Changes In Serum Sodium Levels Research Articles

An RCT: Use of Oxytocin Drip during Hysteroscopic Endometrial Resection and Its Effect on Operative Blood Loss and Glycine Deficit

Objective To estimate the influence of oxytocin infusion on operative blood loss and glycine deficit during hysteroscopic transcervical endometrial resection (TCRE) for abnormal uterine bleeding (AUB). Design Prospective, randomized, placebo-controlled study (Canadian Task Force classification I). Setting Tertiary Care University Hospital. Patients Forty-eight women with abnormal uterine bleeding that was unresponsive to conservative medical management were randomly assigned to undergo hysteroscopic TCRE with either oxytocin infusion (group A) or saline (group B). Intravenous Ringer’s lactate solution was used during surgery. Interventions TCRE was carried out with glycine 1.5% mixed with 2% ethanol as a distension medium. For group A: one ampoule of oxytocin (10 U/mL/amp) was added to 500 mL Ringer’s lactate solution running at a rate of 400 mU/min during surgery. In group B, one ampoule of saline solution was added to the Ringer’s solution and run at a similar rate. The amount of distension medium used, fluid deficit, blood levels of albumin and ethanol, hematocrit, hemoglobin, changes in serum sodium levels (Na+), and central venous pressure were compared between the groups. Measurements and main results The mean volume of distension fluid used and operating time were not significantly different in both groups (4.18 ± 0.2 vs 4.5 ± 0.5 L, and 28.3 ± 4.2 vs 27.5 ± 5.4 min, respectively). Although operating time, volume of distension fluid used, decrease in albumin level and hematocrit were less in the oxytocin than in the saline group, the differences were not statistically significant. The ethanol levels in blood, decrease in serum Na+, and glycine deficit were significantly lower in the oxytocin than in the saline group (17.4 ± 3.8 vs 25.3 ± 4.2 mg/ml, 6.7 ± 1.2 vs 9.1 ± 0.9 mEq/L, and 0.49 ± 0.08 vs 0.66 ± 0.05 L, respectively; p <.05). There was no significant difference in mean total uterine size, endometrial thickness, weight of resected tissue, and other demographic data between the study groups. Conclusions Oxytocin infusion combined with skillful surgical techniques may prevent fluid overload and glycine deficit during hysteroscopic TCRE for abnormal uterine bleeding. Although there is a trend toward a decrease in operative blood loss, further randomized trials are required to confirm this finding.

The relationship between arginine vasopressin levels and hyponatremia following a percutaneous renal biopsy in children receiving hypotonic or isotonic intravenous fluids

Post-operative hyponatremia is a common complication in children which results from hypotonic fluid administration in the presence of arginine vasopressin (AVP) excess. We evaluated the relationship between the change in serum sodium and AVP levels following percutaneous renal biopsy in children receiving either hypotonic or isotonic fluids. This study was prompted after we encountered a patient who developed near-fatal hyponatremic encephalopathy following a renal biopsy while receiving hypotonic fluids. The relationship between the change in serum sodium and AVP levels was evaluated prior to (T0) and at 5 h (T5) following a percutaneous renal biopsy in 60 children receiving either hypotonic (0.6% NaCl, 90 mEq/L) or isotonic fluids (0.9% NaCl, 154 mEq/L). The proportion of patients with elevated AVP levels post-procedure was similar between those receiving 0.6 or 0.9% NaCl (30 vs. 26%). Patients receiving 0.6% NaCl with elevated AVP levels experienced a fall in serum sodium of 1.9 ± 1.5 mEq/L, whereas those receiving 0.9% NaCl had a rise in serum sodium of 0.85 ± 0.34 mEq/L with no patients developing hyponatremia. There were no significant changes in serum sodium levels in patients with normal AVP concentrations post-procedure in either group. In conclusion, elevated AVP levels were common among our patients following a percutaneous renal biopsy. Isotonic fluids prevented a fall in serum sodium and hyponatremia, while hypotonic fluids did not.

The impact of the National Patient Safety Agency intravenous fluid alert on iatrogenic hyponatraemia in children

In March 2007, the National Patient Safety Agency (NPSA) issued an alert regarding intravenous fluid (IVF) prescription to hospitalised infants and children, to be implemented in UK hospitals by September 2007. Previously, the most commonly used IVF (0.18% saline/4% dextrose) has been associated with iatrogenic hyponatraemia, resulting in four deaths and one near miss since 2000. The alert recommended 0.45% (or 0.9%) saline/5% dextrose as maintenance IVF and banned 0.18% saline/4% dextrose. We audited practice and outcome in children receiving maintenance IVF in June 2007 (before guideline implementation) and June 2008 (after guideline implementation). In June 2007, 44 (30%) children were prescribed IVF, six received IVF not recommended by NPSA alert 22 and one became hyponatraemic. In June 2008, 56 (30%) children received IVF; one received IVF not recommended by NPSA alert 22 and became hyponatraemic. The median change in serum sodium levels for all children who received IVF not recommended by NPSA alert 22 [-5 (-15 to 0) mmol/l] was significantly greater than those who received IVF recommended by NPSA alert 22 [0 (-13 to +7) mmol/l, p = 0.002]. In addition, there was a significant (p = 0.04) reduction in the number of children who had electrolytes checked while on IVF after implementation of the guideline. Implementation of a new IVF guideline has been associated with less use of IVF not recommended by NPSA alert 22, resulting in less serum sodium level reduction. The only children who became hyponatraemic received IVF not recommended by NPSA alert 22. Despite the NPSA alert and guideline implementation, less children had electrolyte levels checked while receiving IVF.

