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36yo 60kg severe diarrhea

hypovolemic hyponatremia
Na deficit =
TBW (change in Na)
36*9 = 320meq deficit
now you also want to give volume so you give isotonic
320/154 = 2L --> give 2Lsaline

TREAMENT OF
WATER IMBALANCE

Hala Kilany, MD

TREATMENT OF WATER IMBALANCE


Lecture Outline
Treatment of Hyponatremia
Revisiting hyponatremia classification, pathophysiology, and
symptoms
Approach to hyponatremia treatment
Systematic method of hyponatremia correction
Special topic: Treatment of SIADH

Treatment of Hypernatremia
Approach to hypernatremia treatment
Systematic method of hypernatremia correction
Special topics: Treatment of NDI and CDI

OVERVIEW
[Na+]: 135 145 mEq/L

Osmolality = 2 x (Na+) = 2 x (135 - 145 mEq/L)


Normal (Isotonic) 280 300
Low (Hypotonic) < 280
High (Hypertonic) > 300

REVISITING
HYPONATREMIA

HYPONATREMIA
Classification

Classify hyponatremia according to duration:


Acute: onset < 48 hours
Chronic: onset > 48 hours or unknown onset
48 hrs is the time that the brain cells take to generate
osmotically active particles in response to the cellular
= osmolytes
swelling.
As a general rule, if the patient is completely
asymptomatic, the hyponatremia is most likely a chronic
one.

HYPONATREMIA
Pathophysiology

Water shift from the extracellular space into


the cells.
Brain swelling occurs in the confined space of
the skull
Signs will result in relation to 3 factors:
Severity of hyponatremia
Rapidity of hyponatremia
Risk factors

HYPONATREMIA
Pathophysiology

In the setting of an acute drop in the serum osmolality,


neuronal cell swelling occurs due to the water shift from
the extracellular space to the intracellular space
Swelling of the brain cells elicits the following 2
responses:

1-Inhibition of both arginine vasopressin secretion from


neurons in the hypothalamus and hypothalamic thirst
center causing excess water elimination as dilute urine.
2-Immediate cellular adaptation with loss of electrolytes, and
over the next few days, there is a more gradual loss of organic
intracellular osmolytes.

very important to
correct slowly

HYPONATREMIA
Risk Factors of Cerebral Edema
Risk Factors
Children < 16
Premenopausal women

Pathophysiologic Mechanism
Higher brain-to-intracranial
volume ratio
Sex steroids(estrogens) inhibit
brain adaptation
Increased vasopressin levels
Cerebral vasoconstriction and
hypoperfusion of brain

Hypoxemia

Impaired brain adaptation

Ecstasy use

Syndrome of Inappropriate
ADH (SIADH)

HYPONATREMIA

Clinical Features & Severity


Plasma [Na+] (mEq/L)

Symptoms

Mortality

> 125

Alert

120-125

Nausea, headache,
altered cognition

23%

115-120

Confusion, stupor

30%

< 115

Seizures, coma

50%

Degree of
Depletion

ECF Loss

Signs and
Symptoms

Urine Output

Labs

no Sx. Thirst

30-40ml/hr

Mild in urine
specific gravity

Moderate in
HCT.
Uosm> 500
UNa+< 10-15
Urea/Cr > 10:1

Severe in HCT

Signs and symptoms of ecf depletion according


Mild (<10%)
1500to
mL the degree
2%wt loss. Mild
Mild reduction
Mild in HCT.
ofordepletion

Moderate (10-20%)

3000 mL

4% wt loss
Moderate
tachycardia &
reduction
orthostatic
<30ml/hr
hypotension.
Apathy, drowsiness,
decreased skin
turgor
hypoNa

Severe (> 30%)

4000 mL

6% wt loss
shock with
hypotension
severe tachycardia,
cool skin, pale,
cyanotic, poor skin
turgor, sunken eyes

Severe drop
<10-15ml\hr

TREATMENT OF HYPONATREMIA

HYPONATREMIA
Approach

3 issues must be addressed:

