Sodium Imbalance: Hyponatremia

Euvolemic hyponatremia

Dilutional hyponatremia

SIADH is categorized as

older adults

brain surgery

brai tumors

Pulmonary malignancy

AIDS

Mechanical Ventilation

SSRIs

SIADH at risk group

SIADH

Pulmonary malignancy is associated with?

inappropriate ADH

renal water absorption

Dilutional Hyponatremia + secondary natriuresis

How SIADH disrupt sodium balance

Acute Hyponatremia

• fluid overload in surgical patient

Chronic Hyponatreia

• Outside of hospital, longer duration

Exercise Associated Hyponatremia EAH

Types of Hyponatremia

Acute hypnatremia

Chronic hyponatremia

<135 Sodium <48 hours

<135 Sodium in more than 48 hours

Chronic Hyponatremia due to rapid correction

What type of hyponatremia can ODS occur?

PANSMR

Post-op hypotonic fluids

Acute water intoxication

Nsaids

Molly / ecstasy MDMA

Siadh triggers

Rapid psychogenic polydipsia

Causes of Acute Hyponatremia

Psychogenic Polydipsia (acute hyponatremia)

Urge to drink >6L of water without the need

Chronic Hyponatremia

Which type of hyponatremia has Less serious neurologic complications

Small organic molecules

• maintain osmotic balance

• Protect against water stress

• stabilize protein

What are osmolytes?

Acute

Chronic

Cerebral edema : ______ hyponatremia

ODS: _____ hyponatremia

SIADH

heart failure

Liver cirrhosis

CKD

Diuretics

SSRIs

Thiazide

Chronic Hyponatremia is associated with (causes)?

women + smaller statue

• Extreme temperature

• Excess fluid intake before exercise

• prolonged exercise

EAH is more common in ______

Causes:

Non-osmotic AVP

• seen in EAH

the secretion of the antidiuretic hormone from the pituitary gland triggered by physiological signals other than blood concentration or osmolality

Osmotic Demyelination syndrome

• Central pontine myelinolysis

• Extrapontine Myelinolysis

Types of ODS

PONS

what part of the brain is affected by Central pontine myelinolysis

1. Rapid correction of sodium

2. Alcolol

3. malnutrition

4. Advanced liver disease

5. prolonged Diuretic use
   
   RASAP

ODS happens due to?

• high sodium in urine

• Renal dysfunction/ diuretic use

confirm Renal hyponatremia

• low sodium in urine

• Vomiting, diarrhea, sweating

What confirms Non-renal Hyponatremia

Renal & non renal

Hypoaldosteronism / Addisonian crisis

Medications

• Anticonvulsants

• SSRIs

• Desmopressin Acetate

—

SIADH

hypothyroidism (gluocorticoid deficiency)

Psychogenic polydipsia

—

CHF

Cirrhosis

CKD

nephrotic Syndrome

Causes of Hyponatremia

Causes Hyponatremia

• Increased ADH

Anticonvulsant

SSRIs

Desmopressin Acetate

Thirst: triggered by + osmolaluty

ADH: Triggered by + osmolality and - circulating volume

Renal water handling (RAAS)

Regulatory System for Sodium

Volume restoration first 0.9% NacL

Severe: 3% Nacl

Treatment for Hypovolemic Hyponatremia

Fluid Restriction

Vaptans (Demeclocycline or Vasopreesin Receptor Antagonist)

Severe: 3% NaCl + loop diuretic

Treatment for Euvolemic Hyponatremia (SIADH)

Fluid and Sodium Restriction

Loop Diuretics

Treatment for Hypervolemic Hyponatremia

Hyponatremia

What condition where you cant use Thiazide Diuretics

Orally

NGT

Parenteral rout

How can Sodium be adminsitered

8-10 mEq/24 hours

mx limit for Sodium administration

100 mEq

Usual sodium daily requirement

Fluid Restriction

First line management for Hyponatremia

AVP receptor antagonist (vaptans)

• IV Conivaptan HCL

• Tolvaptan

Pharmacologic Mangement for Hyponatremia

Vaptans ( AVP receptor Antagonist)

Allows Aquaresis, Water out but not sodium

IV Conivaptan HCL

• do not use if seizures, delirium, coma

• Conivaptan can correct sodium too fast through aquaresis, so there’s a risk of osmotic demyelination if overcorrected.

Type of Vaptan that is limitedly used

Clinically significant euvolemic, hypervolemic hyponatremia

Tolvaptan is used for?

Hyponatreia

Lithium toxicity is seen in patient with?

