Severe Hypernatremia Research Articles

Celulitis necrosante estéril en las extremidades de migrantes marinos tras travesías prolongadas

BackgroundIn the past few years, the Canary Islands received immigrants from sub-Saharan countries that arrive to the coast after long boat trips in extreme adverse conditions.The named «trench foot» is a previously described infectious entity developed after feet wounds that get infected by being in contact with water, urine and excrements in these small and crowded boats.We describe a new clinical entity, not published yet, that consists in massive edema in the extremities associating necrosis of the skin and subcutaneous tissue that characteristically respects the muscle and with a non-infectious etiology. Material and methodsA database including 86 patients arrived by boat («patera») from sub-Saharan countries from September 2020 to January 2022 was made and 39 qualitative and quantitative items were analyzed. The Research Unit performed an observational prospective statistical analysis. ResultsA total of 16 patients developed the entity described as necrotizing cellulitis. Its physiopathology completely differs from the one described in the trench foot, since all the cultures resulted sterile. ConclusionsWe postulate an inflammatory theory due to the osmotic effect from ingesting sea water and/or the aggressive fluid reposition when they arrive to the emergency room with severe dehydration and hypernatremia. Early surgical evacuation of the edema with escharotomies incisions alleviate the symptoms and prevents progression of the disorder.

An exhaustive battle of salt: A challenging case of Adipsic Diabetes Insipidus following resection of Craniopharyngioma

Introduction: Even though rare, Adipsic Diabetes Insipidus (ADI) is a potentially life-threatening complication of craniopharyngioma: due to the mass effect of the tumor or perioperative consequences leading to severe hypernatremic dehydration. Even in expert hands, management of water balance, in the absence of thirst is extremely challenging. Case Description: A 25-year-old gentleman, an electrician presented to the neurosurgical casualty with worsening headaches, impaired vision, and features of raised intracranial pressure over 2 months. He was found to have a large cystic suprasellar mass with well-defined margins measuring 2.7cm x 2.7cm x 3cm with chiasmal compression, suggestive of craniopharyngioma, complicating with bitemporal hemianopia, hypogonadotropic hypogonadism (LH 0.78IU/L, FSH 1.2IU/L, Testosterone 33ng/dL), secondary hypothyroidism, cranial diabetes insipidus, prediabetes sparing the cortisol axis. He underwent transcranial resection of the tumor, revealing WHO grade1 adamantinomatous craniopharyngioma followed by radiotherapy. The post-operative period was complicated with severe hypernatremia despite escalating doses and changing dosage forms of desmopressin from parenteral to nasal spray to oral tablets. Two weeks following discharge, he presented with severe hypernatremia (176mEq/L), polyuria, weight loss, hypotension, and altered sensorium where his lack of thirst was appreciated. Conclusions: In those with ADI, for the management of water balance, a “personalized approach” with the involvement of both patient and family is of paramount importance. With appropriate dose titration of desmopressin, careful fluid prescription, and frequent monitoring of electrolytes even at best centers, it is a battle that is hard to win.

Retrospective analysis of 102 neonatal cases hospitalized with diagnosis of the ongoing phenomenon of neonatal period: hypernatremic dehydration

