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NP10 Nephrology

Electrolyte Disorders

Essential Med Notes 2015

Table 5. Disorders Associated with SIADH


Tumor

Pulmonary

CNS

Drugs

Miscellaneous

Small cell cancer


Bronchogenic carcinoma
Pancreatic
adenocarcinoma
Hodgkins lymphoma
Thymoma
Leukemia

Pneumonia
Lung abscess
TB
Acute respiratory failure
Asthma
COPD
Positive pressure ventilation

Mass lesion
Encephalitis
Subarachnoid hemorrhage
Stroke
Head trauma
Acute psychosis
Acute intermittent porphyria

Antidepressants
TCAs
SSRIs
Antineoplastics
Vincristine
Cyclophosphamide
Anti-epileptics
Carbamazepine
Barbiturates
Chlorpropamide
ACEI
Other
DDAVP
Oxytocin
Nicotine

Post-operative
state
Pain
Severe nausea
HIV

Hypernatremia

hypernatremia: serum [Na+] >145 mEq/L


too little water relative to total body Na+; always a hyperosmolar state
usually due to NET water loss, rarely due to hypertonic Na+ gain
less common than hyponatremia because patients are protected against hypernatremia by thirst
and release of ADH
Hypernatremia

Reduced Intake
Elderly (dementia, swallowing
difficulty, stroke, bed-bound)
Infant
Coma
Surgical

Increased Losses
(without adequate intake)

Extra-renal Losses
GI loss (diarrhea, fistulas)
Insensible loss (exercise, seizures)

Renal Losses
Central DI
Nephrogenic DI
Osmotic diuresis (hyperglycemia,
mannitol, urea, NS, polyethylene glycol)

Figure 5. Approach to hypernatremia

Signs and Symptoms


with acute hypernatremia no time for adaptation, therefore more likely to be symptomatic
adaptive response: cells import and generate new osmotically active particles to normalize size
due to brain cell shrinkage: altered mental status, weakness, neuromuscular irritability, focal
neurologic deficits, seizures, coma, death
polyuria, thirst, signs of hypovolemia
Complications
increased risk of vascular rupture resulting in intracranial hemorrhage
rapid correction may lead to cerebral edema due to ongoing brain hyperosmolality
Treatment of Hypernatremia
general measures for all patients
give free water (oral or IV)
treat underlying cause
monitor serum Na+ frequently to ensure correction is not occurring too rapidly
if evidence of hemodynamic instability, must first correct volume depletion with NS bolus
loss of water is often accompanied by loss of Na+, but a proportionately larger water loss
use formula to calculate free water H2O deficit and replace
encourage patient to drink pure water, as oral route is preferred for fluid administration
if unable to replace PO or NG, correct H2O deficit with hypotonic IV solution (IV D5W, 0.45%
NS [half normal saline], or 3.3% dextrose with 0.3% NaCl [2/3 and 1/3])
use formula (see Hyponatremia, NP8) to estimate expected change in serum Na+ with 1 L infusate
aim to to lower [Na+] by no more than 12 mEq/L in 24 h (0.5 mEq/L/h)
must also provide maintenance fluids and replace ongoing losses
general rule: give 2 cc/kg/h of free water to correct serum [Na+] by about 0.5 mEq/L/h or
12 mEq/L/d

H2O Deficit and TBW Equations


TBW = 0.6 x wt (kg) men
TBW = 0.5 x wt (kg) women
H2O deficit = TBW x ([Na+]plasma
140) / 140

Correction of serum [Na+] in


hypernatremia should not exceed
12 mEq/L/24 h

1 L D5W approximately equals 1 L of


free water
1 L 0.45% NS approximately equals
500 mL of free water