<120

• immediate risk for coma, seizure, herniation

Critical Severe Levels of Hyponatremia

Both loss

Water Loss < Na loss

Hypovolemic Hyponatremia Pathophysiology

Water volume increase, Na still the same

Euvolemic Hyponatremia Pathophysiology

Both Increase

Water > Sodium

Hypervolemic Hyponatremia Pathophysiology

irreversible quadriplegia

Dysarthria

“Locked" in “ syndrome

Symptoms of ODS

1-2 mL/ kg/ hr

Hypertonic Saline is administed slowly typically?

No

Is sodium oral intake given to Hypervolemic Hyponatremia?

• <135

• <275 Dilute

• >1.030 Concentrated

• Fluid Restriction, vaptans, 3% Nacl

SIADH Lab

• Sodium

• Osmolality

• Specific Gravity

• Nursing action:

• >145

• >295 mOsm/kg concentrated

• <1.005 dilute

• Desmopressin DDAVP + IV Fluids

Diabetes Insipidus Labs

• Sodium

• Osmolality

• Specific gravity

• Nursing Action:

SIADH

Hyponatremia + High SG

Sodium

Main determinant of ECF Osmolaltiy

500 mEq/L

seawater (which contains a sodium concentration of approximately _____)

Dysnatremia

• A lack of normal sodium level in the bloodstream, either hypernatremia or hyponatremia.

• Confusion, Disorientation, and Stupor

• In performance athletes who lose excessive sodium via perspiration during exercise can lead to excess sodium depletion from the bloodstream. This can manifest as: _____,_____,____

Gradual lowering of Sodium using

• hypotonic solution 0,45 Nacl

• Isotinuc Nonsaline Solution D5W

Medical Management For hYpernatremia

D5W
0.45 Nacl

_______can be used when water needs to be replaced without sodium. However, _____ is thought to be safer than it because it allows a gradual reduction in the serum sodium level.

Hypotonic NaCl

the IV solution of choice in severe hyperglycemia with hypernatremia.

Desmopressin Acetate

_______, a synthetic ADH, may be prescribed to treat diabetes insipidus if it is the cause of hypernatremia.

ok

If the patient is alert and has an intact thirst mechanism, merely providing access to water may be sufficient.

If the patient has a decreased LOC or other disability interfering with adequate fluid intake, parenteral fluid replacement may be prescribed.

Hyponatremia

Hypernatremia

Brain Herniation: ______

Subarachnoid Hemorrhage: _______

>160 mEq /L

• high risk for seizures, coma, Subarachnoid hemorrhage

Severe level for Hypernatremia

8-10 mEq/L in 24 hours

Prevent cerebral edema + Brain herniation

Max Correction speed for Hypernatremia

Hypernatremia

• Conn Syndrome / Cushing Syndrome

Hyperaldosteronism : __________

• seen in?

Hyponatremia

Hypernatremia

Addisonian Crisis: _____

Cushing syndrome:_____

HIGH SODIUM

Hypertonic IV solution

Impaired Thrist mechanism

GI losses (Hypotonic)

Hyperaldosteronism (Conns, Cushing)

Solute Overload

Osmotic Diuresis

Diabetes Insipidus

Inadeqaute water intake

Uncontrolled Sweating / Fever / heatstroke

Medications (corticosteroids, sodium bicarbonate)

Causes of Hypernatremia

Hypernatremia

osmotic diuresis leads to

• Restlessness, Agitation, Confusion

• Seizures, Stupor , Coma

Early sign of Brain shrinkage:

Late sign of Hypernatremia:

Eye Opening (E - Max 4 points)

Verbal Response (V - Max 5 points)

Motor Response (M - Max 6 points)

• 13 to 15: Mild brain injury

• 9 to 12: Moderate brain injury

• 8 or less: Severe brain injury or coma

GCS

Renal Loss

Extrarenal loss

—

Diabetes insipidus

Insensible water loss

Primary hypodipsia

—-

Excessive Hypertonic Sodium

Primary Hyperaldosteronism (conns, cushings)

ingestion of Concentrated salts

Causes of Hypernatremia

Renal

• osmotic diuresis (hyperglycemia, DKA)

• Loop diuretics

Non Renal

• Diarrhea diaphoresis, vomiting, burns

Hypernatremia

• Renal Loss:

• Non-Renal Loss:

Loss

Water loss > na loss

Hypovolemic Hypernatremia Patho

Pure free water loss, Na remains

Euvolemic Hypernatremia Patho

Increase

Water increase < Sodium Increase

hypervolemic Hypernatremia

• O.9% saline First

• Hypotonic 0.45 % next

Treatment for Hypovolemic Hypernatremia

• free water replacement: Oral water intake D5W

• Central DI: Desmopressin DDAVP

• nephrogenic DI: Low sodium Low protein diet + thiazide diuretic / NSAIDS

Treatment for Euvolemic Hypernatremia

nasal, oral, IV

Desmopressin can be administed via?

10-20 L / day

DI amount of fluid excreted

Hypervolemic Hypernatremia

Rares form of Hypernatremia