Impact of Changes in Serum Sodium Levels on 2-Year Neurologic Outcomes for Very Preterm Neonates

The goal was to analyze the relationship between changes in serum sodium levels during the first month of life and impaired functional outcomes at 2 years of age for very preterm infants. All very preterm infants who were born at <33 weeks of gestation between January 1, 2003, and July 31, 2004, were hospitalized in the NICU, and survived to discharge were included in this study. Changes in serum sodium levels were measured, and infants were evaluated at corrected age of 2 years. The analysis involved 237 patients, for whom 3927 serum sodium determinations were performed during the first month of life. We defined 3 tertiles of changes in serum sodium levels. A total of 84 infants demonstrated small changes in serum sodium levels (<8 mEq/ L), 86 demonstrated large changes (8 -13 mEq/L), and 67 demonstrated very large changes (13 mEq/L). The reference group was represented by the first tertile. At 2 years of age, large and very large changes in serum sodium levels were significantly associated with risk of impaired functional outcomes, after adjustment for gestational age and perinatal and neonatal hospitalization characteristics (large changes: odds ratio: 3.5 [95% confidence interval: 1.1-11.8]; P = .04; very large changes: odds ratio: 5.1 [95% confidence interval: 1.3-13.6]; P = .02). Although large and very large changes in serum sodium levels may simply reflect the severity of illness and/or the quality of care, a causal relationship with outcomes cannot be excluded. Cautious fluid and electrolyte management is recommended for very premature infants.

Can we really predict the change in serum sodium levels? An analysis of currently proposed formulae in hypernatraemic patients

Hypernatraemia is common in intensive care patients and may present an independent risk factor of mortality. Several formulae have been proposed to guide infusion therapy for correction of serum sodium. Unfortunately, these formulae have never been validated comparatively. We assessed the predictive potential of four different formulae (Adrogué-Madias, Barsoum-Levine, Kurtz-Nguyen and a simple formula based on electrolyte-free water clearance) in correction and maintenance of serum sodium in 66 hyper- and normonatraemic ICU patients. With daily measurements of sodium/potassium and fluid/electrolyte balances, a day-to-day prediction of serum sodium levels was calculated using the four formulae. This was compared to the measured changes in serum sodium. Six hundred and eighty-one patient-days (194 hypernatraemic) in 66 patients were available for calculations. Prediction of serum sodium levels using all four formulae correlated significantly (P < 0.05) with measured changes in serum sodium. Individual variations were extreme, and the mean differences (+/-SD) for predicted versus measured serum sodium were within the range of 3.4-4.5 (+/-4.4-4.7) mmol/l similar for the Adrogué-Madias, Barsoum-Levine and Nguyen-Kurtz formulae. In comparison, our proposed formula underestimated the changes of serum sodium (mean +/- SD -1.5 +/- 5.3). During hypernatraemia, the differences between predicted and measured values were even greater (mean +/- SD 5.0-6.7 +/- 3.9-4.3) using the published formulae compared to our formula (mean +/- SD 0.2 +/- 4.0). Currently available formulae to guide infusion therapy in hyper- and normonatraemic states do not accurately predict changes of serum sodium in the individual ICU patient. In clinical practice, infusion therapy should be based on the reasons for hypernatraemia and serial measurements of serum sodium to avoid evolution of derangements.

Serum Tonicity, Extracellular Volume and Clinical Manifestations in Symptomatic Dialysis-Associated Hyperglycemia Treated Only with Insulin

