI: 10.3389/fneur.2024.1349710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 03/08/2024] [Indexed: 04/04/2024] Open
Abstract
Background An association between prognosis and high sodium levels in Traumatic Brain Injury (TBI) patients in Intensive Care Units (ICUs) has been noted, but limited research exists on the ideal sodium level in these patients or the impact on early mortality, using the MIMIC-IV database. Methods A retrospective survey was conducted on TBI patients from the MIMIC-IV database. Patients were divided into two categories based on their highest serum sodium level within 24 h of admission exceeding 145 mmol/L: those with hypernatremia, and those with moderate-to-low sodium levels. Collected covariates encompasses demographic, clinical, laboratory, and intervention variables. A multivariate logistic regression model was implemented to forecast in-hospital mortality. Results The study included 1749 TBI patients, with 209 (11.5%) experiencing in-hospital deaths. A non-linear test exposed an L-shaped correlation between sodium level and in-hospital mortality, with mortality rates increasing after a turning point at 144.1 mmol/L. Compared to the moderate-to-low group's 9.3% mortality rate, the hypernatremia group had a significantly higher mortality rate of 25.3% (crude odds ratio = 3.32, 95% confidence interval: 2.37 ~ 4.64, p < 0.001). After adjusting for all covariates, the hypernatremia group continued to show a significant correlation with higher mortality risk (adjusted odds ratio = 2.19, 95% confidence interval: 1.38 ~ 3.47, p = 0.001). This trend remained consistent regardless of the analyses stratification. Conclusion The study reveals an L-shaped relationship between sodium levels and in-hospital deaths, with a pivotal point at 144.1 mmol/L. TBI patients displaying hypernatremia were independently linked to higher in-hospital mortality, underlining the need for further studies into targeted management of sodium levels in these patients.
Collapse
Affiliation(s)
- Xiaoliang Wang
- Neurology Department of Qingdao Municipal Hospital, Nanjing Medical University, Qingdao, Shandong Province, China
| | - Xin Li
- Neurology Department of Qingdao Municipal Hospital, Nanjing Medical University, Qingdao, Shandong Province, China
| | - Jiahao Sun
- Neurology Department of Qingdao Municipal Hospital, Nanjing Medical University, Qingdao, Shandong Province, China
| | - Mengmeng Wang
- Neurology Department of Qingdao Municipal Hospital, Nanjing Medical University, Qingdao, Shandong Province, China
| | - Wenjuan Lang
- Neurology Department of Qingdao Municipal Hospital, Nanjing Medical University, Qingdao, Shandong Province, China
| | - Xin Xu
- Neurology Department of Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| |
Collapse
|
2
|
Li T, Zhang Y, Cheng X, Jia L, Tian Y, He J, He M, Chen L, Hao P, Xiao Y, Peng L, Chong W, Hai Y, You C, Fang F. Association between postoperative changes in natremia and outcomes in patients undergoing elective craniotomy. Neurosurg Rev 2024; 47:69. [PMID: 38270672 DOI: 10.1007/s10143-024-02287-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 12/27/2023] [Accepted: 01/07/2024] [Indexed: 01/26/2024]
Abstract
Postoperative dysnatremias, characterized by imbalances in serum sodium levels, have been linked to increased resource utilization and mortality in surgical and intensive care patients. The management of dysnatremias may involve medical interventions based on changes in sodium levels. In this study, we aimed to investigate the impact of postoperative changes in natremia on outcomes specifically in patients undergoing craniotomy.We conducted a retrospective analysis of patient records from the Department of Neurosurgery at West China Hospital, Sichuan University, covering the period from January 2011 to March 2021. We compared the highest and lowest sodium values in the first 14 postoperative days with the baseline values to define four categories for analysis: no change < 5 mmol/L; decrease > 5 mmol/L; increase > 5 mmol/L; both increase and decrease > 5 mmol/L. The primary outcome measure was 30-day mortality.A total of 12,713 patients were included in the study, and the overall postoperative mortality rate at 30 days was 2.1% (264 patients). The increase in sodium levels carried a particularly high risk, with a tenfold increase (OR 10.21; 95% CI 7.25-14.39) compared to patients with minimal or no change. Decreases in sodium levels were associated with an increase in mortality (OR 1.60; 95% CI 1.11-2.23).Moreover, the study revealed that postoperative sodium decrease was correlated with various complications, such as deep venous thrombosis, pneumonia, intracranial infection, urinary infection, seizures, myocardial infarction, and prolonged hospital length of stay. On the other hand, postoperative sodium increases were associated with acute kidney injury, deep venous thrombosis, pneumonia, intracranial infection, urinary infection, surgical site infection, seizures, myocardial infarction, and prolonged hospital length of stay.Changes in postoperative sodium levels were associated with increased complications, prolonged length of hospital stay, and 30-day mortality. Moreover, the severity of sodium change values correlated with higher mortality rates.
