Treatment of Hyponatremic Encephalopathy With a 3% Sodium Chloride Protocol: A Case Series

Ayus, Juan Carlos; Caputo, Daniel; Bazerque, Fernando; Heguilén, Ricardo; Gonzalez, Claudio; Moritz, Michael L.

doi:10.1053/j.ajkd.2014.09.021

Cited by 62 publications

(40 citation statements)

References 35 publications

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“…Hyponatremia was associated with higher risk of cardiovascular mortality in two large cohorts of maintenance hemodialysis patients from the Dialysis Outcomes and Practice Patterns and Accelerated Mortality on Renal Replacement studies, and lower serum sodium was associated with higher incidence of fatal and non-fatal cardiovascular events in a recent analysis of 441 incident PD patients [9,12,14]. A growing body of evidence also shows that hyponatremia may be a risk factor for infection due to (i) impaired interleukin-17 producing helper T cells that function in host immunity, and (ii) mucosal membrane and cellular edema leading to breakdown of microbial barrier function [31][32][33][34][35]. This bears particular relevance to PD patients, given that infection is the second most common cause of death following cardiovascular disease in this population, as well as a major risk factor for patients undergoing PD to transfer to hemodialysis [36,37].…”

Section: Discussionmentioning

confidence: 99%

Serum sodium and mortality in a national peritoneal dialysis cohort

Ravel

Streja

Mehrotra

et al. 2016

Nephrol. Dial. Transplant.

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A B S T R A C TBackground: Sodium disarrays are common in peritoneal dialysis (PD) patients, and may be associated with adverse outcomes in this population. However, few studies of limited sample size have examined the association of serum sodium with mortality in PD patients, with inconsistent results. We hypothesized that both hypo-and hypernatremia are associated with higher death risk in a nationally representative cohort of US PD patients. Methods: We sought to examine the association of serum sodium over time and mortality among 4687 adult incident PD patients from a large US dialysis organization who underwent one or more serum sodium measurements within the first 3 months of dialysis over January 2007 to December 2011. We examined the association of time-dependent and baseline sodium with allcause mortality as a proxy of short-and long-term sodium-mortality associations, respectively. Hazard ratios were estimated using Cox models with three adjustment levels: minimally adjusted, case-mix adjusted, and case-mix þ laboratory adjusted. Results: In time-dependent analyses, sodium levels <140 mEq/ L were associated with incrementally higher death risk in casemix models (ref: 140 to <142 mEq/L); following laboratory covariate adjustment, associations between lower sodium and higher mortality remained significant for levels <136 mEq/L. In analyses using baseline values, sodium levels <140 mEq/L were associated with higher mortality risk across all models (ref: 140 to <142 mEq/L). Conclusions: In PD patients, lower time-dependent and baseline sodium levels were independently associated with higher death risk. Further studies are needed to determine whether correction of dysnatremia improves longevity in this population.

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Section: Discussionmentioning

confidence: 99%

Serum sodium and mortality in a national peritoneal dialysis cohort

Ravel

Streja

Mehrotra

et al. 2016

Nephrol. Dial. Transplant.

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“…7,38,39 Advanced symptoms of hyponatremic encephalopathy include seizures, respiratory arrest, noncardiogenic pulmonary edema, and decorticate posturing. 7,38,39 Symptoms can occur abruptly and do not always correlate with the plasma sodium concentration or the rapidity of development of hyponatremia. 7,10,38,40 Failure to recognize and treat hyponatremic encephalopathy with hypertonic saline results in a poor neurologic prognosis.…”

