Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
DOI 10.1007/s12630-008-9017-2
REVIEW ARTICLE
Received: 21 August 2008 / Revised: 10 November 2008 / Accepted: 18 November 2008 / Published online: 31 December 2008
Canadian Anesthesiologists Society 2008
123
152 S. M. Bagshaw et al.
accrue, dun dysfonctionnement organique, dune evolution (inception through August 2008), and Cochrane Central
defavorable de la maladie ou de la progression dune Register of Controlled Trials (inception through August
maladie chronique sous-jacente. Les troubles hyponatrem- 2008) databases for recent and relevant articles. We also
iques peuvent etre provoques par des niveaux darginine- searched the bibliographies of all relevant studies and
vasopressine adequatement eleves (depletion volumique) ou review articles. Search terms (water balance OR sodium
inadequatement eleves (syndrome dantidiure`se inappro- OR hyponatremia OR hypernatremia) were combined with
priee), des niveaux darginine-vasopressine adequatement key terms for outcome OR mortality OR diagnosis
supprimes (dysfonctionnement hepatique) ou des alterations OR epidemiology. The search was limited to studies
de losmolarite plasmatique (medicaments ou irrigation des conducted in humans and reported in English.
cavites corporelles par des solutions hypotoniques). Lhy-
pernatremie est la plupart du temps provoquee par une
depletion deau hypotonique non remplacee (etat mental Overview of sodium and water homeostasis
aggrave et/ou acce`s libre a` de leau), mais elle peut egale-
ment etre causee par une translation provisoire de leau Sodium [Na?] is the primary extracellular cation and the
dans les cellules (a` partir de convulsions) et de charge sodee most important osmotically active solute in the body.
iatrogenique (de lapport sodique ou par ladministration Under normal circumstances, the serum [Na?] is preserved
des solutions hypertoniques). within a fine physiologic range (138142 mEq l-1) despite
Conclusion Chez les patients hospitalises, lhyponatre- large variations in daily sodium and water intake. Sodium
mie et lhypernatremie sont souvent iatrogeniques et metabolism is tightly regulated by the kidney through the
pourraient contribuer a` une morbidite grave et un risque interaction of numerous neurohormonal mechanisms,
accrue de dece`s. Ces troubles necessitent une identification including the reninangiotensinaldosterone system, the
rapide et peuvent souvent etre soignes grace a` une inter- sympathetic nervous system, and the presence of atrial
vention adaptee et au traitement des facteurs predisposants natriuretic and brain natriuretic peptides. Sodium regula-
sous-jacents. tion is closely correlated with the bodys effective
circulating volume (ECV), defined as the requisite intra-
vascular volume to provide adequate tissue perfusion. As
such, the major determinant of serum [Na?] is in fact the
Introduction serum water content, and disturbances in sodium balance
most often reflect abnormalities in the ECV and serum
Disorders of sodium and water balance are commonly water content.
encountered in critically ill patients.1 Critical illness, multi- Water metabolism, on the other hand, is predominantly
organ dysfunction, fluid resuscitation, and the numerous regulated by arginine vasopressin (AVP) and is strongly
additional interventions received routinely by patients influenced by water intake and output. Arginine vasopres-
admitted to the intensive care unit can interfere with the sin is produced in the supraoptic and paraventricular
complex mechanisms that maintain total body sodium and hypothalamic nuclei and stored in the posterior pituitary.
water homeostasis.2 Arginine vasopressin secretion is tightly regulated by
Disorders of sodium and water balance are generally changes in serum osmolality (i.e., as little as 12%)
categorized as either hypo-osmolar or hyper-osmolar, detected by osmoreceptors in the anterior hypothalamus
depending on the balance (i.e., excess or deficit) of total and also by changes in mean arterial pressure and/or blood
body water relative to total body sodium content. As sodium volume detected by baroreceptors in the aortic arch and
is the primary extracellular constituent of serum osmolality, carotid bodies. Arginine vasopressin controls the water
disorders of sodium and water balance can classically be permeability of the kidney by directing the insertion of
recognized as hyponatremia and hypernatremia. Both of aquaporin-2 (AQP-2) channels on the luminal surface of
these disorders can contribute to substantial morbidity and the distal tubules and collecting duct. Arginine vasopressin
mortality, and given their prevalence in critically ill patients, induces an increase in AQP-2 channels and acts to stimu-
clinicians need to have a solid understanding of their path- late free water reabsorption and anti-diuresis.
ophysiology, diagnosis, and management.
Hyponatremia
Search methodology
Hyponatremia is commonly defined as a serum
In August 2008, we conducted an electronic search of the [Na?] \ 135 mmol l-1; however, this definition may vary
MEDLINE (inception through August 2008), Embase across different institutional laboratories. The presence of
123
Sodium and water abnormalities 153
hyponatremia most commonly indicates an underlying generally reflect neurologic dysfunction induced by cere-
disorder of an excess in body water relative to body sodium bral edema. A reduction in serum [Na?] creates an osmotic
content. Less commonly, it may result from a depletion of gradient that favours water movement into the brain. This
body sodium content in excess of concurrent body water increase in brain intracellular volume contributes to cere-
losses. bral edema and raised intracranial pressure and leads to the
appearance of neurologic manifestations.
