Management of Hyponatremia2

7/23/2019 Management of Hyponatremia2

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Evolving Strategies for HyponatremiaManagement in the ICU

Mazen Kherallah, MD, FCCPInfectious Disease & Critical Care Medicine

Assistant Professor, University of orth Da!ota



Criti"al Care Patients at In"rease#$is! of Hyponatremia%

Increased age1

Up to 30% of patients with subarachnoid hemorrhage2

Up to 30% of ICU patients3

!er 30% of "ID# patients$

ostoperati!e patients

2'%(3'% of pituitar) surger) for tumor resection'

*30% of acute spinal cord in+ur),

s)chiatric inpatients- ,%(1.%.

%Data not e&"l'sive to patients (ith e'volemi" hyponatremia)1/ awins C/ Clin Chim Acta/ 200333.-1,4(1.2 2/ Ma)er #"/ The Neurologist / 144'1-.1(5'3/ De6ita M6 et al/ Clin Nephrol/ 14403$-1,3(1,, $/ 7ang 88 et al/ Am J Med/ 14434$-1,4(1.$'/ 9hardwa+ "/ Ann Neurol/ 200,'4-224(23, ,/ eru::i 87 et al/ Crit Care Med/ 144$22-2'2(2'5./ #iegler ;< et al/ Arch Intern Med/ 144'1''-4'3(4'./



Mortality $elate# to HyponatremiaAmong Hospitalize# Patients

"nderson1 7er:ian2 7ierne)30%

'%

10%

1'%

20%

2'%

=>a?@ A130 m;B< >ormonatremia

1/ "nderson et al/ An Intern Med. 144'E102- 1,$(1,52/ 7er:ian C et al/ J Gen Intern Md. 144$E4-54(413/ 7ierne) 8M et al/ J Gen Intern Med. 145,1- 350(35'



Mor*i#ities in Hospitalize# Patients (ithSymptomati" Hyponatremia

0%

10%

20%

30%

$0%

'0%

,0%

• #ingle centerE retrospecti!e o!er $ )ears F144.(2001G• 1,5 patients with serum =>a?@ A11' m;B<• #)mptoms of h)ponatremic encephalopath) in 54 of 1,5 patient F'3%G• >o documented s)mptoms in .4 of 1,5 patients F$.%G

>:enue CM et al/ >atl Med "ssoc/ 20034'- 33'(3$3



Me"hanisms of Hyponatremia

H=>a?@

H=>a?@



9rain C7 #can- Cerebral ;dema

ormal C+ S"anFatal

Hyponatremia



Case I

44 year old man with schizophrenia is brought to the ED from his group home after

a witnessed tonic-clonic generalized seizure.

He was well until earlier in the day at which time he became progressively

somnolent.

His medications include haloperidol, quetiapine and citalopram.

n e!am he is afebrile, "# $%&'(), H* +%. He is somnolent but arousable and

following commands, is euvolemic, and there are no focal findings.

His urine output is $%& ml'hour

Ser'm Urine

>a 11, m;B< >a 3' m;B<

K 3/4 m;B< K 1' m;B<

Creat 0/5 mgd< sm 42 msmg

sm 2$0 msmg



'estion

hat is the most liely etiology of this mans

hyponatremia/

a0 1yndrome of inappropriate antidiuresis b0 #sychogenic polydipsia

c0 #seudohyponatremia

d0 2drenal insufficiency

e0 3erebral sat wasting



+he Diagnosis of Hyponatremia-Three Critical Questions

Is it real.Is (ater

e&"retionappropriate.

Is ADHe&"retion

/appropriate0.