Aim: The aim of this study was to examine the prevalence of hypernatremic dehydration (HD) among term neonates admitted to a tertiary care unit over a three-year period and to identify mother and neonate related risk factors associated with HD.
 Material and Method: Medical records of 102 term babies and their mothers were analyzed retrospectively. The gender, weight at birth, type of birth, postnatal day of diagnosis, weight and weight loss percentage at diagnosis, season and presenting complaint upon admission, feeding with human milk/formula/mixed, laboratory findings, usage of antibiotics as well as maternal age, parity, residence, level of education and presence of smoking were recorded. Serum sodium (Na) levels, severity of dehydration, age on admission, and length of stay in the neonatal intensive care unit (NICU) were recorded along with any significant effect of maternal demographic properties, residence, season, gender, and type of birth.
 Results: The average Na levels were found to be 152.1±4.2 mEq/L (max:166 mEq/L). Mild, moderate and severe hypernatremia were found in 34 (33%), 62 (61%) and 6 (6%) patients, respectively. More weight loss was observed in neonates born via cesarean section vs. vaginal delivery (12.8±3.0% vs. 11.6±3.5%, p=0.01). Higher serum Na levels (153.9±4.86 mEq/L vs. 151±2.34 mEq/L, p=0.008) and a greater median age at admission (4.5 [IQR4-6]) days vs. 3 [IQR3-4]) days, p=0.03) were reported for neonates born to mothers residing in rural/suburban vs. urban areas. Serum Na levels were not different based on the mother's level of education or parity (p=0.96 and p=0.29, respectively). There was no difference in serum Na levels (p=0.05) but the percentage of weight loss was higher when the mother smoked (14.3±3.8% vs. 11.7±3.1%, p=0.003). Serum Na and glucose levels were lower, antibiotics usage rates, and prevalence of mixed feedings were higher in early term infants (p=0.01, p=0.002, p=0.04 and p=0.04, respectively). Males had higher creatinine levels (0.89±0.27 mg/dl vs. 0.78±0.28 mg/dl, p=0.005), but there was no difference between the sexes in terms of day of admission, percentage of weight loss, or length of stay in NICU.
 Conclusion: Hypernatremic dehydration is a significant and increasingly prevalent problem of neonatal period. Serum Na levels and severity of dehydration in neonates may be affected by the type of birth, mother's smoking status, residence and early term birth. Counseling on breastfeeding, education of health professionals and caregivers on the signs and symptoms of dehydration, and monitoring of body weight are essential for the prevention, diagnosis, and treatment of HD.

Abstract #1404147: Adipsic Diabetes Insipidus in a Patient with Aggressive Suprasellar Mature Teratoma

Diabetes insipidus (DI) can be life-threatening if not properly diagnosed and managed. There are many etiologies of central diabetes insipidus including neoplasm, vascular disease, trauma, autoimmune disease, infection, granulomatous disease, drugs, and genetic disease. This report presents a patient who developed adipsic DI secondary to a rare etiology, a suprasellar mature teratoma. A 37-year-old man with no significant past medical history presented to the hospital for worsening altered mental status (AMS) for 5 months, headaches, and polydipsia. Hypernatremia with a sodium level of 175 was noted. Magnetic resonance imaging (MRI) of the brain showed a large, heterogenous, mixed solid cystic suprasellar mass measuring 3.4 x 2.6 x 2.7 cm invading the suprasellar structures and extending to the third ventricle with mass effect on the hypothalamus, thalami, and optic chiasm. Panhypopituitarism with DI, hypothyroidism, adrenal insufficiency, and hypogonadism was diagnosed. Open craniotomy for surgical resection of the mass was performed. Pathology revealed endodermal tissues representing small and large intestine and stratified keratinizing and nonkeratinizing squamous epithelium in a background of hemorrhage, fibrosis, chronic inflammation, and mucin consistent with a suprasellar mature teratoma. He was discharged on desmopressin 1 mcg subcutaneously twice daily, hydrocortisone, and levothyroxine. He presented 7 months later for AMS and severe hypernatremia on desmopressin 6 mcg subcutaneously twice daily. There was regrowth of the suprasellar mass with interval worsening in size (3.5 x 3.7 x 3.1 cm) and increased mass effect on the left internal carotid artery, anterior communicating artery, and third ventricle. Subsequently, he underwent endoscopic cyst fenestration and ventriculoperitoneal shunt placement. Panhypopituitarism persisted, and he remained obtunded. He was hospitalized for 2 months, and repeat MRI of the brain showed an interval increase in the size of the mass (4.7 x 3.6 x 3.3 cm) with surrounding vasogenic edema and mass effect on the optic chiasm, hypothalamus, and third ventricle concerning for right ventricular entrapment. Due to the aggressive nature of the tumor, it was deemed inoperable and the patient underwent comfort care measures. Suprasellar mature teratomas are rare tumors which respond to surgical resection with a 10-year survival rate of 93%. Hypothalamic damage from these tumors can lead to an inability to maintain thirst response which can be dangerous in central DI as severe hypernatremia can develop. In these patients, it is vital to evaluate for other pituitary hormone deficiencies.

