Good old fashioned nephrology (with a large dose of pulmonary) Most nephrologists would chose to evaluate and treat a SODIUM of 110 mEq/L rather than a BUN of 110mg% Be careful what you ask for you just might get it Lt.Col. Theodore R. Wall, USMC, Retired Patient admitted from ER with hyponatremia and respiratory failure no problem
Todays lecture: Chronic polydipsia not this case Case presentation Laboratory review Brief discussion of water intoxication Pulmonary aspects @ Dr Weinmeister
Input minus output equals accumulation 75 kg male 60% water = approx 45 Liters TBW
Intracellular Extracellular 30 L 15 L 280mosm/kg 280mosm/kg [K+] 140mEq/l [Na+] 140mEq/l How much water was ingested? Initial TB solute: 280 X 45 =12,600 mosmol Initial ECF solute: 280 X 15 = 4,200 mosmol Initial intracellular: 12600 4200 = 8,400 mosmol
NEW TBW : 45kg + 6 kg = 51 kg NEW TB OSM: 12,600 / 51kg = 251mosm/kg NEW ECF volume: 4200 / 251 = 16.7kg NEW intracellular volume: 8400 / 251 = 33.4kg
How much water? Assume an ingestion of 6 liters: serum osmolality of 251mosmol/kg
Estimated nadir [Na+] = osmolality / 2 = 125.5mEq
Effective Posm is approximately 2 X [Na+] Case Presentation 21 year old AAM student at SMU CC: can not be obtained (intubation) History obtained from family members Patient was asked to drink 3 - 4 gallons of water (with hot sauce), as part of a fraternity hazing on Friday evening Post ingestion, patient was confused, and became less responsive At 4AM, patient developed a seizure, yet was not transported to Presby ER until 7AM Hospital day:one Profound shock/hypotension poor response to high dose pressor medications Immediate respiratory failure with severe agitation and hypoxemia; endotracheal intubation confirmed drowning Transfer to ICU maximal support: 100% oxygen, maximum PEEP, IV norepinephrine Initial SODIUM = 126mEq/L (IV @KO NS) Case presentation: continued Past medical history: none Social history: 2 year football player for Austin College. No drug or alcohol history Mother arrived from Houston; Father arrived from US Virgin Islands (lives in Wash D.C.) Medications: IV pressors, antibiotics ROS: not available
Physical exam: BP 100/60 on very high dose IV pressors; pulse 110 sinus tachycardia; R per vent; high pressures Very muscular patient, intubated PO, who eventually developed subQ crepitation from barotrauma HEENT: mild swelling; anicteric NECK: WNL LUNGS: bilateral breath sounds; increased rate COR: no murmur, increased HR ABD: benign, although later the CT was abnormal Ext: no cyanosis; warm; slowly progressive edema Neuro: unresponsive pupils; ? signs of herniation prompted use of IV mannitol Admit labs WBC 17K 76%neutrophils, 6%lymphs Hgb/Hct 13.2g%/38% Plts 380K Urinalysis: 2+ blood, few RBCs, 360mOs/kg Initial Serum Osm: 272, falling to 263 in 8hrs Toxicology screen negative for tylenol, PCP, ethylene glycol, MDMA, salicylate, ethanol, cocaine, barbiturates, and narcotics CXR: ? RUL pneumonia CT Head: cerebral edema, especially in retrospect Additional admit labs: Calcium 8.6mg/dl Phos 4.2g/dl Total protein 7.6g/dl Albumin 4.8g/dl Alk phos 63 LFTs mildly elevated INITIAL CPK 2100 INITIAL BUN 10mg% CREAT 1.0mg% ANION GAP 21 Therefore, working diagnosis of (+) AG lactic acidosis from seizure, 3 hours PTA Electrolytes day one, as serum osmolality fell from 272 to 263 0800 1130 1320 1800 2300 Na+ 126 117 120 116 117 K+ 4.6 3.8 3.6 4.0 3.8 Cl- 89 88 90 CO2 16 19 22 AG 21 10 9 5 Creat 1.0 1.1 1.1 1.2 U osm 360 473 PO4 4.0 4.4 CPK 2100 3400 4000 Electrolytes: day 2 0300 1045 1300 1600 2000 Na+ 116 128 130 132 134 K+ 4.6 4.4 CO2 26 25 AG 6 8 Creat 1.1 1.3 1.2 PO4 1.7 2.5 CPK 6200 10,500 U osm 803 122 600 therapy DDAVP Hospital course Hemodynamics and oxygenation were tenuous on day one Patient was considered for extra-coporeal oxygenation therapy, resulting in a transfer from 3 ICU to 4 ICU