Hi #medtwitter. Another awesome day deconstructing electrolytes. Join us as we diagnose and manage severe hypernatremia! #tweetorial #FOAMED #nephtwitter @TheSkeletonKG
1/17
What’s the highest level of sodium you have seen with patient walking in your office. renalfellow.org/2020/01/17/ske…
What’s the highest level of sodium you have seen with patient walking in your office. renalfellow.org/2020/01/17/ske…
2/17
You are on consult service and get a page from ER for a stat consult. Patients sodium is 183 !!! You rush to the ER to evaluate the patient. If you are allowed to ask one question, then what would it be?
You are on consult service and get a page from ER for a stat consult. Patients sodium is 183 !!! You rush to the ER to evaluate the patient. If you are allowed to ask one question, then what would it be?
3/17
I would ask about her ability to drink water. Thirst is a defense mechanism against hypernatremia. Under physiologic conditions, normonatremia is achieved through thirst-driven water intake and arginine vasopressin (AVP)–mediated water conservation in the kidney.
I would ask about her ability to drink water. Thirst is a defense mechanism against hypernatremia. Under physiologic conditions, normonatremia is achieved through thirst-driven water intake and arginine vasopressin (AVP)–mediated water conservation in the kidney.
4/17
On review, the patient had a BP of 110/70, HR 74 bpm, Weight 74 kg. Previous Na is unknown as she just moved to the area. She denies any thirst or polyuria. She is neurologically intact on examination. Her current medications are amlodipine and atorvastatin
On review, the patient had a BP of 110/70, HR 74 bpm, Weight 74 kg. Previous Na is unknown as she just moved to the area. She denies any thirst or polyuria. She is neurologically intact on examination. Her current medications are amlodipine and atorvastatin
5/17
Hypernatremia is a reflection of decreased total body water in relation to your body’s sodium stores.
Hypernatremia is a reflection of decreased total body water in relation to your body’s sodium stores.
6/17
It occurs when patients are unable to drink water (ie sedated) or have no access to water (ie lost in the desert, new born etc). Rarely hypernatremia is related to impaired thirst mechanism.
It occurs when patients are unable to drink water (ie sedated) or have no access to water (ie lost in the desert, new born etc). Rarely hypernatremia is related to impaired thirst mechanism.
7/17
Your attending asks you the symptoms of Hypernatremia ?
Your attending asks you the symptoms of Hypernatremia ?
8/17
All of the above. Symptoms depend on the severity and acuity of hypernatremia. Our patient had chronic hypernatremia( > 48 hours). Acute hypernatremia although rare develops less than 48 hours. An elevated sodium has severe unremitting thirst as a debilitating symptom.
All of the above. Symptoms depend on the severity and acuity of hypernatremia. Our patient had chronic hypernatremia( > 48 hours). Acute hypernatremia although rare develops less than 48 hours. An elevated sodium has severe unremitting thirst as a debilitating symptom.
9/17
Your attending also asks, “How does the brain adapt to Hypernatremia?”After hypertonicity exposure,water movement causes shrinkage.The brain adapts by increasing intracellular ions and osmolytes by a process called regulatory volume increase to reestablish normal cell volume
Your attending also asks, “How does the brain adapt to Hypernatremia?”After hypertonicity exposure,water movement causes shrinkage.The brain adapts by increasing intracellular ions and osmolytes by a process called regulatory volume increase to reestablish normal cell volume
10/17
What would you check/calculate as the next best step in this scenario ?
What would you check/calculate as the next best step in this scenario ?
11/17
I agree, we would calculate free water deficit! Her free water deficit was 12 liters. Read our post to see the calculation ! @TheSkeletonKG renalfellow.org/2020/01/17/ske… Tip: It is imperative to also determine and replace insensible volume losses (1 liter/ day) and ongoing losses
I agree, we would calculate free water deficit! Her free water deficit was 12 liters. Read our post to see the calculation ! @TheSkeletonKG renalfellow.org/2020/01/17/ske… Tip: It is imperative to also determine and replace insensible volume losses (1 liter/ day) and ongoing losses
12/17
How quickly do you want to correct the hypernatremia?
How quickly do you want to correct the hypernatremia?
13/17
10-15 mmol/day is a commonly used target rate for correction of hypernatremia, but recent data suggest no evidence that more rapid correction was associated with greater risk of mortality, cerebral edema, or adverse events
ncbi.nlm.nih.gov/pubmed/30948456
ncbi.nlm.nih.gov/pubmed/31064771
10-15 mmol/day is a commonly used target rate for correction of hypernatremia, but recent data suggest no evidence that more rapid correction was associated with greater risk of mortality, cerebral edema, or adverse events
ncbi.nlm.nih.gov/pubmed/30948456
ncbi.nlm.nih.gov/pubmed/31064771
14/17
She denied feeling thirsty. That, combined with her urine osmolality of 1150 mOsm/kg, what would the etiology of her hypernatremia be
She denied feeling thirsty. That, combined with her urine osmolality of 1150 mOsm/kg, what would the etiology of her hypernatremia be
15/17
That’s right! Most likely cause is adipsic hypernatremia. Read more about adipsic hypernatremia on our post !
renalfellow.org/2020/01/17/ske…
The patient was later found on work up to have leptomeningeal enhancement and perihilar lymphadenopathy. Biopsy later confirmed sarcoidosis.
That’s right! Most likely cause is adipsic hypernatremia. Read more about adipsic hypernatremia on our post !
renalfellow.org/2020/01/17/ske…
The patient was later found on work up to have leptomeningeal enhancement and perihilar lymphadenopathy. Biopsy later confirmed sarcoidosis.
16/17
Her Na normalized 3 days after initiating obligatory fluid intake of 500 mL of free water every 3-4 hours and sarcoidosis treatment.Your attending gave you a gold star!
Her Na normalized 3 days after initiating obligatory fluid intake of 500 mL of free water every 3-4 hours and sarcoidosis treatment.Your attending gave you a gold star!
17/17
This amazing visual abstract helps to summarize the case! Read the full post at @RenalFellowNtwk renalfellow.org/2020/01/17/ske…
This amazing visual abstract helps to summarize the case! Read the full post at @RenalFellowNtwk renalfellow.org/2020/01/17/ske…
