HYPONATREMIA

Michael tobin

Vomiting and drowsy

18yo male. Regular visitor to ED with
vomiting/abdominal pain/ requests for hot
shower. Previous Boerhaaves syndrome
Heavy cannabis user.
Has been vomiting for 2 weeks.
Girlfriend states more drowsy since yesterday.
Patient states just feels unwell.

Examination
Obs stable. Afebrile.
Drowsy but oriented.
Dry
Normal cranial nerves. Depressed reflexes globally.
Abdomen generally tender (but always so)

Blood gas
VBG

pH 7.6
BE 21
pC02 45
HCO3 47
Na 115
K 1.8
lactate 1.7

1 week ago Na 128 and K 3.4

Anything else you need to know?
BSL 6
Cr 76
Serum osmolality 249

Initial management
Monitoring
Fluids and electrolytes
How?
What type?
How much and how fast?

Why do we care about sodium?

Tonicity versus osmolality

Osmolality

Total concentration of all particles in solution

Ethanol and urea are osmotically inactive

Tonicity

Concentration of only osmotically active particles

Only impermeable particles contribute to tonicity

When tonicity low, water moves into cells (and

vice versa)

Na, K, Alb, Ca have tonicity

Sodium usually tells

us plasma tonicity

What is hyponatremia?
Serum sodium < 135
True hyponatremia is low sodium AND low osmolality
Pseudohyponatremia is low sodium and high osmolality
High glucose: corrected sodium (mmol/L) = measured sodium
(mmol/L) + 0.024 {(glucose [mmol/L] x 18)-100}
End stage renal failure
High protein/lipids (depending on testing method)

Tests to order
BSL
EUCs
Osmolality
Urine Na
If BSL is normal, then consider testing osmolality if you suspect causes of isotonic or hypertonic
hyponatraemia
Lipemic serum
Obstructive jaundice
Plasma cell dyscrasia
Recent mannitol/glycerol/IV Ig
Can be misleading in renal failure (urea is measured osmol but innefective) and alcohol intoxication.

Pathogenesis
Hyponatremia occurs when water intake exceeds water excretion
1. No urine output (seen in end-stage renal disease GFR <10)
2. Massive water intake
3. A little of both
. In practice, 2 major causes
Effective arterial blood volume depletion
Hypovolaemic (GI losses, renal losses [thiazides])
Hypervolaemic (heart failure or advanced cirrhosis)

SIADH

Other causes
Hormonal: adrenal insufficiency, hypothyroidism.
Marathon runners: excessive water intake, impaired excretion due to
persistent ADH secretion.
Advanced renal failure
Pseudohyponatraemia: high lipids/proteins/glucose.

How does the body control

osmolality?

ADH

Stimuli for
ADH release
Day-to-day life
osmoreceptors are
more sensitive.
Baroreceptors
override
osmoreceptors

Lose >20%
blood volume
Explains why
hyponatraemia
develops in CHF and
cirrhosis.

Symptoms
Neurological- due to cerebral oedema.
Nausea and malaise early findings
Headache, lethargy, coma, seizures and respiratory arrest possible
below Na 120
Symptoms usually if acute change in Na.

Cerebral
adaptation
Initial cerebral oedema causes
increased hydrostatic pressure
Lose brain K quickly then organic
osmolytes over next 24-48 hours
Processes are reversed with
correction of hyponatraemia but at
a slower rate.

Chronic
hyponatraemia
Usually asymptomatic but can
present with nonspecific symptoms
eg fatigue, nausea, confusion.
However, even mild-moderate
chronic hyponatraemia is
associated with increased
mortality, regardless of underlying
condition.
Cumulative rates of survival in patients with heart
failure stratified into two groups based on
pretreatment serum sodium
concentration ( or >130 mmol/L). J Am Coll
Cardiol. 1987;10:837844. 24

Osmotic demyelination

Time course
Patient arrives confused
and lethargic.
Initial Na 106

Rule of sixes
For all patients with chronic hyponatraemia, raise Na by no more than
6mM in first 24 hours.
For patients with severe symptoms (seizure, coma), aim 6mM in first 6
hours then postpone efforts to next day.
Not a target, rather a barrier that should not be crossed.

Hypertonic saline
Use when:
Severe symptoms (seizures/coma)
Acute hyponatraemia with any symptoms.
Hyperacute onset due to self-induced water intoxication
Symptomatic patients with either acute post-operative
hyponatraemia or hyponatraemia associated with intracranial
pathology
100ml bolus over 10 minutes. Can be repeated.
Measure Na every 2 hours.

Hypovolaemic patients not

needing 3% NaCl
Isotonic fluids (NS, Hartmanns, plasmalyte)
Bolus for BP then 0.5-1ml/kg/hr
Monitor electrolytes every 8 hours for 24 hours.