Section: Hospital-acquired Hyponatremiamentioning

confidence: 99%

Maintenance Intravenous Fluids in Acutely Ill Patients

2015

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A critical aspect of the care of acutely ill patients is the administration of intravenous fluids. Intravenous fluids may be required as a bolus infusion for resuscitation or as a continuous infusion when sufficient fluids cannot be ingested orally.The goal of maintenance intravenous fluids is to preserve the extracellular volume while maintaining a normal electrolyte balance. An appropriate maintenance fluid provides an adequate quantity of both water and electrolytes to ensure good tissue perfusion without causing complications related to fluid overload or volume depletion. It also prevents the development of hyponatremia, hypernatremia, and other electrolyte imbalances.Despite the almost ubiquitous need for intravenous fluids in acutely ill patients, there has been little consensus on the most appropriate rate of administration and composition of intravenous fluids, and practice patterns with respect to maintenance fluids vary widely. 1-3 In addition, acutely ill patients frequently have conditions that impair normal water and electrolyte homeostasis (Table 1), and choosing the appropriate volume and composition of intravenous fluids requires great care. 4 Intravenous fluids can be classified, according to the concentration of sodium plus potassium in the fluid, as being either isotonic (approximately equal to the plasma sodium concentration) or hypotonic (less than the plasma sodium concentration). The dextrose content of intravenous fluids has no effect on the tonicity, since the dextrose is rapidly metabolized when it enters the bloodstream and should not produce hyperglycemia.A prevailing practice has been to administer hypotonic maintenance intravenous fluids in both children and adults. 1,5,6 This practice has been associated with a high incidence of hospital-acquired hyponatremia and more than 100 reports of iatrogenic deaths or permanent neurologic impairment related to hyponatremic encephalopathy, 7-11 since acutely ill patients may have disease states associated with an excess of arginine vasopressin (AVP) (Fig. 1). This excess impairs excretion of free water and may aggravate hyponatremia. 15,16 Over the past decade, many studies have evaluated the association between the composition and quantity of maintenance fluids and the development of hyponatremia. Recent data also suggest that rapid volume expansion with 0.9% saline (normal saline), as compared with balanced electrolyte solutions, may result in untoward complications. 17 The current review considers the physiological principles that guide the appropriate selection of intravenous fluids, as well as the recent literature evaluating the safety of various intravenous fluids with respect to their composition and rate of administration.

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“…However, excessive correction (>6 mEq/L) in the first 6h should be avoided [3] . Alternatively, Ayus et al proposed that a total of 500ml of 3% sodium chloride solution over a 6h period should be administered [19] . On the contrary, Adrogue and Madias suggest that these procedures can lead to overcorrection of hyponatremia [5] .…”

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Treatment of Hyponatremia: What the Clinician Needs to Know

Elisaf

Liamis

2015

Journal of Nephrology Research

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have been recently reported [3,4] , several aspects of the proper management of these patients are not clear [5,6] . In this editorial some basic principles for the appropriate management of patients with decreased serum sodium levels are briefly summarized.1) It should be stressed that non hypotonic hyponatremia (with normal or increased Posm) should be carefully excluded by a meticulous medical history and the appropriate laboratory investigation. Consequently, the initial approach to the hyponatremic patient includes the determination of Posm (by an osmometer if it is available) as well as the exclusion of pseudohyponatremia (due to severe hypercholesterolemia, hypertriglyceridemia, and hyperproteinemia) or hypertonic hyponatremia [due to the presence of osmotic active agents, such as glucose (hyperglycemia) or the administration of mannitol or glycine] [2,7,8] . It is worth mentioning that in hyperglycemic individuals the corrected serum sodium levels should be calculated by increasing the measured serum sodium levels by 2.4 mEq/L for each 100mg/dl of glucose above normal [4,8] .2) A growing list of drugs, including thiazides, ecstacy and SSRIs, can cause hyponatremia, while endocrine causes of hyponatremia (mainly adrenal insufficiency) should be carefully and appropriately assessed [9,10] .3) Urine sodium in a random urine specimen is commonly used to differentiate between hypovolemia-induced hyponatremia (urine sodium <20 mEq/L) and the syndrome of inappropriate antidiuresis (SIADH, urine sodium >30 mEq/L). However, increased urine sodium levels (>30 mEq/L) can also be encountered in patients with extracellular volume contraction with renal or adrenal insufficiency, severe metabolic alkalosis, osmotic diuresis, as well as in those on thiazides [2,8] .4) In cases of hypovolemia-associated hyponatremia, 0.9% sodium chloride solution should be administered (with potassium chloride 10% if hypokalemia is also present). In this setting potassium anions should be taken into account in the calculation of the tonicity of the infused solutions. Interestingly, the infusate formula proposed by the Adrogue-Madias and verified by Liamis et al can reliably project the effect of gaining 1L of any infusate on the patient's serum sodium (ΔΝα + s) and thus can be used to calculate the rate of the administered 0.9% NaCl solution [2,11,12] . ABSTRACTHyponatremia due to different pathogenetic mechanisms is the most common electrolyte abnormality and is associated with increased morbidity and mortality. However, several aspects of the proper management of these patients are not clear. In this editorial a brief overview of the basic principles for the appropriate treatment of hyponatremia are summarized. EDITORIALHyponatremia (serum sodium <135mEq/L) is the most common electrolyte abnormality, is due to different pathophysiologic mechanisms, is associated with increased morbidity and mortality and its appropriate treatment is still a therapeutic challenge [1,2] . Even though clinical practice guidelines on the treatment of hyp...

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Treatment of Hyponatremic Encephalopathy With a 3% Sodium Chloride Protocol: A Case Series

Cited by 62 publications

References 35 publications

Serum sodium and mortality in a national peritoneal dialysis cohort

Serum sodium and mortality in a national peritoneal dialysis cohort

Maintenance Intravenous Fluids in Acutely Ill Patients

Treatment of Hyponatremia: What the Clinician Needs to Know

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