Collapse
Affiliation(s)
- Tiangui Li
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan, China
- Department of Neurosurgery, The First People's Hospital of Longquanyi District Chengdu, Sichuan, China
| | - Yu Zhang
- Center for Evidence-Based Medical, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Xin Cheng
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Lu Jia
- Department of Neurosurgery, Shanxi Provincial People's Hospital, Taiyuan, Shanxi, China
| | - Yixing Tian
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Jialing He
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Miao He
- Department of Anesthesia, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Lvlin Chen
- Department of Critical Care Medicine, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Pengfei Hao
- Center for Evidence-Based Medical, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Yangchun Xiao
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Liyuan Peng
- Department of Critical Care Medicine, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Weelic Chong
- Department of Medical Oncology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Yang Hai
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Fang Fang
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan, China.
| |
Collapse
|
3
|
Li X, Jia R, Guo Y. Spontaneous brainstem haemorrhage in a patient with uraemia undergoing initial hemodialysis: A case report. Exp Ther Med 2023; 25:90. [PMID: 36684651 PMCID: PMC9849850 DOI: 10.3892/etm.2023.11789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 12/28/2022] [Indexed: 01/06/2023] Open
Abstract
The present study reports the case of an elderly male inpatient with uraemia who had a sudden onset of numbness and weakness in the right limbs during sleep at night, accompanied by blurred and double vision, during the induction of haemodialysis (HD). Cranial computed tomography and magnetic resonance imaging revealed signs of brainstem haemorrhage. Consequently, a proactive treatment approach was adopted for decreasing the blood and intracranial pressures of the patient, and regular HD was continued. The condition of the patient improved, and the limbs showed no impairment of sensation, with normal movement. To the best of our knowledge, this is the first reported case of an inpatient with uraemia undergoing HD who developed a sudden brainstem haemorrhage during the induction phase of HD and completely recovered after conservative treatment. This unusual case deserves the attention of all clinicians, who should pay more attention to the patients with spontaneous brainstem hemorrhage.
Collapse
Affiliation(s)
- Xiaodong Li
- Department of Nephrology, Baoding First Central Hospital of Hebei Medical University, Baoding, Hebei 071000, P.R. China
| | - Ruili Jia
- Department of Nephrology, Baoding First Central Hospital of Hebei Medical University, Baoding, Hebei 071000, P.R. China
| | - Yancong Guo
- Department of Nephrology, Baoding First Central Hospital of Hebei Medical University, Baoding, Hebei 071000, P.R. China
| |
Collapse
|
4
|
Baba M, Alsbrook D, Williamson S, Soman S, Ramadan AR. Approach to the Management of Sodium Disorders in the Neuro Critical Care Unit. Curr Treat Options Neurol 2022. [DOI: 10.1007/s11940-022-00723-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
5
|
Aleksandrowicz M, Kozniewska E. Hyponatremia as a risk factor for microvascular spasm following subarachnoid hemorrhage. Exp Neurol 2022; 355:114126. [DOI: 10.1016/j.expneurol.2022.114126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 05/20/2022] [Accepted: 05/25/2022] [Indexed: 11/04/2022]
|
6
|
Lubnin AY. [Sitting position in neurosurgery: realizing the risks]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2022; 86:99-108. [PMID: 35758085 DOI: 10.17116/neiro20228603199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The author discusses potential intraoperative complications following neurosurgical interventions in sitting position: venous air embolism and paradoxical air embolism, postural hypotension, pneumocephalus, cervical flexion neuropathy, positional damage to peripheral nerves and others. Naturally, prevention of these complications is also considered, and the most effective approach is surgery in lying position.
Collapse
Affiliation(s)
- A Yu Lubnin
- Burdenko Neurosurgical Center, Moscow, Russia
| |
Collapse
|
7
|
Subba H, Riker RR, Dunn S, Gagnon DJ. Vasopressin-Induced Hyponatremia in Patients With Aneurysmal Subarachnoid Hemorrhage: A Case Series and Literature Review. J Pharm Pract 2021; 36:689-694. [PMID: 34674580 PMCID: PMC9021328 DOI: 10.1177/08971900211053497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Vasopressin may be administered to treat vasospasm following aneurysmal subarachnoid hemorrhage (aSAH). The objectives of this study were to describe five cases of suspected vasopressin-induced hyponatremia after aSAH and to review the literature. DESIGN Single-center, observational case series of intensive care unit (ICU) patients. SETTINGS Ten-bed neurological ICU at Maine Medical Center in Portland, Maine. PATIENTS Convenience sample of patients with aSAH treated with a vasopressin for symptomatic, radiologically confirmed vasospasm. RESULTS A total of five patients were included in the case series with a median age of 57 (51, 65) years and all were women. The median Glasgow coma scale score was 15 (11, 15) on admission, and the Hunt and Hess scale score was 3, (3, 4). All patients were treated with endovascular coiling of their aneurysm. Vasopressin was administered to treat symptomatic, radiographically confirmed vasospasm on median post-bleed day (PBD) 10 (10, 15) at a fixed-dose of .03 units/min. Serum sodium at baseline was 140 (140, 144) mEq/L and decreased to 129 (126, 129) mEq/L within 26 (17, 83) hours of vasopressin initiation for a median change of -16 (-10, -16) mEq/L. Serum sodium returned to baseline within 18 (14, 22) hours of stopping the infusion. CONCLUSIONS Vasopressin use in vasospasm after aSAH may be associated with clinically significant hyponatremia within 24 hours of starting the infusion. Hyponatremia appears to resolve within 24 hours of stopping the infusion. Additional study in a larger sample size is needed to determine if a causal relationship exist.
