Aetiologies of

Hyponatremia
in post-op patients
FELLICIA STANZAH
MBBS IV
Case Vignette
Mrs X, 70yo female
PC to ED for CT confirmed appendicitis
◦ Background: 5/7 abdominal pain
Next day: Laparoscopic caecectomy – perforated appendicitis
Post op Tx
◦ IV metronidazole, IV amoxicillin
◦ DVT prophylaxis
◦ Analgesia
Day 2 post-op: MET call for hypertensive + tachycardia
◦ Abdominal pain + distension
◦ BNO since operation
◦ NGT inserted
 Case Vignette - Investigation
•Afebrile •CXR: unremarkable
•Systolic: 185s •AXR: distended bowel loop – likely ileus related
•HR:100s
•TFTs & LFTs: unremarkable
•Random cortisol: 973 nmol/L
•eGFR: >90
•Nill fluid overload sx
•Serum sodium: 109 mmol/L
•Serum osmolarity: 220 mmol/L
•Urine sodium: 121 mmol/L
•Urine osmolality: 438 mOsm/kg
Hyponatremia
● Definition: serum sodium level of < 135 mEq/L
● Classification by Joint European Guidelines:
○ Mild: 130-134 mmol/L
○ Moderate: 125-129 mmol/L
○ Severe: <125 mmol/L or with cerebral symptoms
● Sign/symptom of hyponatremia
○ asymptomatic
○ Anorexia, nausea/vomiting, lethargy
○ Muscle cramps → muscle weakness
○ Headache, confusion → seizure, coma
Aetiologies post-op hyponatremia
1. Hypotonic
o Hypo-vol
2. Hypertonic
o Eu-vol
(increase serum osmolality)
3. o
Isotonic (normal serum osmolality)
Hyper-vol

*pseudohyponatremia – lab value inaccuracy:

o Hyperglycaemia (translocational hyponatremia ~ dilutional hyponatremia)

o Hyperlipidaemia
o Hyperproteinaemia (e.g. multiple myeloma)
Aetiologies post-op hyponatremia
1. Hypotonic
Hypo-volaemic Eu-volaemic Hyper-volaemic
• Vomiting, diarrhoea, NG suction • Drugs • CHF
• Excess diuretics • SIADH • Liver failure / cirrhosis
• Sepsis • Primary polydipsia • Renal failure, Nephrotic syndrome
• Burns • CNS abnormalities • Dilutional fluid overload
• Pancreatitis • Hypothyroidism
• Hypoaldosteronism
(Iatrogenic)
Aetiologies post-op hyponatremia
1. Hypotonic
Hypo-volaemic Eu-volaemic Hyper-volaemic
• Vomiting, diarrhoea, NG suction • Drugs • CHF
• Excess diuretics • SIADH • Liver failure / cirrhosis
• Sepsis • Primary polydipsia • Renal failure, Nephrotic syndrome
• Burns • CNS abnormalities • Dilutional fluid overload
• Pancreatitis • Hypothyroidism
• Hypoaldosteronism
(Iatrogenic)

ISSUE:
Loss Na+ & H2O
Low intravascular volume → baroreceptor → ADH
→ water repletion > sodium → hypotonic hyponatremia
→ ↓GFR → RAAS
Aetiologies post-op hyponatremia
1. Hypotonic
Hypo-volaemic Eu-volaemic Hyper-volaemic
• Vomiting, diarrhoea, NG suction • Drugs • CHF
• Excess diuretics • SIADH • Liver failure / cirrhosis
• Sepsis • Primary polydipsia • Renal failure, Nephrotic syndrome
• Burns • CNS abnormalities • Dilutional fluid overload
• Pancreatitis • Hypothyroidism
• Hypoaldosteronism
(Iatrogenic)

