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Acute Water Intoxication

Acute Water Intoxication. December 17, 2003 Bruce R. Wall, MD. Good old fashioned nephrology (with a large dose of pulmonary) . Most nephrologists would chose to evaluate and treat a SODIUM of 110 mEq/L rather than a BUN of 110mg% “Be careful what you ask for… you just might get it…”

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Acute Water Intoxication

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  1. Acute Water Intoxication December 17, 2003 Bruce R. Wall, MD

  2. Good old fashioned nephrology (with a large dose of pulmonary) • Most nephrologists would chose to evaluate and treat a SODIUM of 110 mEq/L rather than a BUN of 110mg% • “Be careful what you ask for… you just might get it…” • Lt.Col. Theodore R. Wall, USMC, Retired • Patient admitted from ER with hyponatremia and respiratory failure… no problem…

  3. Today’s lecture: • Chronic polydipsia – not this case • Case presentation • Laboratory review • Brief discussion of water intoxication • Pulmonary aspects @ Dr Weinmeister

  4. Input minus output equals accumulation • 75 kg male • 60% water = approx 45 Liters TBW • Intracellular Extracellular 30 L 15 L 280mosm/kg 280mosm/kg [K+] 140mEq/l [Na+] 140mEq/l

  5. How much water was ingested? • Initial TB solute: 280 X 45 =12,600 mosmol • Initial ECF solute: 280 X 15 = 4,200 mosmol • Initial intracellular: 12600 – 4200 = 8,400 mosmol • NEW TBW : 45kg + 6 kg = 51 kg • NEW TB OSM: 12,600 / 51kg = 251mosm/kg • NEW ECF volume: 4200 / 251 = 16.7kg • NEW intracellular volume: 8400 / 251 = 33.4kg

  6. How much water? • Assume an ingestion of 6 liters: serum osmolality of 251mosmol/kg • Estimated nadir [Na+] = osmolality / 2 = 125.5mEq • Effective Posm is approximately 2 X [Na+]

  7. Case Presentation • 21 year old AAM student at SMU • CC: can not be obtained (intubation) • History obtained from family members • Patient was asked to drink 3 - 4 gallons of water (with hot sauce), as part of a fraternity hazing on Friday evening • Post ingestion, patient was confused, and became ‘less responsive’ • At 4AM, patient developed a seizure, yet was not transported to Presby ER until 7AM

  8. Hospital day:one • Profound shock/hypotension – poor response to high dose pressor medications • Immediate respiratory failure with severe agitation and hypoxemia; endotracheal intubation confirmed “drowning” • Transfer to ICU maximal support: 100% oxygen, maximum PEEP, IV norepinephrine • Initial SODIUM = 126mEq/L (IV @KO NS)

  9. Case presentation: continued • Past medical history: none • Social history: 2 year football player for Austin College. No drug or alcohol history Mother arrived from Houston; Father arrived from US Virgin Islands (lives in Wash D.C.) • Medications: IV pressors, antibiotics • ROS: not available

  10. Physical exam: • BP 100/60 on very high dose IV pressors; pulse 110 sinus tachycardia; R per vent; high pressures • Very muscular patient, intubated PO, who eventually developed subQ crepitation from barotrauma • HEENT: mild swelling; anicteric NECK: WNL • LUNGS: bilateral breath sounds; increased rate • COR: no murmur, increased HR • ABD: benign, although later the CT was abnormal… • Ext: no cyanosis; warm; slowly progressive edema • Neuro: unresponsive pupils; ? signs of herniation prompted use of IV mannitol

  11. Admit labs • WBC 17K 76%neutrophils, 6%lymphs Hgb/Hct 13.2g%/38% Plts 380K • Urinalysis: 2+ blood, few RBC’s, 360mOs/kg • Initial Serum Osm: 272, falling to 263 in 8hrs • Toxicology screen negative for tylenol, PCP, ethylene glycol, MDMA, salicylate, ethanol, cocaine, barbiturates, and narcotics • CXR: ? RUL pneumonia • CT Head: cerebral edema, especially in retrospect

  12. Additional admit labs: • Calcium 8.6mg/dl Phos 4.2g/dl • Total protein 7.6g/dl Albumin 4.8g/dl • Alk phos 63 LFT’s mildly elevated • INITIAL CPK 2100 • INITIAL BUN 10mg% CREAT 1.0mg% • ANION GAP 21 • Therefore, working diagnosis of (+) AG lactic acidosis from seizure, 3 hours PTA