Collapse
Affiliation(s)
- Hilamber Subba
- Department of Critical Care Services, Maine Medical Center, Portland, ME, USA
| | - Richard R Riker
- Neuroscience Institute and Department Critical Care Services, Maine Medical Center, Portland, ME, USA
| | - Susan Dunn
- Division of Nephrology and Transplantation, Maine Medical Center, Portland, ME, USA
| | - David J Gagnon
- Department of Pharmacy, Faculty Scientist I, Maine Medical Center Research Institute, Maine Medical Center, Portland, ME, USA
| |
Collapse
|
8
|
Feng GL, Zheng MM, Yao SH, Li YQ, Zhang SJ, Wen WJ, Fan K, Zhang JL, Zhang X. Risk factors and predictive model of adrenocortical insufficiency in patients with traumatic brain injury. World J Emerg Med 2021; 12:179-184. [PMID: 34141031 DOI: 10.5847/wjem.j.1920-8642.2021.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Neuroendocrine dysfunction after traumatic brain injury (TBI) has received increased attention due to its impact on the recovery of neural function. The purpose of this study is to investigate the incidence and risk factors of adrenocortical insufficiency (AI) after TBI to reveal independent predictors and build a prediction model of AI after TBI. METHODS Enrolled patients were grouped into the AI and non-AI groups. Fourteen preset impact factors were recorded. Patients were regrouped according to each impact factor as a categorical variable. Univariate and multiple logistic regression analyses were performed to screen the related independent risk factors of AI after TBI and develop the predictive model. RESULTS A total of 108 patients were recruited, of whom 34 (31.5%) patients had AI. Nine factors (age, Glasgow Coma Scale [GCS] score on admission, mean arterial pressure [MAP], urinary volume, serum sodium level, cerebral hernia, frontal lobe contusion, diffuse axonal injury [DAI], and skull base fracture) were probably related to AI after TBI. Three factors (urinary volume [X 4], serum sodium level [X 5], and DAI [X 8]) were independent variables, based on which a prediction model was developed (logit P= -3.552+2.583X 4+2.235X 5+2.269X 8). CONCLUSIONS The incidence of AI after TBI is high. Factors such as age, GCS score, MAP, urinary volume, serum sodium level, cerebral hernia, frontal lobe contusion, DAI, and skull base fracture are probably related to AI after TBI. Urinary volume, serum sodium level, and DAI are the independent predictors of AI after TBI.
Collapse
Affiliation(s)
- Gui-Long Feng
- Department of Emergency, the First Hospital of Shanxi Medical University, Taiyuan 030001, China
| | - Miao-Miao Zheng
- Department of Emergency, Zhenjiang First People's Hospital, Zhenjiang 212000, China
| | - Shi-Hong Yao
- Department of Emergency, Yuncheng Central Hospital, Yuncheng 044500, China
| | - Yin-Qi Li
- Department of Emergency, Yuncheng Central Hospital, Yuncheng 044500, China
| | - Shao-Jun Zhang
- Department of Endocrinology, the Fourth Affiliated Hospital, Zhejiang University School of Medicine,Yiwu 322000, China
| | - Wei-Jing Wen
- Department of Emergency, the First Hospital of Shanxi Medical University, Taiyuan 030001, China
| | - Kai Fan
- Department of Emergency, the First Hospital of Shanxi Medical University, Taiyuan 030001, China
| | - Jia-Li Zhang
- Department of Emergency, the First Hospital of Shanxi Medical University, Taiyuan 030001, China
| | - Xiao Zhang
- Department of Emergency, the First Hospital of Shanxi Medical University, Taiyuan 030001, China
| |
Collapse
|
9
|
Zheng JY, Mixon AC, McLarney MD. Safety, Precautions, and Modalities in Cancer Rehabilitation: an Updated Review. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2021; 9:142-153. [PMID: 34178432 PMCID: PMC8214054 DOI: 10.1007/s40141-021-00312-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2021] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Providing rehabilitation to patients with cancer can be challenging due to the medical complexity associated with the illness and its treatments. This article provides the reader with a summary of frequently encountered medical conditions in the cancer population and associated safety considerations and precautions. An update on treatment modalities commonly used for symptom management is also presented. RECENT FINDINGS Cancer and cancer treatments can cause changes in multiple organ systems. Special considerations and precautions are necessary to provide safe and effective rehabilitation. Physical modalities can be used as monotherapy or adjunct to treatment for common cancer-related side effects with recent studies noting benefit with a variety of modalities. SUMMARY Detailed assessment of the cancer patient is necessary before implementing a rehabilitation program. Understanding cancer and side effects of treatments, including newer options, are necessary to provide safe care.
