hyopna 9090909
TRANSCRIPT
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By
Dr:-FATIMA EYAD AL GLAD
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• Definition• Epidemiology• Physiology• Pathophysiology• Types• Clinical Manifestations• Diagnosis • Treatment
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• Definition:– Commonly defined as a serum sodium concentration
135 meq/L
– Hyponatremia represents a relative excess of water in relation to sodium.
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Epidemiology:FrequencyHyponatremia is the most common electrolyte disorderincidence of approximately 1%prevalence of approximately 2.5%surgical ward, approximately 4.4%
30% of patients treated in the intensive care unit
ocw.jhsph.edu
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Epidemiology Cont.›Mortality/Morbidity
Acute hyponatremia (developing over 48 h or less) are subject to more severe degrees of cerebral edema
sodium level is less than 105 mEq/L, the mortality is over 50%
Chronic hyponatremia (developing over more than 48 h) experience milder degrees of cerebral edema
Brainstem herniation has not been observed in patients with chronic hyponatremia
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Epidemiology Cont.›Age
Infants fed tap water in an effort to treat symptoms of
gastroenteritis Infants fed dilute formula in attempt to ration
Elderly patients with diminished sense of thirst, especially when physical infirmity limits independent access to food and drink
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Physiology›Serum sodium concentration
regulation:stimulation of thirst
secretion of ADHfeedback mechanisms of the
renin-angiotensin-aldosterone system
renal handling of filtered sodium
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Physiology Cont.›Stimulation of thirstOsmolality increases
Main driving forceOnly requires an increase of 2% - 3%
Blood volume or pressure is reducedRequires a decrease of 10% - 15%
Thirst center is located in the anteriolateral center of the hypothalamus
Respond to NaCL and angiotensin II
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Physiology Cont.›extracellular-fluid and intracellular-fluid
compartments make up 40 percent and 60 percent of total body water
›renal handling of water is sufficient to excrete as much as 15-20 L of free water per day
›sodium is the predominant osmole in the extracellular fluid (ECF) compartment and serum
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Pathophysiology›hyponatremia can only occur when some
condition impairs normal free water excretion
›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 2 responses for osmoregulation, as follows:
It inhibits ADH secretion and hypothalamic thirst center
immediate cellular adaptation
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TypesHypovolemic hyponatremia
Euvolemic hyponatremiaHypervolemic hyponatremia
Redistributive hyponatremiaPseudohyponatremia
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develops as sodium and free water are lost and/or replaced by inappropriately hypotonic fluids
Sodium can be lost through renal or non-renal routes
www.grouptrails.com/.../0-Beat-Dehydration.jpg
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Nonrenal loss›GI losses
Vomiting, Diarrhea, fistulas, pancreatitis›Excessive sweating›Third spacing of fluids
ascites, peritonitis, pancreatitis, and burns ›Cerebral salt-wasting syndrometraumatic brain injury, aneurysmal
subarachnoid hemorrhage, and intracranial surgery
Must distinguish from SIADH
www.jupiterimages.com
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›Renal LossAcute or chronic renal insufficiency
Diuretics
www.ct-angiogram.com/images/renalCTangiogram2.jpg
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Normal sodium stores and a total body excess of free waterPsychogenic polydipsia, often in psychiatric patients
Administration of hypotonic intravenous or irrigation fluids in the immediate postoperative period
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›administration of hypotonic maintenance intravenous fluids
›Infants who may have been given inappropriate amounts of free water
›bowel preparation before colonoscopy or colorectal surgery
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SIADH›downward resetting of the osmostat
›Pulmonary DiseaseSmall cell, pneumonia, TB, sarcoidosis
›Cerebral DiseasesCVA, Temporal arteritis, meningitis,
encephalitis
›MedicationsSSRI, Antipsychotics, Opiates, Depakote,
Tegratol
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Total body sodium increases, and TBW increases to a greater extent.