Asymptomatic vs. symptomatic


Acute (onset < 48 hrs) vs. chronic (onset > 48 hours or
unknown)
Volume status

2 basic principles for treatment:

Raising plasma sodium at a safe rate


Treating the underlying cause

Mainstay of treatment:
Intravenous isotonic saline
Need to discontinue diuretics

give isotonic if
chronic and
asymptomatic

in siADH we give
furosemide in order
not to have water
reabsorption

HYPONATREMIA

Evaluation of Volume Status

Evaluate volume status by physical examination:


HR and BP
Supine and after 1 min of standing to assess
orthostatic hypotension, defined as any of the
following:
Decrease of 20 mmHg or more of systolic pressure
Decrease of 10 mmHg or more in diastolic pressure
Increase in HR after rising > 15-30 bpm

Skin turgor
Lower extremity edema and sacral edema

HYPONATREMIA
Principles of Treatment

Raise plasma sodium at a


safe rate:
Raise Na by <10 meq/L in the
1st 24 hours
Raise Na by <18 meq/L in the
1st 48 hours

Rapid correction may cause


pontine myelinolysis:
Paraparesis, dysarthria,
dysphagia,coma seizures
May not be detectable until 4
weeks.

2010 by Cleveland Clinic

HYPONATREMIA

Risk Factors of Pontine Myelinolysis

Raising Na > Than 12 mEq/L elevation in the


1st day
Overcorrection to > 140 mEq/L within the 1st
2 days
Hypoxic or anoxic episode prior to therapy

Hypercatabolism or malnutrition due to burns


or chronic alcoholism

HYPONATREMIA

Systematic Method of Correction


1. Calculate Total Body Water (TBW)

1. Decide the desired correction rate based on


pts symptoms and onset of hyponatremia
1. Estimate serum Na+ change on the basis of
Na+ in the infusate

HYPONATREMIA

Systematic Method of Correction


Calculate total body water (TBW)

TBW = 0.60 Patient Weight (kg)


Total body water:

Nonelderly male: 0.60 patient weight (kg)


Nonelderly female: 0.50 patient weight (kg)
Elderly male: 0.50 patient weight in (kg)
Elderly female: 0.45 patient weight (kg)

HYPONATREMIA

Systematic Method of Correction


Decide the desired correction rate based on
pts symptoms and onset of hyponatremia
Symptomatic:
Immediate increase in serum Na+ by 8-10mEq/L in 48 hrs with hypertonic saline.
Acute:
More rapid correction is possible, 8-10mEq/L in 4-6
hrs.
Chronic:
Slower rate of correction: < 10 mEq/L in the 1st 24hrs.

HYPONATREMIA

Systematic Method of Correction

If a patient is symptomatic due to rapid


decline in [Na+], hypertonic (3%) saline
should be considered:
A simple rule of thumb: Correction of 1 mEq/Lhr
using 3% saline by infusing the body weight as
mL/hr
Example: a man with a body weight of 70 kg
will increase by almost 1meq/l/hr when infused
with 3% saline at a rate of 70ml/hr
70cc for 3hrs 3%saline

FIRST HOUR MANAGEMENT IN SEVERE


SYMPTOMATIC HYPONATREMIA

FOLLOW-UP MANAGEMENT IN CASE OF


IMPROVEMENT OF SYMPTOMS AFTER A 5
MEQ/L INCREASE IN SERUM Na+

HYPONATREMIA

Systematic Method of Correction

Estimate serum Na+ change on the basis of


Na+ in the infusate:
SNa+ = {[Na+ + K+]inf SNa+} (TBW+1)

* SNa+=change in serum sodium


* [Na+ + K+]inf = [Na+] and [K+] in 1 L of solution

Solution

Na+ (mEq/L)

Cl- (mEq/L)

Glucose (g/L)

Osmolality
(mosm/kg)

0.9% Saline

154

154

308

Lactate Ringer
(LR)

130

109

275

5% DextroseWater (DW)

50

252

0.45% Saline

77

77

154

3% Saline

513

513

1076

Composition of GI Fluids (mEq/L)