  13. Electrolytes day one, as serum osmolality fell from 272 to 263…

  14. Electrolytes: day 2

  15. Hospital course • Hemodynamics and oxygenation were tenuous on day one… • Patient was considered for extra-coporeal oxygenation therapy, resulting in a transfer from 3 ICU to 4 ICU • Post transfer, his BP and PO2 IMPROVED • Abnormal CXR: bilateral infiltrates, air under R hemidiaphragm • CT scan: larger amt of air surrounds tail of pancreas, (L) kidney, anterior aspect of psoas muscle, tracking down from mediastinum

  16. Hospital course: continued • Electrolytes were normal, by hospital day 3 • EEG always showed electrical activity (patient had been severely hypoxemic, but never required ACLS) • CNS began to improve by hospital day 4 • Ventilator support was weaned by day 7 • Transfer to floor day 8 • Discharged home day 10

  17. CNS damage associated with acute hyponatremia • CPM: rare neurologic disorder reported in malnourished/alcoholic patients • MORE COMMON – brain edema, with uncal and tonsillar herniation with diffuse cerebral demyelination secondary to increased intracranial pressure, with necrosis, and hypoxic brain damage • Compression of medullary respiratory center because of brain swelling, above 5 to 8% of baseline volume can lead to herniation -- fixed pupils, hypoventilation, cardio instability, impaired temperature control, pituitary and hypothalamic infarction also possible

  18. Water intoxication in cattle • J AFR VET ASSOC 1999 DEC; 70(4) • Water intoxication is common in cattle, and also has been described in other domestic animals. Comprehensive description is lacking…

  19. Fatal water intoxication: Journal of Clinical Pathology Oct 2003 p 803DJ Farrell et al • 64 yo woman with known MV disease • Compulsively drinking water, one evening, in range of 30 to 40 glasses • Hours later was described as “hysterical” • Fell asleep, and found dead next morning • Postmortem: no tumor, bilateral pleural effusions, LVH with large heart; increased cortisols • Na+ = 92meq/L (vitreous fluid, usually stable) • Acute delirium, seizures, coma, and death

  20. Autopsy case of rare iatrogenic water ingestion; Chen et al, Tongji Med Univ, Forensic Sci International: Nov 95 • 21 yo female suicide attempt (powder scraped from 18 matches) • 1700 hrs: 3L of water 1730 hrs: 800ml • 1800 hrs: 4L of water, via NG tube • Headache, dyspnea, cyanosis, then coma • Autopsy: cerebellar herniation, Na+ 112, pulmonary edema, trachea and bronchial tubes full of fluid…

  21. Literature review: Forensic Science International (1995): continued • 534 papers over 17 years – only 16 fatalities • 15 cases diagnosed during hospitalization for various types of psychosis • Water intoxication is unusual in normal people, and death is even rarer • Case report of death within 2.5 hrs is rare

  22. Fatal child abuse by forced water intoxication • Pediatrics 1999 JUN;103 Alan Arief,MD • 3 children punished by forced intoxication • > 6 liters • Seizures, emesis, coma, hypoxemia, average sodium 112mEq/L • Autopsy confirmed cerebral edema • Tried and convicted

  23. Death by hyponatremia as result of water intoxication in a Army trainee • MIL MED 1999 MAR;164 • Excessive water intake by athletes during endurance races, to prevent heat injury has been the recommendation • Describe a case of programmed drinking > 8 liters during initial training • One death, cerebral edema with seizure

  24. Death by Water intoxication MIL MED 2002 May; 167 • 3 deaths in recruits, usual water load of 6 to 10 liters in 2 to 3 hrs • “safe limit” probably 1 liter per hour

  25. Chronic Polydipsia and hyponatremia • Psychiatric patients, especially schizophrenia, often have problems with water balance • 6% to 8% have a history compatible with compulsive water drinking; ½ of these pts had intermittent symptoms of hyponatremia • Normal patients can excrete 10 to 15 liters/d by decreasing Uosm from 40 to 100 mosm/kg • Episodes of transient ADH release with acute psychotic episodes • Carbamazepine and fluoxetine are associated with SIADH

  26. Chronic polydipsia • This is an uncommon clinical scenario, but does not apply to our current case (which is rare) • “Rx” hypontremia with acute encephalopathy rate of correction – 0.5 to 1 meq/l per hr (until a sodium of 120meq/l) Never actively correct > 130meq/l

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