Acute Severe Hyponatremia Research Articles

5147 Use of hypertonic saline in severe symptomatic hyponatraemia; results from a national survey from United Kingdom

Abstract Disclosure: M. Arshad: None. A. Iqbal: None. Background: Acute severe symptomatic hyponatraemia is potentially life-threatening. Irrespective of the underlying aetiology, hypertonic saline (HTS) is effective at rapidly correcting serum sodium. Several clinical treatment guidelines have aimed to standardise the administration of HTS. The European Society of Endocrinology (ESE) guidelines (2014) recommend two boluses of 150 mL 3% HTS with an aim to raise serum sodium concentration by 5 mmol/L([1]). It is important to note that the evidence supporting this approach is limited, and concerns have been raised regarding the potential for overcorrection using this protocol(2). Aim: To assess the practices and perceptions surrounding hypertonic saline (HTS) use in severe symptomatic hyponatraemia among United Kingdom (UK) endocrinologists and specialty trainees (fellows). Methods: An anonymous online survey was disseminated to all clinical members of the Society for Endocrinology (UK) between 24/10/2023 and 30/11/2023 using Survey Monkey ®, a web-based multiple-choice questionnaire. Results: Of 133 respondents (60.1% consultants, 33.1% specialty trainees, 6.8% other), 85% employed bolus treatment with HTS only, with 9.8% using both bolus and continuous infusions. Most (50.4%) preferred 150 mL boluses, followed by 100 mL boluses (18.8%). Commonly used HTS strengths were 2.7% (45.1%), followed by 1.8% (31.6%), while the 3% HTS strength recommended by ESE guidance was used by 21.8%. Only 7 (5.3%) respondents used weight-based HTS dosage. Contrary to guidelines, 74.4% did not administer a second bolus without waiting for sodium result from the first bolus. Also, 86% have experience using venous blood gas sodium readings for monitoring, even though this has not been mentioned or recommended in the guidelines. HTS was always administered in high-dependency settings by 16.5% and mostly administered in this setting by 49.6%. Overcorrection targets defined by 10 and 8 mmol/24 hours cut-offs were used by 48.9% and 39.9%, respectively. For definite or expected overcorrection, 75.9% preferred 5% dextrose, while 40.6% had experience with desmopressin (DDAVP). Conclusion: Significant variation exists in HTS use for severe symptomatic hyponatraemia in the UK, deviating from guidelines, especially regarding a second bolus without assessing the first bolus's biochemical impact. European guidelines warrant an evidence-based revision to harmonize clinical practice.

Exploring the Cause of Acute Severe Hyponatremia: Cytarabine vs. Suspected Brain Lesion Due to Acute Myeloid Leukemia

Exploring the Cause of Acute Severe Hyponatremia: Cytarabine vs. Suspected Brain Lesion Due to Acute Myeloid Leukemia

Hazard functioning modeling for dextrose fluids associated hemodilution; Cox-regressional analysis for patients’ Hematocrit Hemoglobin Ratio

Aims: This study looks at the cox-regressional relationships between hematocrit to hemoglobin ratio (HHR) and a group of outcomes of interest (cOI). These outcomes include death from any cause, acute myocardial infarction, stroke, and severe dilutional hyponatraemia incidence. Additionally other outcome of interest in this study will be prolongation of admission days, infection rate, acute kidney injury, and mandating the transition to the critical unit and mechanical ventilation intubation. The study also will investigate the performances of the tested ratio and will explore their sensitivity, specificity, and accuracy indexes. Methods: Between 2018 and 2022, a retrospective study was conducted at the King Hussein Medical Centre in Amman, Jordan, involving 926 patients. The study aimed to determine the potential risk of dilution of red blood cells in circulation caused by dextrose-containing fluids in patients with chronic kidney disease. The study aimed to determine the ideal threshold levels of the investigated ratio (HHR) to enhance clinical outcomes and safety margins, particularly in patients with severe renal impairment or chronic kidney disease in a hospital setting. The study included patients with fluctuating kidney function, renal replacement therapy, uncontrolled diabetes, and conditions necessitating specific fluid regimens. The study used binary logistic regression and cox-regression proportional hazard modelling to examine the correlation between the hematocrit to haemoglobin ratio and the composite outcomes of interest (cOI) in patients from Jordan. The findings suggest that higher cOI likelihood indicates a more advantageous condition, while lower values suggest a less advantageous condition. Results: A retrospective study at the KHMC in Amman, Jordan, involved 1306 patients from 2018 to 2022. The study focused on the hematocrit to haemoglobin ratio (HHR) and achieved correct classification rates of 70.8%. The best HHR was 2.555:1, with a 42.8% chance of occurring at this level. Cox-Regression Proportional Hazard Modelling revealed a censored percentage of 83.4% in HHR>2.555 stratum and 51.5% in HHR≤2.555 stratum. The study found a high percentage of HD patients processed in the analysis. Conclusion: Intravenous dextrose fluids associated hemodilutional state is linked to all-cause mortality in admitted medically and surgically patients and cardiovascular death. Low ratio increases the risk. Factors such as malnutrition and kidney function loss contribute to prognosis. Future studies should focus on mechanistic pathways, optimal targets, age, and sociodemographic factors.

