Sodium Fluctuations Research Articles

Hypernatremia is associated with mortality in severe elderly sepsis patients.

To explore the relationship between hypernatremia and 28-day mortality in elderly sepsis patients. A total of 179 elderly patients (age ≥65 years) with elevated serum sodium admitted to the Department of Critical Care Medicine of Nanjing Hospital affiliated with Nanjing Medical University from September 2021 to September 2022 were included in this retrospective observational study. The clinical data of all patients were collected, and the patients were divided into septic group and nonseptic groups according to the Sepsis 3.0 definition. The clinical features, acute physiological and chronic health II score (APACHE II score), mechanical ventilation time, serum sodium value and duration of serum sodium elevation were compared between the two groups. ROC curves were drawn to evaluate the predictive value of each index on the prognosis of sepsis patients, and Kaplan‒Meier survival analysis was carried out on patients with different serum sodium peaks. (1) The changes in serum sodium within 48 hours after admission in the sepsis group were small and statistically significant compared with those in the nonsepsis group (P = 0.039); however, the serum sodium elevation duration was longer (P = 0.018). (2) Compared with nonseptic patients, the 7-day mortality of septic patients was higher (15.8 vs. 7.7, P<0.001). The 28-day mortality of septic patients was higher than that of nonseptic patients, but there was no significant difference between the two groups (P = 0.086). (3) The serum sodium level in the sepsis group was higher than that in the nonsepsis group on the 1st, 3rd, 5th and 7th days (P<0.001). There was no significant difference in mechanical ventilation time or duration of stay in the ICU between the two groups. (4) The ROC curve analysis showed that the peak value of serum sodium had predictive value for the prognosis severity of elderly patients with sepsis. The area under the curve (AUC) was 0.753, the 95% confidence interval (95% CI) was 0.639~0.867, and the best cut-off value was 154.9 mmol/L. (5) According to the best cut-off value of the serum sodium peak, the septic patients were divided into two groups: the peak value of serum sodium was ≥154.9 mmol/L (group A), and the peak value of serum sodium was <154.9 mmol/L (group B). Among them, the case fatality rate was higher at 7 days and 28 days when the peak value of serum sodium was ≥154.9 mmol/L (group A) (22.0% vs. 8.6%); the χ2 value was 35.379, P<0.05; 75.6% vs. 37.1%, χ2 = 14.21, P = 0.003). There was no significant difference in mechanical ventilation time or duration of stay in the ICU between the two groups. (6) Kaplan‒Meier survival analysis showed that the median survival time of patients with a serum sodium peak ≥154.9 mmol/L (group A) was significantly shorter than that of patients with a serum sodium peak < 154.9 mmol/L (group B) (16.7±1.4 d vs. 24.8±1.2 d, P <0.05). The serum sodium increase in elderly sepsis patients lasts for a long time, and the serum sodium fluctuation is relatively small. The serum sodium peak value has predictive value for 28-day mortality.

6619 An Unlikely Cause of Oligomenorrhea: Acromegaly Secondary to a Sparsely Granulated, Somatotroph-Lactotroph Adenoma

Abstract Disclosure: S.I. Alicea: None. Y. Wu: None. J. Marquez: None. C.S. Botero Suarez: None. M. Kinaan: None. Introduction: Acromegaly most commonly presents as a pituitary tumor that causes excessive production ofgrowth hormone (GH); and rarely due to excess of GHRH or ectopic production of GH. Approximately 15% of surgically removed pituitary adenomas represent GH-producing neoplasms, and about 5% are bihormonal, secreting both GH and prolactin (PRL). We present a case of an unexpected presentation of oligomenorrhea which ended up with the diagnosis of acromegaly secondary to plurihormonal mixed somatotroph-lactotroph sparsely granulated adenoma. Case Description A 32-year-old female with history of prediabetes was referred to our clinic by her gynecologistfor evaluation of oligomenorrhea which was initially attributed to polycystic ovarian syndrome.She reported menarche at age 10 and has experienced irregular menses and periods of amenorrhea over the years. Physical exam revealed macroglossia, a widened thickened nose, acanthosis nigricans in the neck skin folds, facial hair thickening, and significant thickening of all fingers, toes and soft tissues. Given physical exam findings, we evaluated the patient for acromegaly and lab testing revealed markedly high IGF I, mildly elevated prolactin, and hemoglobin A1C of 5.7%. An MRI of the brain with IV contrast revealed a heterogeneously enhancing pituitary macroadenoma measuring 2.9 x 2.9 x 2.2 cm with suprasellar extension resulting in mass effect on the optic chiasm without definite cavernous sinus extension. She was started on Cabergoline 0.5mg twice weekly temporarily and underwent pituitary transsphenoidal resection. Pathology results revealed tumor cells that were positive for Chromogranin and Cam5.2. About 10% of cells showed immunoreactivity for Prolactin and negative for TSH, ACTH, FSH, LH and immunostains. There was also weak focal (about 2%) immunoreactivity for GH. Occasional mitotic figures were present. The MIB-1 proliferation index was 3%. The reticulin stain demonstrates loss of acinar architecture, supporting the diagnosis. Aside from transient sodium fluctuations consistent with triphasic response, she had no long-lasting postoperative complications. One month after her surgery, her IGF I level and hemoglobin A1C are trending down and she reports symptomatic relief. She continues follow up in our clinic. Discussion This patient has acromegaly secondary to a mixed somatotroph-lactotroph sparsely granulated adenoma. Sparsely granulated adenomas are more common in younger populations, can be more aggressive, and are less responsive to somatostatin analogs. Early detection and treatment is imperative in the prevention of complications secondary to the disease. Our case will closely examine the differences in the clinical, prognostic, and pathologic features of sparsely- vs. densely granulated adenomas. We will also discuss the effects of acromegaly on gonadal function. Presentation: 6/1/2024