Vomit / diarrhoea / suction → loss H2O, Na+, Cl-

Aetiologies post-op hyponatremia
1. Hypotonic
Hypo-volaemic Eu-volaemic Hyper-volaemic
• Vomiting, diarrhoea, NG suction • Drugs • CHF
• Excess diuretics • SIADH • Liver failure / cirrhosis
• Sepsis • Primary polydipsia • Renal failure, Nephrotic syndrome
• Burns • CNS abnormalities • Dilutional fluid overload
• Pancreatitis • Hypothyroidism
• Hypoaldosteronism
(Iatrogenic)

Thiazide at DCT → inhibit Na-K-Cl co-transporter

→ limit Na+ & H2O reabsorption
Loop diuretics at thick ascending LOH → inhibit Na-Cl co-transporter
Aetiologies post-op hyponatremia
1. Hypotonic
Hypo-volaemic Eu-volaemic Hyper-volaemic
• Vomiting, diarrhoea, NG suction • Drugs • CHF
• Excess diuretics • SIADH • Liver failure / cirrhosis
• Sepsis • Primary polydipsia • Renal failure, Nephrotic syndrome
• Burns • CNS abnormalities • Dilutional fluid overload
• Pancreatitis • Hypothyroidism
• Hypoaldosteronism
(Iatrogenic)

Third spacing +/- shock → ↓BP → ↓glomerular filtration → RAAS, ADH

Aetiologies post-op hyponatremia
1. Hypotonic
Hypo-volaemic Eu-volaemic Hyper-volaemic
• Vomiting, diarrhoea, NG suction • Drugs • CHF
• Excess diuretics • SIADH • Liver failure / cirrhosis
• Sepsis • Primary polydipsia • Renal failure, Nephrotic syndrome
• Burns • CNS abnormalities • Dilutional fluid overload
• Pancreatitis • Hypothyroidism
• Hypoaldosteronism • Adrenal insufficiency
(Iatrogenic)
Aetiologies post-op hyponatremia
1. Hypotonic
Hypo-volaemic Eu-volaemic Hyper-volaemic
• Vomiting, diarrhoea, NG suction • Drugs • CHF
• Excess diuretics • SIADH • Liver failure / cirrhosis
• Sepsis • Primary polydipsia • Renal failure, Nephrotic syndrome
• Burns • CNS abnormalities • Dilutional fluid overload
• Pancreatitis • Hypothyroidism
• Hypoaldosteronism
(Iatrogenic)

ADH stimulator: narcotics, nicotine, phenothiazines

ADH potentiator: carbamazepine, SSRI, clozapine, ecstasy, vincristine
Aetiologies post-op hyponatremia
1. Hypotonic
Hypo-volaemic Eu-volaemic Hyper-volaemic
• Vomiting, diarrhoea, NG suction • Drugs • CHF
• Excess diuretics • SIADH
SIADH • Liver failure / cirrhosis
• Sepsis • Primary polydipsia • Renal failure, Nephrotic syndrome
• Burns • CNS abnormalities • Dilutional fluid overload
• Pancreatitis • Hypothyroidism
• Hypoaldosteronism
(Iatrogenic)
Aetiologies post-op hyponatremia
1. Hypotonic
Eu-volaemic ● SIADH - Excessive vasopressin (AVP) / ADH
• Drugs ○ ↓serum sodium (<135 mEq/L)
• SIADH ○ ↓serum osmolality (< 275 mOsm/kg)
• Primary polydipsia ○ ↑ urine osmolality (> 100 mOsm/kg H2O)
• CNS abnormalities
• Hypothyroidism
○ ↑ urinary sodium (> 20 mmol/L)
● SIADH post major surgery / Trauma
○ Pain / stress - associated to ↑ADH secretion
■ mediator: reticular formation, ventral thalamus and
hypothalamus
○ ADH response parallel to cortisol & aldosterone
Aetiologies post-op hyponatremia
1. Hypotonic
Hypo-volaemic Eu-volaemic Hyper-volaemic
• Vomiting, diarrhoea, NG suction • Drugs • CHF
• Excess diuretics • SIADH • Liver failure / cirrhosis
• Sepsis • Primary polydipsia • Renal failure, Nephrotic syndrome
• Burns • CNS abnormalities • Dilutional fluid overload
• Pancreatitis • Hypothyroidism
• Hypoaldosteronism
(Iatrogenic)

