Disturbances of sodium in critically ill adult neurologic patients: A clinical review

Disorders of sodium and water balance are common in critically ill adult neurologic patients. Normal aspects of sodium and water regulation are reviewed. The etiology of possible causes of sodium disturbance is discussed in both the general inpatient and the neurologic populations. Areas of importance are highlighted with regard to the differential diagnosis of sodium disturbance in neurologic patients, and management strategies are discussed. Specific discussions of the etiology, diagnosis, and management of cerebral salt wasting syndrome, the syndrome of inappropriate antidiuretic hormone secretion, and central diabetes insipidus are presented, as well as the problems of overtreatment. The importance of diagnosis at an early stage of these diseases is stressed, with a recommendation for conservative management of milder cases. Copyright © 2005 by Lippincott Williams & Wilkins

ICU acquired hypernatremia treated by enteral free water - A retrospective cohort study

Purpose: ICU acquired hypernatremia (IAH) is associated with increased morbidity and mortality, however treat-ment remains controversial. This study aims to determine the effect of enteral free water suppletion in patients with IAH. Materials and methods: Retrospective single center study in a tertiary ICU. Inclusion criteria: patients with IAH and treatment with enteral free water. Exclusion criteria: patients with renal replacement therapy, diabetic ketoacidosis or hyperosmolar hyperglycaemic state. Primary outcome: change in plasma sodium (in mmol/l) after 5 days treatment. Responders were defined as patients with a decrease in sodium level of 5 mmol/l or more. Results: In total 382 consecutive patients were included. The median sodium level at the start of water therapy was 149 mmol/l (IQR 147-150). The median volume of enteral water was 4423 ml (IQR 3349-5379 ml) after 5 days and mean sodium decrease was 1.87 mmol/l (SD 4.84). There was no significant correlation between the volume of enteral water and sodium decrease (r(2) = 0.01). Conclusions: Treatment with enteral free water did not result in a clinically relevant decrease in serum sodium level in patients with IAH. In addition, the volume of enteral free water and the use of diuretics was unrelated with sodium change over 5 days. (C) 2020 Elsevier Inc. All rights reserved

Clinico-investigative profile of hypernatremia in neonates of rural western Maharashtra.

Objectives: To study the Clinico-investigative profile and outcome of hypernatremia in neonates. Methodology: Observational descriptive, longitudinal study conducted at the tertiary rural hospital from August 2021 to August 2022. All the babies with hypernatremia admitted to NICU during the above period were included in the study excluding the preterm babies presenting to our hospital for NICU care. Results: The sex ratio of 1.3:1 was seen in our study with the majority (69%) of babies born to primigravida mothers and 58.7% of the mothers subjected to LSCS. The majority of cases were admitted on the 3rd to 5th day (mean age being 4.2 days). Feeding frequency was less than seven times a day in 91.3% of babies, which could be due to inexperience and inadequacy. 88% of the neonates with hypernatremia had more than 10% weight loss due to dehydration. Fever, lethargy, and irritability were present in the majority of the patients. CNS signs and symptoms at the time of presentation included seizures, decerebrate posturing, and retrocollis. Conclusion: The higher occurrence, as compared to other studies was due to a combination of factors such as summer months, inadequate feeding, early presentation or detection on 3rd or 4th day of birth

Recommendations for active correction of hypernatremia in volume-resuscitated shock or sepsis patients should be taken with a grain of salt: A systematic review

