Management of

Hypernatremia
Dr. pankaj kumar singh
MD(Gen.Medicine)
Hypernatremia
 S.Na > 145 meq/l
 Isotonic 153 meq/l

(1 gm NaCl = 17 meq of Na)

 Quiet often we see hypernatrimia in ICUs
 75% mortality if SNa > 160 meq/l
 It occurs more often due to deficiency of
water rather than by excess of salt
 More commonly observed in old age ,

physically handicapped, mental disorders ,

infants, intubated patients , CVAs  because
they have decreased assess to water.
 Hypernatrimia leads t hyper osmolality
 Serum osmolality mosm/kg

2(Na + K) + Bl. Sugar/18 +

Bl.UreaNitrogen/2.8
 Nomal osmolality is 270-290 mosms/kg
 1% increase in osmolality i.e 2-3 mosm/kg i.e

increase of Na of just 1 meq/l

 Stimulates hypothalamus, which intern

increases thirst to increase water intake

 Increase ADH release from posterior pit.

Causes retention of free water, decreases

urine output and osmolality normalizes.
What if the compensatory mechanism
to normalize osmolality fails?
1. Hypernatremia

Hyperosmolality

A. No thirst 1. Damage to Hypothalamus

Infection, Ischaemic,
malignancy
What if the compensatory mechanism
to normalize osmolality fails?
2. No assess to water
3. Altered level of consciousness
4. Infants
B. No Increase in ADH if CDI , due to damage to
post. Pit. Due to infections ,trauma, surgery,
malignancy
C. ADH is released but not able to act on
Kidney due to NDI
What is the impact of hypernatrimia

Hypernatremia

Hyperosmolality

IC Dehydration Inc. ADH Free

Water

Retention
Dec. UO (<500ml)
Urine osmolality > 800 mosm/kg
If Free Water Retention Not Possible
 So despite hypernatrimia, if UO > 500ml , It
means FWL is occurring which is worsening
hypernatremia
 Causes

1. CDI
2.NDI
3. Osmotic diuresis : mannitol, glucose,
urea
4. Conc. Power is defective
5. Old age
6. Drugs : lethium , Doxycyclin
If Free Water Retention Not Possible

 These patients cont. to produce more urine,

further FWL which worsens hypernatremia
Polyurea
 Non Physiological Def.
More that 3 lts per day on a normal western
diet
 Physiological Def.

UO is compared to same provocative

stimulus
 UO more than expected for that stimulus
 In hypernatremia UO>500 ml is polyurea
 Normal osmole excretion in 24hrs is 600-800

mosm
Polyurea
 Max. Conc. Power Urine osmolality 1200-
1400 mosms
 In dehydration urine output <500ml

So in dehydration is urine output is more

than 500ml is polyurea
 If patient consumes little proteins salts UO

250 will be sufficient , 500 ml is polyurea

 Lowest Urine osmolality could be 50

osmoles/lt
 Max UO 15lts / day on a normal diet
Urine Osmolality Per Kg

2(Na + K + NH4) + urea + glucose +

others(mannitol , ethenol)
Electrolyte FWE
 Clearance of FW = Total UO – isotonic urine
 Spot urine Na, K for calculating electrolytes
 Urine volume of 4-6 hrs
 eg. 1. UO is 3lts
2. Na+K excre. Is 150 meq in 24 hrs,
3. isotonic is 150meq/lt
So ,
3 lts – 1lt = 2lts

This 2lts is the FWL

How to calculate Total Water Deficit
 Serum Na – 140
X
140 TBW
• Eg.
1. 50 yrs, 70 kg male
2. S Na 160 meq/lt

160 – 140
X 42 = 6Kgs
140
So tBW is 6Kgs
 60 % of TBW is water in young males, 50 % of
TBW is water in females
 S Na = Total Body Na + Total Body
K
TBW

• So dec. of Na + K equivalent to TBW

will dec SNa by 1 meq/lt
•Dec. water by 265ml will increase Na by
1
Causes of Hypernatremia
 Hypovolemia

U Na > 20 meq /lt Urine Na < 20

Renal Losses meq/lt
1. Osmotic Extra Renal
Diuresis Losses
(Mannitol, 1. Burns
glucose,Urea) 2. Diarrhea
2. Recovering 3. RT aspiration
ATN 4. Sweating
3. Loop diuretics 5. Fever
6. Ventilation
Hypervolemia
urine Na > 20 Meq/lt
1. 3% saline NaHCo3
2. Hypertonic Dialyses
3. Primary Hyperaldostrenism
 Normal Volume Na and K Loss variable

1. CDI
2. NDI
Fluid Concept
 1 lts NS  Extra cellular space
 1 lt water or 5% dextrose  660ml – IC
340ml – EC
 N/2 saline  330 ml IC
660 ml EC
 So if efwl is 1lt 
660 ml loss from IC , 340 loss from EC
 So if loss is 5lts 3300 is IC , 1700 is EC
 Loss of EC fluid causes hypotention
 So intially we may have to give NS for 2-3 Hrs to
heamodynamically stabalize the patient
Symptoms of Hypernatremia
 Depends upon degree of HN and acuteness of
HN
 In chronic HN symptoms are less
Hn Hyperosmolality Brain
leads contractio
to IC Dehydration n

Venousthrombos Capillaries
is rupture that
leads to IC
and SC
hemorrhage
 Old age patients ,children, altered
sensorium , weakness, myoclonic
movements, convulsions
 Loss of skin turger, hypotention , inc, tmp.
 ARF inc Bl. Urea more than the Serum Creat.
 Urine Infection is generally present
 Symptoms are more in patients if they are

admitted with HN rather than if they develop

HN later on
Treatment
 Fluid of choice water or 5% dextrose
intially NS may have to be given to
haemodynamically stabalize the patient
 Calculate water deficit by the formula

Serum Na – 140
X TBW
140
• 50 % of the water deficit has to be
given in 12 hrs + daily req. + ongoing
losses calculated from the clinical
condition
 Total Correction in 48-72 hrs
 In acute Symtomatic HN, fast correction can be
done 1 meq/lts/hr
 Chromic asymptomatic : slow correction 0.5
meq/lts
 Fast correction can lead to CPM
 See for the total intake and output of water and
electrolytes along with the clinical condition
Diabetes Insipidus
 HypoOsmolar Urine
Urine osmolality < 250 mosms despite
HN
 Give desmopressin 10-20 micro gm IN

0.5 to 1 micro gm SC or IV 12hrly

 If response come its CDI if not its NDI
NDI
 Dec salt and protein intake
 Hydrochlor thiazide 25mg BD
 Lithium induced NDI to be treated with

amiloride
In Hypervolemic HN
 Give lasix to inc salt and water excretion
 Dec fluid intake
 Give only 5% dextrose or water.