Etiology, Clinical Approach, and Therapeutic Consequences of Hyponatremia

A perturbation in the water balance rather than any change in salt content is the main cause of hyponatremia, the most frequent electrolyte abnormality, defined as a serum sodium concentration <135 mEq/L. Hyponatremia may be divided between mild (Na > 120 mEq/L) or severe (Na < 120 mEq/L) hyponatremia, and is most frequently observed in elderly ICU hospitalized patients. Based on tonicity, hyponatremia may be hypotonic (a decreased concentration of the solute), isotonic, and hypertonic (falsely low sodium). According to the volume of extracellular fluid (ECF), hyponatremia is further divided among hypovolemic, euvolemic, or hypervolemic hyponatremia. Finally, hyponatremia may develop rapidly as acute (<48 h), usually with severe symptoms, or slowly as chronic hyponatremia, usually being asymptomatic or with mild symptoms. Acute severe hyponatremia presents with severe CNS problems, increased hospitalization rates, and mortality. The treatment with 3% sodium chloride and a 100 mL IV bolus based on severity and persistence of symptoms needs careful monitoring. A non-severe hyponatremia may be treated with oral urea. In asymptomatic mild hyponatremia, an adequate solute intake with an initial fluid restriction of 500 mL/d adjusted according to the serum sodium levels is preferred. Vaptans could be considered in patients with high ADH activity regardless of whether they are euvolemic or hypervolemic. In general, the treatment of hyponatremia should be based on the underlying cause, the duration and degree of hyponatremia, the observed symptoms, and volume status of patient.

A Rare Presentation of a Common Disorder : Severe Hyponatremia Presenting as Reversible Unstable Bradyarrythmias

Severe hyponatraemia is defined as a sodium level of less than 120 mEq/L, and it is frequently accompanied by neurological symptoms like coma, convulsions, respiratory arrest, and death. Clinical cardiac toxicity from hyponatremia, such as bradyarrhythmia, is extremely rare. In this article, we present a case of acute severe hyponatraemia that induced unstable bradyarrhythmia and led to refractory bradycardia, which did not improve despite receiving treatment in accordance with the standard Advanced Cardiovascular Life Support protocol. The patient’s bradyarrhythmia has completely resolved with the administration of 3% hypertonic saline, which restored her sodium levels. Due to the possibility that severe hyponatremia may contribute to the aetiology of cardiac malfunction, this case raises awareness about the significance of closely monitoring electrocardiograms and telemetry in patients with severe hyponatremia.