Epidemiology Mild hyponatremia (serum [Na?] 130135 mmol l-1)
can often be asymptomatic, but with further acute declines
Hyponatremia is recognized as the most common electro- in serum [Na?], overt symptoms become more apparent.
lyte abnormality encountered in clinical medicine. Its Non-specific symptoms occur with a serum [Na?] in the
prevalence in the United States is estimated to be between range of 120130 mmol l-1, such as fatigue, malaise,
3.2 and 6.1 million patients/year.3 Approximately 1% of nausea, and unsteadiness. Rapid declines to serum
these cases are classified as acute and symptomatic, 4% as [Na?] \ 115120 can provoke headache, restlessness,
acute and asymptomatic, 1520% as chronic and sympto- lethargy, and obtundity that may progress to seizures,
matic, and 7580% as chronic and asymptomatic. This coma, brainstem herniation, respiratory arrest, and death.14
prevalence is associated with a considerable burden on Alternatively, hyponatremia that evolves more gradually
health resources, as an estimated 75% of these patients (i.e., over days or weeks) may present with a much lower
require treatment in hospital.3 serum [Na?] prior to the development of symptoms. This
Epidemiologic studies have found that hyponatremia occurs as a result of the brain undergoing a process of
occurs in approximately 12% of hospitalized patients.4 intracellular adaptation to preserve osmotic balance and
However, the incidence varies depending on the threshold prevent edema. Throughout hours and days, the brain
for diagnosis, and the population assessed. For example, transports osmoles (i.e., sodium, potassium, chloride) from
hyponatremia (serum [Na?] B 130 mmol l-1) has been the intracellular to the extracellular space, followed later by
described in 4.4% of patients after surgery5 and in nearly active transport of several organic solutes (i.e., osmolytes),
30% of patients admitted to intensive care (serum such as glutamine, glutamate, taurine, and myo-inositol.
[Na?] B 134 mmol l-1).6 A variety of risk factors have This process aids in maintaining osmotic balance by con-
been reported for hospital-acquired hyponatremia, includ- tributing to early water loss from the brain, which
ing older age, diabetes mellitus, chronic kidney disease, attenuates subsequent hyponatremia-induced brain edema,
surgery, pulmonary infection, diuretic therapy, adminis- and hence, leads to a greater threshold decline in serum
tration of antibiotics, opioid analgesia, and the use of [Na?] prior to symptoms.
hypotonic intravenous fluids.79
It is important to recognize that hyponatremia, while
frequent, is not a trivial diagnosis. It is associated with Diagnostic approach
serious complications that have been linked to increased
morbidity and mortality.1,8,1013 The presence of hyponat- Hyponatremia can be broadly classified, based on serum
remia after an acute ST-elevation myocardial infarction in osmolality, into the categories of hypo-osmolar, iso-osm-
congestive heart failure and in patients with cirrhosis has olar, or hyper-osmolar disorders. The underlying cause of
been found to predict mortality.1013 Similarly, in critically hyponatremia is usually evident after a thorough medical
ill patients, severe hyponatremia (serum [Na?] \ 125 history, a physical examination, and selected serum and
mmol l-1) has been shown to be an independent predictor urinary tests, particularly, serum osmolality, urine osmol-
of hospital mortality, with an estimated risk for death ality, and urine [Na?]. The medical history should focus on
approaching 40%.1 Gill et al.8 recently found that severe presence of co-morbid illnesses, acute illnesses, medica-
hyponatremia (serum [Na?] \ 125 mmol l-1) was associ- tions, and other therapies or interventions that may
ated with significantly higher mortality (27% vs. 9%, predispose to the development of hyponatremia (Table 1).
P = 0.009) and a longer duration of hospitalization A focused physical examination should provide an estimate
(16 days vs. 13 days, P \ 0.005). Moreover, mortality was of volume status; a reduction in ECV may be suggested by
reported higher for those patients whose hyponatremia orthostatic changes in heart rate and blood pressure, large
initially worsened after hospital admission.8 variations in pulse pressure, low jugular or central venous
pressure, and other surrogates, such as reduced skin turgor,
Clinical presentation of hyponatremia furrowed tongue, and dry mucus membranes, or axillae. On
the other hand, an expansion in ECV would be suggested
Symptoms attributable to hyponatremia correlate both with by increased jugular or central venous pressure, pleural
the severity and the rate of decline in serum [Na?] and effusions, ascites, and peripheral edema.
123
154 S. M. Bagshaw et al.
Table 1 Major causes of hyponatremia This form of hyponatremia has emerged as an important
Disorders causing hyponatremia associated with elevated AVP
cause of morbidity in endurance athletes. An estimated
Decreased effective circulating volume
13% of runners in the 2002 Boston marathon had serum
[Na?] \ 135 mmol l-1, and approximately 1% had critical
True volume depletion
values \120 mmol l-1.15 Moreover, the frequent use of
Congestive heart failure
non-steroidal anti-inflammatory drugs may further com-
Cirrhosis
pound hyponatremia in these athletes. In the absence of
Diuretic therapy (i.e., thiazides)
exposure to diuretics, true hypovolemia in these patients
Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
may be corroborated by demonstration of a urine
Reset osmostat
[Na?] \ 1020 mmol l-1.
