Hypo/Hypernatremia

isotonic, hypotonic, hypertonic

Hyponatremia

• Normal Serum Osmo = _________ hyponatremia

  • Hyperproteinemia, Hyperlipidemia

• Low Serum Osmo = ___________ Hyponatremia

  • Can be hypovolemic (dehydration/diuretics), euvolemic (SIADH), Hypervolemic (Edema states)

• High serum Osmo = ____________ hyponatremia

  • hyperglycemia, radiocontrast agents

sodium, water, dehydration, diuretic, cerebral

Hypotonic Hyponatremia → Hypovolemic State

• _______ depletion >>> _____ depletion

• Etiologies

  • Renal and Extrarenal Sodium Losses

    • ___________

    • __________ induced

    • Vomiting

    • Diarrhea

    • ___________ salt wasting

    • Mineralocorticoid deficiency

• Treatment: 0.9% and 3% NaCl

0.9% NaCl

How do you treat hypovolemic hypotonic hyponatremia with the following presentations?

• Non-symptomatic

• Chronic conditions

• Ongoing Na losses present

3% NaCl

How do you treat hypovolemic hypotonic hyponatremia with the following presentations?

• Severe, symptomatic patients

• Pts high risk for experiencing symptoms

fatal, myelinolysis, 2-3

Rapid Na correction is _____

• Central pontine ______________

• Monitor rate of Na correction Q_-_ hours

• Target symptom resolution

50, 2, 0.5, 1-2

Sodium Rate of Correction

• Acute

  • __% of calculated dose over 12 hours

  • MAX _ mEq/L/hr (up to 8-12 mEq/L/day

• Chronic

  • MAX _._ mEq/L/hr (up to 8-12 mEq/L/day)

• Seizures/Coma

  • _-_ mL/kg/hr over 2-3 hours (RESERVED)

remove, restriction, Loop, AVP, Demeclocycline

Euvolemic Hypotonic Hyponatremia Treatment

• Etiology: SIADH

  • _______ cause

  • Fluid _________-

  • ____ diuretics

  • ___ antagonists

  • ________________ - for chronic management only

steroids, hydrocortisone

Euvolemic Hypotonic Hyponatremia Treatment

• Etiology: Adrenal Insufficiency

  • _________ (mineralcorticoid)

    • Fludrocortisone

    • _____________

Thyroid replacement

Euvolemic Hypotonic Hyponatremia Treatment

• Etiology: Hypothyroidism

  • ________ _____________

Vasopressin Antagonist

MoA: Promotes water excretion (without the loss of electrolytes)

• Pushes H+ ions out and oxygen follows

conivaptan, tolvaptan

Vasopressin antagonist agents

2nd, 1st, CYP3A4, hypovolemic, 3A4

Vasopressin Antagonist Info

• ___ line to fluid restriction

• ___ line when fluid restriction NOT an option

• Agents: Conivaptan, Tolvaptan

• Both are ______ inhibitors

• Contraindications

  • ___________ hyponatremia

  • Use with strong CYP___ inhibitors

  • Anuria

orthostatic, kalemia, reactions

Vasopressin Antagonist → Conivaptan ADRs

• __________ hypotension

• Hypo________

• Injection site ____________

dizziness, thirst, xerostomia, polyuria

Vasopressin Antagonist → Tolvaptan ADR

• Fatigue

• ___________

• Increased _______

• Nausea

• ___________

• diarrhea

• ___________

water, sodium, heart, liver, kidney

Hypervolemic Hypotonic Hyponatremia

• ______ excess >>> ________ excess

• Etiologies

  • ______ failure

  • _______ failure (cirrhosis)

  • ________ injury

diuretics, water restriction

How would you treat hypervolemic hypotonic hyponatremia?

Treat Cause

1

Replace water and sodium (crystalloids, 3% NaCl)

2

Restrict water, vasopressin antagonist

3

remove/restrict water, diuretics, restrict sodium

4

treat glucose, remove cause

5

0.9% NaCl

How do you treat hypovolemic hypernatremia with shock?

D5W

How do you treat hypovolemic hypernatremia without shock?

DDAVP (desmopressin)

How do you treat isovolemic hypernatremia that has a central cause?

Thiazide

How do you treat isovolemic hypernatremia that has a nephrogenic cause?

Stop the cause, diuretics

How do you treat hypervolemic hypernatremia?

half, 24-48, 0.5

D5W Clinical Pearls (hypernatremia)

• Correct ____ of the deficit over first 24 hours, remaining over next __-__ hours

• MAX Na correction _._ mEq/L/hr