HYPOTONIC HYPONATREMIA

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1 Hyponatremia template key 1. What are the criteria for admitting this patient, as opposed to managing them as an outpatient? Why would they come to the hospitalist service (compared to a subspecialist or a transition bed)? Hyponatremia is generally a finding with an underlying cause. Therefore, while admission to hospital may be required due to symptoms of hyponatremia alone (nausea, malaise, headache, lethargy, obtundation, seizures, and coma), admission due to the concurrent illness is more common. Consider MTU admission if: Patient is obtunded or has seizures Sodium less than (especially if chronic) Any situation where intensive monitoring is required to decrease risk of permanent neurological sequellae. 2. What is your differential diagnosis? Include at least three most likely, as well as at least one sinister hypothesis. HYPOTONIC HYPONATREMIA Hypovolemic - UNA >20, FENa >1 : Renal losses ( diuretics, salt wasting nephropathy, cerebral salt wasting, mineralocorticoid deficiency) -UNA <10, FENa <1 : Extra - renal (GI losses, third spacing, low intake, insensible losses) Euvolemic - Uosm >100 : SIADH - malignancy, pulmonary, intracranial, drugs, pain, nausea, post - op Endocrinopathies - Glucocorticoid deficiencies and hypothyroidism Uosm < Low solute - Tea and toast, polydipsia Uosm varies - Re-set osmostat - malnutrition or pregnancy Hypervolemic - UNA <10, FENa <1 : CHF, cirrhosis, nephrotic syndrome - UNA >20, FENa >1 : Renal failure 3. What investigations will you order? What ongoing follow-up should be done during the admission?

2 1-Plasma Osmolality - Hypotonic - most common (excess water relative to sodium) Hypertonic - excess of another effective osmol (mannitol, glucose) Isotonic - hyperlipidemia, hyperproteinuria 2- Urine Osmo - Limited usefulness as almost always greater than 300. <100 - Primary polydipsia, decreased solute intake 3- Urine lytes to calculate FENa Serum glucose, creatinine, protein, urea, and potentially cholesterol to identify underlying causes +/- TSH and AM cortisol. Ongoing follow-up: Monitor rate of increase of Na when correcting. Once corrected, monitor to see if it falls again when treatment ceases. 4. What will be the management principles for the most likely condition? Include both pharmacologic and non-pharmacologic management. What contra-indications could exist for these choices? Be ready to discuss these with your preceptor in detail. Hypovolemic - Volume repletion first, free water excess must be calculated: Total body water (weight x 0.6 for men or x 0.5 for women) x (140 serum Na) correct slower than 1-2 mmol / L per hour, as in chronic hyponatremia. Aim for a correction of 0.5 mmol/l per hour, using isotonic normal saline in most cases. Determining whether the Na level dropped suddenly is important, as this should also correlate with the rapidity of correction. Rate of sodium correction should not exceed 6 meq /L/d in chronic cases and 8 in acute. If symptomatic 2 meq /L/h for the first 2-3 hours until sx resolve. Patients with SIADH might worsen with IV fluids, which would help with the diagnosis. SIADH Fluid restriction to maximum of 1 litre per day and treat underlying cause. Hypertonic saline and loop diuretic if does not respond to fluid restriction or symptomatic. Salt tabs (if chronic and no CHF) Aquaresis

3 Urea discontinue any contributing medications as able: Tegretol, SSRI, and opiates can stimulate inappropriate release of ADH NSAIDs and cyclophosphamide can potentiate the effect of ADH Haldol, amitriptyline, and ecstasy can also cause SIADH by an unknown mechanism Hypervolemic - Free water restrict - loop diuretics, increase EAV (tx to increase CO in CHF, colloid infusion in cirrhosis). Aquaresis. 5. What complications could arise during this patient s stay? How could you attempt to prevent these? Central pontine myelinolysis can occur with rapid overcorrection of hyponatremia, which results in neurological manifestations one to six days later which are irreversible. Search for systemic causes of hyponatremia such as lung cancer or pneumonia, neurological disease, alcohol withdrawal, HIV, or porphyria. Some lung cancers can produce ectopic ADH. There are long-term medications that can prevent the recurrence of hyponatremia from SIADH, such as lithium or demeclocycline, but these are not often used. In both CHF and cirrhosis, use of a potassium-sparing diuretic in addition to a loop diuretic can help prevent hypokalemia and can lessen edema. 6. What other resources can you enlist to assist you in the management of this patient? In complicated cases, where electrolytes need to be calculated often in the initial management, the Internal Medicine service might need to be involved either as the admitting team or as consultants. Patients who require information about a fluid and sodium restricted diet might benefit from seeing the nutritional expert in consultation while admitted. Na is often restricted to 70 mmol / day in patients with low sodium and hypervolemia. 7. How will you know this patient is ready for discharge what parameters will be your guide and what needs to be in place at their residence? Sodium levels can sometimes be corrected as an outpatient, if the level dropped slowly over time and IV fluids are not deemed necessary. However, patients might need admission and ongoing investigation to determine the cause of the electrolyte disturbance. Once this has been sorted, and any reversible cause managed, then a long-term management plan needs to be decided.

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