Endocrinologic
Cerebral salt wasting syndrome (CSWS) is a unique
Adrenal insufficiency
disorder of the hypothalamic-renal axis characterized by
Hypothyroidism
natriuresis and volume depletion, followed by AVP-
Pregnancy
induced water retention. This leads to hyponatremia typi-
Disorders causing hyponatremia in which AVP may be appropriately
fied by an inappropriately high urine osmolality, a high
suppressed
urine [Na?] generally [40 mEq l-1, and, if measured, an
Advanced renal failure
increased serum [AVP]. While the pathogenesis is not
Primary polydipsia (i.e., associated with psychiatric illness or ecstasy)
completely understood, increased sympathetic nervous
Malnutrition
system outflow, along with raised levels of atrial and brain
Beer drinkers potomania
natriuretic peptides, may, in part, mediate the inciting
Disorders causing hyponatremia with normal or elevated plasma
osmolality
natriuresis and volume depletion. Cerebral salt wasting
High plasma osmolality
syndrome typically occurs in critically ill patients with
intracranial injury, which is often associated with sub-
Hyperglycemia
arachnoid hemorrhage or traumatic brain injury, and is less
Mannitol
commonly described after neurosurgical procedures with
Maltose (i.e., IVIg)
glioma, tuberculous, or carcinomatous meningitis.16 Cere-
Normal plasma osmolality
bral salt wasting syndrome is often difficult to differentiate
Pseudohyponatremia due to hyperlipidemia or hyperproteinemia
from the syndrome of inappropriate antidiuretic hormone
Glycine or sorbitol solution
(SIADH) secretion, which is also common after neurologic
Transurethral prostate resection
injury. The key difference for CSWS is clear evidence of
Hysteroscopy
volume depletion and increased urine sodium excretion
AVP arginine vasopressin prior to development of hyponatremia; whereas in SIADH,
patients are typically euvolemic or mildly volume
Hypo-osmolar hyponatremia expanded.17
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Sodium and water abnormalities 155
Table 2 Criteria for the diagnosis of syndrome of inappropriate Table 3 Common causes of syndrome of inappropriate antidiuretic
antidiuretic hormone secretion (SIADH) hormone secretion (SIADH)
Major Central nervous system disorders
Decreased extracellular fluid osmolality (\275 mOsm kg-1 H2O) Mass lesions (i.e., tumours, brain abscess, subdural hematoma)
Inappropriately elevated urine osmolality ([100 mOsm kg-1 H2O Inflammatory disorders (i.e., encephalitis, meningitis, systemic
and usually [300 mOsm kg-1 H2O) in the context of normal lupus)
kidney function Degenerative-demyelinative (i.e., multiple sclerosis,
Clinical euvolemia GuillainBarre)
Urine [Na?] [ 40 mEq l-1 Other (i.e., SAH, delirium tremens, TBI, acute psychosis,
Absence of hypothyroidism, hypocortisolism (primary or postoperative pituitary, stalk section, hydrocephalus)
secondary), and diuretic use Pulmonary disorders
Relatively normal serum [creatinine] Infections (i.e., bacterial-viral pneumonia, tuberculosis, empyema,
Normal acid-base and potassium balance aspergillosis)
Low serum [urea] and serum [uric acid] Mechanical-ventilatory (i.e., mechanical ventilation, NIPPV,
COPD, asthma, acute respiratory failure, pneumothorax,
Minor
hypercapnea)
Abnormal water load test
Medication-related
Inappropriately elevated plasma [AVP] relative to plasma
Stimulate AVP release (i.e., nicotine, phenothiazines, TCA)
osmolality
Direct renal effects or potentiation of AVP (i.e., dDAVP, oxytocin,
No significant correction of plasma [Na?] with volume expansion,
prostaglandin, synthesis inhibitors)
but improvement after fluid restriction
Mixed (ACE inhibitors, carbamazepine, chlorpropamide,
AVP arginine vasopressin clozapine, cyclophosphamide, ecstasy, omeprazole, SSRIs,
Adapted from Ref.2 vincristine)
Tumour-related-paraneoplastic
confirmed in the context of normal kidney, thyroid, and Pulmonary-mediastinal (i.e., bronchogenic carcinoma,
mesothelioma, thymoma, lymphoma)
adrenal function. There are several conditions encountered
Non-chest (i.e., pancreatic carcinoma, nasopharyngeal carcinoma,
in critically ill patients that can lead to SIADH. The
leukemia)
SIADH can be broadly categorized into disorders of the
Other
central nervous system, pulmonary disorders, disorders
Acquired immunodeficiency syndrome
associated with medications or tumours, and a variety of
Prolonged strenuous activity (i.e., marathon running)
miscellaneous causes (Table 3). Interestingly, an estimated
Senile atrophy
one-third of patients with SIADH counter the inappropri-
Postoperative pain
ately elevated AVP by resetting the osmostat downwards to
a serum [Na?] typically in the range 125130 mmol l-1. SAH subarachnoid hemorrhage, TBI traumatic brain injury, NIPPV
These patients are often asymptomatic and achieve relative non-invasive positive-pressure ventilation, COPD chronic obstructive
pulmonary disease, AVP arginine vasopressin, TCA tricyclic antide-
stability in serum [Na?]. As such, confirming the diagnosis pressants, dDAVP desmopressin arginine vasopressin, ACE
is important and can have significant implications for angiotensin converting enzyme, SSRIs selective serotonin reuptake
subsequent therapy. inhibitors
Adrenal insufficiency generally leads to hyponatremia,
due to an increased release of AVP and subsequent output that stimulate the non-osmotic release of AVP and
diminished water excretion. Cortisol deficiency may con- by reductions in glomerular filtration that further impair
tribute to reductions in cardiac output and blood pressure, free water clearance.19
thus stimulating a non-osmotic release of AVP. In addition, During pregnancy, increased serum levels of human
AVP is an adrenocorticotropic hormone (ACTH) secreta- chorionic gonadotropin released from the placenta is
gogue, thus AVP release may be stimulated secondary to believed to be associated with a downward reset osmo-
increased release of ACTH, due to the lack of negative stat (B5 mmol l-1) leading to mild asymptomatic
feedback from absent serum cortisol.18 Similarly, aldos- hyponatremia.20
terone deficiency leads to sodium wasting and reductions in
ECV stimulating AVP release. Hypervolemic hypo-osmolar hyponatremia
The pathophysiology of hyponatremia in hypothyroid-
ism remains incompletely understood. Studies have There are several conditions that can predispose to hypo-
suggested these patients have impaired free water excretion osmolar hyponatremia in the context of an excess of total
due to inability to maximally suppress AVP secretion; body water and sodium. Congestive heart failure, cirrhosis,
however, this may be aggravated by declines in cardiac and chronic kidney disease (i.e., nephrotic syndrome) all
123
156 S. M. Bagshaw et al.
share a similar pathophysiology for the development of have appropriately dilute urine; however, due to a low intake
hyponatremia in edematous states. of solute (i.e., sodium and potassium), the daily solute
Congestive heart failure is classically associated with excretion will decrease to \200250 mOsm kg-1 (normal
extracellular fluid overload. However, the reductions in 600900 mOsm kg-1) and lead to a reduction in the maxi-
cardiac output (and blood pressure) cause a relative mal achievable urine output.
reduction in ECV. These hemodynamic changes activate
carotid baroreceptors that stimulate the non-osmotic Hyperosmolar hyponatremia
release of AVP. Additionally, the impaired cardiac output
contributes to reduced renal perfusion, which, in turn, The accumulation of osmotically active particles in the
activates the renin-angiotensin-aldosterone system and plasma induces an osmotic efflux of water from the intra-
sympathetic nervous system, thereby amplifying renal cellular space to the extracellular space, resulting in both
sodium retention and secondarily decreasing free water hyponatremia and hyperosmolality. This is often encoun-
excretion. These alterations are further exacerbated by tered with marked hyperglycemia (i.e., diabetic
concomitant diuretic therapy. However, this maladaptive ketoacidosis, hyperosmolar non-ketotic hyperglycemia)
positive feedback leads to dilutional hyponatremia associ- and less commonly with use of mannitol, glycerol, or
ated with progressive hypervolemia.21 sorbitol, and the administration of radiocontrast media.