Collapse
Affiliation(s)
- Jasmine Y. Zheng
- Department of Physical Medicine and Rehabilitation, University of Pennsylvania, 1800 Lombard St, 1st Floor, Philadelphia, PA 19146 USA
| | - Alyssa C. Mixon
- Department of Physical Medicine and Rehabilitation, University of Pennsylvania, 1800 Lombard St, 1st Floor, Philadelphia, PA 19146 USA
| | - Mitra D. McLarney
- Department of Physical Medicine and Rehabilitation, University of Pennsylvania, 1800 Lombard St, 1st Floor, Philadelphia, PA 19146 USA
| |
Collapse
|
10
|
Patel S, Chiu RG, Rosinski CL, Chaker AN, Burch TG, Behbahani M, Sadeh M, Mehta AI. Risk Factors for Hyponatremia and Perioperative Complications With Malignant Intracranial Tumor Resection in Adults: An Analysis of the Nationwide Inpatient Sample from 2012 to 2015. World Neurosurg 2020; 144:e876-e882. [DOI: 10.1016/j.wneu.2020.09.097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 09/17/2020] [Indexed: 12/16/2022]
|
11
|
Konakondla S, Brimley CJ, Timmons SD. Neurosurgical Physiology and Neurocritical Management of the Acute Neurosurgical Patient. Oper Neurosurg (Hagerstown) 2020; 17:S17-S44. [PMID: 31099840 DOI: 10.1093/ons/opz090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 04/03/2019] [Indexed: 11/14/2022] Open
Affiliation(s)
- Sanjay Konakondla
- Department of Neurosurgery, Geisinger Health System, Danville, Pennsylvania
| | - Cameron J Brimley
- Department of Neurosurgery, Geisinger Health System, Danville, Pennsylvania
| | - Shelly D Timmons
- Department of Neurosurgery, Milton S. Hershey Medical Center, Penn State University, Hershey, Pennsylvania
| |
Collapse
|
12
|
Zeynalov E, Jones SM, Elliott JP. Vasopressin and vasopressin receptors in brain edema. VITAMINS AND HORMONES 2020; 113:291-312. [DOI: 10.1016/bs.vh.2019.08.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
|
13
|
Cui H, He G, Yang S, Lv Y, Jiang Z, Gang X, Wang G. Inappropriate Antidiuretic Hormone Secretion and Cerebral Salt-Wasting Syndromes in Neurological Patients. Front Neurosci 2019; 13:1170. [PMID: 31780881 PMCID: PMC6857451 DOI: 10.3389/fnins.2019.01170] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 10/16/2019] [Indexed: 12/13/2022] Open
Abstract
The differential diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH) and cerebral salt-wasting syndrome (CSWS) in patients with neurological disorders has been a perplexing clinical controversy. The purpose of this review is to summarize the characteristics and risk factors of patients with different types of neurological disorders complicated by hyponatremia (HN) and review various methods to distinguish SIADH from CSWS. Common neurological disorders with high rates of HN include subarachnoid hemorrhage (SAH), traumatic brain injuries, stroke, cerebral tumors, central nervous system (CNS) infections, and Guillain-Barré syndrome (GBS), which have their own characteristics. Extracellular volume (ECV) status of patients is a key point to differentiate SIADH and CSWS, and a comprehensive assessment of relevant ECV indicators may be useful in differentiating these two syndromes. Besides, instead of monitoring the urinary sodium excretion, more attention should be paid to the total mass balance, including Na+, K+, Cl-, and extracellular fluid. Furthermore, the dynamic detection of fractional excretions (FE) of urate before and after correction of HN and a short-term infusion of isotonic saline solution may be useful in identifying the etiology of HN. As for brain natriuretic peptide (BNP) or N-terminal prohormone of BNP (NT-proBNP), more prospective studies and strong evidence are needed to determine whether there is a pertinent and clear difference between SIADH and CSWS.
