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Interactive session on Sodium

Homeostasis

Dr.M.Emmanuel Bhaskar
Assistant Professor in Medicine
SRMC & RI
Plan for Interaction
• Presentation of scenario-1.
• 7 Interactive questions followed by
answers for the same
• Presentation of scenario-2.
• 3 Interactive questions followed by
answers for the same
• Questioning by the delegates.
Approach to Hyponatremia…
My first question

Sir…What should I read to evaluate


and treat Sodium imbalance
Good…read about behaviour
of……….
…….water!!
Scenario-1
A 55 yr old lady with complaints of :

Fever and Cough with expectoration-5 dys

Altered behaviour-8 hours


Examination
An Unconscious patient with preserved
brain
Stem reflexes, preserved perception of deep
Stimuli and hemodynamically stable

Other systems unremarkable


Investigations
In the Emergency Room:
CBG- 125 mg/Dl

ABG-Ph:7.46 , PCo2-26 mmHg,


HCO3-21meq/L, Pao2-110 mmHg
Investigations
CXR-PA View:Rt Upper lobe consolidation
Hb%-12 g/dl Na-106 meq/l
TC-20,000 cells K- 3.6 meq/l
DC-P 75 L 20 E 5 Cl-92 meq/l
Creatinine-1 mg/dl HCo3-20 meq/l
BUN-8mg/dl S.Osmolality-213 osm
Urine:
Specific gravity:1.015 Ph: 5.0
Sugar :Nil
Albumin- trace
Pus cells-4-5, no casts
Urinary spot Na- 80 meq/L

CT-Brain –Normal CSF- Normal


1.Comment on the scenario with
stress on hyponatremia
Summary
Euvolemic symptomatic hyponatremia

Serum Hypo-osmolality

Normal urine specific gravity

Urinary spot Na-80 meq/L


Possibilities to be considered

SIADH

Cerebral / Renal salt wasting with


subclinical hypovolemia.
2.How to diagnose SIADH
Diagnosis of SIADH
Euvolemia

↓Serum Osmolality [<275 mOsm/kg]

↑Urine Osmolality [ >100 mOsm/kg ]

Spot urinary Na > 40 meq/L


Diagnosis of SIADH
Euvolemia

More water in serum

Inappropriately Less water in urine

Abnormal urinary sodium loss


Practical Problems in diagnosing
SIADH

By definition serum and urine osmolality


should be measured

But most of us get only the calculated value


Practical way of diagnosing SIADH
-Euvolemia
-Calculated serum.osmolality is as good as
measured , except in cases of CRF and
toxin intake.
-Urine specific gravity may be used in place
of urine osmolality [newer methods
eliminates sugar and protein ]
-Urine Na >40 meq/L
How to use urine sp.gravity to
diagnose SIADH

When serum osmolality↓ the appropriate


Urine specific gravity must be <1.005

A specific gravity of >1.005 indicates a


Urine osmolality >100 mOsm/kg
Our Patient

Euvolemic

Serum osmolality-213 mOsm

Urine specific gravity-1.015

Urinary Na- 80 meq/L


3.Conditions to be ruled out
when SIADH is suspected
Conditions to be ruled out when
SIADH is suspected

Adrenal Insufficiency

Hypothyroidism

Diuretic use

CSW / RSW with sub-clinical hypovolemia


SIADH vs CSW/RSW

How to differentiate???
SIADH vs Wasting Hyponatremia
CSW/RSW is a volume contracted state

But in early stages hypovolemia-subclinical

↑BUN in CSW / RSW ,N or ↓BUN in SIADH

Urinary Na>150 meq points to Na wasting


Our Patient has SIADH
4.What is the plan of Na
correction over the next 24 hours
Plan of Na correction over the next
24 hours

0.75 meq/hour for 8 hours= 6meq over 8hr

If appropriate response occurs,


0.20 meq/hour for 16 hours=3meq over 16h

Total=9 meq over 24 hours


5.What is the infusate and how to
decide the rate per hour ?
Adrogue-Madias Formula???
Adrogue-Madias Formula

Overcorrects the Na in 60% of cases

Required modification

A correction factor was evolved.


