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Hyponatraemia

Electrolyte imbalance causing plasma sodium level < 135mmol/L Usually treated when <125 with symptoms Symptoms due to osmotic shift of water into brain cells, include: o Nausea & vomiting o Headache o Malaise & anorexia o Confusion / aggitation o Reduced reflexes o Convulsions o Coma & death Very common in the elderly. Has been shown that approx 20% of NH residents are hyponatraemic & 50% have had 1+ episode within the last year.

Classification is according to volume status: Hypovolaemic (total body water decreases but sodium decreases more) Patients get orthostatic decr in blood pressure & incr in pulse rate, dry mucus membranes, decreased skin turgor o Renal loss Addisons disease Renal failure Diuretic excess o Non-renal loss Diarrhoea & vomiting Fistula Burns Small bowel obstruction Euvolaemic o SIADH o Water overload (inappropriate thirst, excess IV fluids, polydipsia in psychiatry patients) o Hypothyroidism o Glucocorticoid deficiency o Drugs, commonly: Carbamazepine Chlorpromazine Indapamide SSRIs Theophylline Amiodarone Ecstasy Hypervolaemic (inappropriate Na stores cause inappropriate total body water stores) Patients get subcutaneous oedema & ascites o Nephrotic syndrome o Cardiac failure o Liver cirrhosis o Renal failure Pseudo-hyponatraemia (erroneous measurement of Na caused by other metabolic abn)

Serum hyperglycaemia extracellular glucose can shift water to extracellular space, causing dilution o Hyperproteinaemia usually caused by large infusion of mannitol / IV immunoglobulins Chronic stable hyponatraemia o Due to reset osmostat syndrome threshold of ADH secretion is reset downward o Can be caused by: Pregnancy Malignancy Malnutrition Chronic debilitating disease o Algorithm:

Investigations Serum osmolality o Low if <280 o Used to rule out pseudo-hyponatraemia & to compare with urine osmolality to prove SIADH Urinary Na o If increased (>20) Renal loss, endocrine loss, SIADH, drugs (cause must be excess Na excretion via kidneys) If decreased Non-renal loss (kidneys attempt to compensate by decr Na excretion) If normal pseudo-hyponatraemia

o o

Urine osmolality o Used to establish if it is SIADH o Usually >100 in SIADH o Urine osmolality is increased relative to serum osmolality TFTs rule out hypothyroidism

Short synacthen test o Rules out Addisons disease o Procedure: Basal cortisol level taken, 250mcg Synacthen IV/IM administered, cortical levels at 30min & 60min taken o Normal result - basal cortisol >170nmol/L, rise of >580nmol/L, poor response in Addisons disease

SIADH Syndrome of inappropriate anti-diuretic hormone secretion ADH secretion becomes independent of the bodys need to conserve water Osmoreceptors (in hypothalamus) detect changes in plasma osmolality & switch of ADH secretion. Derangement in osmoreceptors causes excess ADH, which acts on distal renal tubules & collecting ducts, causing increased water reabsorption but not salt. Management Treat any reversible causes, e.g. hypothyroidism Stop any offending drugs Treat hypovolaemia with cautious N saline IVIs Euvolaemic patients: o Fluid restriction 1-1.5L/day (for mild to moderate hyponatraemia, often all that is required in SIADH) o In patients who have difficulty adhering to fluid restriction or who have persistent severe hyponatremia despite fluid restriction, demeclocycline 300mg tds-qds can be used to induce a negative free-water balance by causing nephrogenic diabetes insipidus. Caution in renal / hepatic insufficiency. Reduce to maintenance dose of 300mg bd-tds after approx 2 weeks. Hypervolaemic patients: o Diuretics o Treat underlying cause Emergency, e.g. seizures & severe neuro signs, usually Na < 115: o Over-aggressive correction of hyponatraemia can cause central pontine myelinolysis (brain stem damage causes quadraparesis, dysphagia, dysarthria, diplopia, LOC and death) o Saline 0.9% or 1.8% infused at max rate of 70mmol/hr o Aim to incr Na until asymptomatic or to 120-130mmol/L o 100 mL bolus of 3 % hypertonic saline (if life threatening) o Haemodialysis may be necessary if severe renal impairment Daily monitoring of U&Es Daily weights

References:

Emedicine http://emedicine.medscape.com/article/767624-diagnosis American Family Physician http://www.aafp.org/afp/20040515/2387.html

Miller M, Morley JE, Rubenstein LZ. Hyponatremia in a nursing home population. J Am Geriatr Soc 1995;43:1410-3. Elderly Care Medicine Lecture Notes, C Nicholl et al Diagram provided by: www.wikipedia.org Addisons disease www.addisons.org.uk Synacthen test www.gpnotebook.co.uk Management of electrolyte disturbances in adults (Intranet document) www.BNF.org Oxford handbook of clinical medicine