The association between nutritional status measured by body mass index and outcomes in the pediatric intensive care unit.

The relationship between nutritional status upon admission to a pediatric intensive care unit (PICU) and clinical outcomes remains unclear. We examined the relationship between nutrition status, as indicated by body mass index-for-age (BMI-for-age), and clinical outcomes in the PICU. In this retrospective study at a tertiary care center, records of 1,015 critically ill children and adolescents aged one month to 18 years old with available anthropometric parameters were included. The nutritional status upon admission was determined by calculating the BMI-for-age z-score using the WHO growth charts as the reference. The participants were categorized as underweight (BMI-for-age z-score < -2), normal weight (-2 ≤ BMI-for-age z-score ≤ +1), and overweight/obese (BMI-for-age z-score > +1). Multi-variate odds ratios (OR) with 95% confidence intervals (CI) were used to investigate the association between malnutrition (being underweight and overweight/obese) and odds of Prolonged PICU stay (≥7 days) and PICU mortality after controlling for descriptive characteristics, Glasgow Coma Scale score status, fluctuations in serum sodium, and acute kidney injury confounders. The proportions of patients in underweight, normal weight, and overweight/obese categories were 34.2%, 45.8%, and 20%, respectively. During the study period, 21.5% of patients had prolonged PICU stay, and 5.6% of patients in PICU died. Compared to normal-weight patients, underweight patients had higher odds of prolonged PICU stay (OR: 1.52; 95% CI: 1.05-2.22) and PICU mortality (OR: 2.12; 95% CI: 1.22-4.01). Age- and gender-stratified full-adjusted analysis showed that the increased odds of prolonged PICU stay remained significant among underweight boys and underweight individuals aged 5-19 years old. Furthermore, the increased odds of PICU mortality remained significant among underweight individuals aged 2-5 years old. However, being overweight or obese during PICU admission did not demonstrate a significant association with our outcomes in the total sample or subgroup analysis. Our findings showed that PICU patients who were underweight had higher odds of prolonged PICU stay and PICU mortality than their normal-weight counterparts. This underscores the importance of closely monitoring underweight patients in the PICU upon admission in order to improve clinical outcomes.

Sodium fluctuation as a parameter in predicting mortality in general hospitalized patients.

Dysnatremia is the most common electrolyte disorder in hospitalized patients. Sodium fluctuation level may be a better parameter in dysnatremia management. We aimed to examine the association between sodium fluctuation level during hospitalization and mortality and to evaluate its value in predicting poor prognosis among general hospitalized patients. Data were collected from patients admitted to Peking Union Medical College Hospital. The generalized estimated equation (GEE) was used to examine the relationship between sodium fluctuation level and mortality. Receiver-operating characteristic (ROC) curve analysis was performed to calculate the optimal cutoff value and the area under the ROC curve (AUC). Sodium fluctuation level showed a dose-dependent association with increased mortality in general hospitalized patients. After adjusting age, sex, length of hospital stay, and Charlson comorbidity index, the ORs of group G2 to G6 were 5.92 (95% CI 5.16-6.79), 26.45 (95% CI 22.68-30.86), 50.71 (95% CI 41.78-61.55), 104.38 (95% CI 81.57-133.58), and 157.64 (95% CI 112.83-220.24), respectively, p trend <0.001. Both normonatremia and dysnatremia patients on admission had the dose-dependent associations similar to general hospitalized patients. The AUC of sodium fluctuation level was 0.868 (95% CI 0.859-0.877) in general hospitalized patients, with an optimal cutoff point of 7.5 mmol/L, a sensitivity of 76.5% and a specificity of 84.2%. We determined that sodium fluctuation level had a dose-dependent association with increased mortality in general hospitalized patients. Sodium fluctuation level could be used to develop a single parameter system in predicting mortality in general hospitalized patients with acceptable accuracy, sensitivity, and specificity.