Can be renal or non-renalacute or chronic renal failuredysfunctional kidneys are unable to excrete the ingested sodium load
cirrhosis, congestive heart failure, or nephrotic syndrome
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›Water shifts from the intracellular to the extracellular compartment, with a resultant dilution of sodium. The TBW and total body
sodium are unchanged. This condition occurs with hyperglycemiaAdministration of mannitol
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Pseudohyponatremia›The aqueous phase is diluted by excessive
proteins or lipids. The TBW and total body sodium are unchanged.
hypertriglyceridemiamultiple myeloma
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Clinical Manifestations ›most patients with a serum sodium
concentration exceeding 125 mEq/L are asymptomatic
›Patients with acutely developing hyponatremia are typically symptomatic at
a level of approximately 120 mEq/L›Most abnormal findings on physical
examination are characteristically neurologic in origin
›patients may exhibit signs of hypovolemia or hypervolemia
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Diagnosis›CT head, EKG, CXR if symptomatic›Repeat Na level›Correct for hyperglycemia›Laboratory tests provide important initial
information in the differential diagnosis of hyponatremia
Plasma osmolality Urine osmolality Urine sodium concentration Uric acid levelFeNa
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Laboratory tests Cont.›Plasma osmolality
normally ranges from 275 to 290 mosmol/kgIf >290 mosmol/kg :
Hyperglycemia or administration of mannitol
If 275 – 290 mosmol/kg :hyperlipidemia or hyperproteinemia
If <275 mosmol/kg :Eval volume status
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Laboratory tests Cont.›Plasma osmolality < 275 mosmol/kg
Increased volume:CHF, cirrhosis, nephrotic syndrome
Euvolemic SIADH, hypothyroidism, psychogenic polydipsia, beer
potomania, postoperative states
Decreased volumeGI loss, skin, 3rd spacing, diuretics
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Laboratory tests Cont.›Urine osmolality
Normal value is > 100 mosmol/kgNormal to high:
Hyperlipidemia, hyperproteinemia, hyperglycemia, SIADH
> 100 mosmol/kghypoosmolar hyponatremia
Excessive sweatingBurnsVomitingDiarrheaUrinary loss
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Laboratory tests Cont.›Urine Sodium
<20 mEq/L SIADH, diuretics
>20 mEq/Lcirrhosis, nephrosis, congestive heart failure, GI loss,
skin, 3rd spacing, psychogenic polydipsia
›Uric Acid Level> 4 mg/dl consider SIADH
›FeNaHelp to determine pre-renal from renal causes
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Treatment›four issues must be addressed
Asymptomatic vs. symptomaticacute (within 48 hours(
chronic (>48 hours(Volume status
›1st step is to calculate the total body watertotal body water (TBW) = 0.6 × body weight
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• Treatment Cont. ›next decide what our desired correction rate
should be›Symptomatic
immediate increase in serum Na level by 8 to 10 meq/L in 4 to 6 hours with hypertonic saline is recommended
›acute hyponatremiamore rapid correction may be possible
8 to 10 meq/L in 4 to 8 hours
›chronic hyponatremiaslower rates of correction
12 meq/L in 24 hours
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›Symptomatic or AcuteTreatment Cont. - Here comes the Math!!!
estimate SNa change on the basis of the amount of Na in the infusate
ΔSNa = {[Na + K]inf − SNa} ÷ (TBW + 1(ΔSNa is a change in SNa
]Na + K]inf is infusate Na and K concentration in 1 liter of solution
OH MY GOD, what did he just say!!!!!!!!!!!!!!!!!!
