WATER BALANCE : HYPONATREMIA AND HYPERNATREMIA

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CHAPTER 3

Disorder of Water Balance: Hyponatremia & Hypernatremia

Clancy Howard,MD & Tomas Berl,MD DIBACAKAN OLEH:

dr. I GEDE PUTU JARWA ANTARA

Term use in this textbook

Osmolarity is defined as the number of osmoles of solute

per liter (L) of solution. It is expressed in terms of osmol/L or Osm/L Osmolality is defined as the number of osmoles of solute per kilogram of solvent. It is expressed in terms of osmol/kg or Osm/kg.

Cont
The molality and molarity of a weak aqueous

solution happen to be nearly the same, as one kilogram of water (the solvent) occupies 1 liter of volume at room temperature and the small amount of solute would have little effect on the volume
Ex. Density of water in room temperature is 1 kg/L Density of ethanol is 0.789 kg/L

 Millimoles (mmol) used by SI to express electrolyte

concentrations in millimoles per liter (mmol/L).

For monovalent species, the numeric values of the

milliequivalent and millimole are identical

Ex : 1 mmol of Na+ = 1 mEq Na

1 mmol of Ca++ = 2 mEq Ca++

Physiology of Water Balance

In steady state water intake = water losses The tonicity of body fluid within narrow range controlled by Vassopressin/AVP/ADH This regulation maintain serum osmolality to 280-290 mOsm/kg

Physiology of Water Balance

ADH acts at the distal nephron to

decrease the renal excretion of water. Action of ADH: to concentrate the urine and, as a result, dilute the serum.

Physiology of Water Balance

Hyponatremia

General Considerations
Hiponatremia present when sodium concentration falls

below 135 mEq/L Hyponatremia develops when the intake of water exceeds the ability to excrete it leading to dilution of total body sodium.

 Sodium concentration is the major determinant of plasma

osmolality, therefore hyponatremia usually indicates a low plasma osmolality. Plasma osmolality can be estimated by the following equation:
= 2

+ / /2.8 +

/ /18

Clinical Findings
A. Symptoms & Sign of hyponatremia Hyponatremia Cellular edema occurs and the symptoms of hyponatremia can result. Over a period of days the cells of the brain adaptation decreasing intracellular tonicity.

Clinical Findings
A. Symptoms & Sign of hyponatremia Result from cellular and cerebral edema :
Headache Confusion Weakness

psychosis,
ataxia, seizures,

coma

Clinical and laboratory findings of hypovolemia:

Diminished skin turgor
flattened neck veins dry mucous membranes

orthostatic hypotension
tachycardia. a urinary sodium

concentration < 10 mEq/L.

 An increased extracellular

Hypervolemic hyponatremia is

volume may be evidenced by

distended neck veins pulmonary edema

generally due to:

congestive heart failure,
Cirrhosis nephrotic syndrome, or advanced

Ascites
lower extremity edema. sodium concentration < 10

renal failure.

mEq/L.

Differential Diagnosis

Differential Diagnosis

Water move from intracellular to ekstrasellulear

Differential Diagnosis

Adding 1.62.4 mEq/L for every 100 mg/dL increase in the plasma glucose

Differential Diagnosis

hypotonic fluid administration

inability to appropriately dilute the urine

TREATMENT
EUVOLEMIC HYPONATREMIA Conservative Restricting fluid intake by 1 L/24 hr Rapid correction if acute symptomatic hyponatremia (< 48 hr) with 3% salin with initial rate 1-2 ml/kgbw/hr until sodium rise 10% or neurologic symptoms resolve Rate of sodium rise not exceed 1 mEq/L/hr or 12 Meq/day to minimize CPM

TREATMENT
EUVOLEMIC HYPONATREMIA Body water excess (L) = 0.6 x Wgt (kg) x [1-([Na]/[desired [Na])] Low dose of loop diuretic can be used to initiate diuresis

TREATMENT
HYPOVOLEMIC HYPONATREMIA Correction of the volume deficit Asymptomatic hyponatremia should be treated with volume restoration with isotonic 0,9% saline If present more than 48 hr, correct slowly with 0,9% saline or 0,45 saline The rise should not exceed 1 mEq/L/hr or 12 mEq/L in 24 hr

TREATMENT
HYPERVOLEMIC HYPONATREMIA Generally chronic and relatively mild Treatment involves sodium and water restriction Using loop diuretic and manage underlying disorder

Perkiraan Total Body Water (TBW) dihitung sebagai fraksi berat badan.
Pada anak-anak 60% BB Pria dan wanita dewasa masing

masing 60% dan 50%

Pria dan wanita lansia masing

masing 50% dan 45%.

