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Evolving Strategies for Hyponatremia Management in the ICU

Evolving Strategies for Hyponatremia Management in the ICU . Mazen Kherallah, MD, FCCP Infectious Disease & Critical Care Medicine Assistant Professor, University of North Dakota. Critical Care Patients at Increased Risk of Hyponatremia*. Increased age 1

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Evolving Strategies for Hyponatremia Management in the ICU

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  1. Evolving Strategies for Hyponatremia Management in the ICU Mazen Kherallah, MD, FCCP Infectious Disease & Critical Care Medicine Assistant Professor, University of North Dakota

  2. Critical Care Patients at Increased Risk of Hyponatremia* • Increased age1 • Up to 30% of patients with subarachnoid hemorrhage2 • Up to 30% of ICU patients3 • Over 30% of AIDS patients4 • Postoperative patients • – 25%-35% of pituitary surgery for tumor resection5 • ~30% of acute spinal cord injury6 • Psychiatric inpatients: 6%-17%7 *Data not exclusive to patients with euvolemichyponatremia. 1. Hawkins RC. ClinChimActa. 2003;337:169-172; 2. Mayer SA. The Neurologist. 1995;1:71-85; 3. DeVita MV et al. ClinNephrol. 1990;34:163-166; 4. Tang WW et al. Am J Med. 1993;94:169-174; 5. Bhardwaj A. Ann Neurol. 2006;59:229-236; 6. Peruzzi WT et al. Crit Care Med. 1994;22:252-258; 7. Siegler EL et al. Arch Intern Med. 1995;155:953-957.

  3. Mortality Related to Hyponatremia Among Hospitalized Patients 1. Anderson RJ et al. An Intern Med. 1995,102: 164-168 2. Terzian C et al. J Gen Intern Md. 1994,9:89-91 3. Tierney WM et al. J Gen Intern Med. 1986;1: 380-385

  4. Morbidities in Hospitalized Patients with Symptomatic Hyponatremia • Single center, retrospective over 4 years (1997-2001) • 168 patients with serum [Na+] <115 mEq/L • Symptoms of hyponatremic encephalopathy in 89 of 168 patient (53%) • No documented symptoms in 79 of 168 patients (47%) Nzenue CM et al. J Natl Med Assoc. 2003;95: 335-343

  5. Mechanisms of Hyponatremia ↓[Na+]= ↓[Na+]=

  6. Brain CT Scan: Cerebral Edema Normal CT Scan Fatal Hyponatremia

  7. 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. • On exam he is afebrile, BP 120/78, HR 92. He is somnolent but arousable and following commands, is euvolemic, and there are no focal findings. • His urine output is 120 ml/hour

  8. Question • What is the most likely etiology of this man’s hyponatremia? • Syndrome of inappropriate antidiuresis • Psychogenic polydipsia • Pseudohyponatremia • Adrenal insufficiency • Cerebral sat wasting

  9. The Diagnosis of Hyponatremia:Three Critical Questions

  10. Assessment of Hyponatremia:Three Critical Questions 240 mOsm/kg 92 mOsm/kg

  11. Case II • 46-year-old woman admitted to NeurocriticalCare Unit confused and mildly lethargic secondary to subarachnoid hemorrhage • Past medical history: hypertension, tobacco smoker • BP 170/78 mm Hg, HR 71 bpm • 0.9% saline administered at 100 mL/h • CVP 6-8 mm Hg • Mildly positive fluid balance • Remained confused and disoriented, but lethargy gradually resolved

  12. In the Step-Down Unit • Day 9 post-SAH • Patient transferred to step-down unit • Central venous IV catheter discontinued • IV fluid: normal saline administered at 100 mL/h through peripheral IV • Day 10 post-SAH • The patient appeared to be more confused • Serum [Na+] = 126 mEq/L

  13. Question • What is the most likely etiology of this patient’s hyponatremia? • SIADH • Psychogenic polydipsia • Pseudohyponatremia • Adrenal insufficiency • Cerebral sat wasting

  14. Assessment of Hyponatremia:Three Critical Questions 258 mOsm/kg 292 mOsm/kg

  15. Question How would you treat this patient? • Fluid restriction (<2 L/d) • Salt tablets (NaCl 2 g/d) • Normal saline infusion • 3% hypertonic saline • IV Conivaptan

  16. Treatment Considerations

  17. Treatment Strategies • Sodium deficit= TBW (desired SNa-actual SNa) • Increase in SNa= (infusate [Na]-SNa) ÷ (TBW+1)

  18. Treatment Options

  19. Treatment Course for This Patient • A 20 mg loading dose of conivaptan followed by a continuous infusion of 20 mg/d • 24 hour after the start of the loading dose, the serum [Na+] increased from 126 to 132 • A second 24 hour contineous infusion given

  20. Day 2 of Treatment • The next day serum [Na+] increased from 132 to138 mEq/L • Mental status: less confused • Conivaptandiscontinued • Patient discharged to rehabilitation on SAH Day 13

  21. Receptor-Mediated Effects of VAP Lee CR et al. AM Heart J. 2003;143:9-18

  22. Hyponatremia in Acute Brain InjuryTherapeutic Options

  23. Thank you

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