NURS-14. DEVELOPMENT OF A CLINICAL PRACTICE INTERVENTION TO SUPPORT NURSES CARING FOR PATIENTS WITH DIABETES INSIPIDUS (DI) DURING CHEMOTHERAPY HYDRATION

Abstract BACKGROUND Pediatric neuro-oncology patients with germ cell tumors (GCT) and diabetes insipidus (DI) often require management with vasopressin (DDAVP). Fluid and sodium balance, ordinarily managed successfully with DDAVP, can be disrupted during chemotherapy and associated hydration. Patients with an intact thirst mechanism may be able to self-regulate fluid and salt balance under the right conditions, whereas patients without an intact thirst may experience sodium fluctuations if intravenous hydration exceeds the amount they drink independently. Patients may be unable to maintain adequate hydration and sodium levels due to nausea and/or sedating antiemetics. These factors create a unique clinical challenge for nurses. Nurses sought guidance in understanding DI and its impact on hydration during chemotherapy. METHODS Two nursing education sessions were held and focused on DI management. Nurses were surveyed pre and post education. The goals of the intervention were that the oncology nurse will be to describe the pathophysiology of diabetes insipidus, the role of desmopressin, the ability to differentiate between management of patients with and without an intact thirst mechanism, and the special care of a DI patient receiving chemotherapy. RESULTS Nurses reported an increased awareness post education of the need to closely assess patients and manage their DI in collaboration with clinicians. Routine chemotherapy management does not apply to this population, because drastic fluctuations in sodium and water balance put them at risk of other complications. Nurses identified the need to closely manage hydration, DDAVP, recording strict intake/output, monitoring sodium levels, assessing for nausea/vomiting and the degree of sedation from antiemetics. CONCLUSION Outcomes from this educational intervention were that nurses had an increased understanding of DI management in patients with GCT receiving chemotherapy. Future goals would be to implement a standard approach to hydration, DDAVP administration, and monitoring sodium levels in patients with GCT and DI.

Effect of fosfomycin-induced hypernatremia on patients' hospital stay length and survival.

Hypernatremia is a possible side effect of intravenous fosfomycin. The aim of this study was to investigate the effects of changes in sodium (Na) levels on hospital stay and survival in patients hospitalized in the intensive care unit receiving fosfomycin. This study was conducted retrospectively on the files of patients over the age of 60, who were admitted to the Internal Medicine Intensive Care Unit. Plasma sodium levels were observed and documented over a period of 14days. The patients were divided into two groups (Hypernatremia group Na > 145 mEq/L vs normonatremia group 135-145mEq/L). In addition, daily sodium changes were noted for 14days in patients. The mean age of the patients was 75years. Hospitalization days were longer for hypernatremia patients (31.5days vs 41days, p = 0.003). Patients with hypernatremia had an extended duration of stay in the intensive care unit. (21days vs 31days p = 0.002). The 1-month survival rate was 61.4% in patients with hypernatremia and 24.9% in patients without hypernatremia (p = 0.004). The absence of hypernatremia increases mortality by 2.09 times (95% CI 1.35-3.23). When discharge and mortality rates were analyzed according to sodium fluctuation, discharged patients exhibited a lower sodium fluctuation (4min/max (-10/19) vs 6min/max (-16/32) p < 0.001). In conclusion, the strength of our study is that it specifically focuses on the consequences of the sodium fluctuation on patient management and provides results.

Association between serum sodium trajectory and mortality in patients with acute kidney injury: a retrospective cohort study

IntroductionDysnatremia is strongly associated with poor prognosis in acute kidney injury (AKI); however, the impact of sodium trajectories on the prognosis of patients with AKI has not yet been well elucidated. This study aimed to assess the association between sodium trajectories in patients with AKI and mortality at 30-day and 1-year follow-up.MethodsThis retrospective cohort study used data from Medical Information Mart for Intensive Care (MIMIC)-IV database, and patients diagnosed with AKI within 48 h after admission were enrolled. Group-based trajectory models (GBTM) were applied to map the developmental course of the serum sodium fluctuations. Kaplan–Meier survival curve was used to compare differences in mortality in AKI patients with distinct serum sodium trajectories. Hazard ratios (HRs) were calculated to determine the association between trajectories and prognosis using Cox proportional hazard models.ResultsA total of 9,314 AKI patients were enrolled. Three distinct sodium trajectories were identified including: (i) stable group (ST, in which the serum sodium levels remained relatively stable, n = 4,935; 53.0%), (ii) descending group (DS, in which the serum sodium levels declined, n = 2,994; 32.15%) and (iii) ascending group (AS, in which the serum sodium levels were elevated, n = 1,383; 14.85%). There was no significant difference in age and gender distribution among the groups. The 30-day mortality rates were 7.9% in ST, 9.5% in DS and 16.6% in AS (p < 0.001). The results of 1-year mortality rates were similar (p < 0.001). In adjusted analysis, patients in the DS (HR = 1.22, 95% confidence interval [CI], 1.04–1.43, p = 0.015) and AS (HR = 1.68, 95% CI, 1.42–2.01, p = 0.013) groups had higher risks of 30-day mortality compared to those in the ST group.ConclusionIn patients with AKI, the serum sodium trajectories were independently associated with 30-day and 1-year mortality. Association between serum sodium level trajectories and prognosis in patients with AKI deserve further study.