The absence of osmotic diuresis modifies the effects of hyperglycemia on body fluids in patients with advanced renal failure. To determine the relationship between clinical manifestations and abnormalities in tonicity and extracellular volume in such patients, we analyzed 43 episodes of severe dialysis-associated hyperglycemia (serum glucose exceeding 600 mg/dL) treated only with insulin. The main manifestations were dyspnea in 22 cases (pulmonary edema in 19), nausea and vomiting in 15, coma in 13 and seizures in 3, while 5 patients had no symptoms. Treatment with insulin resulted in a decrease in serum glucose value from 913 +/- 197 mg/dL to 170 +/- 78 mg/dL, an increase in serum sodium level from 125 +/- 5 to 136 +/- 5 mmol/L, and a fall in calculated serum tonicity value from 300 +/- 13 to 282 +/- 11 mmol/kg (all at p < 0.001). The ratio of the change in serum sodium level over change in serum glucose concentration was -1.50 +/- 0.22 mmol/L per 100 mg/dL. The percent increase in extracellular volume secondary to hyperglycemia developing from the prior euglycemic state and calculated from changes in serum sodium and chloride concentrations, was 10.9% +/- 4.6% (1.5% +/- 0.6% per 100 mg/dL increase in serum glucose level). All clinical manifestations dissipated after correction of hyperglycemia in 42 patients. One woman developed during treatment a fatal myocardial infarction. Dialysis patients with severe hyperglycemia may develop symptoms as a result of hypertonicity and extracellular expansion. Insulin alone may be sufficient treatment for these symptoms. The changes in serum tonicity and electrolytes during treatment are consistent with theoretical predictions.

The effect of sertraline on routine blood chemistry values.

Sertraline is an antidepressant of the selective serotonin reuptake inhibitor (SSRI) class. Although SSRIs are believed to have a milder side effect profile than the tricyclic antidepressants, there are some potentially serious side effects. These include hyponatremia, which has been seen with each of the SSRIs. We reviewed the charts of 246 patients treated with sertraline at a veterans' hospital. We obtained values for each patient's basic chemistry panel (sodium, potassium, chloride, glucose, carbon dioxide, blood urea nitrogen, and creatinine) before and after institution of sertraline therapy. We studied the patients' ages and sertraline doses to see if there was a relationship between any laboratory value changes and these variables. We found no relationship between maximum sertraline dose, age, and changes in routine blood chemistry results with the exception of a small (0.5%) contribution of maximum sertraline dose to variance in serum creatinine levels. Sertraline therapy was not noted to cause any significant changes in serum sodium levels.

VASOPRESSIN SECRETION AND MEMORY IMPAIRMENT IN ALCOHOLIC KORSAKOFF'S SYNDROME

The response of arginine vasopressin (AVP) to an intravenous hypertonic saline infusion was investigated in 19 patients with alcoholic Korsakoff's syndrome, 17 non-amnesic alcoholics and 21 non-alcoholic controls. Compared with non-alcoholic controls the Korsakoff patients had elevated basal AVP levels and showed erratic fluctuation of AVP secretion, not related to changes in serum sodium levels. The non-amnesic alcoholics had a similar, but less severe derangement. Neuropsychological tests revealed significant correlations between basal AVP levels and memory performance in the non-amnesic alcoholics, raising the possibility of a common lesion--most likely in the diencephalon--for memory impairment and AVP dysregulation in chronic alcoholics.

Octreotide ameliorates vasodilatation and Na+ retention in portal hypertensive rats

Background: Whether long-term octreotide treatment given to portal hypertensive rats could prevent or ameliorate peripheral vasodilatation and thereby modify sodium retention was investigated. Methods: Starting at the time of partial portal vein ligation or sham operation, rats received a 4-day course of either octreotide (15 μg/kg in 5% dextrose in water) or placebo (5% dextrose in water) subcutaneously every 8 hours. Results: In portal hypertensive rats, octreotide induced a 13% increase in mean arterial pressure (P < 0.01) and a 19% increase in total peripheral resistance (P < 0.01). Octreotide treatment induced a decrease in extracellular sodium space (22Na injection) (34.2 ± 0.5 vs. 36.7 ± 0.4 mL/100 g; P < 0.01) without changes in serum sodium level. In addition, octreotide treatment significantly reduced portal pressure as well as glucagon levels and plasma renin activity. In contrast, octreotide treatment had no effect on mean arterial pressure and extracellular sodium space in shamoperated rats. Conclusions: Long-term octreotide treatment ameliorated peripheral vasodilatation and sodium retention only in portal hypertensive rats. These findings suggest that in portal hypertension sodium retention can be modified by pharmacological agents that affect peripheral vasodilatation. The specificity of octreotide's effect sheds additional light into the vasodilatory syndrome associated with portal hypertension in liver diseases.

Psychogenic polydipsia and water intoxication—Concepts that have failed

Ten patients (8 men, 2 women; mean age 38.7 ± 8.1 years), 7 of whom had schizophrenic disorders and 3 of whom had bipolar disorder (manic-depressive illness), manifested psychosis, intermittent hyponatremia, and polydipsia (PIP syndrome). The relationship between serum sodium and urinary water excretion among the 10 PIP patients is described in detail. The success of lithium in improving serum sodium levels and in decreasing urinary water excretion among the three PIP patients with bipolar disorder and the failure of changes in urinary water excretion to explain changes in serum sodium levels among the 10 PIP patients argue against “psychogenesis” as the explanation for the polydipsia and excessive water intake as the sole explanation for hyponatremia or complications ascribed to water intoxication.