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S P R T OPIC : H YPONATRAEMIA Jamilla Hussain ST3 April 2012 St. Catherine’s Hospice.

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Presentation on theme: "S P R T OPIC : H YPONATRAEMIA Jamilla Hussain ST3 April 2012 St. Catherine’s Hospice."— Presentation transcript:

1 S P R T OPIC : H YPONATRAEMIA Jamilla Hussain ST3 April 2012 St. Catherine’s Hospice

2 AIMS 2 Case study Definition Pathogenesis Epidemiology

3 C ASE 1: SM 39 year old female A+E: fatigue, headache, nausea and vomiting, and profound weight loss ~ 1/12 OE: nil acute Ix: Na 115, CXR: RUL mass, enlarged mediastinum Seen by KC - Admitted

4 CLINICAL ASSESSMENT

5 H X AND E XAMINATION VOLUME STATUS CAUSES SEVERITY

6 V OL STATUS :C AUSES Clinical characteristics Causes Hypovolaemic ↑P, ↓BP, postural drop, ↓skin turgor, raised urea+ renin Diarrhoea or vomiting Burns Sweating Diuretics Addison’s CSWS Salt-losing nephropathy Euvolaemic Urea normal/slightly ↓ Hypothyroid Any cause+ hypotonic fluid SIADH ACTH defficiency HypervolaemiaOedema, ascites, ↑JVP Nephrotic CCF Liver failure Renal failure CCF+diuretics

7 S EVERITY Plasma sodiumSymptomsMortality >125 Alert Nausea, headache, altered cognition 23% Confusion, stupor30% <115 Seizures, coma50%

8 I NVESTIGATIONS -

9

10 Clinical characteristics Causes Urine Na<30Urine Na>30 Hypovolaemic ↑P, ↓BP, postural drop, ↓skin turgor, raised urea+ renin Diarrhoea or vomiting Burns Sweating Diuretics Addison’s CSWS Salt-losing nephropathy Euvolaemic Urea normal/slightly ↓ Hypothyroid Any cause+ hypotonic fluid SIADH ACTH defficiency HypervolaemiaOedema, ascites, ↑JVP Nephrotic CCF Liver failure Renal failure CCF+diuretics P LASMA O SMOLALITY < 280

11 E SSENTIAL C RITERIA FOR SIADH Plasma Na<135mmol/l Urine osmolalilty >100mOsm/kg Urine Na >20 mmol/l Euvolaemic Exclusion of glucocorticoid defficiency Normal salt intake Euvolaemic, urine Na>20, repeat Na 113

12 M ANAGEMENT

13 M ANAGEMENT OF ACUTE HYPONATRAEMIA + SEVERE SYMPTOMS Acute <48 hours Fall >0.5mmol/l per day Mortality 5-8% IV hypertonic saline solution 1.8% Saline = 0.3mmol/l Na 1ml/kg body weight/hour Aim 0.5mmol/l per hour correction No more than 4-6 mmol/12 hr, stop >120mmol/l

14 C ENTRAL PONTINE MYELINOSIS Balance risk of mortality with low Na with risk of irreversible myelinosis 1-2 days post correction Coma, confusion Quadraparesis CN defects, bulbar palsy (pons) Cerebral irritation by low Na can produce irreversible brain damage, therefore hypertonic solution is life saving/brain preserving 2 hourly assessment of Na Worse if chronic/alcoholic

15 SM Infusion on ward whilst waiting transfer Deteriorated rapidly on ward Spoke to consultant Opted for supportive care + uninterrupted time with children

16 D EFINITION Na < 136mmol/l SIAD more appropriate (15% no vasopressin) Concentrated urine + hypo-osmolar plasma suggest abnormal free water excretion

17 P HYSIOLOGY Vasopressin gene on Ch. 20 Peptide produce Arginine vasopressin (AVP) + vasopressin-specific neurophysin II (NP II) Hypothalamus  Post. Pituitary  AVP + NPII 3 AVP receptions, V2 on renal CD AVP binds V2  c-AMP  inserts AQP2 Acquaporin water channels into apical plasma membrane CD Allow passage of free water but not ions

18 E PIDEMIOLOGY Stimulation of HPA Distal nephrons Paraneoplastic -tumour secretes ectopic AVP - OR vasopressin-like peptide

19 E PIDEMIOLOGY Commonest SCLC, carcinoid Pancreatic, oesophageal, prostatic, haematological 523 SCLC- 9%SIAD 32% ↑ AVP, 53% renal handling abnormal Prognosis and response same +/- SIAD Incomplete restoration of renal handling

20 O THER CAUSES Drugs: Opiates, TCA, Haloperidol, AED, SSRI, NSAIDS Vincristine, cyclophosphamide Chest: Pneumonia, TB, abscess CNS: Meningitis, CVA, Tumour/mets Post operative, NV, pain

21 C ASE 2 JE 67, Ca Prostate 2009 bone/liver mets -Previous TURP, RDx, Bicalutamide, stilbeosterol, zoladex -Neuroendocrine tumour-small cell -Etoposide and carboplatin and dex -Admitted to SCH prior to 1 st cycle

22 C LINICAL ASSESSMENT Nausea Poor appetite Dizziness P=100, JVP not visible, grossly oedematous legs/scrotum Meds: codanthramer, ondansetron, dex, domperidone

23 I NVESTIGATIONS 31/1/127/2/1210/2/12 Na P.Osm 274 K U.Osm 524 U Urine Na 20 Cr SIAD

24 M ANAGEMENT

25 M ANAGEMENT OF CHRONIC SEVERE ↓N A Fluid restrictions -500ml IP -several days Distal nephron inhibitors -Demeclocycline (tetracycline) -Nephrogenic DI-stops cAMP production -900 to1200mg per day, takes 3 days - SE: GI and photosensitive rash

26 C HRONIC SEVERE HYPONATRAEMIA Urea -osmotic diuretic, increases free water excretion -oral 30g in orange juice -no need for fluid restriction Vasopressin analogues VAPTANS -promote sustained aquaresis -Tolvaptan, selective V2 -check Na 8hrs after 1 st dose then daily

27 10/2/1214/216/217/229/2 Na K U Cr

28 M IXED PICTURE Usually have other contributing factors -Vomiting -CCF -Liver failure -Renal impairment -Diuretics -Hyperglycaemia -need to consider other additional causes and manage

29 M ILD - MODERATE SYMPTOMS N A >125 Acute: Tx cause and fluid restrict Chronic: Tx cause and Vaptans ASYMPTOMATIC NA>125 -Tx cause and fluid restrict

30 S UMMARY Clinical Assessment: FLUID STATUS/ CAUSE/SEVERITY Ix: UEs, Paired osm, urine Na, TFTs, (synacthen) LFTs, lipids and glucose Tx: Acute vs. Chronic Severe vs. mild-moderate vs. asymptomatic ? Mixed picture


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