Abstract #1408214: Severe Hypernatremia Due to Central Diabetes Insipidus with Adipsia: Challenges in Management

Hypernatremia (serum sodium >145meq/L) is independently associated with increased mortality as high as 40-60%. Mortality correlates with the rapidity of the rise in sodium and the degree of severity. Central Diabetes Insipidus (DI) associated with adipsia pose a unique management challenge, leading to recurrent hospital admissions due to hypernatremia. We report, a patient with Central DI who presented with severe hypernatremia following desmopressin non-compliance and inadequate water intake. A 25-year female with a past history of obstructive hydrocephalous underwent ventriculoperitoneal shunt revision and had a complicated hospital course including new onset Central DI. The patient was discharged on desmopressin and a serum sodium of 148 meq/L. She presented to the hospital 3 days later with altered mentation, dehydration, and a heart rate of 124bmp. Other vital signs were stable. CT head showed no acute intracranial abnormalities. Labs showed: serum sodium 190meq/L, serum osmolality 393mOsm/kg, urine sodium 44mEq/L, and urine osmolality 878mEq/L. She initially received IV isotonic fluid, and IV DDAVP, and later started on hypotonic fluid and oral DDAVP. Labs were monitored every 6 hours. The patient didn’t have a sense of thirst, didn’t like the taste of water, and had a suboptimal response to oral DDAVP. Multiple measures were taken to stabilize her serum sodium: switched to DDAVP Nasal spray, placed alarms on her cell phone as a reminder to drink water, flavored powders were used to make the water palatable, and provided education on the importance of DDAVP, adequate water intake, and outpatient follow-ups. The patient was safely discharged home after demonstrating the ability to maintain normal serum sodium on oral fluid intake and self-administered nasal DDAVP. Thirst is a critical adaptive mechanism to protect against hypernatremia. Intense thirst may be present initially, but it dissipates as hypernatremia progresses and is absent in patients with adipsia. Destruction or improper functioning of osmoreceptors in the hypothalamus that controls the thirst mechanism can result in adipsia; this may result from a congenital malformation or acquired as in the case of stroke, trauma, or infection. It was most likely secondary to multiple intracranial procedures in our patient. This case also highlights cerebral adaptation to chronic hypernatremia. Brain shrinkage is countered by an adaptive response initiated promptly and consists of solute gain (initial uptake of sodium and potassium, followed by the later accumulation of osmolytes; mainly myoinositol and the amino acid glutamine) by the brain that tends to restore lost water. This response leads to the normalization of brain volume and accounts for the milder symptoms of hypernatremia that develops slowly, as seen in this patient. In conclusion, patients with Central DI associated with adipsia can pose a significant management challenge. This case highlights the importance of addressing all the barriers that affect patients’ compliance with DDAVP and ensuring adequate hydration to prevent recurrent hospital admission and associated morbidity and mortality.

Intraoperative Central Diabetes Insipidus during Aneurysmal Clipping Surgery: An Unusual Phenomenon

AbstractCentral diabetes insipidus (DI) is a known complication associated with pituitary surgeries occurring in postoperative period. However, development of DI following aneurysmal subarachnoid hemorrhage (SAH) is rarely reported. We describe here a case of intraoperative DI in a patient undergoing aneurysmal clipping surgery that posed a challenge for both diagnosis and management. Intraoperative development of central DI was attributed to the evolving ischemic injury to the hypothalamus at the time of rebleeding that was not apparent in the preoperative scan. DI resolved postoperatively after 18 hours of medical management. A careful observation of preoperative scans and vigilant monitoring may help in early diagnosis and management of such complication in the perioperative period.

Hypernatremic hemorrhagic encephalopathy as an unexpected critical complication in children: a case report from a tertiary hospital

Introduction: Hypernatremic hemorrhagic encephalopathy (HHE) is one of the complications of hypernatremic dehydration which is relatively uncommon in patients with hypernatremia. Severe hypernatremia might lead to brain shrinkage resulting in intracranial bleeding which can increase morbidity and mortality, especially in children. Hypernatremic hemorrhagic encephalopathy is harmful, but only limited cases are reported. This case highlights the role of cautious management of hypernatremic dehydration and the need for intense monitoring due to the unexpected complication of HHE. Case presentation: A 4 months old female infant presented with a decreased consciousness. She showed signs of shock along with acute diarrhoea and severe dehydration. Laboratory findings revealed severe hypernatremia and high septic marker. Rehydration and correction of hypernatremia were done, but during the process, several episodes of general tonic-clonic seizure occurred. A Head CT scan was done and showed subdural hemorrhage in the posterior interhemispheric fissure and intraventricular hemorrhage in the posterior horn of the right lateral ventricle. Conservative management was undertaken and the patient was clinically improved progressively. On the 11th day of hospitalization, the patient's condition had been significantly improved without neurological sequelae and was later discharged on the 11th day of hospitalization. Conclusion: Close monitoring of clinical, neurological, and laboratory examination is essential in the management of hypernatremic dehydration due to the possibility of HHE, even when on the right procedure. Once neurological complication is suspected, an immediate imaging study should be performed and modifying therapy is required.