Advanced cirrhosis is typically characterized by signif- Similarly, hyperosmolar hyponatremia has also been
icant splanchnic and systemic vasodilatation. This leads to described with the use of IVIg suspended in 10% maltose
relative reductions in ECV, non-osmotic release of AVP, solution.29
and diminished capacity for free water excretion, leading to The calculation to correct the serum [Na?] for hyper-
serum [Na?] of \125130 mmol l-1 in up to 50% of glycemia was shown on average as a decrease of
patients. The increase in AVP secretion, and thus level of 2.4 mmol l-1 in serum [Na?] per 5.6 mmol l-1 increase in
hyponatremia, is often proportional to the underlying pro- serum [glucose].30 However, this relationship was non-
gression and severity of cirrhosis.22 Diuretic therapy, often linear and may vary, indicating that this calculation is at
used to treat ascites, can worsen hyponatremia in cirrhotic best an estimate. Other variables are not factored in, such
patients by reducing ECV, stimulating compensatory as ongoing water loss from osmotic diuresis and the
increases in AVP release, and further impairing free water influence of insulin administration, both of which will
excretion. contribute to raising the serum [Na?].
In advanced chronic kidney disease (Cstage IV), the
reduction in nephron mass and glomerular filtration are Iso-osmolar hyponatremia
associated with progressive impairments in capacity for
maximal urine dilution and free water excretion, such that Iso-osmolar hyponatremia can occur with the accumulation
water retention commonly predisposes to hyponatremia. of isotonic non-sodium containing fluid to the extracellular
Primary polydipsia is characterized by an abnormal space or by marked elevations in serum compounds such as
thirst stimulus leading to an increased and/or excess of free proteins and lipids (i.e., pseudohyponatremia). This has
water intake. It is often found in psychiatric illness or with been reported during selected surgical procedures (i.e.,
prescription of anti-psychotic medications that cause a dry transurethral resections of the prostate, bladder tumour
mouth.23 Infrequently, primary polydipsia can occur from resection, and hysteroscopy) that involve the large volume
infiltrative diseases of the hypothalamus (i.e., sarcoidosis) irrigation of closed body spaces with hypotonic glycine or
that disrupt the normal sensation of thirst.24 Severe hypo- sorbitol-containing solutions (see below).
natremia has also been described after acute water The normal content of serum is approximately 93% water
intoxication in workers undergoing urine drug testing.25 In and 7% non-aqueous substances that principally include
these circumstances, water intake exceeds the renal proteins and lipids. In general, the non-aqueous proportion
capacity for excretion, despite a maximally dilute urine of serum does not influence osmolality. However, in disor-
(i.e., osmolality \ 100 mOsm kg-1). Ingestion of ecstasy ders causing marked elevations in serum proteins (i.e.,
(3,4 methyldioxymethamphetamine or MDMA) has also multiple myeloma, hypergammaglobulinemia) or lipid
been associated with severe acute hyponatremia.26 The content (i.e., hypertriglyceridemia, elevated chylomicrons),
underlying pathophysiology is thought to result from a the non-aqueous proportion of serum is increased relative to
large intake of free water coupled with SIADH. the aqueous portion, leading to an artifactual decrease in
Poor dietary intake of solute can directly impair capacity serum [Na?] (i.e., pseudohyponatremia) despite no actual
for free water excretion and lead to dilutional hyponatremia. change to serum [Na?] or serum osmolality. This problem
This may be encountered in chronic alcoholics (i.e., beer has largely been overcome by the use of ion-selective
potomania) and malnourished patients.27,28 These patients electrodes that directly measure serum [Na?].
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Sodium and water abnormalities 157
Hyponatremia in the perioperative period compensatory decreases in brain cell osmolality that occur
in response to changes in extracellular tonicity.33,41
Hyponatremia after surgery is common; it can often go The concept of sick cell syndrome may be an under-
unrecognized due to clinical overlap with the sequale of recognized mechanism of hyponatremia in critically ill and
postanesthesia, and may contribute to iatrogenic morbidity postoperative patients.4245 Sick cell syndrome is believed
and mortality.3133 Observational studies report variable to be caused by dysfunctional cell membrane integrity and
occurrences of early postoperative hyponatremia, largely increased permeability associated with cellular Na?/K?
due to different surgical populations and serum [Na?] ATPase pump dysfunction. Loss of membrane integrity
thresholds for defining hyponatremia. In general, ortho- may lead to leakage of intracellular solutes that induce an
pedic, and gynecologic surgery, the incidence of acute increase in extracellular osmolality and predispose to
postoperative serum [Na?] \ 135 mmol l-1 has been water translocation and redistributive (rather than dilu-
reported to occur in 210% of patients; however, the risk tional) hyponatremia. The redistributive hyponatremia is
may be modified by illness severity (i.e., acute physiologic unrelated to total body free water or sodium balance and
stress), and rates of up to 31% have been reported.3437 may be characterized by an increase in both serum and
More significant hyponatremia (serum [Na?] \ 120 urine osmolar gap.