McKittrick-Wheelock Syndrome Secondary to Rectal Adenocarcinoma

Abstract Introduction McKittrick-Wheelock syndrome is a rare condition that arises from a hypersecretory state secondary to large colorectal tumors, mainly villous adenomas, leading to an electrolytic disorder associated with chronic diarrhea that usually persists for years. It is a relatively unknown disease that can lead to severe complications such as acute kidney injury, severe hyponatremia, and hypokalemia. In fact, it causes death in most untreated cases. Surgical removal of the tumor is the most successful treatment, and symptoms tend to disappear after proper management. Case Report A 62-year-old man with a 2-year history of mucoid diarrhea preceded by abdominal pain presented with acute kidney injury, hyponatremia, and hypokalemia. A digital rectal examination and sigmoidoscopy were performed, and revealed a large laterally-spreading tumor in the rectum. Further investigation showed a rectal tubulovillous adenoma with secondary McKittrick-Wheelock syndrome. An anterior resection of the rectum with a colonic J-pouch and a diverting ileostomy were performed, and the patient improved with the resolution of the renal failure and electrolyte disturbances. The histopathological analysis revealed an invasive rectal adenocarcinoma. Discussion McKittrick-Wheelock syndrome is a condition with a low incidence that needs early intervention and proper diagnosis. It is of extreme importance that this disease is included in the differential diagnoses for chronic diarrhea associated with an electrolytic disorder.

Acute and Chronic Hyponatremia.

Hyponatremia is the most common electrolyte disorder in clinical practice. Catastrophic complications can occur from severe acute hyponatremia and from inappropriate management of acute and chronic hyponatremia. It is essential to define the hypotonic state associated with hyponatremia in order to plan therapy. Understanding cerebral defense mechanisms to hyponatremia are key factors to its manifestations and classification and subsequently to its management. Hypotonic hyponatremia is differentiated on the basis of urine osmolality, urine electrolytes and volume status and its treatment is decided based on chronicity and the presence or absence of central nervous (CNS) symptoms. Proper knowledge of sodium and water homeostasis is essential in individualizing therapeutic plans and avoid iatrogenic complications while managing this disorder.

A Rare Case of Water Intoxication in Unusual Chiropratic Prescription: A Medico-Legal Analysis Due to Alleged Malpractice.

Water intoxication is a well-recognized cause of symptomatic hyponatremia, whose often fatal consequences are de-scribed in a wide variety of conditions such as psychiatric disorders, metabolic dysfunctions, child abuse, drug abuse and several medical procedures. We here report a rare case of a 67-year-old woman with severe acute hyponatremia due to an excessive voluntary water intake - 14 litres in two days - following a chiropractic prescription. The patient developed sudden severe symptoms, including water retention, sensory alteration, altered mental status and tonic-clonic seizures. She was thus admitted to the Intensive Care Unit with a diagnosis of coma due to electrolyte alterations following water intoxication. The evaluation, in the present case, of the medico-legal implications related to malpractice involving a practitioner of Complementary and Alternative Medicine, led to the admission of a professional liability of the chiropractor.

Co-presentation of Acute Sheehan Syndrome with Raised Intracranial Pressure in a Post-partum Lady

Sheehan’s syndrome (SS) or necrosis of pituitary gland is a rare complication of severe postpartum hemorrhage. It may cause hypopituitarism immediately or several years later, depending on the degree of tissue destruction. Sheehan’s syndrome though rare is still one of the commonest causes of hypopituitarism in developing countries like ours. The presence of an intercurrent infection and administration of thyroxine exacerbated her corticosteroid insufficiency. Intracranial hypertension (IH) manifested as bilateral optic disc swelling with reduced visual acuity, bilateral sixth nerve palsies, and impaired consciousness. Intracranial hypertension (IH) has been associated with hypocortisolism caused by either primary adrenocortical insufficiency or corticosteroid withdrawal. The author describes a case of a young lady with IH with acute SS who presented on 3rd day postpartum after lower uterine cesarean section with acute severe symptomatic hyponatremia which was complicated by postpartum hemorrhage. The clinical manifestations of IH resolved with corticosteroid replacement

Pulmonary thromboembolism-caused acute severe euvolemic hyponatremia complicated by COVID-19 infection: A case report

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

A Case of Central Pontine Myelinolysis due to Severe Acute Prolonged Hyponatremia in Our County Hospital