Early and prolonged continuous hypertonic saline infusion in patients with acute liver failure

PurposeTo study patient characteristics, physiological changes, and outcomes associated with prolonged continuous hypertonic saline (HTS) infusion in acute liver failure (ALF). Materials and methodsRetrospective observational cohort study of adult patients with ALF. We collected clinical, biochemical, and physiological data six hourly for the first week, daily until day 30 or hospital discharge, and weekly, when documented, until day 180. ResultsOf 127 patients, 85 received continuous HTS. Compared with non-HTS patients they were more likely to receive continuous renal replacement therapy (CRRT) (p < 0.001) and mechanical ventilation (p < 0.001). Median HTS duration was 150 (Interquartile range (IQR): 84–168) hours, delivering a median 2244 (IQR: 979–4610) mmol sodium load. Median peak sodium concentration was 149 mmol/L vs 138 mmol/L in non-HTS patients (p < 0.001). The median rate of sodium increase with infusion was 0.1 mmol/L/h and median rate of decrease during weaning was 0.1 mmol/L every 6 h. Median lowest pH value was 7.29 vs. 7.35 in non-HTS patients. Survival of HTS patients was 72.9% overall and 72.2% without transplantation. ConclusionsIn ALF patients, the prolonged administration of HTS infusion was not associated with severe hypernatremia or rapid shifts in serum sodium upon commencement, delivery, or weaning.

Hypernatremia in Critically Ill COVID-19 Patients: Is it a manifestation of COVID-19 or acquired in the ICU?

Objective: It has been noted that COVID-19 patients experienced electrolyte problems more frequently, and these disturbances were linked to unfavorable results. The purpose of this study was to investigate the incidence and consequences of hypernatremia in severely ill COVID-19 patients receiving intensive care (ICU). Methods: Retrospective data analysis was done on COVID-19 patients who were admitted to ICUs over a six-month period at two centers. Results: Data from 270 patients were collected in total. 138 (51%) patients developed hypernatremia (Na &amp;gt;145 mmol/l) during ICU stay. Hypernatremia was observed to be more in older or ventilated patients, whereas less in patients with chronic kidney disease. However, in patients with and without hypernatremia, unfavorable outcomes like length of stay (LOS) or mortality were comparable. Frequency of hypertension, septic shock as well as SOFA score, and serum BUN levels were significantly higher in moderate to severe hypernatremic (Na ≥150 mmol/l) vs mild hypernatremic (Na=146-149 mmol/l) group. Moderate to severe hypernatremia had worse prognosis than the mild group: ICU LOS (12 vs 9-day, p=0.033), ICU mortality (86% vs 61%, p=0.001 and 28-day mortality (89% vs 68%, p=0.004). Elevated serum BUN levels and moderate to severe hypernatremia were independent predictors of both ICU and 28-day mortality. Conclusion: Critically ill COVID-19 patients experienced hypernatremia more frequently than expected, suggesting that hypernatremia may be a manifestation of systemic involvement of COVID-19 rather than iatrogenic. Patients with and without hypernatremia were found to have similar outcomes.

Persistent Flaccid Paralysis in a Patient with Bartter Syndrome.

A two-year-old girl with an unremarkable family history was transferred to our tertiary care centre showcasing a severe dyselectrolytemia and a suspicion of tubulopathy. She was born to healthy nonconsanguienous parents at 35 weeks of gestation from dizygotic twins with birth weight of 2,550 g, polyhydramnios was not reported. One week prior to her admission to our department, she exhibited symptoms of acute upper respiratory tract infection and was admitted to the local hospital. Her physical examination showed mild dehydration, general muscle weakness, significantly reduced spontaneous physical activity and feeding difficulties initially attributed to an electrolyte imbalance. Laboratory examination revealed severe hypokalemia (2.1 mmol/L), hypernatremia (154.9 mmol/L), hypochloremia (91.0 mmol/L) and metabolic alkalosis (pH 7.6, bicarbonate 31.0 mmol/L). Both plasmatic renin and aldosterone were high: 643.5 ng/L and 5.9 nmol/L, respectively.