ISSUE:
end result ↑Na+ & H2O in body,
BUT H2O >>>> Na+
Aetiologies post-op hyponatremia
1. Hypotonic
Hypo-volaemic Eu-volaemic Hyper-volaemic
• Vomiting, diarrhoea, NG suction • Drugs • CHF
• Excess diuretics • SIADH • Liver failure / cirrhosis
• Sepsis • Primary polydipsia • Renal failure, Nephrotic syndrome
• Burns • CNS abnormalities • Dilutional fluid overload
• Pancreatitis • Hypothyroidism
• Hypoaldosteronism
(Iatrogenic)

↓CO → ↑RAAS (from ↓GFR ) + ADH → volume overload, dilutional hyponatremia

 Aetiologies post-op hyponatremia
1. Hypotonic
Hypo-volaemic Eu-volaemic Hyper-volaemic
• Vomiting, diarrhoea, NG suction • Drugs • CHF
• Excess diuretics • SIADH • Liver failure / cirrhosis
• Sepsis • Primary polydipsia • Renal failure, Nephrotic syndrome
• Burns • CNS abnormalities • Dilutional fluid overload
• Pancreatitis • Hypothyroidism
• Hypoaldosteronism
(Iatrogenic)

Portal HTN → systemic vasodilation → stimulate RAAS & ADH release → H2O reabsorption > Na+ → dilutional hyponatremia
Aetiologies post-op hyponatremia
1. Hypotonic
Hypo-volaemic Eu-volaemic Hyper-volaemic
• Vomiting, diarrhoea, NG suction • Drugs • CHF
• Excess diuretics • SIADH • Liver failure / cirrhosis
• Sepsis • Primary polydipsia • Renal failure, Nephrotic syndrome
• Burns • CNS abnormalities • Dilutional fluid overload
• Pancreatitis • Hypothyroidism
• Hypoaldosteronism
(Iatrogenic)

↓Kidney function → ↓↓GFR → ↓water excretion

Treatment
TREAT UNDERLYING CAUSE
◦ Adrenal insufficiency: glucocorticoids - direct ADH release supression
◦ Hypothyroidism: replace
◦ Cessation drug
◦ (true) Vol ↓ : isotonic saline
◦ Loop diuretic for CHF / nephrotic syndrome
◦ Spironolactone for cirrhosis / ascites
◦ Mild/Moderate w/o cerebral sx hyper/euvolaemic: fluid restriction, monitor

ACUTE (<48h) + SEVERE (<125 mmol/L) &/or with cerebral sx

◦ Na replacement
◦ IV sodium chloride 3% (513 mmol/L)
◦ 100mL over 10 minutes – repeated PRN, max 3x
◦ Acute onset risk: cerebral oedema
Treatment
CHRONIC (>48h)
Central Pontine myelinosis
◦ High correction rate → osmotic demyelination, permanent damage
◦ (Chronic hyponatremia is more at risk)
◦ Avoid overcorrection: goal 4-8mmol/L daily
◦ AT RISK: hypokalemia, serum sodium < 105mmol/L, alcoholism, malnutrition, advance liver disease
◦ Limit goal to 4-6mmol/L daily

Calculation of serum sodium increase

↑ serum sodium / L [𝟓𝟏𝟑 − 𝒎𝒆𝒂𝒔𝒖𝒓𝒆𝒅 𝒔𝒆𝒓𝒖𝒎 𝒔𝒐𝒅𝒊𝒖𝒎 𝒄𝒐𝒏𝒄 𝒎𝒎𝒐𝒍/𝑳 ]

=
of infused NaCl 3% [𝒕𝒐𝒕𝒂𝒍 𝒃𝒐𝒅𝒚 𝒘𝒂𝒕𝒆𝒓 𝒌𝒈 + 𝟏]
*Women: total body water (kg) = body weight x 0.5 (nonelderly) or x 0.45 (elderly).
*Men: total body water (kg) = body weight x 0.6 (nonelderly) or x 0.5 (elderly)
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