CARDS, a Novel Prognostic Index for Risk Stratification and In-Hospital Monitoring.

Background: Sodium fluctuation is independently associated with clinical deterioration. We developed and validated a prognostic index based on sodium fluctuation for risk stratification and in-hospital monitoring. Methods: This study included 33,323 adult patients hospitalized at a tertiary care hospital in 2014. The first 28,279 hospitalizations were analyzed to develop the model and then the validity of the model was tested using data from 5044 subsequent hospitalizations. We predict in-hospital mortality using age, comorbidity, range of sodium fluctuation, and duration of sodium fluctuation, abbreviated as CARDS. Results: In-hospital mortality was similar in the derivation (0.6%) and validation (0.4%) cohorts. In the derivation cohort, four independent risk factors for mortality were identified using logistic regression: age (66-75, 2 points; >75, 3 points); Charlson comorbidity index (>2, 5 points); range of sodium fluctuation (7-10, 4 points; >10, 10 points); and duration of fluctuation (≤3, 3 points). The AUC was 0.907 (95% CI: 0.885-0.928) in the derivation cohort and 0.932 (95% CI: 0.895-0.970) in the validation cohort. In the derivation cohort, in-hospital mortality was 0.106% in the low-risk group (0-7 points), 1.076% in the intermediate-risk group (8-14 points), and 8.463% in the high-risk group (15-21 points). In the validation cohort, in-hospital mortality was 0.049% in the low-risk group, 1.064% in the intermediate-risk group, and 8.403% in the high-risk group. Conclusions: These results suggest that patients at low, intermediate, and high risk for in-hospital mortality may be identified by CARDS mainly based on sodium fluctuation.

Numerical simulation of fluid dynamics and mixing in headers of sodium-air heat exchangers

The paper presents the results of a numerical simulation for sodium fluid dynamics and mixing in the tubing system of an air-cooled heat exchanger (AHX), which is a part of the emergency cooldown system (ECS) of sodium fast reactors (SFRs). Non-uniform sodium flows in the AHX tubing system may lead to the mixing of different-temperature sodium flows, temperature fluctuations and tube breaks. It was found in the course of investigating accidents involving breaks in the PFR and Phénix reactor AHX tubing systems that the failure was caused by the metal temperature fluctuations (Cruickshank and Judd 2005). The numerical simulation used three- and one-dimensional computer codes. It has been found that the calculations of the AHX sodium flow rate distribution with a practically acceptable accuracy can be performed using a one-dimensional code. The factors that influence the non-uniform distribution of sodium flows in the AHX tubing system have been analyzed. Calculations have been performed for the AHX sodium flow distributions and for the mixing of different-temperature sodium flows in the AHX outlet header. The results are presented from calculating the amplitude of sodium fluctuations near the AHX header walls. The effect from shutting down several modules on the non-uniform flow distribution and temperature fluctuations in the AHX has been investigated. Approximations of numerical solutions have been obtained for the sodium flow distribution as a function of the number of the modules shut down.

Serum sodium level fluctuations following the resection of childhood-onset craniopharyngioma.

Craniopharyngiomas are low-grade malignancies (WHO I) in the sellar region. Most cases of childhood-onset craniopharyngioma are adamantinomatous craniopharyngioma, and neurosurgery is the treatment of choice. Affected patients have postoperative complications, including water and electrolyte disturbances, because these malignancies develop near the hypothalamus and pituitary gland. Determining postoperative serum sodium fluctuation patterns in these patients can reduce postoperative mortality and improve prognosis. To measure changes in serum sodium levels in pediatric patients who underwent craniopharyngioma surgery and identify influencing factors. This retrospective study measured the serum sodium levels of 202 patients aged 0-18 years who underwent craniopharyngioma resection in Beijing Tiantan Hospital and Beijing Children's Hospital and identified predictors of severe hyponatremia and hypernatremia. The mean age of the cohort was 8.35±4.35 years. The prevalence of hypernatremia, hyponatremia, and their severe forms (serum Na+ >150mmol/L and serum Na+ <130mmol/L) within 14 days after surgery was 66.3%, 72.8%, 37.1%, and 40.6%, respectively. The mean postoperative serum sodium level showed a triphasic pattern, characterized by two peaks separated by a nadir. Sodium levels peaked on days 2 (143.6±7.6mmol/L) and 14 (143.2±6.7mmol/L) and reached their lowest on day 6 (135.5±7.5mmol/L). A total of 31 (15.3%) patients met the diagnostic threshold for hyponatremia and hypernatremia of the triphase response, whereas 116 (57.4%) patients presented this pattern, regardless of met the diagnostic criteria or not. The prevalence of severe hyponatremia varied depending on preoperative endocrine hormone deficiency, tumor status (primary or recurrent), and surgical approach. Serum sodium levels after craniopharyngioma resection in children showed a triphasic pattern in most cases. The risk of postoperative hyponatremia varied depending on preoperative endocrine hormone deficiency, tumor status (primary or recurrent), and surgical approach.

