Survival Following Extreme Hypernatraemia Associated with Severe Dehydration and Undiagnosed Diabetes Mellitus

Abstract

We report a case of a previously well 58-year-old man, who presented with delirium and low GCS, and was found to have extreme hypernatraemia (Na+ = 191 mmol/L) and hyperglycaemia (glucose = 31 mmol/L). This resulted in a corrected serum sodium of 202 mmol/L. He was treated with fluid and electrolyte replacement in the intensive care unit, and had returned to essentially normal function by hospital discharge. The aetiology was believed to be due to severe dehydration and a new diagnosis of diabetes mellitus. Extreme hypernatraemia (serum sodium level greater than 190 mmol/L) is rare and associated with a high mortality. The mainstay of treatment is careful fluid and electrolyte management. Most recommendations advise to reduce the serum sodium by 0.5 mmol/L/hour, due to concerns over cerebral oedema; however, there are reports that slower correction is associated with higher mortality. In this case, the initial corrected sodium of 202 mmol/L was steadily corrected to 160 mmol/L over 91 hours, at a rate of 0.46 mmol/L/hour. This demonstrates the safety of the recommended approach.

The Corrected Serum Sodium Concentration in Hyperglycemic Crises: Computation and Clinical Applications

“…Table 2 shows presenting values for [Glu], [Na], tonicity, and corrected [Na] in reports of DKA ( 66 – 171 ), HHS ( 3 , 9 , 13 , 75 – 78 , 110 , 129 , 169 , 172 – 251 ), and hyperglycemia in chronic kidney disease (CKD) stage V ( 12 , 16 , 47 – 49 , 156 , 171 , 252 – 277 ), which was included in Table 2 as the control group because it causes limited or no water and electrolyte losses through osmotic diuresis. All but three of the cases in this last group were on maintenance dialysis.…”

Metabolic and Endocrine Challenges

“…The patient's body loses too much pure water, as is the case with diabetes insipidus, for example. 179 A restricted or missing supply of water leads to dehydration and, thus, to a relative increase in plasma sodium concentration.…”

“…The correction of [Na þ ] p should not exceed 10 to 12 mmol/L per 24 hours. 161,179 Overly rapid correction can induce cerebral edema, followed by permanent neurological damage. However, it must be considered that slow correction of acute extreme hypernatremia ([Na þ ]p > 190 mmol/L) is associated with higher mortality.…”

“…However, it must be considered that slow correction of acute extreme hypernatremia ([Na þ ]p > 190 mmol/L) is associated with higher mortality. 179…”