Hyponatremia and hypernatremia in the emergency department: severity and outcomes.

Hyponatremia and hypernatremia are common electrolyte disorders. Few studies to date have focused on patients presenting to the emergency department (ED) with sodium (Na) disorders. Our objective was to determine the incidence and outcomes of hyponatremia and hypernatremia in ED patients. This study was a retrospective, single-center review of electronic medical records at an academic suburban ED with approximately 100,000 annual visits. Subjects included consecutive adult ED patients with Na levels measured while in the ED in 2019. Demographic, clinical, and laboratory data were recorded. Outcomes data, including hospital admission, intensive care unit (ICU) admission, mortality, and length of stay (LOS), were recorded. The primary outcome was inhospital death. Secondary outcomes were hospital admission, ICU admission, ED LOS, and hospital LOS. Univariable and multivariable linear and logistic regression analyses were performed to explore the association of candidate predictor variables and outcomes. Na was measured in 57,427 adults (54%) among a total of 106,764 assessed ED visits in 2019. The mean±standard deviation age was 54±21 years, and 47% of participants were male. Mild, moderate, and severe hyponatremia and hypernatremia occurred in 8%, 2%, and 0.1% of patients and 1%, 0.2%, and <0.1% of patients, respectively. Hospital and ICU admission and mortality rates increased as Na levels increased or decreased further from normal. Adjusted odds ratio (95% confidence interval) values for hospital mortality were 2.39 (1.97-2.90) for mild hyponatremia, 3.93 (2.95-5.24) for moderate hyponatremia, 6.98 (2.87-16.40) for severe hyponatremia, 3.65 (2.47-5.40) for mild hypernatremia, 8.58 (4.92-14.94) for moderate hypernatremia, and 55.75 (11.37-273.30) for severe hypernatremia. Hypernatremia was associated with a greater risk of death than hyponatremia. Patients with hyponatremia and hypernatremia had increased LOS times compared to those with normal Na levels. Hyponatremia and hypernatremia were associated with greater rates of hospital admission, ICU admission, mortality, and prolonged hospital LOS times.

Intractable Vomiting

Nausea and vomiting constitute one of the most common presenting symptoms in a variety of diseases in clinical practice. Recurrent vomiting can be due to simple gastritis which may lead to dehydration and electrolyte disturbances to threatening intracranial hypertension. Prolonged recurrent vomiting can also lead to malnutrition. Esophageal dysmotility is usually associated with dysphagia but is infrequently associated with recurrent vomiting. We report a case of acute-onset intractable vomiting in a 50-year-old Indian female who presented with severe dehydration and hypernatremia. A timed barium esophagogram revealed dilated esophagus with a rat-tail appearance. Upper gastrointestinal endoscopy revealed dilated esophagus with a tight esophageal-gastric junction. With a diagnosis of achalasia cardia, the patient underwent peroral endoscopic myotomy with complete resolution of symptoms.

Chordoid gliomas of the third ventricle

Chordoid glioma is a rare slow-growing tumor of the central nervous system. Available world experience includes no more than 200 cases (lesion of the third ventricle in absolute majority of cases). Recognition and treatment of chordoid glioma are currently difficult problems due to small incidence of this disease. To describe clinical manifestations and surgical treatment of chordoid glioma of the third ventricle considering literature data and own experience. There were 12 patients (6 men and 6 women) with chordoid glioma between 2004 and 2023 (10 patients with lesion of the third ventricle, 1 - lateral ventricle, 1 - pineal region). Only patients with tumors of the third ventricle were analyzed. Total and subtotal resection was performed in 1 and 3 cases, respectively. Five patients underwent partial resection, 1 patient underwent biopsy. The follow-up data were available in 7 out of 10 patients (mean 25 months). Radiotherapy was performed in 4 patients (continued tumor growth in 2 cases). One patient died. Chordoid glioma is a benign tumor predominantly localized in the third ventricle. Preoperative MRI and CT in some cases make it possible to suspect chordoid glioma and differentiate this tumor from craniopharyngioma, meningioma and pituitary adenoma by such signs as isointense signal in T1WI, hyper- or isointense signal in T2WI, homogeneous contrast enhancement and edema of basal ganglia in T2 FLAIR images. The only effective treatment for chordoid glioma is surgery. Total resection is often impossible or extremely dangerous due to location of tumor, large size and invasion of the third ventricle. Postoperative mental disorders and diabetes insipidus, including severe hypernatremia, are common that requires mandatory monitoring of water and electrolyte balance.