Background: Healthcare-acquired hypernatremia (serum sodium >145 mEq/dL) is common among critically ill and other hospitalized patients and is usually treated with hypotonic fluid and/or diuretics to correct a “free water deficit.� However, many hypernatremic patients are eu- or hypervolemic, and an evolving body of literature emphasizes the importance of rapidly returning critically ill patients to a neutral fluid balance after resuscitation. Objective: We searched for any randomized- or observational-controlled studies evaluating the impact of active interventions intended to correct hypernatremia to eunatremia on any outcome in volume-resuscitated patients with shock and/or sepsis. Data sources: We performed a systematic literature search with studies identified by searching MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, ClinicalTrials.gov, IndexCatalogue of the Library of the Surgeon General’s Office, DARE (Database of Reviews of Effects), and CINAHL and scanning reference lists of relevant articles with abstracts published in English. Data synthesis: We found no randomized- or observational-controlled trials measuring the impact of active correction of hypernatremia on any outcome in resuscitated patients. Conclusion: Recommendations for active correction of hypernatremia in resuscitated patients with sepsis or shock are unsupported by clinical research acceptable by modern evidence standards.ECU Open Access Publishing Support Fun

Correction Factor Calculation by Comparison of Electrolyte Values done by Blood-Gas Analyzer and Laboratory Serum Autoanalyzer

BACKGROUND: Arterial blood gas (ABG) analyzers and laboratory serum auto analyzers (AA) both can measure serum electrolytes sodium and potassium. In Intensive Care Unit (ICU) setups, physician mostly uses the point-of-care analysis of electrolytes by ABG analyzer. It prevents time delay and early treatment for the patient. Minimum 2 hours needed to get laboratory report for serum electrolytes measured by auto analyzer in most of the tertiary care hospitals in developing countries. The ABG analyzer and laboratory AA uses ion-sensing electrode technology to assay electrolytes. This method is used in many tertiary care hospitals. OBJECTIVES: To evaluate sodium and potassium values measured by using arterial blood gas analyzers (ABG) and laboratory serum auto-analyzers (AA) are may be equivalent and correlating the values. Calculate a correction factor for sodium and potassium; to minimize the difference between two methods. MATERIALS AND METHODS: Patients in study group are tested for ABG electrolytes and compared with Laboratory Auto Analyzer serum electrolytes and analysed in med calc software. RESULTS: The test results of ABG and AA are not equivalent. Correlation between ABG and AA should be obtained by adding correction factor. Higher difference between two methods is 10.7 mEq/L for sodium; lower difference is 1.8 mEq/L. Mean ± standard deviation: 6.2 mEq/L ± 1.96 mEq/L. Correction factor: current difference = 6.2. Higher difference between two methods is 0.72 mEq/L for potassium; lower difference is 0.08 mEq/L. Mean ± standard deviation: 0.40 mEq/L ± 1.96 mEq/L. Correction factor: current difference = 0.40. CONCLUSION: The results obtained by using ABG analyzer and Laboratory AA differ significantly. After adding correction factor with ABG value, there will be no significance difference between corrected ABG value and Laboratory AA value

Fluids and Sodium Imbalance: Clinical Implications

Fluids and electrolytes are basic components of the human body and essential for the survival of most species. Any imbalance can potentially lead to serious conditions and death. The replacement of fluids and electrolytes has been used since the ancient age. Modern medicine still requires certain degree of expertise in these areas, which ranges from simple replacement in patients with mild illness to a more complex management in critically ill or hospitalized patients. Training and education in the evaluation and management of patients with fluids and electrolyte abnormalities are fundamental for patient’s outcomes. Severe sodium abnormalities are associated with increased morbidity and mortality, and they are markers of poor outcomes. This review presents a concise discussion of frequently asked questions in the evaluation and management of patients with fluids and sodium abnormalities

Changes in selected electrolytes in adult intensive care patients at the University Teaching Hospital, Lusaka, Zambia

