Elderly with refractory chronic severe hyponatremia and anesthesia management dilemma: a case report with literature review

Abstract

Hyponatremia is a common electrolyte disorder, especially in the frail elderly population. With the increasing number of surgeries in the aging population, hyponatremia is frequently encountered by anesthesiologists and surgeons. Unfortunately, management of hyponatremia is often complex in the elderly population as it is often multifactorial, and they are physiologically susceptible. While it is well known that preoperative hyponatremia is associated with increased perioperative morbidity and mortality, a lack of recommendations or guidelines adds to the dilemma in managing such cases. The most common cause of chronic hyponatremia in the elderly is the syndrome of inappropriate antidiuretic hormone (SIADH), which can be resistant to conventional treatment. On the other hand, paraneoplastic SIADH leading to hyponatremia is rare, and surgery may be the only option available for its correction. We present a case of a 78- years-gentleman to highlight such a dilemma. He was diagnosed with renal cell carcinoma and had chronic refractory severe hyponatremia despite treatment with fluid restriction, low dose hydrocortisone, tolvaptan, and 3% sodium chloride.