Extreme hypernatremia exceeding the reportable value of the blood gas analyzer in a 64-year-old female

pernatremia is a relatively common electrolyte imbalance in hospitalized patients and is considered an independent predictor for increased mortality. Concomitant sepsis and thromboembolism are also common with severe hypernatremia and management of the fluid therapy is a challenging issue

Diagnosis and treatment of brain injury complicated by hypernatremia.

Hypernatremia is a common electrolyte disorder in patients with brain injury. The mortality of brain injury patients with severe hypernatremia may be as high as 86.8%. The efficacy of conventional treatment for hypernatremia is limited. Continuous renal replacement therapy (CRRT) can slowly, controllably, and continuously reduce the blood sodium concentration and gradually become an important treatment for severe hypernatremia patients. This review aims to provide important information for clinicians and clinical researchers by describing the etiology, diagnosis, hazards, conventional treatment, and CRRT treatment of hypernatremia in patients with traumatic brain injury.

Effect of continuous infusion of hypertonic saline solution on survival of patients with brain injury: a systematic review and meta-analysis

BackgroundThe objective was to determine the effects of continuous infusion of hypertonic saline solutions on outcomes of patients with brain injury. MethodsPreferred Reported Items for Systemic Reviews and Meta-Analysis guidelines were followed. We searched the MEDLINE and COCHRANE clinical trials register (through December 2021) and reference lists of articles. We included all clinical trials conducted in brain-injured patients hospitalized in intensive care units evaluating continuous infusion of hypertonic saline solution (osmolarity above 308 mOsm/L). Two reviewers extracted data that were checked by two others. The primary outcome was the in-hospital mortality rate. The main secondary outcomes were the rates of intracranial hypertension, an unfavorable neurological outcome at day 90, and adverse events. ResultsWe identified 23 clinical trials reporting the use of continuous infusion of hypertonic saline solution in brain-injured patients. The primary outcome was available in 10 studies (n = 1883 patients). The odds ratio (OR) for in-hospital death with the intervention was 0.68 (95% confidence interval (CI), 0.54−0.85, I2 = 0%). In the subgroup of studies including only traumatic brain-injured patients (7 studies, n = 1521 patients), the OR for the primary outcome was 0.74 (95%CI 0.57−0.95) with the intervention. The OR for intracranial hypertension and unfavorable neurological outcome at day 90 were 0.66 (95%CI 0.49−0.88, I2 = 42%, n = 787 patients) and 0.61 (95%CI 0.46−0.81, I2 = 15%, n = 956 patients), respectively. Regarding safety, the OR of acute kidney injury and severe hypernatremia were 0.82 (95%CI 0.47–1.44, I2 = 0%) and 3.38 (95%CI 2.16–5.27, I2 = 24%). ConclusionsContinuous hypertonic saline solution infusion reduced in-hospital mortality without increasing the risk of unfavorable neurological outcome at day 90 in brain-injured patients hospitalized in intensive care units. Given the inclusion of observational and heterogeneous studies, further randomized studies are needed before developing recommendations for implementation at the bedside. Systematic review registrationPROSPERO CRD42021221367. Registered 13 May 2021.