Assessment of Hyponatremia-Three Critical Questions

Hypovolemia Appropriate ADH Secretion

EuvolemiaInappropriate ADH

HypervolemiaMaladaptive ADH Secretion

Total body water ↓Total body Na+ ↓↓

Total body water ↑Total body Na+ ↔

Total body water ↑↑Total body Na+↑

U[Na+ !"# $%&'( U[Na+ )"# $%&'( U[Na+ !"# $%&'( U[Na+ !"# $%&'( U[Na+ "# )$%&'(

Renal LossesDi*retic ece,,Mineralocorticoidde-iciency.icarbonat*ria wit/t*bal acido,i, and$etabolic al0alo,i,

1eton*ria2,$otic di*re,i,

Extrarenal losses3o$itin4Diarr/eaT/ird ,pacin4 o--l*id,.*rn,5ancreatiti,

Tra*$a

6l*cocorticoid de-iciencyHypot/yroidi,$Syndro$e o-inappropriate ADH,ecretion

Ac*te or c/ronicrenal -ail*re

Nep/rotic ,yndro$e7irr/o,i,7ardiac -ail*re

1. Is it real? 5la,$a 2,$olality Normal or High5,e*do/yponatre$iaHyper4lyce$ia A8ote$ia9 %T2H Intoication

Low

2. Is water excretion appropriate? Urine 2,$olalityLow

:) ;## $2,$'04<5,yc/o4enic polydip,ia

High:!;## $2,$'04<

3. Is !H secretion appropriate? "3ol*$e Stat*,#

123m4sm5!g

61m4sm5!g



Case II

4-year-old woman admitted to

5eurocritical 3are 6nit confused and

mildly lethargic secondary to subarachnoid

hemorrhage

#ast medical history7 hypertension, tobaccosmoer

"# $(&'() mm Hg, H* ($ bpm

&.+8 saline administered at $&& m9'h

3:# -) mm Hg

;ildly positive fluid balance *emained confused and disoriented, but

lethargy gradually resolved



In the Step7Do(n Unit

Day + post-12H

#atient transferred to step-down unit

3entral venous <: catheter discontinued

<: fluid7 normal saline administered at $&& m9'h through peripheral <:

Day $& post-12H

=he patient appeared to be more confused

1erum >5a?@ A $% mEq'9

Ser'm Urine

>a 12, m;B< >a $' m;B<

K 3/, m;B< K 1. m;B<

Creat 0/. mgd< sm 242 msmg

sm 2'5 msmg



'estion

hat is the most liely etiology of this patients

hyponatremia/

a0 1<2DH b0 #sychogenic polydipsia

c0 #seudohyponatremia

d0 2drenal insufficiency

e0 3erebral sat wasting



Assessment of Hyponatremia-Three Critical Questions

Hypovolemia Appropriate ADH Secretion

EuvolemiaInappropriate ADH

HypervolemiaMaladaptive ADH Secretion

Total body water ↓Total body Na+ ↓↓

Total body water ↑Total body Na+ ↔

Total body water ↑↑Total body Na+↑

U[Na+ !"# $%&'( U[Na+ )"# $%&'( U[Na+ !"# $%&'( U[Na+ !"# $%&'( U[Na+ "# )$%&'(

Renal LossesDi*retic ece,,Mineralocorticoidde-iciency.icarbonat*ria wit/t*bal acido,i, and$etabolic al0alo,i,

1eton*ria2,$otic di*re,i,

Extrarenal losses3o$itin4Diarr/eaT/ird ,pacin4 o--l*id,.*rn,5ancreatiti,

Tra*$a

6l*cocorticoid de-iciencyHypot/yroidi,$Syndro$e o-inappropriate ADH,ecretion

Ac*te or c/ronicrenal -ail*re

Nep/rotic ,yndro$e7irr/o,i,7ardiac -ail*re

1. Is it real? 5la,$a 2,$olality Normal or High5,e*do/yponatre$iaHyper4lyce$ia A8ote$ia9 %T2H Intoication

Low

2. Is water excretion appropriate? Urine 2,$olalityLow

:) ;## $2,$'04<5,yc/o4enic polydip,ia

High:!;## $2,$'04<

3. Is !H secretion appropriate? "3ol*$e Stat*,#

189m4sm5!g

161m4sm5!g



'estion

ow would )ou treat this patientL

aG luid restriction FA2 <dG

bG #alt tablets F>aCl 2 gdGcG >ormal saline infusion

dG 3% h)pertonic saline

eG I6 Coni!aptan



+reatment Consi#erations

• ften unnown• N2 da)s• "cute reduction

in chronic state• More brain

adaptation withchronic

A"'te orChroni"