130 mmol l-1) is less common and has been reported in Large volume irrigation of closed body spaces with
the range of 15% of patients.3538 hypotonic solutions can lead to significant perioperative
The pathophysiology of postoperative hyponatremia is fluid and electrolyte shifts and is a well recognized iatro-
complex and often multifactorial.39 In general, impaired free genic cause of hyponatremia in patients undergoing
water excretion (i.e., reduced renal function, reduced renal transurethral prostatectomy or hysteroscopy. These proce-
tubular dilution capacity, non-osmotic release of AVP), dures use large volumes of glycine or sorbitol-containing
together with continued hypotonic fluid administration or intra-cavitary irrigating solutions. As a consequence, vari-
water intake in the perioperative period, contribute to able amounts of this fluid can be absorbed, either directly
reductions in serum [Na?]. The constellation of clinical through large prostatic veins or indirectly via leaked fluid
contributors may include non-osmotic stimuli for the release in the retroperitoneal space, and can lead to a dilutional
of AVP, such as surgical pain, nausea, anxiety, stress, reduction in serum [Na?].46 Postoperative decreases in
inflammation, and various medications, along with sub- serum [Na?] to \100110 mmol l-1 have been described
clinical volume depletion from a prolonged preoperative and can be associated with serious neurologic sequelae and
fast. Although relatively uncommon, a true excess in total death.46 Similar problems have been described with use of
body free water, characterized by a positive fluid balance in large volume glycine irrigation during hysteroscopy.47 This
the postoperative period, coupled with a relatively preserved diagnosis is supported by the finding of a large serum os-
total body sodium content (i.e., acute water intoxication) is a molal gap C3040 mOsm kg-1, whereas a normal serum
potentially devastating iatrogenic complication.31,40 osmolal gap is B510 mOsm kg-1. The osmolar gap is
Data have accumulated to indicate that women may be determined by the laboratory measure minus the calculated
at a higher risk than men for acute reductions in serum serum osmolality and can be estimated by the equation:
[Na?] in the immediate postoperative period. In a small
observational study, Amede et al.41 found that women 2 serum [Na serum [glucose] serum [urea]
undergoing pelvic surgery had acute declines in estrogen,
progesterone, and aldosterone, postoperatively. These Recently, several series and small randomized trials
changes correlated with acute reductions in serum [Na?] have shown that large volume saline irrigation with bipolar
and elevated serum AVP levels, despite fluid therapy with transurethral resection is equally efficacious and results in a
only normal saline/Ringers lactate and a positive net reduced risk of postoperative dysnatremia compared with
sodium and fluid balance in the 24 h after surgery. The glycine-based conventional monopolar transurethral
implications are that women may have a greater tendency resection.4852
to retain free water in response to surgical stress. In a case- In general, many patients undergoing surgery should be
control study, Ayus et al.33 found that women and men are considered at risk for the development of postoperative
equally likely to develop hyponatremia and hyponatremic hyponatremia. Any neurologic symptoms during the peri-
encephalopathy after surgery; however, menstruant women operative period should raise suspicion for hyponatremia as
were 28 times more likely than men or postmenopausal a contributor and should prompt urgent evaluation of serum
women to die or to suffer permanent neurologic injury. [Na?]. Judicious attention to perioperative water intake,
There is speculation that estrogen and/or progesterone may fluid therapy, and balance, along with other contributors to
facilitate brain cell adaptation to plasma hypotonicity and hyponatremia can help to avoid the potential consequences
that decreased levels may interfere with the normal of this preventable and often iatrogenic complication.
123
158 S. M. Bagshaw et al.
Principles of clinical management correction should ideally be limited to B10 mmol l-1 and
B18 mmol l-1 over the first 24 and 48 h, respectively.53
There are a few essential questions that should be asked in This course of action requires frequent monitoring of
the approach to the clinical management of the patient with serum [Na?] in response to therapy and continual assess-
hyponatremia: ment for over-correction.
In patients with severe hyponatremia (serum
1. What is the underlying diagnosis of hyponatremia,
[Na?] \ 120 mmol l-1) associated with milder symptoms
and, if known, is there an etiology-specific treatment?
(i.e., nausea, fatigue, lethargy, confusion, unsteadiness),
2. What rate of serum [Na?] correction is considered
active intervention is warranted; however, there is less
safe, given the clinical context?
urgency than for patients with clinical evidence of cerebral
3. What is the risk of central pontine myelinolysis
edema. In these symptomatic patients, serum [Na?] can be
(osmotic demyelination)?
increased at a rate of 1.0 mmol l-1 per hour for 34 h;
4. What is the optimal method for raising the serum
however, the same true rate of correction over the first 24
[Na?]?
and 48 h should be observed.53
5. What is the management approach when the serum
For asymptomatic patients, serum [Na?] must be cor-
[Na?] has been corrected too rapidly?
rected slowly, as cerebral adaptation has occurred at a
recommended rate \1012 mmol l-1 and \18 mmol l-1
Underlying diagnosis and etiology-specific treatment per 24 and 48 h, respectively.53
After correction of hyponatremia, the development of
The initial step in managing the patient with hyponatremia central pontine myelinolysis appears most commonly
is confirming the diagnosis and instituting and/or discon- associated with the underlying chronicity of hyponatremia
tinuing cause-specific predisposing factors. For example, (i.e., allowance for cerebral adaptation) and the rate of rise
this may include correction of ECV depletion with isotonic of serum [Na?] within the first 48 h.54 Sterns et al.54 found
saline, discontinuation of diuretic therapy or other medi- no neurologic complications for patients with serum [Na?]
cations that may contribute to SIADH; initiation of corrected at a rate \12 mmol l-1 per 24 h and
corticosteroid or thyroid hormone replacement, if deficient; \18 mmol l-1 per 48 h, or for patients with an initial
and restriction of free water intake in SIADH or primary serum [Na?] \ 120 mmol l-1 corrected at a rate
polydipsia. B0.55 mmol l-1 per hour. Risks for osmotic demyelination
may also include hypokalemia, liver disease, poor nutri-
tional state, or burn injury.55 Unfortunately, central pontine
Rate of correction of serum [Na?] and central myelinolysis has no effective therapy. Also, it generally
pontine myelinolysis has a poor prognosis, often characterized by permanent or
only partially recovered neurologic deficits. Prevention is
The rate of correction of serum [Na?] depends on the paramount.
clinical presentation and the presence of symptoms.