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IV Fluids›One liter of Lactated Ringer's Solution contains:
130 mEq of sodium ion = 130 mmol/L
109 mEq of chloride ion = 109 mmol/L 28 mEq of lactate = 28 mmol/L
4 mEq of potassium ion = 4 mmol/L 3 mEq of calcium ion = 1.5 mmol/L ›One liter of Normal Saline contains:
154 mEq/L of Na+ and Cl−
›One liter of 3% saline contains:514 mEq/L of Na+ and Cl−
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Example:›a 60 kg women with a plasma sodium of 110
meq/L›Formula:
ΔSNa = {[Na + K]inf − SNa} ÷ (TBW + 1(›What is the TBW?›How high will 1 liter of normal saline raise the
plasma sodium? Answer:
›TBW is 30 L›Serum sodium will increase by approximately
1.4 meq/L for a total SNa of 111.4 meq/L
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Example:›a 90 kg man with a plasma sodium of 110
meq/L
›Formula:ΔSNa = {[Na + K]inf − SNa} ÷ (TBW + 1(
›What is the TBW?›How high will 1 liter of 3% saline raise the
plasma sodium? Answer:
›TBW is 54 L›Serum sodium will increase by approximately
7.3 meq/L for a total SNa of 117.3 meq/L
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Asymptomatic or Chronic›SIADH
response to isotonic saline is different in the SIADH
In hypovolemia both the sodium and water are retained
sodium handling is intact in SIADHadministered sodium will be excreted in the
urine, while some of the water may be retained
possible worsening the hyponatremia
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Asymptomatic or Chronic›SIADH
Water restriction0.5-1 liter/day
Salt tabletsDemeclocycline
Inhibits the effects of ADHOnset of action may require up to one week
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Example:–85 y/o male with weakness and head ache–SNa is 118 mEq/L–Plasma osmolality is 254 mosmol/kg–Urine osmolality is 130 mosmol/kg–Urine sodium >20 mEq/L–Uric acid is 3mg/dl
•What type of hyponatremia does this patient have?
•What additional labs/studies would you want?
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Example Cont.:›Noncontrast CT
Head:Tx
›Call Neurology and neurosurgery
›Free water restriction
Ouch!!!!!
trismus1.wordpress.com
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•Example:–63 y/o female at 75 Kg with N/V/D for 4 days–SNa is 108 mEq/L–She has had one seizure in the ambulance
•Plasma osmolality is 251 mosmol/kg•Urine osmolality is 47 mosmol/kg•Uric acid is 6mg/dl
•What type of hyponatremia does this patient have?
•What additional labs/studies would you want?
hollywoodphony.files.wordpress.com
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How will you Tx her?›Calculate the total body water
0.5 x weight = 37.5 L
›What rate of correction do you want?8 to 10 mEq/L in 6 to 8 hours
›What fluid will you use?3% Saline
›How will you calculate the amount of sodium to give her?
ΔSNa = {[Na + K]inf − SNa} ÷ (TBW + 1(
›How will her sodium increase after 1 liter of 3% saline?
By 10.8 mEq/L to 118.8 mEq/L
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What other medication will she need?›Lasix and a foley
Her sodium increases to 118.8 mEq/L over the next 8-10 hours. How will you continue to
correct her hyponatremia?› ΔSNa = {[Na + K]inf − SNa} ÷ (TBW + 1(›ΔSNa = 154mEq/L – 118.8mEq/L ÷ 38.5L = 0.9
mEq/LSo 2 liters of normal saline over the next 14
hours
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The syndrome of inappropriate antidiuretic hormone secretion or SIADH (other names: Schwartz-Bartter syndrome, SIAD—syndrome of immoderate antidiuresis) is characterized by excessive release of antidiuretic hormone from the posterior pituitary gland or another source. The result is often dilutional hyponatremia in which Athe sodium remains normal but total body fluid increases. It was originally described in people with small-cell carcinoma of the lung, but it can be caused by a number of underlying medical conditions. The treatment may consist of fluid intake restriction, various medicines, And management of the underlying cause.
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Gastro-intestinal •Anorexia• Nausea
Skeleto-muscular Muscle aches•Generalised muscle weakness
Neuro-muscular•Myoclonus•Hyporeflexia•Ataxia•Pathological reflexes•TremorAsterixiRespiratory•Cheyne-Stokes respirationNeurologica•Dysarthria•Lethargy•Confusion•Delirium•Seizures•Coma (from cerebral oedema)
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Some common causes of SIADH include:[citation needed]•Meningitis•Head injury
• Subarachnoid hemorrhage•Cancers
• Lung cancer (especially small-cell lung cancer, as well as other small-cell malignancies of other organs)
•Infections• Brain abscess• Pneumonia• Lung abscess
•Guillain-Barré syndrome•Drugs
• Chlorpropamide• Ciprofloxacin[2]• Clofibrate• Moxifloxacin[2]
Phenothiazine
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Congrats!!!!!!!! You saved her!
Questions????
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