PSUN242 Severe Hypernatremia in a patient with combined Hyperosmolar Hyperglycemic State and Diabetic Ketoacidosis

Abstract Introduction Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are the complications of diabetes with highest morbidity. In both, there are fluid shifts and osmotic diuresis with electrolyte disturbances that result in hyponatremia. With high glucose levels, sodium become falsely decreased due to dilutional effects of water shifting from intracellular to extracellular space. Hypernatremia is an uncommon electrolyte abnormality in this setting, with unclear exact etiology. We present a 35-year-old gentleman who was found to have severe hypernatremia in the setting of combined DKA and HHS. Clinical Case A 35-year-old male with class III obesity presented to the emergency department with altered sensorium and lethargy. Patient was having nausea and vomiting, along with polyuria, polydipsia and nocturia, prior to worsening encephalopathy. Physical exam showed rapid shallow breathing and lethargy. No focal neurologic deficits noted.Initial labs revealed severe hyperglycemia and hypernatremia with sodium at 164 mmol/L, severe metabolic acidosis, and acute kidney injury. Hemoglobin A1C was 9.8%. Ketonuria and ketonemia were present. Given the high osmolality, he was diagnosed with DKA and HHS.Free water deficit was 15.4 L. Insulin drip was started, along with 5 liters of intravenous Lactated Ringer's boluses. As blood glucose improved, patient was placed on dextrose-5% water infusion at 200 mL/hour.Encephalopathy improved approximately 48 hours after admission. His glucose stabilized, renal function improved, acidosis resolved, and sodium returned to normal. Sodium was corrected at a rate of 8 mmol/L daily. He was transitioned to general wards and started on an oral carbohydrate-restricted diet and subcutaneous insulin regimen containing long- and short-acting insulin analogs. Conclusion During severe hyperglycemia, glucose increases extracellular osmolality, creating a gradient for water to move from intracellular to extracellular compartments, leading to hyponatremia. As the renal threshold is reached, glucosuria ensues, causing osmotic diuresis and water loss. If this process continues, excess water loss can cause dehydration, further increase serum osmolality, and lead to hypernatremia.A previous study evaluated patients who present with hypernatremia during DKA. It was found that patients with new-onset diabetes are more likely to present with hypernatremia (1).Several etiologies contribute to altered sensorium in such patients, including cerebral hypoperfusion in the setting of dehydration and excess water loss, acidosis, and direct effect of ketone bodies on brain cells (2). As electrolyte abnormalities are corrected with adequate fluid selection, patients return to baseline mentation. It is best to correct hypernatremia at a rate of 6-8 mmol/L daily to prevent the complications of rapid correction. References KW Monroe, WD King, MH Nichols, JA Atchinson. Hypernatremia in diabetic ketoacidosis. Practical Diabetes Int 1997;14(6): 159-61. Elias Estifan, Sushant M. Nanavati, Vinod Kumar, et al. Salty diabetes: a case series of hypernatremia presenting with diabetic ketoacidosis. AME Case Rep 2019;3: 27. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

ODP225 Mixed Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar Syndrome with recent diagnosis of Diabetes Mellitus.

Abstract Background Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemia syndrome (HHS) are often discussed as two distinct clinical entities but can present in the same patient. Combined DKA and HHS is associated with higher mortality than either DKA or HHS alone. Clinical case: A 68 years old female diagnosed with type 2 diabetes 3 months prior to hospitalization was brought into the hospital with severe hyperglycemia and altered mental status. On exam she was unresponsive with grimace only to sternal rub. Pulse was elevated at 113, RR 31, temperature 100.3, and blood pressure 130/80. Initial labs showed severe hyperglycemia with glucose of 1454 (74-106 mg/dL), elevated beta-hydroxybutyrate of 8.6 (0. 02-0.27 mmol/L), sodium 138 (135-145 mmol/L), potassium 5.3 (3.6-5.2 mmol/L), serum bicarbonate 16 (21-32 mmol/L), anion gap 31 (6-18), plasma osmolality 353 (273-304 osm/kg), pH 7.33 (7.35-7.45) and lactic acid 4 (0.7-1.9 mmol/L). DKA protocol with normal saline, intravenous insulin infusion, and potassium replacement initiated and patient was transferred to ICU for further management. Sequential labs revealed development of hypernatremia with calculated free water deficit of 8.8 liters. Fluids changed to ½ normal saline. On Day 2 of hospitalization, she became responsive. She had resolution of acidosis but continued to have severe hypernatremia with peak sodium level of 163 on day 3. Urine studies showed urine osmolality of 700 mOsm/kg ruling out diabetes insipidus; urine sodium level was 5 mmol/L. Fluids were again changed to ¼ Normal saline with careful monitoring of serum sodium and glucose at 2 hour intervals. Hypernatremia resolved with aggressive fluid resuscitation. Her A1c prior to discharge was found to have increased to 13.3% from 6.5% (&amp;lt; 5.6%), 3 months prior. Prior to discharge she had measurable C-peptide, insulin autoantibodies and negative GAD antibodies making autoimmune diabetes unlikely. Conclusion Individuals with concomitant DKA and HHS may have normal sodium or even hyponatremia at presentation due to the pseudo-hyponatremia induced by severe hyperglycemia. However, actual sodium concentration may be markedly elevated due to the osmotic diuresis induced by severe hyperglycemia. Aggressive fluid resuscitation is required to treat the profound dehydration found in HHS but the serum sodium concentration must be monitored carefully. A switch from normal saline to hypotonic fluids may be necessary to treat hypernatremia in HHS but overly rapid correction of serum sodium must be avoided for volume overload especially in elderly, owing to heart failure and due to higher mortality. The incidence of hypernatremia is noted in 14% of children and 27% of adults, however degree of hypernatremia is variable from mild to moderate and in rare instances is severe. Presentation: No date and time listed

