Causes/Mechanisms

⚫ The following mechanisms can lead to hypernatremia:

1. Pure Water loss (Diabetes Insipidus)

2. Water loss in excess of Na loss (Diarrhoea)
3. Sodium Excess (Salt poisoning)(Aggressive
correction of HypoNatremia)
4. Breast Feeding Hypernatremia (more sodium than
water in milk d/t poor mother-baby interaction low
water and high salt content of milk)
5. Improper Formula milk preparation
Symptoms:
⚫ Loose Stools
⚫ Polyuria e polydipsia
⚫ Adipsia
⚫ Lethargy or
⚫ Excessive cry/insomnia
⚫ Altered sensorium
⚫ Stiff limbs / Weakness/ Paralysis
⚫ Seizures
Specific Signs
⚫ Feeble Pulse
⚫ Doughy skin
⚫ Irritability
⚫ Hypertonia
⚫ Hyperreflexia
⚫ Pinpoint pupils?
⚫ Focal neurologic deficit?
⚫ Shallow breathing/apnoeas?
WorkUp
⚫ Serum Sodium

⚫ Calculate Serum Osmolarity

>>> Blood Glucose
>>> BUN = Urea(mg/dl) / 2.14

▪ CT scan & MRI

For Tumors , T.B , Cerebral Edema, Haemorrhage
T/M :

1. If Patient is Pulseless ,
give Normal Saline Bolus 20 ml /Kg

2. Repeat till pulses are palpable.

3. CALCULATION OF WATER DEFICIT:
As We said , in Hypernatremic dehydration there is
Water deficit in Excess of Sodium.
So first we Calculate how much water is deficient .
4. Selection Of Type of Fluid:

If : Salt poisoning , Select 5% Dextrose Water .

If : Any Other Cause , Select N/5 e 5% DW or N/2 e 5% DW

Why Only 5 % DW in salt poisoning ?

Why N/5 e 5% DW or N/2 e 5% DW in other causes ?
Why not Whole Normal Saline ?
Why add Dextrose in fluids ?
When to Add Potassium ?
5. Calculation Of Volume Of Replacement Fluid :
6. Selection of Time over which Replacement Fluid
has to be given :

24 hour --- 145-157 mEq/L

48 hour --- 158 – 170 mEq/L
72 hour --- 171 – 183 mEq/L
84 hour --- 184 – 196 mEq/L
Administer fluid via Infusion Pump if available.

If it is not available, Use this equation to calculate

Drip Set Rate :

This will give drops/minute

7. Next : Daily Serum Electrolytes
Daily Weight
BSL Monitoring

8. Based on Daily Serum Sodium levels, fluid infusion rate may need
adjustment:

Sodium decreases too rapidly

Increase sodium concentration of intravenous fluid
Decrease rate of intravenous fluid
Sodium decreases too slowly
Decrease sodium concentration of intravenous fluid
Increase rate of intravenous fluid
9. Treatment of Complications of the Treatment

If sodium correction (decrease in serum sodium) is done

too RAPIDLY , there is risk of cerebral edema as brain
cells do not get enough time to destroy the idiogenic
osmoles, which manifests as Seizures.

So, to acutely manage this emergency, we again increase

plasma Osmolarity by inj. 3% Saline ; the 1ml/Kg of
which increases serum osmolarity by 1 mEq/L
10. The recommended dose of 3% Normal saline is
4ml/kg as infusion over 30 min

11. The exact requirement of serum Sodium can be

calculated by this formula :

Na+ requirement (mEq/L) = wt(kg) X 0.6 x (desired Na+ - serum Na+ )

12 . Consultations:

Paediatric Intensivist to revise all calculations &

correlate with lab data
Paediatric Endocrinologist : If patient has Diabetes
insipidus or Primary hyperaldosteronism
Paediatric Nephrologist : If there is renal failure or when
sodium levels are above 180 mEq/L so that need for
Peritoneal Dialysis may be assessed.
Questions ?