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04/05/2013

Syndrome Inappropriate ADH

(SIADH)

Titis Kurniawan, MNS

Outline

Physiology of ADH Hyponatremia SIADH & Etiology Diagnostic test Sign & Symptom SIADH Patofisiology SIADH SIADH Management

04/05/2013

Physiology of Anti Diuretic Hormone (ADH)

Pituitary gland;

Posterior menghasilkan ADH & oxitosin Anterior; growth hormone, LH, FSH

ADH released when:

Osmolality serum >> Exercise Dehidration

Work on ductus colektivus renal >> water absorbtion << ADH << water absorbtion in ductus collectivus renal hypernatremia, poliuria & low urine osmolality Diabetes Insipidus

>> ADH (SIADH) >> water aborbtion in ductus colectivus renal >> Dilutional Hyponatremia, oliguria, & high urine osmolality

Physiology of ADH

Physiology of ADH

04/05/2013

04/05/2013 Hyponatremia Normal range; 135 – 145 mmol/L Sign & symptoms: Cells swelling Cerebral

Hyponatremia

Normal range; 135 – 145 mmol/L

Sign & symptoms:

Cells swelling Cerebral edema; Seizure, headache, confusion, unconsciousness/coma Restlessness Muscle weakness Muscle spasm/cram Nausea/vomiting

Caused by SIADH and other causes Mortality rate 50x higher than nonhyponaremia & increased twice Na serum < 120. Adult patients (5-50%) >> infant (8%)

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SIADH

Is: condition where ADH hypersecreted from posterior pituitari gland >> retensi water retention/intoksikasi air (hipoosmolality serum & hyponatremia)

Diagnostic Criteria:

1.

Hypo-osmolality; plasma osmolality <280 mosmol/kg, or plasma sodium concentration < 134 mmol/l 2. Inappropriate urinary concentration (Uosm >100 mosmol/kg) for hyponatraemia

3.

Elevated urinary sodium (> 40 mmol/l), with normal dietary salt and water intake

4.

Patient is clinically euvolaemic

5.

Exclusion of hypothyroidism, diuretics and glucocorticoid deficiency – particularly in patients with neurosurgical conditions

Laboratory test;

Electrolyte test;

Na; < 134 mmol/L

SIADH

Serum & urine osmolality;

Serum osmolality <<(Normal 278 – 300 mOsm/Kg) Urine osmolality >> Natrium urine >>

BUN urea << (Normal = 7-18 mg/dL) Other laboratory test; blood glucose (fasting Normal ; 70-110 mg%)

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Etiology of SIADH

Malignancy; small cell lung cancer, nasopharyngeal cancer, mesothelioma, GI tract malignancy, Lymphoma, sarcoma. CNS Disorder/Intracranial Diseases; tumor, meningitis, encephalitis, abscess, subarachnoid hemorrhage, subdural hemorrhage, traumatic brain injury Medication; desmopressin, selective serotonin reuptake inhibitors (SSRI, carbamazepine, haloperidol, quinolones, vincristine, etc), narcotic, general anesthesia, thiazide diuretic, hypoglycemic agent Pulmonary; pneumonia, TB, vasculitis, Positive pressure ventilation

Patophysiology

Cerebral edema

GIT
GIT

Headache, seizure, confusion, ICP >>, coma

m a GIT Headache, seizure, confusion, ICP >>, coma X Nausea, Vomiting, Abdominal cramp, anorexia, thirst
X
X

Nausea, Vomiting, Abdominal cramp, anorexia, thirst

coma X Nausea, Vomiting, Abdominal cramp, anorexia, thirst Cardiovascular CVP= Normal/high, TD relatif Normal Musculo-

Cardiovascular

Vomiting, Abdominal cramp, anorexia, thirst Cardiovascular CVP= Normal/high, TD relatif Normal Musculo- sceletal

CVP= Normal/high, TD relatif Normal

Musculo-

sceletal

Weakness

, fatigue,

muscle

cramp

Cell edema

Hypoosmolar extracellular Hyponatremia
Hypoosmolar
extracellular
Hyponatremia

Urinary

Water Excess

Oliguria, BJ urine >>, Na urine >>

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Sign & Symptoms

Plasma sodium (> 130 mmol/L) Asymptomatic

Plasma Sodium (125 – 130 mmol/L); anorexia, nausea, vomiting, & abdominal pain/cramp

Plasma Sodium (115 – 125 mmol/L); headache, agitation, confusioon, hallucination, incontinence, & other neurological symptoms

Hyponatremia < 115 mmol/L; pulmonary edema, neurological squele, seizure & coma due to >> Intracranial pressure

Patient with intracranial problem (space-occupaying lesion & neurosurgical treatment), the onset of symptom my occur at higher level of sodium concentration

In chronic hyponatremia asymptomatic (addaptation mechanism)

SIADH Management

Fluid restriction (7-10ml/KgBB/Day) depend on hyponatremia severity lower serum level more aggressive restriction

Gradual correction of sodium serum level with IV electrolyte, food, fluids.

Medication; demecocycline/lithium (block ADH)

Identified underlying causes of SIADH and provide recommended therapy (surgery, radiation, antibiotic)

Drugs suspected as SIADH etiology must be STOPED

04/05/2013

Nursing Management

Assessment:

History; medication, malignancy, lung infection, etc

Hydration: skin turgor, I:O, daily weight, vital sign (TD, RR, HR, etc),

CVP, urine characteristic etc Cells edema signs & symptoms; neurological status, GIT, etc

Diagnosis:

Excess fluid volume

Electrolyte imbalance

Disturbed thought process

Intervention

Monitoring I/O (including educating family in recording I/O & BW)

Monitoring neurological status; take seizure precautions

Work with patients & family to run fluid restriction

Encouraged high sodium fluids (tomato juice, milk)

Sugar less gum for minimizing dry mouth during fluid restriction

Therapy of underlying causes of SIADH

Central Pontine Myelinosis

Is; Neurological disease caused by severe damage of the myelin sheath of nerve cells in the brainstem Characterized by acute paralysis, dysphagia (difficulty swallowing), and dysarthria (difficulty speaking), and other neurological symptoms sometimes presence of liver disease & concurent Hypoxemia

Resulted from overcorrection of sodium

Correction of > 25 mEq per 24-48 hrs Acute correction limit 25 mEq /day Chronic correction limit 10 mEq/day