Post transfer, his BP and PO2 IMPROVED Abnormal CXR: bilateral infiltrates, air under R hemidiaphragm CT scan: larger amt of air surrounds tail of pancreas, (L) kidney, anterior aspect of psoas muscle, tracking down from mediastinum Hospital course: continued Electrolytes were normal, by hospital day 3 EEG always showed electrical activity (patient had been severely hypoxemic, but never required ACLS) CNS began to improve by hospital day 4 Ventilator support was weaned by day 7 Transfer to floor day 8 Discharged home day 10 CNS damage associated with acute hyponatremia CPM: rare neurologic disorder reported in malnourished/alcoholic patients MORE COMMON brain edema, with uncal and tonsillar herniation with diffuse cerebral demyelination secondary to increased intracranial pressure, with necrosis, and hypoxic brain damage Compression of medullary respiratory center because of brain swelling, above 5 to 8% of baseline volume can lead to herniation -- fixed pupils, hypoventilation, cardio instability, impaired temperature control, pituitary and hypothalamic infarction also possible Water intoxication in cattle J AFR VET ASSOC 1999 DEC; 70(4) Water intoxication is common in cattle, and also has been described in other domestic animals. Comprehensive description is lacking Fatal water intoxication: Journal of Clinical Pathology Oct 2003 p 803 DJ Farrell et al 64 yo woman with known MV disease Compulsively drinking water, one evening, in range of 30 to 40 glasses Hours later was described as hysterical Fell asleep, and found dead next morning Postmortem: no tumor, bilateral pleural effusions, LVH with large heart; increased cortisols Na+ = 92meq/L (vitreous fluid, usually stable) Acute delirium, seizures, coma, and death
Autopsy case of rare iatrogenic water ingestion; Chen et al, Tongji Med Univ, Forensic Sci International: Nov 95 21 yo female suicide attempt (powder scraped from 18 matches) 1700 hrs: 3L of water 1730 hrs: 800ml 1800 hrs: 4L of water, via NG tube Headache, dyspnea, cyanosis, then coma Autopsy: cerebellar herniation, Na+ 112, pulmonary edema, trachea and bronchial tubes full of fluid Literature review: Forensic Science International (1995): continued 534 papers over 17 years only 16 fatalities 15 cases diagnosed during hospitalization for various types of psychosis Water intoxication is unusual in normal people, and death is even rarer Case report of death within 2.5 hrs is rare Fatal child abuse by forced water intoxication Pediatrics 1999 JUN;103 Alan Arief,MD 3 children punished by forced intoxication > 6 liters Seizures, emesis, coma, hypoxemia, average sodium 112mEq/L Autopsy confirmed cerebral edema Tried and convicted Death by hyponatremia as result of water intoxication in a Army trainee MIL MED 1999 MAR;164 Excessive water intake by athletes during endurance races, to prevent heat injury has been the recommendation Describe a case of programmed drinking > 8 liters during initial training One death, cerebral edema with seizure Death by Water intoxication MIL MED 2002 May; 167
3 deaths in recruits, usual water load of 6 to 10 liters in 2 to 3 hrs safe limit probably 1 liter per hour Chronic Polydipsia and hyponatremia Psychiatric patients, especially schizophrenia, often have problems with water balance 6% to 8% have a history compatible with compulsive water drinking; of these pts had intermittent symptoms of hyponatremia Normal patients can excrete 10 to 15 liters/d by decreasing Uosm from 40 to 100 mosm/kg Episodes of transient ADH release with acute psychotic episodes Carbamazepine and fluoxetine are associated with SIADH Chronic polydipsia This is an uncommon clinical scenario, but does not apply to our current case (which is rare) Rx hypontremia with acute encephalopathy rate of correction 0.5 to 1 meq/l per hr (until a sodium of 120meq/l) Never actively correct > 130meq/l