Risk stratification and predictive value of serum sodium fluctuation for adverse prognosis in acute coronary syndrome patients

BackgroundSerum sodium fluctuation (SF) as an indicator of the extent of changes in serum sodium is associated with increased mortality in hospitalized patients. However, there is no consensus on diagnostic criteria for SF, and its impact on the outcome of patients with acute coronary syndrome (ACS) remains uncertain. We defined SF and assessed its association with adverse prognosis in hospitalized ACS patients. MethodsPatients diagnosed with ACS were consecutively recruited. The serum SF rate (SFR) was defined as the ratio of the difference between the highest and lowest serum sodium levels during hospitalization to the initial serum sodium level on admission. The Cox proportional hazards model was performed to evaluate the association between SFR and mortality. The dose–response relationships of SFR with mortality was characterized by restricted cubic splines (RCS) model. The predictive performance of SF for mortality was assessed by the area under the receiver operating characteristic curves (AUCs). ResultsThe study retrospectively enrolled 1856 ACS patients, of which 36 (1.94%) patients dead within 1 year. Multivariate Cox analysis showed that SFR was independently associated with higher risk of 1-year mortality (HR = 1.17, 95% CI: 1.111–1.244, P < 0.001). RCS analysis showed the optimal threshold for SFR was 5%, and the 1-year cumulative mortality was higher in the abnormal SF group (SFR ≥ 5%) compared with the normal SF group (SFR < 5%, P < 0.01). The AUCs of SF for predicting mortality within 1 month, 6 months, and 1 year were 0.842 (95% CI: 0.781–0.904), 0.830 (95% CI:0.736–0.926), 0.703 (95% CI:0.595––0.811), respectively. Even in patients with normal baseline serum sodium, abnormal SF group demonstrated a significantly higher 1-year mortality compared to normal SF group (HR = 4.955, 95% CI: 1.919–12.795). ConclusionThe SFR during hospitalization is an adequate predictor of adverse outcomes in ACS patients, independent of serum sodium level at admission. Additional research is warranted to ascertain whether interventions targeting SF confer measurable clinical benefits.

Pathologically- confirmed Osmotic Demyelination in the Case of Clinically and Radiographically Progressive Encephalopathy due to Liver Disease and Malnutrition. (P4-4.007)

<h3>Objective:</h3> To report a case of osmotic demyelination syndrome (ODS) in a patient with alcoholic liver cirrhosis and normal sodium levels. <h3>Background:</h3> Correction of hyponatremia and chronic alcoholism have been identified as the most frequent conditions associated with osmotic demyelination syndrome (ODS). <h3>Design/Methods:</h3> N/A <h3>Results:</h3> A 77 year old female with a history of gastric bypass surgery complicated by copper deficiency, and alcoholic liver cirrhosis was hospitalized for failure to thrive and encephalopathy. Initial MRI brain showed non-specific white matter hyperintensities. Mental status continued to worsen despite treatment with IV thiamine, copper (low 41 mcg/dL, normal 80–155), and antibiotics for presumed peritonitis. Repeat MRI brain showed T2 signal abnormality within the central pons and midbrain with sparing of the anterior pontine periphery. Serum sodium on presentation was 138 mEq/L (normal 135–145) and fluctuated during hospitalization between 133–150. She subsequently developed hypoxemic respiratory failure requiring intubation and kidney failure requiring hemodialysis. Despite all aggressive measures she remained severely encephalopathic with repeat MRI brain revealing new confluent large areas of T2 hyperintensity in the centrum semiovale and corona radiata. T2 hyperintensity in the midbrain and central pons remained unchanged. The family declined lumbar puncture and pursued comfort measures. Autopsy was performed which revealed extensive demyelination in the midbrain tegmentum with relative preservation of axons; capillary and arterial cerebral amyloid angiopathy most prominent in the cerebellar leptomeninges, extending into the cerebellar cortex; and moderate Alzheimer’s type 2 astrocytosis in the basal ganglia consistent with prior history of hepatic encephalopathy. <h3>Conclusions:</h3> Our patient was diagnosed with toxic-metabolic, hepatic encephalopathy and had progressive radiological findings suggestive of ODS. Demyelination was confirmed on autopsy with copathology including cerebral amyloid angiopathy and findings of hepatic encephalopathy. ODS must be considered with progressive MRI findings in the setting of encephalopathy with liver disease and malnutrition despite absence of significant serum sodium fluctuations. <b>Disclosure:</b> Dr. Hanson has nothing to disclose. Dr. Bronstein has nothing to disclose. Dr. Fong has nothing to disclose. Dr. Ashikian has nothing to disclose.