Background: Central pontine myelinolysis (CPM)is unique and rare clinical entity. It could be a neurological complication of prolonged hyponatraemia. Many predisposing risk factors (chronic alcoholism, malnutrition, malignancy) may aggravate the development of CPM. CPM usually have a poor or even fatal outcome. However, CPM does not inevitably have a bad prognosis, and could occur with proper restoration of normal serum sodium concentrations. Case Summary: Here, we presented a case of a 48-year-oldfemale. She used to drink alcohol. She presented to Our Lady’s Hospital/Navan with a history of four days feeling unwell, confused diarrhea, vomiting and by investigations, she had severe hyponatraemia. She was managed optimally in the ICU with close monitoring of her urea and electrolytes. Unfortunately, she got progressive neurological deficits (lower limbs weakness, and slurred speech) irrespective of gentle treatment of hyponatremia in intensive care unit. After Neurological and radiological input from Dublin institute, CPM confirmed under background of alcoholism and malnutrition. Following the diagnosis of CPM, she was discharged home after been rehabilitated with physiotherapy with ongoing recovery.

Severe hyponatremia with seizures and confirmed mild brain edema by hysteroscopic myomectomy: a case report

BackgroundHyponatremia can be developed during hysteroscopic surgery with electrolyte-free irrigation fluid. We experienced severe hyponatremia with postoperative seizures and confirmed mild brain edema.Case presentationA quadragenarian female patient underwent a 2-h hysteroscopic myomectomy with electrolyte-free fluid for uterine distension under general anesthesia. Plasma sodium level of 84.1 mmol/L 100 min after the start of surgery indicated excessive absorption of the irrigation fluid. Acute severe hyponatremia was diagnosed with significant edema in the conjunctiva, lip, and extremities. She was treated with a continuous infusion of hypertonic saline. However, seizures and cerebral edema developed 7 h later. The patient recovered without neurological deficits at postoperative day 2.ConclusionThe electrolyte-free irrigation fluid can be absorbed rapidly during hysteroscopic surgery. Its interruption with hyponatremia should be considered against prolonged surgery. Especially under general anesthesia, caution should be exercised because the typical symptoms of hyponatremia such as nausea and confusion are blinded.

Síndrome de secreción inadecuada de hormona antidiurética

The syndrome of inappropriate antidiuretic hormone secretion (SIADH) is the commonest form of normovolaemic or dilutional hyponatraemia, and it is caused by either excessive hormone excretion or dysregulated hormone action. Etiology is multifactorial, including drugs, neoplasms, brain and hypophysis lesions, benign lung lesions or human immunodeficiency virus. Clinical features depend on the severity and rate of fall of hyponatremia. Diagnosis demand a normal thyroid, adrenal, liver, renal and cardiovascular function, as well as to rule out diuretic intake. Hypertonic (3%) saline infusion is the treatment of choice of severe acute hyponatremia; whereas fluid restriction is the treatment of asymptomatic chronic hyponatremia. Other pharmacological alternatives are urea, demeclocycline or tolvaptan (the latter having aroused great interest in the last decade).

Quality improvement project: identifying the barriers to accurate assessment and documentation of fluid status monitoring

To identify the barriers to accurate assessment and documentation of fluid balance. Fluid status monitoring was identified as an essential component in the care of patients with a presenting diagnosis of heart failure, sepsis, acute kidney injury and severe hyponatraemia. To measure the assessment

AMIODARONE INDUCED HYPONATREMIA CONSISTENT WITH SIADH

Amiodarone is frequently used for rhythm control in cardiac arrhythmias & has an extensive toxicity profile. We present a rare case of amiodarone induced severe acute hyponatremia consistent with syndrome of inappropriate antidiuretic hormone secretion (SIADH). A 90-year-old female with

Focal Neurological Deficit Secondary to Severe Hyponatraemia Mimicking Stroke.

Hyponatraemia is a common electrolyte abnormality seen by internists. Clinical features of hyponatraemia are primarily related to CNS dysfunction, and depend on the severity and acuity of changes in serum sodium concentration. Neurological manifestations of hyponatraemia range from nausea and malaise, with a mild reduction in the serum sodium, to lethargy, decreased level of consciousness, headache, seizures and coma in extreme cases. Focal neurological deficits are very rare in the setting of hyponatraemia. Here, we describe a patient with acute severe symptomatic hyponatraemia presenting with focal neurological deficits that resolved after correction of acute hyponatraemia.LEARNING POINTSA rare presentation of hyponatraemia is described.Neuroimaging should be performed in patients with focal neurological deficits and hyponatraemia in order to rule out other serious neurological diseases.Correction of severe hyponatraemia can result in resolution of focal neurological deficits.

