Adult data sparse. Rapidly dropping the sodium concentration could theoretically cause cerebral edema and herniation. Retrospective studies actually correlate slower correction of sodium with worse outcomes. Patients with active neurologic disease and pre-existing cerebral edema. Bottom line? By far the most common problem is dropping the sodium too slowly.
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Adult data sparse. Rapidly dropping the sodium concentration could theoretically cause cerebral edema and herniation. Retrospective studies actually correlate slower correction of sodium with worse outcomes. Patients with active neurologic disease and pre-existing cerebral edema.
Bottom line? By far the most common problem is dropping the sodium too slowly. The precise rate of change which is safe is unknown. For patients with neurologic deterioration due to acute hypernatremia, very rapid correction is probably safer than the alternative leaving the patient with an elevated sodium for a prolonged period could create a risk of osmotic demyelination! In one epic case, a year-old man drank a quart of soy sauce and developed acute hypernatremia with sodium mM, seizures, and coma.
He was treated with six liters of free water over 30 minutes and recovered well. This is easy and effective. The remainder of this chapter describes how to do this. You are not trying to calculate the total free water deficit here, only what you need to give them in the next 24 hours.
For example, in this case illustrated below, we would add 1 liter to 2. However, this may be limited in some cases by ileus or NPO status. If the enteral route is unavailable, free water should be given as D5W intravenously. It would be preferable to provide either pure water via central line or D2. If the patient needs additional volume resuscitation, then provide that separately e.
Using two infusions allows for separate titration of the amount of water and volume you are providing. When this occurs, both problems must be simultaneously and aggressively treated as follows: 1 Free water should be administered as described above. If only furosemide is used, this will stimulate production of a dilute urine which will hamstring the ability to treat hypernatremia.
Diuretics should be up-titrated as necessary to maintain a negative fluid balance. Potassium supplementation will typically be required. Additional free water may be needed as well, to overcome renal losses. It generally requires a lot of free water, fairly high doses of diuretics, and a lot of potassium supplementation. However, it is generally achievable over time otherwise dialysis may be required. A common misconception is that volume overload plus hypernatremia cannot be treated; this is entirely false.
Since water is distributed into both the intracellular and extracellular spaces, it tends to cause less edema generation than an isotonic solution which distributes purely into the extracellular fluid. Under-correction will occur if there is ongoing free water loss. This is frequently seen in patients remaining on lactulose for the treatment of hepatic encephalopathy. Up-titrate the free water as needed to achieve your target sodium.
These patients may gradually develop profound hypernatremia e. This will trigger panic and a desire to admit the patient to the ICU. However, ICU admission is generally not needed for these patients for the following reasons. Since humans are incapable of generating water, it is unlikely that the patient will suddenly overcorrect and abruptly drop their sodium level. The only way that over-correction could occur is if the patient abruptly woke up and started drinking lots of water.
This mechanism cannot occur in patients with hypernatremia due to a water deficit. As discussed above, there is no evidence that rapid falls in sodium are dangerous in older adults. This is likely to be especially true among the elderly, who often have decreased brain size and thus greater room in which to swell should edema occur. In severe hypernatremia, the safest way to provide this is either as a continuous infusion of D5W or via gastric tube.
Hypernatremia & dehydration in the ICU
Overview Hypernatremia is the medical term used to describe having too much sodium in the blood. Sodium is an important nutrient for proper functioning of the body. Read on to learn more about the role of sodium and when high levels may result in a medical emergency. How are sodium levels controlled? Hypernatremia can occur when there is a too much water loss or too much sodium gain in the body. The result is too little body water for the amount of total body sodium.
Everything You Should Know About Hypernatremia