Poor expression of miR-195-5p can assist the diagnosis of cerebral vasospasm after subarachnoid hemorrhage and predict adverse outcomes.

Patients with spontaneous subarachnoid hemorrhage (SAH) may develop refractory arterial cerebral vasospasm (CVS), which is the leading cause of death in SAH patients. This study explored the clinical diagnostic value of serum miR-195-5p levels in CVS after SAH (SAH + CVS) and its relationship with the prognosis of SAH + CVS. A total of 110 patients with spontaneous SAH were divided into the SAH group (N=62) and SAH + CVS group (N=58), with 60 healthy subjects as controls. The clinical data of blood glucose, blood sodium fluctuation, and serum lactic acid were recorded. miR-195-5p serum level was detected by RT-qPCR and its diagnostic value on SAH + CVS was analyzed by receiver operating characteristic curve. Serum levels of PDGF/IL-6/ET-1 and their correlation with miR-195-5p were analyzed using RT-qPCR, enzyme-linked immunosorbent assay, and Pearson's method. The patient prognosis was evaluated by Glasgow Outcome Scale. The effect of miR-195-5p levels on adverse prognosis was analyzed by Kaplan-Meier method and Cox regression analysis. miR-195-5p was lowly expressed in the serum of SAH patients and lower in SAH + CVS patients. Serum miR-195-5p level assisted the diagnosis of SAH and SAH + CVS and was negatively correlated with PDGF/IL-6/ET-1 levels and was an independent risk factor together with ET-1 and blood glucose for SAH + CVS. miR-195-5p low expression predicted a higher cumulative incidence of adverse outcomes and was an independent predictor of adverse outcomes. Poor expression of miR-195-5p can assist the diagnosis of SAH + CVS and predict higher adverse outcomes.

Association between serum sodium and in-hospital mortality among critically ill patients with spontaneous subarachnoid hemorrhage.

The aim of this study was to retrospectively explore the relationship between serum sodium and in-hospital mortality and related factors in critically ill patients with spontaneous subarachnoid hemorrhage (SAH). Data were collected from the Medical Information Mart for Intensive Care IV database. Restricted cubic splines were used to explore the relationship between serum sodium and in-hospital mortality. Receiver operating characteristic analysis was used to calculate the optimal cutoff value of sodium fluctuation, and decision curve analysis was plotted to show the net benefit of different models containing serum sodium. A total of 295 patients with spontaneous SAH were included in the retrospective analysis. The level of sodium on ICU admission and minimum sodium in the ICU had a statistically significant non-linear relationship with in-hospital mortality (non-linear P-value < 0.05, total P-value < 0.001). Serum sodium on ICU admission, minimum serum sodium during ICU, and sodium fluctuation were independently associated with in-hospital mortality with odds ratios being 1.23 (95% confidence interval (CI): 1.04-1.45, P = 0.013), 1.35 (95% CI: 1.18-1.55, P < 0.001), and 1.07 (95% CI: 1.00-1.14, P = 0.047), respectively. The optimal cutoff point was 8.5 mmol/L to identify in-hospital death of patients with spontaneous SAH with sodium fluctuation, with an AUC of 0.659 (95% CI 0.573-0.744). Among patients with spontaneous SAH, we found a J-shaped association between serum sodium on ICU admission and minimum sodium values during ICU with in-hospital mortality. Sodium fluctuation above 8.5 mmol/L was independently associated with in-hospital mortality. These results require being tested in prospective trials.