In general, patients presenting with severe symptomatic Methods to raise the serum [N?]
hyponatremia (i.e., altered mental status, seizures, coma)
require urgent therapy to prevent serious neurologic injury The methods primarily used to raise serum [Na?] are
(i.e., brain herniation) or death. These patients present with broadly divided into the following categories: fluid
acute severe falls in serum [Na?] (i.e., postoperative, restriction, sodium administration, or use of selective va-
associated with ecstasy, exercise-induced), acute or chronic sopressin receptor antagonists.56 The specific therapy
declines in serum [Na?], where brain adaptation to hypo- prescribed will vary depending on the underlying etiology
natremia has already occurred; or they have low tolerance and its severity.
to changes in brain water content (i.e., pre-existing intra- Fluid restriction with the goal of achieving a negative
cranial pathology). In these circumstances, where patients fluid balance is suitable therapy for primary polydipsia and,
manifest symptoms of cerebral edema, a rapid initial cor- in clinical conditions, is associated with either normovol-
rection at a rate of 1.52.0 mmol l-1 per hour for 34 h is emia (i.e., SIADH) or volume overload (i.e., cirrhosis,
necessary. These patients often receive hypertonic saline to congestive heart failure, renal failure).
achieve rapid initial rises in serum [Na?]. While those Administering sodium, most often as saline solution, is
patients with acute declines in serum [Na?] developing in appropriate therapy for the hyponatremia associated with
\24 h often tolerate more rapid correction, determination volume depletion. A crude estimate of the degree to which
of the onset and duration of hyponatremia prior to pres- 1000 ml of saline solution will raise the serum [Na?] can
entation is often not possible. Therefore, the rate of be calculated by the following formula56:
123
Sodium and water abnormalities 159
Epidemiology
Management of overly rapid serum [Na?] correction
Hypernatremia (serum [Na?] [ 148 mmol l-1) has been
Excessively rapid correction of hyponatremia can predis- reported to occur in an estimated 1% of hospitalized elderly
pose to the development of cerebral edema, central pontine patients;64,65 yet, this incidence will fluctuate depending on
myelinolysis, coma, and death. By identifying patients the threshold serum [Na?] and the population being eval-
considered at-risk, attending appropriately to clinical uated. Hypernatremia (serum [Na?] C 150 mmol l-1) has
management, and frequent monitoring, these disabling, been reported in approximately 9% of critically ill patients
largely iatrogenic complications are preventable. at the time of admission and has increased by an additional
There are selected patient cohorts and/or therapies 5.7% of patients during their course in the intensive care
where there may be an increased risk for overly rapid unit.66
correction. Potentially, physicians should anticipate these Several factors have been associated with an increased
clinical contexts where rapid correction may occur. The risk of hypernatremia, including older age, prior brain
administration of hypertonic saline to patients with severe injury, diabetes mellitus, surgery, diuretic therapy, and
symptomatic hyponatremia can contribute to rapid eleva- altered mental status.6466 Most hypernatremia is hospital-
tions in serum [Na?]. Similarly, rapid correction can occur acquired iatrogenic and can be attributed to inadequate or
in hypovolemic patients with hypo-osmolar hyponatremia, inappropriate prescription of fluid therapy to patients with
where ECV has been restored with 0.9% NS. Rapid cor- identifiable water losses, impaired thirst, or reduced access
rection occurs in response to both administration of 0.9% to free water.65
NS (hypertonic relative to serum) and subsequent AVP Similar to hyponatremia, a diagnosis of hypernatremia
suppression after correction of ECV deficit, leading to has been associated with an increased risk for hospital
123
160 S. M. Bagshaw et al.
123
Sodium and water abnormalities 161
insufficient water intake, hypotonic insensible or gastro- another etiology to account for the high urine osmolality
intestinal losses, or sodium overload. The measurement of such as osmotic diuresis, this generally reflects the presence
urinary [Na?] may further aid in discriminating a reduced of DI.
ECV from sodium overload. In conditions of reduced ECV, Central DI refers to polyuria and a urinary concentrating
the urinary [Na?] is typically \25 mEq l-1; whereas, in defect as a consequence of a deficiency of AVP secretion
circumstances of sodium overload, urinary [Na?] is often from the hypothalamic-pituitary axis. True central DI is
[100 mEq l-1. uncommon and most cases can be linked to lesions or
Alternatively, a serum [Na?] [ 145 mmol l-1 or serum injury to the hypothalamus after pituitary surgery, trau-
osmolality [ 295 mOsm kg-1 H2O associated with a urine matic brain injury, aneurysmal subarachnoid hemorrhage,
osmolality \ 700800 mOsm kg-1 H2O suggests a defect and brain death, as well as with tumours, granulomatous
in the capability for urinary concentration. More specifi- infiltration or autoimmune disease. (Table 5) Damage to
cally, if the urine osmolality is less than the serum the neurohypophyseal stalk during neurosurgery or by
osmolality, then a diagnosis of either central (AVP defi- trauma can result in a classic triphasic response.81 This
ciency) or nephrogenic (AVP insensitivity) diabetes syndrome that reflects inhibited release of AVP due to
insipidus (DI) is confirmed. These can be distinguished by hypothalamic dysfunction typically manifests as early
administering exogenous AVP (i.e., dDAVP 10 lg intra- (\24 h) postoperative polyuria lasting 35 days. The sec-
nasal or vasopressin 5 lg subcutaneous). In central DI, ond phase is characterized by release of stored AVP from
urine osmolality will increase by C50%, whereas no sig- the posterior pituitary, often resulting in hyponatremia.
nificant change will occur in nephrogenic DI. Finally, the third phase can again be characterized by
central DI, due to potentially permanent hypothalamic
Insufficient water intake dysfunction that usually occurs in 510 days once stored
AVP is completely depleted from the posterior pituitary.