• Mild- N124• Moderate-

121(124• #e!ere A120

Severity ofHyponatremia

• #e!ere #)mptoms

or Intracranialatholog)- sei:uresEimpaired mentalstatus or coma

• Moderate-confusionE letharg)E

• Mild- fatigueEnauseaE di::inessEgait disturbancesEforgetfulness nd

muscle cramps• "s)mptomatic

Severity ofSymptoms

• 7reat cerebraledema

• elie!e s)mptomsand pre!entprogression of

neurologicd)sfunction• re!ent osmotic

dem)elinations)ndrome

• $(, meB2$ hrsFA4 meB< in an)2$ hrsG

+reatment:oals



+reatment Strategies

• 7reat painEnauseaE!omitingE//

• cessation oftherap) withcertain drugs

• glucocorticoidsto patients withadrenal

insuOcienc)

+reatUn#erlying

Ca'se

• #aline to patientswith true !olumedepletion

• Diuretics inedematous statesFsuch as heart

failure andcirrhosisG

$estoration of

E'volemia

• luid restrictionin #I"D

;alan"ing theE<e"t of ADH

• )pertonicsaline

• >ormal saline• #alt tablets

Corre"tion ofa an# $ate of

Corre"tion

So#i'm #e="it> +;? @#esire# Sa7a"t'al Sa

In"rease in Sa> @inf'sate Ba7Sa @+;?



+reatment 4ptions

• F># in h)po!olemiaG• luid restriction FAU or A500

mlda)G• #alt tablets• 62 receptors antagonists

• F># in h)po!olemiaG• )pertonic saline• Increase >a 0/'(1 meBhour in the

Prst $ hours• $(, meB in 2$ hours

•

• )pertonic saline• Increase >a 0/'(1 meBhour in

the Prst $ hours• $(, meB in 2$ hours FA4 meBin

an) 2$ hoursG

• apid increase in >a $(, meB<Fin , hoursG

• 3% saline 100 m< I6 bolus• epeat 1(2 Q at 10 minutes

inter!als if s)mptoms persist• R 4 meB< in 2$ hours

SevereSymptoms- Seiz'reor "oma

Mo#erate

Symptoms-Conf'sion

an#5orlethargy

Mil# ora*s"ent

symptoms- a G

13me5

Mil# ora*s"ent

symptoms- aJ13me5



+reatment Co'rse for +his Patient

" 20 mg loading dose of coni!aptan followed b) acontinuous infusion of 20 mgd

2$ hour after the start of the loading doseE the serum=>a?@ increased from 12, to 132

" second 2$ hour contineous infusion gi!en

SAH

Day

Ser'm Ba

@mE5

12 Ho'r

Fl'i#;alan"e @

Conivaptan

+reatmentDay

10 12, ?0/2 1

11 132 (0/5 2

12 135 (1/2 3



Day 1 of +reatment

7he neSt da) serum =>a?@ increased from 132 to135 m;B<

Mental status- less confused

Coni!aptan discontinued

atient discharged to rehabilitation on #" Da) 13



$e"eptor7Me#iate# E<e"ts of AP

Receptor Subtype Site of Action Activation Effects

:$a :ascular smooth musclecells

#latelets9ymphocytes andmonocytes2drenal corte!

:asoconstriction#latelet aggregation

3oagulation factor releaseBlyconeogenesis

:$b 2nterior pituitary 23=H and C-endorphin

release:% *enal collecting duct

principal cellsree water absorption

<ee C et al/ "M eart / 20031$3-4(15



Hyponatremia in A"'te ;rain InL'ry+herape'ti" 4ptions

Spee# Sit'ation Pl'ses Min'ses

Free (aterrestri"tion

#low ard toregulate

Sf'rosemi#e #ow ;lectrol)tedepletion

Fl'#ro"ortisone

#low luid o!erload

AP Inhi*itor aster "s)mptomatic

h)ponatremia

eliable eTect Infusion sitereactions

Mannitol atsest #)mptomatich)ponatremia

educe;dema

Can worsenh)po!olemia;lectrol)tedepletion

Hypertoni"

saline

astest #)mptomatic

h)ponatremia

educe brain

edema

luid o!erload



7han )ou

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Management of Hyponatremia2