HYPONATREMIA SECONDARY TO VASOPRESSIN IN AN ECMO DEPENDENT PATIENT WITH SEVERE ARDS DUE TO COVID-19

Abstract

TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: Vasopressin infusion induced hyponatremia is a rare phenomenon. It occurs especially when vasopressin is utilized as an adjunct vasopressor in non-septic shock states. 1 CASE PRESENTATION: 35-year-old Hispanic female without any comorbidities was hospitalized at our institution at the peak of COVID-19 pandemic in New York due to severe hypoxemic respiratory failure requiring ventilatory support and ultimately had to be placed on VV Extracorporeal membrane oxygen (ECMO) support for refractory ARDS. Patient required high doses of intravenous (IV) sedation while on ECMO, with ketamine, hydromorphone and versed. Subsequently, she developed worsening hypotension requiring vasopressor support with low to medium doses of nor-epinephrine (NE) infusion. Fixed dose vasopressin infusion was started in an effort to wean off NE infusion. Serum sodium trended down from 139 to 123 in following four days. Urine output (UOP) progressively dropped from >125 ml/hour to 1.035;calculated serum osmolarity-258;serum cortisol-4.7 and TSH-T4 of 0.948-0.8. Renal evaluation was obtained, vasopressin infusion was discontinued with a subsequent strong diuretic effect and a rapid correction in serum sodium. Patient was already on antibiotics for ventilator associated pneumonia, but shock was not attributed to sepsis considering patient was afebrile with a downtrend in leukocytosis preceding hyponatremia. DISCUSSION: Vasopressin is widely used for co-administration with catecholamines to obtain a dose sparing effect in septic shock. 1 Vasopressin due to an antidiuretic activity via renal V2 receptors can result in decreased in UOP with a secondary hyponatremic effect by causing a state of iatrogenic SIADH. 2 Developing hyponatremia shortly after vasopressin infusion and an anti-diuretic effect should be considered a strong indicator of vasopressin as an underlying etiology. CONCLUSIONS: Vasopressin use an adjunct vasopressor should be avoided in non-septic shock states to prevent a state of hyponatremia and a state of water intoxication. A state of volume overload may have a secondary negative impact on ventilator weaning. REFERENCE #1: Dunser MW, Mayr AJ, Ulmer H, et al. Arginine vasopressin in advanced vasodilatory shock.Circulation. 2003;107(18):2313-2319. REFERENCE #2: Miguel Salazar, Bee Bee Hu, Joyce Vazquez et al. Exogenous Vasopressin-Induced Hyponatremia in Patients with Vasodilatory Shock: Two Cas Reports and Literature Review. Journal of Intensive Care Medicine 2015;30(5) 253-258. DISCLOSURES: No relevant relationships by Zeeshan Hafeez, source=Web Response No relevant relationships by Sana Shahid, source=Web Response No relevant relationships by Abeer Zeeshan, source=Web Response