Clinical practice guideline on diagnosis and treatment of. Hyponatremia is common in both inpatients and outpatients. Hyperosmotic measure serum osmolality isoosmotic osmotic hyponatremia hypoosmotic hyperlipidemia mannitol hyperglycemia hyperproteinemia. It is evident that hyponatremic patients are symptomatic with a potential for serious consequences at sodium levels that were once considered trivial. Clinical practice guideline on the diagnostic approach and treatment of hyponatraemia as a joint venture of three societies representing specialists with a natural interest in hyponatraemia. Clinical practice guideline on the diagnostic approach and treatment of. Hyponatremia is the most common electrolyte disorder. Laboratory results reveal a serum sodium sna concentration of 120 mmoll and creatinine concentration of 1. Virtually all investigators now agree that selfinduced water intoxication, symp tomatic hospitalacquired hyponatremia, and hyponatremia associated with intracranial pa. Pdf hyponatremia is an important and common clinical problem. Phaedrus draws out the picture of a nephron figure w1 and points to the distal convoluted tubule. In 10% of cases, hyponatremia is hypovolemic,3,4 typically from overdiuresis. The varied etiologies of hyponatremia and the multiple formulae for its correction make it a nightmare for the students and physicians alike. When sodium levels are low, your body holds onto too much water.
A resource for interprofessional providers hyponatremia in. Sodium helps to control the amount of water in your body. The differential diagnosis of hyponatremia is often challenging because of its association with multiple underlying pathophysiological mechanisms, diseases, and treatment options. Euvolemic, osmolality, osmotic demyelination, siadh, vaptans. Be aware that clinical signs and symptoms may not develop until na hyponatremia what is hyponatremia. A practical approach manisha sahay, rakesh sahay department of nephrology, osmania medical college and general hospital, hyderabad, andhra pradesh, india abstract hyponatremia is an important and common clinical problem. Palmer, md department of internal medicine, division of nephrology, university of texas southwestern medical center, 5323 harry hines boulevard, dallas, tx 75390, usa employing a systematic approach to the interpretation of serum chemis. Palmer, md department of internal medicine, university of texas southwestern medical center, dallas, texas. Approach to hyponatremia in congestive heart failure. Hyponatremia and hypernatremia symptom to diagnosis. Total body water at birth 75% of the wt for a term infant, which decreases to 60% by 1 year of age up to puberty. Several algorithms are available to guide the diagnostic approach to hyponatremia, but their diagnostic and clinical utility has never been evaluated. Hoorn and robert zietse department of internal medicine, division of nephrology and transplantation, erasmus medical center, rotterdam, the netherlands abstract hyponatremiais acommonwater balancedisorder that oftenposesadiagnosticor.
Hypervolemic hyponatremia responds well to fluid restriction and diuretics. D department of medicine, university of arizona prevalence hyponatremia, defined as serum sodium level less than 5meql, is one of the most common electrolyte abnormalities seen in older adults. Treatment varies with the nature of onset acute or chronic, severity and symptoms. Practical document on the management of hyponatremia in critically. Approach to fluid and electrolyte disorders and acidbase. Oct 28, 2012 approach to hyponatremia for medical students. Introduction hyponatremiamost common abnormality 1530% of hospitalized pnts independent predictor of mortality acute 50 %. Medications are often the cause of acute or chronic hyponatremia. The stepbystep diagnostic evaluation of hyponatremia is shown in fig. Consult case a 60yearold woman with nonalcoholic steatohepatitis nash cirrhosis complicated ascites who is taking diuretics presents to clinic for followup with lower extremity edema.
Defining hyponatremia abnormally low sodium level electrolyte regulates water in and out of cells normal serum sodium 5145 meql hyponatremia is typically defined as a serum sodium concentration below 5 meql. This condensed and translated version of the clinical practice guideline on diagnosis and treatment of hyponatraemia focuses on recommendations on. Respondents completed 15 multiplechoice style questions in 3 case scenarios regarding the approach to management of hyponatremia complicating chf using an online survey on between november 2012 and may 20. Chronic 1020% challenge among physicians cause basically a water imbalance. The risk threshold for starting the treatment of hyponatremia depends on the background. I know that people who are on diuretics waste potassium. Watch in hd 1080p and fullscreen for best resolution. P mbbs,dch,dnb,dm asst prof in nephrology case scenario 1. Be aware that clinical signs and symptoms may not develop until na 10 meql. Jun 17, 2019 hyponatremia is defined as a serum sodium level of less than 5 meql and is considered severe when the serum level is below 125 meql. Disorders of sodium and water homeostasis pharmacotherapy. Certificates will be available electronically or in print format after successful. Proper interpretation of the various laboratory tests helps to differentiate the various types of hyponatremia. Results were presented as a proportion of averaged correctincorrect responses amongst canadian nephrologists, cardiologists.