Hypernatremia, due to inadequate water intake, is usually a Nephrogenic DI refers to polyuria and a urinary con-
consequence of insufficient access to free water, an centrating defect resulting from renal resistance to the
impaired or altered sensation of thirst, or neurologic injury antidiuretic effects of AVP. There are hereditary forms of
with alterations to mental status. Inadequate access to free nephrogenic DI that are usually encountered in children
water, particularly in hospitalized patients, is probably and less commonly in critically ill patients. Hereditary
more common than appreciated. For instance, in one nephrogenic DI can result from either gene mutations to the
observational study, 86% of hospitalized patients (mostly
elderly) found with hypernatremia had evidence of inade-
Table 5 Differential diagnosis of central diabetes insipidus
quate access to water.65 In addition, there are likely age-
related declines in thirst (i.e., hypodipsia-adipsia). For Idiopathic-autoimmune
example, in response to a 24-h water deprivation, despite Primary neurologic
increases in serum osmolality, serum [Na?], and vaso- Neurosurgery (usually transphenoidal)
pressin levels, elderly men experienced reduced thirst and Traumatic brain injury
water intake when compared with younger adults.78,79 Aneurysmal subarachnoid hemorrhage
True deficits in thirst and osmoregulation are more Hypoxic-ischemic encephalopathy
likely to occur in patients with acquired hypothalamic Brain death
structural lesions from conditions such as traumatic brain Tumours
injury, tumours, granulomatous infiltration (i.e., sarcoid), Leukemia
and vascular disease.80 Lymphoma
Conditions that cause an alteration in a patients mental Metastatic lung cancer
status (i.e., delirium) or that bring about a significant Infiltrative disorders
neurologic injury (i.e., stroke) would certainly aggravate Histiocytosis X-eosinophilic granuloma
age-related declines in thirst and hypodipsia from hypo- Sarcoidosis
thalamic lesions. Wegeners granulomatosis
Autoimmune lymphocytic hypophysitis
Diabetes insipidus Other
Anorexia nervosa
In general, a urine osmolality\ 800 mOsm kg-1 H2O, in the Acute fatty liver of pregnancy
setting of an elevated serum osmolality ([295 mOsm kg-1 Post-supraventricular tachycardia
H2O) or hypernatremia (serum [Na?] [ 145 mmol l-1), is Familial-Wolfram syndrome
indicative of a renal concentrating defect. In the absence of
123
162 S. M. Bagshaw et al.
AVP-2 receptor or to the AQP-2 water channels. Acquired and/or function of the AQP-2 channels. Similar to lithium
nephrogenic DI is typically related to either AVP resistance and hypercalcemia, persistent hypokalemia (serum
at the site of action in the distal tubule or collecting ducts [K?] \ 2.5 mmol l-1) can decrease the renal responsive-
or interference in the medullary countercurrent mechanism, ness to AVP through reduced AQP-2 expression and/or
causing impaired renal concentrating capacity. Lithium function and diminished thick ascending loop reabsorption
toxicity and metabolic abnormalities, particularly hypo- of Na? and Cl-.
kalemia and hypercalcemia, are the most common causes
of acquired nephrogenic DI, but numerous other etiologies Other renal hypotonic fluid losses
have been implicated82 (Table 6). Long-term lithium
therapy can lead to polyuria and impaired renal concen- There are several additional renal causes of hypotonic fluid
trating defects in an estimated 2030% of patients and DI losses.
in 1012% of patients, due to the down-regulation of AVP- Osmotic diuresis is caused by an excess of urinary sol-
2 receptors and/or reduced expression of AQP-2 chan- ute, typically non-reabsorbable, that induces polyuria and
nels.83,84 Hypercalcemia (serum [Ca?] [ 2.75 mmol l-1) hypotonic fluid loss. Osmotic diuresis can result from hy-
can impair maximal urine concentrating capacity by perglycemia (i.e., diabetic ketoacidosis), use of mannitol,
causing a reversible defect in Na? and Cl- reabsorption in increased serum urea concentration, or administration of
the ascending loop of Henle and by decreased expression other hypertonic therapies.
The use of diuretics (i.e., loop or thiazide diuretics) is
also common in critically ill patients and can contribute to
Table 6 Differential diagnosis of nephrogenic diabetes insipidus
hypotonic urinary fluid losses.
Antibiotics The relief of complete post-renal urinary obstruction can
Demeclocycline initially be associated with a large diuresis. While much of
Ofloxacin this diuresis may be appropriate, there may also be a mild
Rifampin urinary concentrating defect due to down-regulation of
Netilmicin AQP-2 channels that can predispose to significant hypo-
Antifungals tonic fluid loss.
Amphotericin B
Antivirals Non-renal hypotonic fluid losses
Cidofovir
Foscarnet Insensible fluid losses from the skin (i.e., sweat) and from
Indinavir the respiratory tract (i.e., evaporation) are generally hyp-
Tenofovir otonic to serum; hence, if losses are not replaced,
Antineoplastics hypernatremia will ensue in circumstances of increased
Cyclophosphamide insensible fluid loss, such a fever, diaphoresis or tachypnea.
Ifosfamide Critically ill patients with burns or postoperative patients
Methotrexate with open abdominal or other surgical wounds may be at
Metabolic abnormalities risk for greater insensible fluid loss and need to be moni-
Hypokalemia tored accordingly.
Hypercalcemia Fluid losses from the gastrointestinal tract are also
Other drugs generally hypotonic to serum, and, consequently, will lead
Radiocontrast media to hypernatremia if not replaced. These losses can occur
Colchicine from vomiting, nasogastric drainage, enterocutanous fistu-
Ethanol las, or diarrhea. The use of osmotic cathartic agents (i.e.,
Orlistat
lactulose) or various oral medication suspensions (i.e.,
Lithium
sorbitol) can also lead to hypotonic fluid losses.
