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Objectives
To understand water and sodium hemostasis
in the body
To know the relation between water, sodium and volume disorders To know the types of hyponatremia and hypernatremia T o know the Causes of hyponatremia and hypernatremia To understand the management of hyponatremia and hypernatremia
Introduction
The human body tightly regulates blood volume and plasma osmolality as both are essential for..? Blood volume determinant of tissue perfusion deliver O2 & nutrients + remove metabolic waste products from tissues. Plasma osmolality is an important determinant of ICV. Maintenance of normal intracellular volume is particularly critical in the brain, (prevent neural dysfunction & death).
Introduction
The homeostatic mechanisms for regulating blood volume and plasma osmolality involve control of sodium and water balance. Blood volume are controlled by sodium balance.
In contrast, the homeostatic mechanisms for controlling plasma osmolality, which is largely determined by serum sodium concentration, are focused on controlling water balance.
Sodium and water balance are closely related and are frequently considered together. T or F ?
98%
Serum Sodium
CNS Symptoms
Hyponatremia
Defined as sodium concentration < 135 mEq/L. Generally considered a disorder of water as opposed to disorder of salt. Results from increased water retention. Normal physiologic measures allow a person to excrete up to 10 liters of water per day which protects against hyponatremia. Thus, in most cases, some impairment of renal excretion of water is present.
Hyponatremai
Normal ADH response to low sodium is to be suppressed to allow maximally dilute urine to be excreted thereby raising serum sodium level Psuedohyponatremia High blood sugar (DKA) or protein level (multiple myeloma) can cause falsely depressed sodium levels Causes of Hyponatremia can be classified based on volume status and osmolality.
Hypovolemic, Euvolemic or Hypervolemic Hypertonic, hypotonic or normotonic
Hyponatremia
Serum OSM Low Normal
Marked hyperlipidemia Hyperproteinemia (Multiple myeloma)
Hypotonic Hyponatremia
High
CHF Cirrhosis Nephrosis
Or it may present with more severe symptoms such as seizures, coma or respiratory arrest
Euvolemia
SIADH Primary Polydipsia
Hypervolemia (Edema)
Cirrhosis and CHF
Diagnostic Tests
3 mandatory lab tests
Serum Osmolality Urine Osmolality Urine Sodium Concentration
If volume depletion is present, isotonic (0.9%) saline can be given intravenously Careful monitoring should be used whether symptoms are present or not
Serum sodium levels should be drawn every 4-6 hours or more frequently if hypertonic saline is used
Rx Hyponatremia
Na deficit = 0.6 x wt(kg) x (desired [Na] - actual [Na]) (mmol)
Then SLOW down correction to 0.5 mEq/L/h with 0.9% NS or simply fluid restriction. Aim for overall 24h correction to be < 10-12 mEq/L/d to prevent myelinolysis
Summary of Hyponatremia
Hyponatremia has variety of causes Treatment is based on symptoms
Severe symptoms = Hypertonic Saline Mild or no symptoms = Fluid restriction
Overcorrection, more than 12 mEq increase in 24 hours must be avoided with monitoring Serum Osmolality, Urine Osmolality and Urine sodium concentration are initial tests to order
SIADH
Treatment
Fluid Restriction < 1000-12000 ml/day Oral Salt, Hi-protein diet or Urea(30 g/d): promote solute diuresis Lasix 20 mg po od-bid: Loop direct Demeclocycline 300-600 mg bid Inhibit tubular AVP activity Delayed onst (3-6 day) so what? Cant be used in children (can be nephrotoxic) Vasopressin receptors antagonist, V1, Conivaptan V1V2 (only I.V.)
IV salt solution:
Rarely if ever needed (i.e. only if symptomatic with SZ/coma) Solution given must be of greater OSM than UOSM or in long run will just make hyponatremia worse (often IV NS not sufficient)
HYPERNATREMIA
Hypernatremia
Produced by either administration of hypertonic fluids or much more frequently, loss of thirst Because of extremely efficient regulatory mechanisms such as ADH and thirst, hypernatremia generally occurs only in people with prolonged lack of thirst mechanism Patients with loss of ADH (Diabetes Insipidus) usually can compensate with increased fluid intake
Causes of Hypernatremia
Insensible water losses GI losses (hypotonic) ex; NV Diabetes Insipidus (both central and nephrogenic) Osmotic Diuresis DKA Hypothalamic lesions which affect thirst function Causes include tumors, granulomatous diseases or vascular disease Sodium Overload Infusion of Hypertonic sodium bicarbonate for metabolic acidosis Salt ingestion
Symptoms of Hypernatremia
Initial symptoms include lethargy, weakness and irritability Can progress to seizures, obtundation or coma Resulting decrease in brain volume can lead to rupture of cerebral veins leading to hemorrhage Severe symptoms usually occur with rapid increase to sodium concentration of 158 mEq or more Sodium concentration greater than 180 mEq are associated with high mortality
Diagnosis of Hypernatremia
Same labs as workup for hyponatremia: Serum osmolality, urine osmolality and urine sodium Urine sodium should be lower than 25 mEq/L if water and volume loss are the cause. It can be greater than 100 mEq/L when hypertonic solutions are infused or ingested If urine osmolality is lower than serum osmolality then DI is present
Administration of AVP will differentiate
Urine osmolality will increase in central DI, no response in nephrogenic DI
TREATMENT OF HYPERNATREMIA
Goal is to restore normal volume & osmolality Slow correction over 48 hours Replace concomitant continuous losses Treat the cause of hypernatremia
Treatment of Hypernatremia
First, calculate water deficit Water deficit = CBW x ((plasma Na/desired Na level)-1) CBW = current body water assumed to be 50% of body weight in men and 40% in women So lets do a sample calculation:
60 kg woman with 168 mEq/L How much water will it take to reduce her sodium to 140 mEq/L
Calculation continued
Water deficit = 0.4 x 60 ([168/140]-1) = 4.8 L But how fast should I correct it? Same as hyponatremia, sodium should not be lowered by more than 12 mEq/L in 24 hours
Overcorrection can lead to cerebral edema which can lead to encephalopathy, seizures or death
Treatment of DI
DI: Excessive urination and extreme thirst CDI or NDI Rx Dehydration
NS initially if ECFv contraction Then IV D5W or enteral free water to lower serum [Na]
AVP (Desmopressin)
Reduces U/O and therefore simplifies fluid therapy Long t: duration 8-12h, up to 24h AVP 1ug IV/SC x 1 Once nasal mucosa stable can switch to intranasal Also oral form DDAVP now available
AVP Analoge
Dose should be adjusted to prevent nocturia, Daily urine volume of approximately 1.5 to 2 L. Maintain the serum sodium conc. n in the 137 to 142 mEq/L range. Measure Na conc.d every 3 to 4 days during the initial dose titration period, and then every 2 to 4 months. SEs: water intoxication caused by excess water retention ( montor for signs and symptoms of hyponatremia and hypervolemia).
Treatment of DI
Chlorpropamide HTCZ Amiloride Indomethacin Clofibrate Tegretol
Summary of Hypernatremia
Loss of thirst usually has to occur to produce hypernatremia Rate of correction same as hyponatremia D5 water infusion is typically used to lower sodium level Same diagnostic labs used: Serum osmolality, Urine osmolality and Urine sodium Beware of overcorrection as cerebral edema may develop
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