Collapse
Affiliation(s)
- Haiying Cui
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, Changchun, China
| | - Guangyu He
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, Changchun, China
| | - Shuo Yang
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, Changchun, China
| | - You Lv
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, Changchun, China
| | - Zongmiao Jiang
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, Changchun, China
| | - Xiaokun Gang
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, Changchun, China
| | - Guixia Wang
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, Changchun, China
| |
Collapse
|
14
|
Garrahy A, Dineen R, Hannon AM, Cuesta M, Tormey W, Sherlock M, Thompson CJ. Continuous Versus Bolus Infusion of Hypertonic Saline in the Treatment of Symptomatic Hyponatremia Caused by SIAD. J Clin Endocrinol Metab 2019; 104:3595-3602. [PMID: 30882872 DOI: 10.1210/jc.2019-00044] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 03/12/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Acute hyponatremia is a medical emergency that confers high mortality, attributed primarily to cerebral edema. Expert guidelines advocate the use of intravenous boluses of hypertonic saline rather than traditional continuous infusion to achieve a faster initial rise in plasma sodium (pNa) concentration. However, there is a limited evidence base for this recommended policy change. METHODS We prospectively assessed the clinical and biochemical outcomes in patients treated for symptomatic hyponatremia caused by syndrome of inappropriate antidiuresis in response to intravenous bolus treatment with 3% saline (100 mL, repeated up to two more times) and compared the outcomes to retrospective data from patients treated with continuous intravenous infusion of low-dose (20 mL/h) 3% saline. RESULTS Twenty-two patients were treated with bolus infusion and 28 with continuous infusion. Three percent saline bolus caused more rapid elevation of pNa at 6 hours [median (range) 6 (2 to11) vs 3 (1 to 4) mmol/L, P < 0.0001], with a concomitant improvement in Glasgow Coma Scale (GCS) [median (range) 3 (1 to 6) vs 1 (-2 to 2), P < 0.0001] at 6 hours. Median pNa concentration was similar at 24 hours in the two treatment groups. The administration of a third saline bolus was associated with greater need for dextrose/dDAVP to prevent overcorrection (OR 24; P = 0.006). There were no cases of osmotic demyelination in either group. CONCLUSION Three percent saline bolus produces faster initial elevation of pNa than continuous infusion with quicker restoration of GCS, and without osmotic demyelination. Frequent electrolyte monitoring, and judicious intervention with dDAVP is required to prevent overcorrection with bolus therapy.
Collapse
Affiliation(s)
- Aoife Garrahy
- Academic Department of Endocrinology, Beaumont Hospital/RCSI, Dublin, Ireland
| | - Rosemary Dineen
- Academic Department of Endocrinology, Beaumont Hospital/RCSI, Dublin, Ireland
| | - Anne Marie Hannon
- Academic Department of Endocrinology, Beaumont Hospital/RCSI, Dublin, Ireland
| | - Martin Cuesta
- Academic Department of Endocrinology, Beaumont Hospital/RCSI, Dublin, Ireland
| | - William Tormey
- Department of Chemical Pathology, Beaumont Hospital, Dublin, Ireland
| | - Mark Sherlock
- Academic Department of Endocrinology, Beaumont Hospital/RCSI, Dublin, Ireland
| | - Chris J Thompson
- Academic Department of Endocrinology, Beaumont Hospital/RCSI, Dublin, Ireland
| |
Collapse
|
15
|
Esposito D, Olsson DS, Ragnarsson O, Buchfelder M, Skoglund T, Johannsson G. Non-functioning pituitary adenomas: indications for pituitary surgery and post-surgical management. Pituitary 2019; 22:422-434. [PMID: 31011999 PMCID: PMC6647426 DOI: 10.1007/s11102-019-00960-0] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE Non-functioning pituitary adenomas (NFPAs) are associated with impaired well-being, increased comorbidities, and reduced long-term survival. Data on optimal management of NFPAs around surgical treatment are scarce, and postoperative treatment and follow-up strategies have not been evaluated in prospective trials. Here, we review the preoperative, perioperative, and early postoperative management of patients with NFPAs. METHODS We searched Medline and the Cochrane Library for articles published in English with the following items "Pituitary neoplasms AND Surgery" and "Surgery AND Hypopituitarism". Studies containing detailed analyses of the management of NFPAs in adult patients, including pituitary surgery, endocrine care, imaging, ophthalmologic assessment and long-term outcome were reviewed. RESULTS Treatment options for NFPAs include active surveillance, surgical resection, and radiotherapy. Pituitary surgery is currently recommended as first-line treatment in patients with visual impairment due to adenomas compressing the optic nerves or chiasma. Radiotherapy is reserved for large tumor remnants or tumor recurrence following one or more surgical attempts. There is no consensus of optimal pre-, peri-, and postoperative management such as timing, frequency, and duration of endocrine, radiologic, and ophthalmologic assessments as well as management of smaller tumor remnants or tumor recurrence. CONCLUSIONS In clinical practice, there is a great variation in the treatment and follow-up of patients with NFPAs. We have, based on available data, suggested an optimal management strategy for patients with NFPAs in relation to pituitary surgery. Prospective trials oriented at drawing up strategies for the management of NFPAs are needed.