Adrogue, HJ: Hyponatremia. NEJM 2000; 342:21 p1581-89

DAFTAR BEBERAPA JENIS INFUS DI RS SANGLAH DAN KANDUNGANNYA

NAMA Glucose 50 g/L Na + mEq/L 38,5 Chlrid mEq/L 38,5 Ptssim mEq/L Lactat mEq/L Ca mEq/L Mg mEq/L Asetat mEq/L Osm

D5 NS

355

D5 NS RL NaCl 0,9% NaCl 3 % KAEN 3B KAEN 3A ASERING INFUSAN RING-AS TRIDEX 27 B KALBE

50

77 130 154 513 50 60 130 131

77 108,7 154 513 50 50 108,7 109 20 10 4 4 20 20 2,7 2,7 28 28 4 28 2,7

431 273 308

290 290 273,4 273

27

50

50

20

20

290

Case
Ex M, 45 yo , BW 60 kgs, hyponatremia hypoosmolar euvolemic acute symptomatic, with sodium level 110 Problem:
Sodium target ? Rate of fluid ?

Case
TBW = 60% x 60 kg = 36 Cairan yg dipakai NaCl 3% kandungan Na 513 mmol/L Maka 1 liter NaCl 3% akan menaikkan Na sebanyak

513 110 36+1

= 10.8 mmol

Jika target nya adalah dalam sehari adalah peningkatan sebanyak 10%( 11 mEq) maka, jumlah NaCl yang diberikan dalam 1 hari adalah 11/10.8 1 liter dengan kecepatan 14 tts/mnt Atau jika target nya sampai gejala hilang dengan maksimal koreksi 2 mmol/L per jam maka kecepatan tetesannya 60 tts/mnt

HYPERNATREMIA
When sodium concentration > 145 mEq/L Reflection of hyperosmolar state Clinical sign of neurogical symptom include irritability,

lethargy, muscle spasm, seizures, coma and death. Chronic hypernatremia is less symptomatic at the same degree than acute hypernatremia

DIFFERENT DIAGNOSIS

TREATMENT

TREATMENT
Hipovolemic Hypernatremia Restoration of volume deficit with isotonic salin (0,9%) Once signs of circulatory compromise are resolved, the remain of sodium and water deficit should be carefully replaced with 0.45 % saline

TREATMENT
Euvolemic Hypernatremia Estimation of water deficit Water deficit (L) = 0.6 x Wgt (kg) x [([Na]/140 - 1] Symptomatic acute hypernatremia should be treated by rapid replacement of water deficit Once neurologic symptom have resolved, the remainder of deficit may be replaced over 24-48 hr Symptomatic chronic hypernatremia , requires urgent therapy but should not exceed than 1 mEq/L/hr

TREATMENT
Euvolemic Hypernatremia Requires the estimation and replacement of water deficit Estimation of hourly water replacement (mL/hr) = [water deficit (ml) / ([Na] 140)] + ongoing water losses (mL) Water deficit may be replaced either enterally as water or intravenously as 5% dextrose in water.

TREATMENT
Hypervolemic Hypernatremia Requires the removal of excess sodium by administration of diuretic. For those with significantly impaired renal function, dialysis can be employed.

Perkiraan Total Body Water (TBW) dihitung sebagai fraksi berat badan.
Pada anak-anak 60% BB Pria dan wanita dewasa masing

masing 60% dan 50%

Pria dan wanita lansia masing

masing 50% dan 45%.

Adrogue, HJ: Hypernatremia. NEJM 2000; 342:22 p1493-9

DAFTAR BEBERAPA JENIS INFUS DI RS SANGLAH DAN KANDUNGANNYA

NAMA Glucose 50 g/L Na + mEq/L 38,5 Chlrid mEq/L 38,5 Ptssim mEq/L Lactat mEq/L Ca mEq/L Mg mEq/L Asetat mEq/L Osm

D5 NS

355

D5 NS RL NaCl 0,9% NaCl 3 % KAEN 3B KAEN 3A ASERING INFUSAN RING-AS TRIDEX 27 B KALBE

50

77 130 154 513 50 60 130 131

77 108,7 154 513 50 50 108,7 109 20 10 4 4 20 20 2,7 2,7 28 28 4 28 2,7

431 273 308

290 290 273,4 273

27

50

50

20

20

290

Case
Ex M, 45 yo , BW 60 kgs, hypernatremia hyperosmolar euvolemic acute symptomatic, with sodium level 170 Problem:
Sodium target ? Rate of fluid ?

Choosing of fluid ?

Case
TBW = 60% x 60 kg = 36
Jika cairan yg dipakai D5% kandungan Na 0 mmol/L Maka 1 liter D5% akan menurunkan Na sebanyak

0 170 36+1

= 4.6 mmol

Jika target mencapai kadar Na 140 maka diperlukan cairan D5% sebanyak nya (170 140) / 4.6 = 6.5 ltr Jika menghitung dengan rumus water deficit diperoleh 0.6 x 60 x (170/140 1) = 7.7 ltr

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