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[Blocked from Release] 0901201702

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Topic updated on 09/01/17 11:06am

HYPOnatremia HYPERnatremia
  • A 17-year-old schizophrenic patient presents with new onset of seizures. He has a history of psychogenic polydipsia.
  • A 32-year-old woman with Cushings disease presents with mental status changes and lethargy.
Introduction
  • Serum sodium < 135 mEq/L 
  • Causes include
    • copious bladder irrigation
    • TURP - transurethral resection of the prostate
    • high output ileostomy
    • adrenal insufficiency
    • psychogenic polydipsia 
      • associated with schizophrenia
    • volume depletion 
  • Serusodium > 145 mEq/L
  • Causes include
    • fluid loss
    • steroid use
    • hypertonic fluids
Presentation
  • Symptoms
    • asymptomatic
    • nausea
    • vomiting
    • confusion
    • muscle cramps
    • lethargy
  • Can progress to (Na < 115 mEq/L)
    • seizures
    • status epilepticus
    • coma
  • Symptoms
    • lethargy
    • weakness
    • irritability
  • Can progress to
    • seizures
    • coma
Treatment
  • Mild hyponatremia
    • water restriction
  • Moderate/severe hyponatremia
    • hypertonic saline IV
    • loop diuretics + normal saline
    • ADH blockers (conivaptan, tolvaptan)
  • Chronic SIADH
    • demeclocycline
      • can induce nephrogenic diabetes insipidus
    • ADH blockers
  • Normal saline IV 
  • Do not correct faster than 12 mEq/L/d
    • faster treatment could cause cerebral edema and seizures
  • Correct half deficit in first 24 hrs
  • Correct second half of deficit over next 2-3 days
  • Oral route preferred
  • D5W, normal saline, or half-normal saline could be appropriate choices
  • Switch to 0.45% (half-normal) saline after volume deficit is corrected 
  • Nephrogenic diabetes insipidus
    • no response to DDAVP administration
    • treat with correction of underlying cause + thiazides
  • Central diabetes insipidus
    • treat with DDAVP
Prognosis, Prevention, and Complications
  • Central pontine myelinolysis
    • occurs if replace sodium to fast
    • raise serum levels < 12-15 mEq/day
    • characterized by:
      • paraparesis
      • quadraparesis
      • dysarthia
      • dysphagia
      • coma
  •  Seizures
    • in response to hypernatremia, brain makes idiopathic osmolytes to maintain fluid balance
    • this equalizes the osmotic pull keeping the volume of cells constant
    • sudden correction of hypernatremia causes cerebral edema and swelling → seizures


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