A swine model of intracellular cerebral edema – Cerebral physiology and intracranial compliance

Cerebral edema leading to elevated intracranial pressure (ICP) is a fundamental concern after severe traumatic brain injury (TBI), stroke, and severe acute hyponatremia. We describe a swine model of water intoxication and its cerebral histological and physiological sequela. We studied female swine weighing 35–45 kg. Four serum sodium intervals were designated: baseline, mild, moderate, and severe hyponatremia attained by infusing hypotonic saline. Intracranial fluid injections were performed to assess intracranial compliance. At baseline and following water intoxication wedge biopsy was obtained for pathological examination and electron microscopy. We studied 8 swine and found an increase in ICP that was strongly related to the decrease in serum sodium level. Mean ICP rose from a baseline of 6 ± 2 to 28 ± 6 mm Hg during severe hyponatremia, while cerebral perfusion pressure (CPP) decreased from 72 ± 10 to 46 ± 11 mm Hg. Brain tissue oxygen tension (PbtO2) decreased from 18.4 ± 8.9 to 5.3 ± 3.0 mm Hg. Electron microscopy demonstrated intracellular edema and astrocytic foot process swelling following water intoxication. With severe hyponatremia, 2 cc intracranial fluid injection resulted in progressively greater ICP dose, indicating a worsening intracranial compliance. Our model leads to graded and sustained elevation of ICP, lower CPP, and decreased PbtO2, all of which cross clinically relevant thresholds. Intracranial compliance worsens with increased cerebral swelling. This model may serve as a platform to study which therapeutic interventions best improve the cerebral physiological profile in the face of severe brain edema.

NSAIDS related hyponatremia in brain injury patients: A silent factor for their deterioration

Hyponatremia is the most common disorder of electrolytes encountered in clinical practice, occurring in 22% of hospitalized patients. Acute severe hyponatremia can cause severe morbidity and mortality. Adverse outcomes are higher in hyponatremic patients with a wide range of underlying conditions. There are different causes of hyponatremia but NSAID's used commonly in brain injury patients for managing pain can result in hyponatremia leading to complications such as lethargy, confusion, dizziness, gait disturbances, muscle cramps, seizures, coma and even death. Too rapid correction of hyponatremia in these patients can also lead to life threatening complications. A case study was conducted on a brain injury inpatient who suffered from hyponatremia in our unit secondary from NSAID's which were started for her arthritis. Patient responded to the treatment initially very well but later on showed quick decline in her clinical status with varying signs and symptoms ranging from confusion, lethargy, speech and swallowing decline as well as seizures and gait disturbance. Her blood tests showed gradual hyponatremia and this was co-related exactly with the time of starting NSAID's. Patient responded slowly but very well with stopping NSAID's and treating with fluid restriction for a time being although the clinical decline remained there for sometime. Avoid the use of NSAID's in brain injury patients as their use can cause significant hyponatremia, which could result in life threatening complications. Even the rapid correction of this hyponatremia can be too dangerous or fatal. NSAIDs related Hyponatremia in Brain Injury patients has been proven as a silent factor for their deterioration and thus needs careful monitoring and treatment.

A rare cause of acute severe hyponatraemia secondary to the syndrome of inappropraite anti-diuretic hormone (SIADH) secretion

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Hyponatremia: A clinical approach

Hyponatremia is the most common electrolyte metabolic abnormality in clinical practice. The unfavorable course of many diseases is associated with hyponatremia. Acute severe hyponatremia is life-threatening because cerebral edema may develop. Less obvious chronic hyponatremia increases the risk of balance problems, falls and fractures, especially in elderly patients. In any occasion, hyponatremia should not be now regarded only as a laboratory phenomenon in critically ill patients, but it necessitates a thorough clinical analysis of each individual case and appropriate therapy. The paper presents approaches to diagnosing and treating hyponatremia in various clinical situations.