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Dr. Mobeen Syed
Dr. Pei Purdom (DNP)
Dr. Benish Zahra
Dr. Iqra Batool
Dr. Heba Alzawahri

Duration: 1:05:55

Diagnosis and Treatment of Hyponatremia

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2 Comments

HOW DID YOU TREAT THIS PATIENT

nags@kwic.com

Apr 12th 2020, 1:56 pm REPLY

Dear Dr Verduzco,

I have admitted an elderly male patient with altered mental status. He got constipation and was given unknown medicine diluted in a large amount of water (about 2 liters), given by his wife. Since then, he developed vomiting and was supplied free water (unknown amount). He was admitted with GCS of 6 (E1V1M4), dry skin, Plasma Na+ 108, urine Na+ 78, normal brain MRI, Plasma Glucose 280mg/dL, Ketones/ urine dipstick (+), Anion gap 19.2 (plasma OSM, urine OSM, plasma and urine ketones results were not available immediately). His internal jugular vein was collapsed seen by ultrasound during my central venous catheterisation. Later, he developed hypotension. Looking back to his history, I found that his plasma Na+ half year before was 131-135 in constant and diabetes mellitus.
I would like to ask whether this case is only acute hypotonic hyponatremia or a combination of both hypotonic hyponatremia and ketoacidosis? At the time of hypotension, would giving 0.9% saline for resuscitation worsen the hyponatremia? Is treating ketoacidosis necessary or not? I have been confused about this case and hope you could help me clarify it.

Thank you.

bstranthanhquyen@gmail.com

Jul 4th 2019, 4:08 pm REPLY

Hi, Quyen:

thank you for the question! Usually, your body can get rid of free water to keep your sodium stable (lowers ADH levels)---you produce dilute urine in that situation. This is a multifactorial problem. The unfortunate man appears to be hypovolemic as noted by his IJV exam as well as dry skin; his elevated urine Na is interesting. If hypovolemic, one would think that his urine Na would be low (<10) to retain blood volume however, it's possible that he's losing sodium in his urine because of glucosuria and ketonuria (Na being pulled with those solutes); at the same time, he has a ton of ADH being produced to try to maintain blood volume, which worsens his hyponatremia. In any hyponatremia problem, the story is key and then obtaining urine sodium, urine osmoles and plasma osmoles will be helpful; I suspect his urine osmoles would have been high (bc of solutes and increased ADH) and plasma osmolality would have been relatively low (a serum glucose of 280 isn't too high). The serum glucose isn't contributing too much to the hyponatremia as when you correct it, it corrects to around 112.

The anion gap isn't too terribly high (assuming a normal albumin) and his ketoacidosis is probably due to starvation ketosis (I suspect he wasn't eating---is he a type 2 diabetic?). Giving him NS would have helped him unless he has an unknown cancer causing SIADH--again, though, we would have to make him euvolemic first to test that theory as at this point, his ADH will be high to try to maintain volume. The key thing is to increase his Na by 8-10 over 24 hours to prevent cerebral pontine myelinolysis.

Hope this helps!

luis

luisverduzco1981@gmail.com |

Apr 12th 2020, 8:45 pm REPLY

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In this lecture, we review sodium homeostasis in the human body as well as hyponatremia. Critical care management of hyponatremia is discussed. The differential diagnosis of hyponatremia will be outlined and an approach to its etiology is reviewed.

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Instructor

Luis A Verduzco M.D.

Luis A. Verduzco M.D. is certified by the American Board of Anesthesiology in anesthesiology and critical care medicine. He completed his undergraduate degree with distinction from Yale University and then went on to medical school at Harvard, having graduated as an Arthur Lehman and LInnane Scholar. Dr Verduzco received his residency training at Stanford and was elected chief resident during his final year. He stayed at Stanford for critical care fellowship training. He is a former Academy of Achievement Student Delegate and Howard Hughes Medical Institute Research Training Fellow. Dr Verduzco has authored multiple book chapters and peer-reviewed manuscripts, with primary authorships in prestigious journals such as Stroke and Blood. He is an avid learner who practices evidence-based medicine and enjoys teaching.

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Diagnosis and Treatment of Hyponatremia

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