Transcript Morning report

Morning report
Karen Estrella-Ramadan
Hypernatremia
Definition
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serum sodium concentration >145 mEq/L.
It is characterized by a deficit of total body water (TBW)
relative to total body sodium levels due to either loss of
free water, or infrequently, the administration of
hypertonic sodium solutions
Na140meq
Na180meq
Na180meq
Symptoms:
-Irritability
-High-pitched cry
-Intermittent
lethargy
-Seizures
-Increased muscle
tone
-Fever
-Rhabdomyolysis]
-Oligoanuria
-Excessive diuresis
Extracellular and plasma volumes tend to be maintained in hypernatremic dehydration
until dehydration is severe (ie, when the patient loses >10% of body weight).
Cerebral edema
Na140meq
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Sustained hypernatremia can occur only when thirst or
access to water is impaired.
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groups at highest risk are infants and intubated patients.
Mortality rate: 10%
In children with acute hypernatremia, mortality rates are
as high as 20%.
Neurologic complications occur in 15% of patients
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intellectual deficits, seizure disorders, and spastic plegias
Mechanisms:
1. Hypovolemic hypernatremia
Increase water loss > than Na loss
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Excessive perspiration
Diarrhea
Renal dysplasia
Obstructive uropathy
Osmotic diuresis
Mechanisms:
2. Euvolemic hypernatremia
PURE WATER DEPLETION
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Central diabetes insipidus
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*adipsic diabetes insipidus : When ADH secretion and thirst are both impaired, affected patients are vulnerable
to recurrent episodes of hypernatremia
Idiopathic causes
Head trauma
Suprasellar or infrasellar tumors (eg, craniopharyngioma, pinealoma)
Granulomatous disease (sarcoidosis, tuberculosis,Wegener granulomatosis)
Histiocytosis
Sickle cell disease
Cerebral hemorrhage
Infection (meningitis, encephalitis)
Associated cleft lip and palate
Nephrogenic diabetes insipidus
Congenital (familial) conditions
Renal disease (obstructive uropathy, renal dysplasia, medullary cystic disease, reflux nephropathy, polycystic
disease)
Systemic disease with renal involvement (sickle cell disease, sarcoidosis, amyloidosis)
Drugs (amphotericin, phenytoin, lithium, aminoglycosides, methoxyflurane)
Mechanisms:
3. Hypervolemic hypernatremia
Sodium excess
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Improperly mixed formula
NaHCO3 administration
NaCl administration
Primary hyperaldosteronism
In summary….
Lab work-MUST HAVE!!!
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Serum: NA, osmolality, BUN, and creatinine
Urine: [Na]
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In hypovolemic hypernatremia:
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extrarenal losses: <20 mEq/L
renal losses: [Na]urine >than 20 mEq/L.
In euvolemic hypernatremia, urine sodium data vary.
In hypervolemic hypernatremia, the urine sodium level is more than
20 mEq/L.
Urine: Osmolarity
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Uosm < Posm then the patient has either central or nephrogenic
diabetes insipidus (DI)
Uosm is intermediate (between 300 to 600 mosmol/kg), the
hypernatremia may be due to an osmotic diuresis or to DI
Uosm above 600 mosmol/kg, then both the secretion of and
response to endogenous ADH are intact.
Imaging-should we do any?
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Head: should be considered in alert patients with severe
hypernatremia to rule out a hypothalamic lesion affecting
the thirst center
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CT scans may help in diagnosing intracranial tumors,
granulomatous diseases (eg, sarcoid, tuberculosis, histiocytosis),
and other intracranial pathologies
Other tests
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Aldosterone test
Cortisol test
Antidiuretic hormone (ADH) test
Corticotropin (ACTH) test
Gral principles management
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SODIUM correction: 0.5 mEq/h or as much as 1012 mEq/L in 24 hours
Dehydration should be corrected over 48-72 hours.
If the serum sodium concentration is more than 200
mEq/L, peritoneal dialysis should be performed using a
high-glucose, low-sodium dialysate.
Main 2 calculations
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Maintenance fluids
Water deficit (in L) = [(current Na level in mEq/L ÷ 145
mEq/L) - 1] X 0.6* X weight (in kg)
*60% BW in children
40% BW in adults
Election of fluids
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If the patient is hypotensive: use NS, LR or 5% albumin
regardless of a high serum sodium concentration.
In hypernatremic dehydration, 0.45% NS or 0.2% NaCl
should be used as a replacement fluid to prevent excessive
delivery of free water and a too-rapid decrease in the serum
sodium concentration.
In cases of hypernatremia caused by sodium overload,
sodium-free intravenous fluid (eg, 5% dextrose in water) may be
used, and a loop diuretic may be added.
In cases of associated hyperglycemia, 2.5% dextrose
solution may be given. Insulin treatment is not recommended
because the acute decrease in glucose, which lowers plasma
osmolality, may precipitate cerebral edema.
Follow-up
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Serum sodium levels should be monitored every 4-6
hours
Once the child is urinating, add 40 mEq/L KCl to fluids to
aid water absorption into cells.
Calcium may be added if the patient has an associated low
serum calcium level
Record daily body weights.
Restrict sodium and protein intake.
Treat the underlying disease.
More about management
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To be continued…
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on Thursday at noon : )
References
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http://emedicine.medscape.com/article/907653followup#a2651
http://www.uptodate.com.elibrary.einstein.yu.edu/content
s/etiology-and-evaluation-ofhypernatremia?source=see_link#H6017722
http://www.uptodate.com.elibrary.einstein.yu.edu/content
s/treatment-ofhypernatremia?source=search_result&search=hypernatre
mia&selectedTitle=1%7E150
http://pediatrics.uchicago.edu/chiefs/resources/documents
/HyperHypoNatremia.pdf