The impact of hormonal dynamics and serum sodium fluctuations on symptomatic vasospasm after subarachnoid hemorrhage

BackgroundSymptomatic vasospasm (SVS) is a major cause of morbidity and mortality in aneurysmal subarachnoid hemorrhage (SAH), and serum sodium frequently decreases before SVS. Serum sodium changes might be regulated by sodium metabolism-related hormones. This multi-institutional prospective cohort study therefore investigated the measurement of sodium metabolism-related hormones to elucidate the pathophysiology of serum sodium changes in SAH. MethodsSAH patients were treated with clipping or coiling from September 2017 to August 2020 at five hospitals. The laboratory data of 133 SAH patients were collected over 14 days and correlations between changes in serum sodium, sodium metabolism-related hormones (plasma adrenocorticotropic hormone (ACTH), serum cortisol, plasma arginine vasopressin (AVP)), and SVS were determined. Serum sodium concentrations were measured every day and serum sodium levels >135 mEq/L were maintained until day 14. ResultsOf the 133 patients, 18 developed SVS within 14 days of subarachnoid hemorrhage onset (SVS group) and 115 did not suffer from SVS (non-SVS group). Circulating AVP, ACTH, and cortisol concentrations were significantly higher on day 1 in the SVS group compared with the non-SVS group. Fluctuations in serum sodium in the SVS group were significantly higher than those in the non-SVS group. There were antiparallel fluctuations in serum sodium and potassium from days 2 to 14. ConclusionsElevated levels of ACTH/cortisol and AVP on day 1 may be predictive markers for the occurrence of SVS. Multiple logistic regression analysis showed that serum sodium fluctuations were associated with SVS occurrence. Serum sodium fluctuations were associated with stress-related hormonal dynamics. (249 words)

Neurodevelopmental consequences of early plasma sodium changes in very preterm infants.

BackgroundSodium fluctuations in very preterm neonates and their neurodevelopmental consequences are not well described.MethodsWe assessed the changes in plasma sodium and glucose in the first days of life in very preterm neonates and studied the association of glucose-corrected plasma sodium fluctuations on neurodevelopmental outcomes. We included 147 consecutive neonates born before 29 weeks of gestation in our center and retrospectively obtained plasma sodium, glucose, and glucose-corrected sodium levels. Neurodevelopmental assessment was obtained from the Canadian Neonatal Follow-Up Network.ResultsMean ± standard deviation of plasma sodium changes within the first 10 days of life were 16.2 ± 6.0, 14.8 ± 5.3, and 11.1 ± 5.2 mmol/l in neonates born ≤25, 25–26, and 26–27 weeks of gestation, respectively (p < 0.001). Non-steroidal anti-inflammatory drug administration was associated with larger plasma sodium fluctuation. Eighty-six percent had a known neurological status at 18 months. Higher fluctuations in glucose-corrected plasma sodium were associated with death or neurodevelopmental impairment at 18 months corrected age (B = 3.19, 95% CI [1.24, 5.14]), and this association remained after adjustment for gestational age (B = 2.1, 95% CI [0.16, 4.04]).ConclusionsNeonates born very preterm show fluctuations in glucose-corrected plasma sodium during the first days of life, which may increase the risk of death or developmental impairment.Impact Risk factors and neurodevelopmental consequences of plasma sodium changes in early neonatal life of preterm infants are not well characterized.This study shows for the first time that glucose-corrected plasma sodium fluctuations within the first days of life are more severe in preterm infants receiving non-steroidal anti-inflammatory drugs (NSAIDs) and are associated with death or neurodevelopmental impairment at 18 months corrected age.Large plasma sodium and glucose fluctuations should be expected more often in preterm infants receiving NSAIDs and should be avoided.

Sodium supply from administered blood products was associated with severe intraventricular haemorrhage in extremely preterm infants.

AimThe aim of this study was to investigate the associations between sodium supply, fluid volume, sodium imbalances and severe intraventricular haemorrhage (IVH) in extremely preterm (EPT) infants.MethodsWe used data from the EXtremely PREterm infants in Sweden Study (EXPRESS) cohort consisting of all infants born at 22 to 26 gestational weeks from 2004 to 2007 and conducted a nested case–control study. For every infant with severe IVH (grade 3 or peri‐ventricular haemorrhagic infarction), one IVH‐free control infant with the birthday closest to the case infant and matched for hospital, sex, gestational age and birth weight was selected (n = 70 case–control pairs).ResultsTotal sodium supply and fluid volume were higher in infants with severe IVH compared with controls [daily total sodium supply until postnatal Day 2: mean ± SD (mmol/kg/day): 5.49 ± 2.53 vs. 3.95 ± 1.91, p = 0.009]. These differences were accounted for by sodium and fluid from transfused blood products. High plasma sodium concentrations or large sodium fluctuations were not associated with severe IVH.ConclusionOur results suggest a relationship between sodium‐rich transfusions of blood products and severe IVH in EPT infants. It is unclear whether this is an effect of sodium load, volume load or some other transfusion‐related factor.

Postoperative dysnatremia in infants after open-heart surgery occurs frequently and is associated with prolonged intensive care length of stay.