Collapse
Affiliation(s)
- Daniela Esposito
- Department of Endocrinology, Institute of Medicine, Sahlgrenska University Hospital, Sahlgrenska Academy, University of Gothenburg, SE-413 45, Gothenburg, Sweden.
| | - Daniel S Olsson
- Department of Endocrinology, Institute of Medicine, Sahlgrenska University Hospital, Sahlgrenska Academy, University of Gothenburg, SE-413 45, Gothenburg, Sweden
| | - Oskar Ragnarsson
- Department of Endocrinology, Institute of Medicine, Sahlgrenska University Hospital, Sahlgrenska Academy, University of Gothenburg, SE-413 45, Gothenburg, Sweden
| | - Michael Buchfelder
- Department of Neurosurgery, University of Erlangen-Nürnberg, Schwabachanlage 6, 91054, Erlange, Germany
| | - Thomas Skoglund
- Department of Neurosurgery, Sahlgrenska University Hospital, SE-413 45, Gothenburg, Sweden
| | - Gudmundur Johannsson
- Department of Endocrinology, Institute of Medicine, Sahlgrenska University Hospital, Sahlgrenska Academy, University of Gothenburg, SE-413 45, Gothenburg, Sweden
| |
Collapse
|
16
|
Donovan J, Figaji A, Imran D, Phu NH, Rohlwink U, Thwaites GE. The neurocritical care of tuberculous meningitis. Lancet Neurol 2019; 18:771-783. [PMID: 31109897 DOI: 10.1016/s1474-4422(19)30154-1] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Revised: 02/28/2019] [Accepted: 03/05/2019] [Indexed: 12/16/2022]
Abstract
Tuberculous meningitis is the most severe form of tuberculosis and often causes critical illness with high mortality. Two primary management objectives are reducing intracranial pressure, and optimising cerebral perfusion, while killing the bacteria and controlling intracerebral inflammation. However, the evidence base guiding the care of critically ill patients with tuberculous meningitis is poor and many patients do not have access to neurocritical care units. Invasive intracranial pressure monitoring is often unavailable and although new non-invasive monitoring techniques show promise, further evidence for their use is required. Optimal management regimens of neurological complications (eg, hydrocephalus and paradoxical reactions) and of hyponatraemia, which frequently accompanies tuberculous meningitis, remain to be elucidated. Advances in the field of tuberculous meningitis predominantly focus on diagnosis, inflammatory processes, and antituberculosis chemotherapy. However, clinical trials are required to provide robust evidence guiding the most effective supportive, therapeutic, and neurosurgical interventions for tuberculous meningitis that will improve morbidity and mortality.
Collapse
Affiliation(s)
- Joseph Donovan
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Anthony Figaji
- Division of Neurosurgery and Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Darma Imran
- Cipto Mangunkusumo Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Nguyen Hoan Phu
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam; Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Ursula Rohlwink
- Division of Neurosurgery and Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Guy E Thwaites
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| |
Collapse
|
17
|
Smolinsky K, Sediva I. A Case of Delayed-Onset Posthypoxic Leukoencephalopathy in a Pediatric Patient. Child Neurol Open 2018; 5:2329048X18792441. [PMID: 30182033 PMCID: PMC6116073 DOI: 10.1177/2329048x18792441] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 06/26/2018] [Accepted: 07/12/2018] [Indexed: 01/14/2023] Open
Abstract
We present a 16-year-old female status post traumatic brain injury from severe motor
vehicle crash with prolonged extrication. Initially with a Glasgow Coma Scale of 4 and
blood pressure of 80/40, she required emergent intubation. Head computed tomography was
notable for skull fracture with hematoma, diffuse axonal injury, and 6-mm midline shift
with right uncal herniation. On hospital day 1, she underwent decompressive R
hemicraniectomy. She received neuroprotective treatment including a hypocarbic,
hypernatremic state with close blood pressure monitoring for appropriate cerebral
perfusion. On hospital day 4, patient was extubated and weaned off pressors and hypertonic
saline. On hospital day 6, she was able to get out of bed to a chair, was speaking some
words, following commands, and tolerating bites of food. On hospital day 8, she developed
sudden agitation, combativeness, confusion, and could no longer follow commands. Magnetic
resonance imaging now demonstrated confluent restricted diffusion consistent with acute
changes. Imaging and examination findings were consistent with delayed-onset posthypoxic
leukoencephalopathy.