Postpartum Hypernatremia with Extrapontine Rhabdomyelinolysis: A Case Report.

Hypernatremia (serum sodium>160 meq/L) present with diverse neurological manifestations, ranging from flaccid paralysis to impaired cognition, encephalopathy, and even deep coma. Osmotic demyelination refers to changes in brain cells because of an acute change in plasma osmolality. It is further divided into two types, i.e., central pontine myelinolysis (CPM) and extrapontine myelinolysis (EPM). Patients with EPM, besides spasticity, may also present with other movement disorders such as catatonia, parkinsonism, and dystonia. We present a case of a postpartum woman bought to the emergency department by her relatives in an unconscious state. In view of poor sensorium (Glasgow coma scale < 7), she was intubated and received mechanical ventilatory support. On admission, computed tomography ofthebrain was normal, and the patient was transferred to the intensive care unit (ICU) for further management. The preliminary work-up in the ICU showed hypernatremia (serum sodium of 182 mEq/L) with hyper-osmolality (359 mOsm/kgH2O). She was managed as per the ICU protocol for hypernatremia. During her ICU stay, her sensorium improved, but she developed flaccid paralysis and was quadriplegic. Thus, a tracheostomy was performed, and she was weaned from the ventilator. After ventilator weaning, she was transferred to the ward for further rehabilitation. During rehabilitation, the patient was able to sit and takefoodorally.To date, only a few cases are reported in postpartum women with acute severe hypernatremia caused by high-grade fever and loss of body fluids leading to extra-pontine demyelination and flaccid paralysis. This case highlightsthat prompt recognition and appropriate intervention can improve the outcomes in these patients.

Donor hypernatremia is associated with increased mortality after heart transplantation

Abstract Objective Donor hypernatremia has been associated with primary graft dysfunction in heart transplantation and is known to be associated with impaired outcome following liver and renal transplantation. However, controversial data exist regarding the impact of sodium deregulation in patient survival after heart transplantation (HTx). This study aims to investigate the impact of donor sodium levels on early morbidity and short- and midterm survival following HTx. Methods Between September 2010 and June 2021, a total of n=218 patients underwent HTx in our centre. From those, 214 could be included retrospectively in our study. For each donor, sodium levels were collected and different cut-off levels from 145 to 159 mmol/l were investigated by Kaplan-Meier-analysis. Then, recipients were divided in three groups regarding donor sodium: Normonatremia (133–145 mmol/l, n=73), mild hypernatremia (146–156 mmol/l, n=105) and severe hypernatremia (&amp;gt;156 mmol/l, n=35). Recipient and donor variables were reviewed and compared, including peri- and postoperative characteristics and recipient survival after up to 5 years after transplantation. Results All patients were comparable regarding baseline characteristics and perioperative parameters. Regarding early mortality, 90-day survival was significantly reduced only in patients with severe donor hypernatremia in comparison to normonatremia (see table 1 and fifgure 1, 90% vs. 71%, p=0.02), but not in mild normonatremia (89%, p=0.89). 1-year survival was comparable in all groups (p&amp;gt;0.28). Conclusion Donor hypernatremia was associated with reduced short-term survival, while correlation weakens &amp;gt;1 year after HTx. Future prospective studies are needed to confirm the possible cut-off value of 156 mmol/l for donor-acceptancy. Funding Acknowledgement Type of funding sources: None.