Other conditions
Water shift into cells
Sjogrens syndrome
Sickle cell disease
Transient hypernatremia can be induced by intense exer-
Release of urinary tract obstruction
cise or by prolonged convulsive seizure activity.85,86 This
Amyloidosis
phenomenon typically occurs in the context of marked
Pregnancy
lactic acidosis and can transiently raise serum [Na?] by
From Ref.82 1015 mmol l-1. The breakdown of glycogen into
123
Sodium and water abnormalities 163
osmotically more active solutes acutely raises intracellular insensible fluid losses (i.e., treating fever), treating hyper-
osmolality and, as a consequence, induces a shift of hyp- glycemia and glucosuria, and adjusting enteric-parenteral
otonic fluid from the extracellular to the intracellular feeding solutions.
compartment. The serum [Na?] generally returns to normal Diabetes insipidus causes hypernatremia by inducing
in ten to 15 min and is not associated with any apparent polyuria and renal free water loss. Management should be
sequelae. directed at the underlying precipitating factor(s), when
possible; at strategies to reduce urine output, and at
Sodium overload replacement of previous and ongoing fluid losses. In central
DI, where the primary defect is AVP deficiency, patients
Acute and often severe hypernatremia can be induced by with normal mental status and access to free water often
administering hypertonic solutions containing sodium or by have mild hypernatremia, due to the compensatory stimu-
ingesting a massive amount of salt. lation of thirst. However, hypernatremia can develop
In critically ill patients, the administration of sodium rapidly in those with altered mental status, impaired thirst
bicarbonate for a range of conditions, such as metabolic mechanisms, and/or reduced access to free water. In gen-
acidosis, tricyclic antidepressant overdose, and rhabd- eral, the polyuria associated with DI can usually be
omyolysis, can potentially lead to hypervolemic controlled by hormone replacement with AVP analogues
hypernatremia. Similarly, hypernatremia can occur with that have potent anti-diuretic properties, such as desmo-
hypertonic saline treatment, as may be used to manage pressin (dDAVP) (intranasal 520 lg once or twice per
intracranial hypertension in traumatic brain injury. day; oral 0.050.8 mg in divided doses per day; and sub-
Enteral nutrition with hyperosmolar or high protein cutaneous 1 lg every 12 h).94,95 Desmopressin use is
feeds accompanied by insufficient free water may lead to generally considered safe; however, it can be associated
hypernatremia, particularly in patients receiving chronic with an increased risk for development of hyponatremia,
nutritional support. due to impaired free water excretion from non-suppressible
Numerous reports of severe hypernatremia after surgery AVP activity after administration, particularly if free water
with hypertonic saline irrigation for hydatid cysts (echi- intake or administration is continued.95,96 Additional
nococcus granulosus) have been reported.8789 Iatrogenic medications, either alone or in combination with desmo-
hospital-acquired hypernatremia has also been reported pressin, may occasionally be needed to control polyuria for
with use of hypertonic saline in gastric lavage and hyper- the chronic management of central DI. These can be used
tonic saline-soaked wound packs for gas gangrene.90,91 to increase AVP release (clofibrate 500 mg every 6 h), to
There are also several reports of accidental or non- enhance renal response to AVP or desmopressin (chlor-
accidental acute salt poisoning and extreme hypernatremia, propamide 125 mg once or twice per day; carbamazepine
due to massive ingestion of table salt or use of salt or 100300 mg twice daily), or to act to reduce urine output
hypertonic saline as an emetic.92,93 independent of AVP (hydrochlorothiazide 2550 mg once
or twice per day; selected therapy with non-steroidal anti-
Principles of management of hypernatremia inflammatory drugs). In nephrogenic DI, where the primary
defect results from partial or complete renal resistance to
In the approach to the clinical management of the patient AVP after correction of potential precipitation factors, the
with hypernatremia, there are three essential questions that management is generally aimed at reducing polyuria by a
should be asked: combination of low sodium-low protein diet (reduced sol-
ute excretion), thiazide diuretics (mild volume depletion),
1. What is the underlying diagnosis of hypernatremia,
and/or selective use of non-steroidal anti-inflammatory
and, if known, is there an etiology-specific treatment?
drugs (altered renal prostaglandin synthesis). For those
2. What rate of correction of serum [N?] is considered
patients with partial resistance, supplemental dDAVP may
safe, given the clinical context?
increase the renal response to AVP.97
3. What is the volume of free water that is needed to raise
In patients with hypothalamic lesions, whereby the
the serum [N?] and correct the deficit?
stimulus for thirst is impaired, management can be chal-
lenging and may resort to forced water intake to maintain
Underlying diagnosis and etiology-specific treatment normal or near normal serum [Na?]. Therapy for essential
hypernatremia, whereby osmostat has been reset, remains
The initial step in managing the patient with hypernatremia uncertain; however, this condition is more often chronic,
is confirming the diagnosis and instituting and/or discon- mild, and asymptomatic.
tinuing cause-specific predisposing factors. For example, Primary sodium overload can lead to acute and severe
this may include preventing further gastrointestinal or hypernatremia, usually after administration of hypertonic
123
164 S. M. Bagshaw et al.
sodium-containing solutions (i.e., hypertonic saline, It is important to recognize that this formula only pro-
sodium bicarbonate) or massive salt ingestion. In patients vides an estimate of the free water deficit or the positive
with preserved kidney function, the excess sodium is water balance that is needed to restore serum [N?] to
generally excreted rapidly in the urine. Serum [Na?] cor- 140 mmol l-1. This estimate for water replacement does
rection can be further augmented by the addition of a loop not account for ongoing water losses (i.e., insensible, urine
diuretic to promote diuresis along with replacement of output, gastrointestinal tract). Similarly, this formula does
urine fluid losses with electrolyte-free water. Management not account for iso-osmotic fluid losses (i.e., osmotic diu-
can be more challenging for patients with acute kidney resis or diarrhea) that may contribute to ECV depletion. As
injury and/or with pre-existing chronic kidney disease a consequence, when determining the amount and rate of
where sodium elimination is impaired. These patients free water replacement, these ongoing losses must be
should be considered for early initiation of renal replace- considered in addition to the pre-existing deficit.
ment therapy, particularly if symptomatic.
123
Sodium and water abnormalities 165
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