Collapse
Affiliation(s)
- Kristen Smolinsky
- Brown University Pediatric Program, Hasbro Children's Hospital, Providence, RI, USA
| | - Ivona Sediva
- Division of Pediatric Intensive Care, Hasbro Children's Hospital, Providence, RI, USA
| |
Collapse
|
18
|
Burke WT, Cote DJ, Iuliano SI, Zaidi HA, Laws ER. A practical method for prevention of readmission for symptomatic hyponatremia following transsphenoidal surgery. Pituitary 2018; 21:25-31. [PMID: 29075986 DOI: 10.1007/s11102-017-0843-5] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Patients undergoing transsphenoidal pituitary surgery (TSS) are at risk for several serious complications, including the syndrome of inappropriate antidiuretic hormone and subsequent hyponatremia. OBJECTIVE In this study, we examined the effect of 1 week of post-discharge fluid restriction to 1.0 L daily on rates of post-operative readmission for hyponatremia. METHODS We retrospectively analyzed all patients undergoing TSS from 2008 to 2014 and prospectively recorded patient data from 2015 to 2017. Patients were divided into a control cohort (2008-2014), who were discharged with instructions to drink to thirst; and an intervention cohort (2015-2017) who were instructed to drink less than 1.0 L daily for 1 week post-operatively. RESULTS This study included 788 patients; 585 (74.2%) in the control cohort and 203 (25.8%) in the intervention cohort. Overall, 436 (55.3%) were women, the median age was 47 (range 15-89), and average BMI was 29.4 kg/m2 (range 17.7-101.7). Patients were relatively well matched. Of patients in the intervention group, none was readmitted for hyponatremia (0/203), compared to 3.41% (20/585) in the control group (p = 0.003). Patients in the intervention group also had significantly higher post-operative week one sodium levels (140.1 vs 137.5 mEq/L; p = 0.002). No fluid balance complications occurred in patients who followed this protocol. CONCLUSION Hyponatremia can be a life-threatening complication of TSS, and prevention of readmission for hyponatremia can help improve patient safety and decrease costs. Mandatory post-discharge fluid restriction is a simple and inexpensive intervention associated with decreased rates of readmission for hyponatremia and normal post-operative sodium levels.
Collapse
Affiliation(s)
- William T Burke
- University of Louisville Medical School, Louisville, KY, USA
- Pituitary/Neuroendocrine Center, Brigham and Women's Hospital, 60 Fenwood Road, Boston, MA, USA
| | - David J Cote
- Pituitary/Neuroendocrine Center, Brigham and Women's Hospital, 60 Fenwood Road, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Sherry I Iuliano
- Pituitary/Neuroendocrine Center, Brigham and Women's Hospital, 60 Fenwood Road, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Hasan A Zaidi
- Pituitary/Neuroendocrine Center, Brigham and Women's Hospital, 60 Fenwood Road, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Edward R Laws
- Pituitary/Neuroendocrine Center, Brigham and Women's Hospital, 60 Fenwood Road, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
| |
Collapse
|
19
|
Garrahy A, Sherlock M, Thompson CJ. MANAGEMENT OF ENDOCRINE DISEASE: Neuroendocrine surveillance and management of neurosurgical patients. Eur J Endocrinol 2017; 176:R217-R233. [PMID: 28193628 DOI: 10.1530/eje-16-0962] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 01/30/2017] [Accepted: 02/13/2017] [Indexed: 01/01/2023]
Abstract
Advances in the management of traumatic brain injury, subarachnoid haemorrhage and intracranial tumours have led to improved survival rates and an increased focus on quality of life of survivors. Endocrine sequelae of the acute brain insult and subsequent neurosurgery, peri-operative fluid administration and/or cranial irradiation are now well described. Unrecognised acute hypopituitarism, particularly ACTH/cortisol deficiency and diabetes insipidus, can be life threatening. Although hypopituitarism may be transient, up to 30% of survivors of TBI have chronic hypopituitarism, which can diminish quality of life and hamper rehabilitation. Patients who survive SAH may also develop hypopituitarism, though it is less common than after TBI. The growth hormone axis is most frequently affected. There is also accumulating evidence that survivors of intracranial malignancy, who have required cranial irradiation, may develop hypopituitarism. The time course of the development of hormone deficits is varied, and predictors of pituitary dysfunction are unreliable. Furthermore, diagnosis of GH and ACTH deficiency require dynamic testing that can be resource intensive. Thus the surveillance and management of neuroendocrine dysfunction in neurosurgical patients poses significant logistic challenges to endocrine services. However, diagnosis and management of pituitary dysfunction can be rewarding. Appropriate hormone replacement can improve quality of life, prevent complications such as muscle atrophy, infection and osteoporosis and improve engagement with physiotherapy and rehabilitation.