Source
Saliva
Gastric

Daily Loss

Na+

K+

Cl-

HCO3-

1000

30-80

20

70

30

1000-2000 60-80

15

100

Panc

1000

140

5-10

60-90

40-100

Bile

1000

140

5-10

100

40

SB

2000-5000

140

20

100

25-50

LB

200-1500

75

30

30

Sweat

200-1000

20-70

5-10

40-60

EXAMPLE: ONE
154

110

36

SNa+ = {[Na+ + K+]inf SNa+} (TBW+1)

A 60 kg woman with a plasma [Na+] =110 mEq/L:


What is her total body water (TBW)?
How high will 1 liter of NS raise the plasma Na+?
If 40meq/l of K+ to the liter of NS are added, how
much will the plasma Na+ rise?
60*0.6

EXAMPLE: TWO
513

110

90*0.6

SNa+ = {[Na+ + K+]inf SNa+} (TBW+1)

A 90 kg man with a plasma [Na+] of 110mEq/L:


What is the TBW?
How much 1 liter of 3% saline will raise the plasma
Na+?
90*0.6

EXAMPLE: THREE
A 60 kg woman with a plasma sodium concentration of
120mEq/ L:
you should know if
shes acute or chronic

choose 130 in order


not to have over
correction

consider here she is


hypovolemic due to
diarrhea

Correction of sodium deficit?


60*0.5

120

Sodium deficit = TBW x (130 [Na+]p) = 0.5 x 60 x (130120) = 300mEq


3% NaCl contains 513 mEq sodium/L: Volume of 3% NaCl
needed = 300/513 = 585 mL so give 600cc of 300ml saline to correct the deficit
At 0.5 mEq/L/hr
a correction of 10 mEq should be done
in order not to over correct
over 20 hours: 585 mL/20 hours = 29 mL/hour of 3% NaCl

HYPONATREMIA
Exception to the Rule: Treatment of SIADH
SIADH is a cause of hyponatremia that cannot be
treated conventionally:
In hypovolemia, both Na+ and water are retained.
In SIADH, Na+ handling is intact
Administered Na+ will be excreted in the urine. Some water will be
retained leading to worsening of hyponatremia
Instead, water restriction is mainstay of therapy in SIADH
Treatment of SIADH
Acute

Water restriction
Hypertonic saline
NaCl tablets
Loop diuretics

Chronic

Water restriction

High salt, high protein diet


Loop diuretic
Other: demecleocycline,
lithium, or urea.

you never correct Na completely within 48hrs

EXAMPLE: FOUR
85 year old male with weakness and
headache:

is someone has hyponatremia,


then you stop the thiazide
diuretic

80Kg

Serum [Na+ ] = 118meq/l


Plasma Osmolality = 236mosm/kg
Urine Osmolality = 450mosm/kg
Urine Na+ = 54meq/l
Uric acid = 3mg/dl

1. What is the cause of hyponatremia?


2. How to correct hyponatremia?

siADH

3% saline (if his heart is good, if not give normal


salne , furosemide (loop diuretic) and water
restriction)

80 cc of 3% saline for 3 hrs

TREATMENT OF HYPERNATREMIA

HYPERNATREMIA
Approach

General principles:
Rapid correction can induce cerebral edema,
seizures, permanent neurologic damage, and
death.
Correct slowly, not exceeding 12mEq/L per day
to prevent edema

HYPERNATREMIA
Systematic Method of Correction

Most cases of hypernatremia are due to


water deficit
Water deficit
=
0.4 x lean body weight x (plasma Na+/[140 1])

HYPERNATREMIA
Treatment of Nephrogenic Diabetes Insipidus (NDI)

Thiazide diuretics
Amiloride in lithium-induced NDI
Amiloride inhibits entry of lithium to collecting
tubules through Na+ channels
Increased Li+ absorption proximally

Low protein and low sodium diet

HYPERNATREMIA
Treatment of Central Diabetes Insipidus (CDI)

Vasopressin by nasal insufflation or oral form


Thiazide diuretic: Less helpful than in NDI
Loop diuretics should not be used