Volume of infusate to attain the
desired Na value

Body water X Desired increment in Na


Infusate Na X 1.5

3% NaCl- 513 meq/L


0.9% NaCl- 154 meq/L
Plan for the first 8 hours
Body water X Desired increment in Na
Infusate Na X 1.5

30x6 = 0.23 litre or 230 ml


513X1.5
230 ml in 8 hours=30 ml/hour
For the next 16 hours
If appropriate response occurs over the
first 8 hours, then
3 meq/L increment in Na next 16 hours
120 ml over 16 hours = 8 ml/hour next 16h
6.When does overcorrection
occur ?
When does overcorrection occur

Failure to diagnose subclinical hypovolemia


Caused by a wasting syndrome

Sub-clinical hypovolemia can be effectively


diagnosed using BUN.
7.When does undercorrection
occur ?
When does undercorrection occur
In SIADH:
-Failure to restrict fluids < 1 liter/24 hours
-Excessive 0.9% saline administration
leads to selective water retention due to
the action of ADH.This blunts the response
to hypertonic saline.
Hyponatremia-Summary
• SIADH can be diagnosed using calculated
serum osmolality and urine sp.gravity
• Rule out Adrenal insuff,hypothy,wasting
hyponat with subclinical hypovolemia
• BUN helps to identify subclin hypovol
• 0.75 meq – 8 hours and subseq slow corr
• Causes of inappropriate correction
Scenario-2
A 75 yr old man admitted with
Impaired level of Consciousness-24 hours

This was preceded by fatigue and impaired


Ambulation for 3 days.
On Examination:
An Unconscious patient responding to deep
Stimuli

Other systems were unremarkable


Investigations
In ER:

CBG-98 mg/dl

ABG-Normal
Investigations
Hb%-16 g/dl Na-158meq/l
PCV-42 K- 4 meq/l
TC-10,000 cells Cl-106 meq/l
HCo3-26meq/l
Creatinine-1.3 meq/l
BUN-28 mg/dl CT-Brain:Normal
CSF: Normal
Comment on the Scenario
Comment on the Scenario

Symptomatic Hypernatremia

Probably due to inadequate water intake


1.What is the plan for Na
correction ?
Comment on volume and fluid to
be administered, rate of correction
Plan for Na correction
Step 1: Calculate water deficit

??????
Plan for Na correction
Step 1: Calculate water deficit
Patient Na-140 X Body water
140

158-140 X 30 = 4 litres
140
Plan for Na correction
Step 2: Decide on Fluid to be administered

??????????
Plan for Na correction
Step 2: Decide on Fluid to be administered
-Free water through ryles tube
-i.v 5% Dextrose
-i.v 0.45% Saline

Advantages and Disadvantages???


Plan for Na correction
Step 3: Rate of correction

??????????
Plan for Na correction
Step 3: Rate of correction
-0.5 meq/hour
- less than 12 meq/day
2.How to correct?

Formulae ??????
Formulae for Hypernatremia
-Formulae for determining infusate rate
may not be clinically useful.

WHY???
-Correction depends on renal handling of
administered water. This may be unique
for a given patient
A helpful protocol for correction
-Holds good if renal handling is normal
-Na<165 meq/L

Administer 50% of water deficit-36 hrs


If appropriate response occurs,
Remaining 50% of water deficit-36 hrs
For Our Patient

2 litres[free water or 5% Dex]-36 hours


If appropriate response occurs,
2 litres[free water or 5% Dex]-36hours
3.Can you predict impaired
response to treatment
Can you predict impaired response
to treatment
Indicators of poor response after initiating
treatment:
Urine output > 2ml/kg/hour
Urine specific gravity < 1.010
Can you predict impaired response
to treatment
Indicators of poor response after initiating
treatment:
Urine output > 2ml/kg/hour
Urine specific gravity < 1.010

INAPPROPRIATE WATER IN URINE


Hypernatremia -Summary
• Calculate water deficit
• Decide on fluid to be administered
• Correction depends on renal handling of
administered water. Formulae less useful.
• A 50+50 approach over 72 hours.
• High urine output and a dilute urine
indicates a possible poor resp to treatment
To treat dysnatremias you need
to know little about sodium more
about water
……………….look at the urine of
our patient. It solves most of your
problems
Questions?????