Collapse
Affiliation(s)
- Aoife Garrahy
- Academic Department of EndocrinologyBeaumont Hospital/RCSI Medical School, Dublin, Ireland
| | | | - Christopher J Thompson
- Academic Department of EndocrinologyBeaumont Hospital/RCSI Medical School, Dublin, Ireland
| |
Collapse
|
20
|
Low JCM, Welbourne J, McMillan H, Whitfield PC. Early versus late readmission of subarachnoid haemorrhage patients into neurocritical care. Br J Neurosurg 2016; 30:545-8. [PMID: 27333293 DOI: 10.1080/02688697.2016.1199782] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Subarachnoid haemorrhage (SAH) patients will typically require monitoring in a specialised Neurocritical Care Unit (NCCU) regardless of the primary treatment modality. Once discharged from NCCU, readmission within 48 h is regarded as a "failed" discharge. The aims of this study are to (1) Evaluate the readmission rate of SAH patients into NCCU, (2) Identify the indications for readmission, (3) Analyse clinical parameters on discharge between patients readmitted early and late. MATERIALS AND METHODS Retrospective observational study of the Intensive Care National Audit and Research Centre (ICNARC) database of patients from our unit diagnosed with SAH from January 2009-December 2014, who were readmitted into NCCU. Demographic data, World Federation of Neurosurgical Societies (WFNS) grade, Fisher grade, length of initial and subsequent NCCU stay, time of readmission, indication for readmission, and mortality rate data were collected. Patients were categorised by early (<48 h) and late (>48 h) readmission, and their clinical parameters on NCCU discharge were statistically analysed. RESULTS Five hundred and seventy-five SAH patients were admitted into NCCU, of which 49 patients (9%) were readmitted after discharge to ward-level care. The mean age of readmitted patients was 64.1 ± 11.6 years old. The most common indications were delayed cerebral ischaemia (DCI) (50%) and infection (19%). Readmitted SAH patients were typically WFNS grade I-II (n = 22) and Fisher grade III-IV (n = 44). 17 (35%) patients were readmitted early, and were older (p = 0.0049) with a lower GCS (p = 0.0077) compared to patients readmitted later. White cell count and C-reactive protein were higher in patients readmitted early, but did not reach statistical significance (p = 0.09, p = 0.07). CONCLUSION DCI and infection were the most common indications for NCCU readmission in SAH patients. "Failed" discharged patients from NCCU are typically older with a lower GCS than patients readmitted after 48 h, and therefore clinicians should be more cautious in discharging these patients prematurely.
Collapse
Affiliation(s)
- Jacob C M Low
- a South West Neurosurgical Centre , Derriford Hospital , Plymouth , UK
| | - Jessie Welbourne
- b Department of Critical Care , Derriford Hospital , Plymouth , UK
| | - Helen McMillan
- b Department of Critical Care , Derriford Hospital , Plymouth , UK
| | - Peter C Whitfield
- a South West Neurosurgical Centre , Derriford Hospital , Plymouth , UK
| |
Collapse
|
21
|
Ichimura S, Fahlbusch R, Lüdemann W. Treatment of Hyponatremia with Tolvaptan in a Patient after Neurosurgical Treatment of a Pituitary Tumor: Case Report and Review of Literature. J Neurol Surg Rep 2015; 76:e279-81. [PMID: 26623242 PMCID: PMC4648721 DOI: 10.1055/s-0035-1564605] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Accepted: 08/11/2015] [Indexed: 11/24/2022] Open
Abstract
Hyponatremia is a frequent complication following pituitary surgery. We report a case with hyponatremia after surgery of a pituitary adenoma that was successfully treated with tolvaptan. A 68-year-old man with a pituitary tumor presented with mild hyponatremia (133 mEq/L) before surgery. The patient developed hyponatremia (125 mEq) 4 days postsurgery, and 10% sodium chloride was infused. Seven 7 days postsurgery, hyponatremia was improved (132 mEq/L), and tolvaptan 15 mg was given orally as a single dose instead of the 10% sodium chloride infusion. His serum sodium remained within normal limits. The syndrome of inappropriate antidiuretic hormone secretion (SIADH) after pituitary surgery most probably led to the hyponatremia, and tolvaptan was effective because it is an oral vasopressin receptor antagonist.
Collapse
Affiliation(s)
- Shinya Ichimura
- Department of Neurosurgery, International Neuroscience Institute, Hannover, Germany
| | - Rudolf Fahlbusch
- Department of Neurosurgery, International Neuroscience Institute, Hannover, Germany
| | - Wolf Lüdemann
- Department of Neurosurgery, International Neuroscience Institute, Hannover, Germany
| |
Collapse
|