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Acute Hyponatremia Management in a PGY-2 Case Study: A Focus on Sodium Correction

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This case study outlines the presentation and management of a 78-year-old male patient with acute hyponatremia, who was brought in with generalized weakness, vomiting, and diarrhea. The patient experienced a brief generalized tonic-clonic seizure upon assessment. Key considerations include the patient's chemistry results, possible causes of hyponatremia, differential diagnoses, fluid distribution, and the safe correction of sodium levels. Special emphasis is placed on the calculation of sodium deficit, the risks of rapid correction, and appropriate therapeutic interventions, such as hypertonic saline (HTS).

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Acute Hyponatremia Management in a PGY-2 Case Study: A Focus on Sodium Correction

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  1. Lab Rounds Shawn Dowling PGY-2

  2. Case • 78 yo M. Brought in by EMS from NSG home • c/o generalized weakness, V, D for past 2-3 days • Brief GTC seizure while nurses are checking patient in • PMHx: HTN (on HCTZ), • allergies: ex-wife

  3. Physical Exam • VS: HR-110, BP110/70, T/RR/sats N • Stopped seizing but still altered sensorium (?post-ictal), GCS 13-14 • Fluid: looks dry • Chest/abdo/extremeties – N • Neuro: no focal abnormalities, neck supple

  4. Want to order anything NOW?

  5. Want to order anything NOW? • Chemstrip

  6. Want to order anything NOW? • Chemstrip • The paramedics had noticed this by his bedside

  7. Want to order anything NOW? • Chemstrip – 8.0 • ABG • Na – 108, K - 3.0, Cl - 90

  8. Objectives • Acute Hyponatremia • Touch of physiology • DDx • The Na calculating game • How and when to use HTS • FOR INDEPTH REVIEW OF HYPONATREMIA SEE MORITZ’S PRESENTATION FROM 2003

  9. Sodium • H20 makes up  60% of total body weight (:. TBW = 0.6 x wgt(kg)) • H20 is distributed between 3 compartments • Intracellular space (ICS) • Interstitial space (ISS) • Intravascular space (IVS) • Na is the predominant cation in the ECS and is distributed primarily in the TBW Extracellular Space

  10. Na+ balance primarily controlled by renin-angiotensin-aldosteronesystem • Na governs the movement of fluid between these compartments • Water balance largely driven by Na+ balanceand ADH

  11. Fluid Distribution TBW = wgt (kg) x 0.6 Distribution of TBW (and Na):

  12. “TRUE”  Na Hypovolemic GI/insensible losses Poor H20 intake Diuretics Euvolemic SIADH Psychogenic polydipsia Hypervolemic CHF Cirrhosis Nephrotic syndrome Lab Error PseudoNa* lipids/proteins No longer an issue Redistributive (osm) Hyperglycemia Mannitol *No longer an issue since the lab uses a different technique to calculate Na Hyponatremia DDx(abridged version)

  13. Making the Diagnosis • Hx in particular ROS, PMHx, Meds • Physical exam: hypo-,eu- or hypervolemic • Labs: • Serum electrolytes (ABG if needed urgently) • Urine lytes, Cr (if not on diuretics or have not received fluids yet) • Urine Osmols • Serum Glucose

  14. Approach to sodium • Need to determine: • Is the patient symptomatic? • Is this an acute or chronic process? • Do I need to intervene emergently? • Seizure? • Comatose? • Focal Neuro Deficits?

  15. Sx HA Lethargy N,V Anorexia Dizzy Confusion Signs Psychosis Confusion Focal Neuro deficits Ataxia Seizures Comatose S/Sx

  16. 37M. Diabetic. • Glucose 35 • Na – 126 • How do you correct the sodium for the glucose?

  17. Back to our case • His Na is 108. • What info do you need to calculate his Na deficit? • What is his Na deficit?

  18. Fluid Distribution TBW = wgt (kg) x 0.6 Distribution of TBW:

  19. Calculating Na deficit • His wgt is 60kg. • Since Na is primarily distributed in the Total body water which is wgt(kg) x 0.6* • (Desired Na-actual Na) x TBW Or • The drop in Na x where the Na is distributed ***Some sources suggest using 0.5 for females/elderly males and 0.45 for elderly females – probably not important acutely

  20. (140-108) x 0.6x60kg = (32) x 36 =1152mEq of Na • How quickly can we replace Na? Why? • How are we going to calculate how much to replace over 24 hours? • What solution are you going to use? • Pt is not seizing, no focal deficits, no coma

  21. Na correction • CANNOT correct sodium quicker than 10-12mEq/24 hours, • 0.5 mEq/hr rule is not absolute – this rule can be broken as long as 10-12/day is not • Risk of over-aggressive Na replacement is central pontine myelinolysis • Demyelination of the pons, flaccid paralysis and death -- BAD

  22. Determining how much Na to give • What is the Na content of… • NS • RL • HTS (3%)

  23. Determining how much Na to give • What is the Na content of… • NS – 154mEq • RL – 130mEq • HTS (3%) – 513mEq

  24. Calculating volume of fluid • His Na deficit is 1152mEq, but we only want to increase 10-12mEq/24H • (Desired Na-actual Na) x TBW • (118-108) x 36 • 360mEq • NS 360/154 = 2.33 L over next 24 hours – check lytes Q2-4H to ensure not correcting too quickly

  25. The Divine Brine – HTS • HTS (3%) – Na content is 513mEq • Indications • Moderate-Severe hyponatremia (<120) • And 1 of the following • Seizures • Focal neuro deficit • Comatose • Dose: 3cc/kg ½ half given over 10 minutes, 2nd ½ given over 50 minutes • Then STOP & check lytes (usually  Na by 3-6mEq). STILL LTD BY 10-12mEq/DAY

  26. Summary • Order Urine lytes prior to giving fluid • Calculate target Na • (Goal Na - actual Na) x TBW & DO NOT EXCEED • HTS saline indications • Seizure • Focal neuro deficits • Comatose • HTS: 3cc/kg, 1st ½ over 10min, 2nd ½ over next fifty minutes, then STOP & check lytes • Usu by 3-6 mEq, STILL ltd by 10-12mEq/24hrs

  27. References • EMRAP March 2006 • Yeates K. Salt and Water: A simple Approach. CMAJ. Feb 2004;170, 365-69 • Rosen’s • Harrison’s • Moritz’s presentation 2003

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