Approach to a patient with hyponatremia ourmedical. Its diagnostic and therapeutic approaches are in a state of flux. Cause of hyponatremia causes of hyponatremia can be grouped into three categories based upon the pathophysiologic mechanism. Hyponatremia is an important electrolyte abnormality with the potential for significant mor. Hyponatremia is defined as serum sodium concentration hyponatremia is long but the diagnostic approach can be easily framed in a few simple steps. They do not stimulate the neurohormonal system and cause no renal impairment. When hyponatremia is first discovered, some elements of the history, key features of the physical exam, and the results of several helpful laboratory tests are usually already available, and these guide the subsequent diagnostic approach algorithm 1. Post turp hyponatremia massive uremia measure urine osmolality high urine osmolality 100mosmkg an abnormal response to hyponatremia measure urinary sodium water excretion mechanism is normal, but free water intake is abnormally high polydipsia inappropriate iv fluid reset osmostat approach to hyponatremia in cirrhosis bashar attar, m. It can be induced by a marked increase in water intake primary polydipsia andor by impaired water excretion due, for example, to advanced renal failure or persistent release of antidiuretic hormone adh. The recommendation to treat virtually all hyponatremics exposes the need to resolve the diagnostic and therapeutic dilemma. Water balance made easier osu center for continuing medical. Laboratory results reveal a serum sodium sna concentration. Although urea does not prevent over correction, it may reduce the risk of the. Clinical approach to hypernatremia think of hypernatremia and hyponatremia as disturbances of water balance along a continuum.
As an example, when a patient infected with the human immunodeficiency virus hiv becomes hyponatremic, volume depletion, the syndrome of. In addition to a rigorous approach to methodology and evaluation, we were keen to ensure the document focused on patientimportant outcomes and had utility for clinicians involved in everyday practice. Hyponatremia may be euvolemic, hypovolemic or hypervolemic. Vaptans are the most appropriate physiological approach to treat hyponatremia as they do not deplete electrolytes and restriction of fluids is not needed. Sodium plus potassium concentration in urine exceeds that in the plasma, which directly lowers plasma. Sodium disorders are associated with an increased risk of morbidity and mortality. Serum osmolality the initial approach to the hyponatremic patient is to measure the serum osmolality to determine whether the hyponatremia represents a true hypoosmolar state. Episode 60 emergency management of hyponatremia approach. Hyponatremia represents a relative excess of water in relation to sodium. Treat neurologic emergencies related to hyponatremia in the event of a seizure, coma or suspected cerebral herniation as a result of hyponatremia, iv 3% hypertonic saline should be administered as soon as possible according to the following guide. Measuring the serum osmolality, urine sodium concentration and urine osmolality will help differentiate among the possible causes. But tell me, do you have an approach for diagnosing hypokalemia.
Hyponatremia is a common electrolyte disorder defined as a serum sodium level of less than 5 meq per l. A survey of canadian specialist physicians and trainees amanda miller, bonnie kuehl, karthik tennankore, and steven soroka canadian journal of kidney health and disease 2016 10. Judicious use of vaptans may help in treatment of hyponatremia. A subscription is required to access all the content in best practice. A resource for interprofessional providers hyponatremia in older adults. Asymptomatic or mildly symptomatic hyponatremia should be managed conservatively with treatment directed at the underlying cause. New horizons in the pharmacologic approach to hyponatremia. The guidelines for management of hyponatremia have been revised recently and, in addition new agents vaptans have become available in market for. Hyponatremia is the most common fluid and electrolyte disorder encountered in. Soft margarine, vegetable oil such as canola, corn, olive, or safflower, lowfat. Your guide to lowering your blood pressure with dash.
Hyponatremia is a condition that occurs when sodium levels in the body are too low. Sep 05, 2015 approach to hyponatremia in children 1. The initial approach to the hyponatremic patient is to measure the serum osmolality to determine whether the hyponatremia represents a true hypoosmolar state. Normal saline forms the mainstay of treatment for hypovolemic hyponatremia while 3% nacl and fluid restriction are important for euvolemic hyponatremia. Hyponatremia is an important and common clinical problem. Hyponatremia due to ecf volume loss true hypovolemia. Many medical illnesses, such as congestive heart failure, liver failure, renal failure, or pneumonia, may be associated with hyponatremia. Hyponatremia is the most common electrolyte abnormality. Utility and limitations of the traditional diagnostic. Choose one of the access methods below or take a look at our subscribe or free trial options. Treatment of hyponatremia according to associated disease. The treatment of hyponatremia saint lukes health system.
Hyponatremia in the physical states of extracellular fluid ecf volume contraction and. Management of hyponatremia american family physician. Hyponatremia is common, is potentially reversible, and has important consequences in a variety of clinical conditions. Hyponatremia is typically defined as a serum sodium concentration of less than 4 mmoll.
Many patients with hyponatremia have a single cause, but multiple factors sometimes contribute to the fall in plasma sodium. Clinical significance hyponatremia is a marker of the severity of cirrhosis and is more prevalent in patients with cirrhosis with childpugh class c. Approach to hyponatremia thiazides, may be severe and is common in elderly females. In addition to a rigorous approach to methodology and evaluation, we were keen to ensure the document.
The management of hypotonic hyponatremia depends primarily on whether the onset is acute i. Preoperative hyponatremia and perioperative complications. Utility and limitations of the traditional diagnostic approach to hyponatremia. Virtually all investigators now agree that selfinduced water intoxication, symptomatic hospitalacquired hyponatremia, and hyponatremia associated with intracranial pa. Differentiating siadh from cerebralrenal salt wasting. Diagnosis, evaluation, and treatment of hyponatremia american. Diagnosis and treatment of hyponatremia inside the silver fridge. Assess the affectoreffector systems the same way we did for hyponatremia. Hypertensive on amlodepine and hydrochlorthiazide was admitted with nausea and hiccoughs vitals. Approach to fluid and electrolyte disorders and acidbase problems bi.
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