Dysnatremia after surgery for congenital heart disease (CHD) is well known and has been associated with prolonged pediatric intensive care unit length of stay (PICU-LOS). Fluctuations in plasma sodium levels occur perioperatively. The primary aim of the study was to evaluate the occurrence of dysnatremia during the first 48h after surgery and whether it was associated with PICU-LOS. The secondary aim was to evaluate if the degree of sodium fluctuations was associated with PICU-LOS. A retrospective observational, single-center study including infants undergoing surgery for CHD. The highest and lowest plasma sodium value was registered for the prespecified time periods. PICU-LOS was analyzed in relation to the occurrence of dysnatremia and the degree of plasma sodium fluctuations. The occurrence of dysnatremia was evaluated in relation to surgical procedure and fluid administration. Two hundred and thirty infants who underwent 249 surgical procedures were included. Dysnatremia developed in more than 60% within 48h after surgery. Infants with normonatremia had a 40%-50% shorter PICU-LOS among children in RACHS-1 category 3-6, compared with infants developing either hypo- or hyper-/hyponatremia within 48h after surgery (p=.006). Infants who had a decline of plasma sodium >11mmol/L had almost double the PICU-LOS compared to those with a decline of <8mmol/L. Dysnatremias were common after surgery for CHD and associated with prolonged PICU-LOS. The degree of decline in plasma sodium was significantly associated with PICU-LOS. Fluid administration both in terms of volume and components (blood products and crystalloids) as well as diuresis were related to the occurrence of dysnatremias.

Evaluating a standardized protocol for the management of diabetes insipidus in pediatric neurosurgical patients

Central diabetes insipidus (DI) is a known complication following surgical resection of a suprasellar mass. There are limited data analyzing the outcomes of a standardized protocol for the management of postoperative DI in the pediatric population. We sought to fill this gap and hypothesized that utilizing a standardized protocol for fluid management (3-bag system) would reduce serum sodium fluctuations in the postoperative period after suprasellar surgery. A retrospective chart review was performed. Patients were identified with the following criteria: age≤18 years, undergoing a surgical procedure for suprasellar mass that also had postoperative DI. The primary outcome was the variability in serum sodium during the first 48h and between 48 and 120h postoperatively. There were 21 encounters pre-protocol and 22 encounters post-protocol for neurosurgical procedures. Use of the standardized protocol was associated with a lower range of sodium within 48h postoperatively (p=0.065) and 83% lower odds of hypernatremia (Na>150mmol/L) within 48h postoperatively (CI 0.039-0.714) after controlling for age, gender, and prior DI diagnosis. History of DI conferred a lower risk of hypernatremia as well as less sodium fluctuation within 48h postoperatively. Younger patients, those <9.7 years of age were associated with increased risk of hyponatremia and greater sodium fluctuations during the postoperative period. In patients with postoperative DI after suprasellar surgery, using a standardized protocol for fluid management (3-bag system) appears to reduce serum sodium variability in the first 48h after surgery.

Triphasic Response And More - Post-Operative Diabetes Insipidus in A Patient With Sphenoid Meningioma: A Case Report

<h3>Research Objectives</h3> To describe the management of water homeostasis fluctuations and difficulties associated with rehabilitating a patient with post-surgical central diabetes insipidus who manifested a rare triphasic response. <h3>Design</h3> Case report. <h3>Setting</h3> Tertiary hospital. <h3>Participants</h3> 47-year-old female office worker. <h3>Interventions</h3> The patient was initially diagnosed with a left sphenoid wing meningioma and underwent elective excision. Her post-operative sodium levels fluctuated wildly, corresponding to central diabetes insipidus (DI), followed by a triphasic response comprising antidiuresis due to SIADH and subsequent DI which required longer-term desmopressin therapy. This case was notable for extreme serum sodium swings of 30mEq in a day requiring urgent reversal and titration. <h3>Main Outcome Measures</h3> Serum sodium and osmolality; Montreal Cognitive Assessment; Ambulation distance; Functional Independence Measure. <h3>Results</h3> In contrast with published reports of pituitary manipulation-induced DI, this case illustrates the possibility of brain surgery in areas remote to the pituitary to be capable of inducing the rare triphasic DI pattern. This patient developed psychiatric disturbances that may have led to inconsistent technique in self-administration of intranasal desmopressin, in addition to inappropriate polydipsia. With stabilization of her sodium fluctuations, the patient was able to continue with rehabilitation for her other deficits of diplopia, gait dysfunction, and cognition. No new neurocognitive sequelae arose from the water balance disorder and she was discharged well to independent living. Her sodium levels were stable at follow-up 1 and 3 months later, with good treatment compliance to long-term desmopressin. <h3>Conclusions</h3> Water balance disorders post-neurosurgery can be rapid and drastic, and a triphasic response of post-surgical DI can arise from seemingly-minor pituitary manipulation and even remote sphenoid meningioma excision. Post-treatment monitoring of fluid status in such patients remains crucial and physiatrists should maintain sensitivity to psychiatric disturbances and changes in mentation, if any. <h3>Author(s) Disclosures</h3> None.