The importance of regulating potassium and sodium levels is well recognized in most Intensive Care Units (ICU). Various institutions across the globe have found varying figures on the extent and causes of electrolytes derangements in ICUs. Some tertiary hospitals in Africa similar to the University Teaching Hospital (UTH), Lusaka, have reported prevalence’s of over 66% of the patients in ICU having multiple electrolyte abnormalities. However, the extent of electrolyte derangements in patients admitted to the Main Intensive Care Unit (MICU) at UTH, Lusaka, Zambia is unknown. This study aimed to evaluate the twenty-four-hour changes in selected electrolytes in adult patients admitted to MICU at UTH, Lusaka, Zambia. An Observational Cross-Sectional Study. Blood samples obtained from a peripheral vein in Heparinized bottles for renal function tests were measured using the Beckman Counter/Au480 (Serial: 2013102691) machine at UTH. Normal serum concentrations of sodium and potassium were considered as 135-145 and 3.5 - 4.5mmol/L, respectively. Statistical analysis was performed with Stata. A total number of one hundred (100) patients were enrolled in this study with a mean age of 36.8 (SD = 12.1). The mean value of sodium level was 136.7 (SD = 8.9) mmol/L and 139.0 (SD = 11.6) mmol/L, on admission and 24 hours post admission respectively. This difference in serum sodium level was shown to be statistically significant with a P-value = 0.005. Hypernatremia was shown to be associated with an increased risk of death (p = 0.02) in the Unit with an odds ratio of 4.3at 95% confidence interval of 1.3 to 13.9. Hyponatremia was the most prevalent electrolyte imbalance but was neither shown to be associated with mortality (P-value = 0.2) nor prolonged ICU stay at 24 hours post admission. The mean value of potassium level was 4.2 (SD = 1.1) mmol/L and 4.3 (SD = 1.1), on admission and 24 hours post admission respectively. This difference was shown to be not statistically significant (P-value = 0.6). Neither hypokalaemia (p = 0.2) nor hyperkalaemia (p = 0.1) were associated with mortality at 24 hours post admission and there was no association with duration of stay in ICU. There is a significant change in serum sodium levels after 24 hours post admission but there is no significant change in potassium level. Hyponatremia being the most prevalent. Hypernatremia remains significantly associated with mortality and therefore, correcting electrolyte imbalances in ICU patients is an urgent necessity. vi Keywords: Hypernatremia, Hyponatremia, Hypokalaemia, Hyperkalaemia, Electrolyte

Severe COVID-19 and routine biomarker patterns

In acute infectious diseases, the composition of the blood changes. That includes proteins, blood cells and smaller solutes. Routine blood tests have a fundamental role in the diagnosis and follow-up of patients with severe infections. Similar to other severe infections, high levels of inflammatory markers are seen during the acute phase of a SARS-CoV-2 or COVID-19 infection. What distinguished COVID-19 in year 2020 from other viral diseases, was the high pathogenicity increasing the likelihood of affecting other common biomarkers. The aim of this thesis was to investigate the prognostic importance of dynamics and trends of routine electrolyte, coagulation and kidney biomarkers in patients with severe COVID-19 at Karolinska University Hospital during the first phase of the pandemic in Sweden. Study I: A retrospective cohort study of 429 patients. In this study we investigated how trends of platelet counts and D-dimer levels were associated with mortality, thrombosis and difference in anticoagulant treatment routine. We found that increasing platelet levels and decreasing D-dimer levels, during the first week of hospitalization, were associated with improved survival and reduced thrombotic risk and enhanced prophylaxis with LMWH coincided with improved outcomes. Study II: In this retrospective cohort study of 406 patients, we evaluated presence and importance of electrolyte and acid-base imbalance. Hyponatremia was seen in many patients at admittance and was found to be associated with future need of mechanical ventilation. However, development of hypernatremia was common, occurring in 42% of the patients in the cohort, and was associated with increased hospital stay and death. Study III: A retrospective study of 45 patients with COVID-19, undergoing brain magnetic resonance imaging (MRI), which were assessed for the presence/absence of a normal posterior pituitary gland (bright spot). Hypernatremia and polyuria consistent with central diabetes insipidus (DI) were observed in 14 patients (31%), whereof 6 (13%) had a full laboratory workup and fulfilled the diagnostic criteria of DI; all 14 patients with suspected DI lacked the bright spot, suggesting a vasopressin-depleted state. Study IV: In the last study, designed as a retrospective cohort study of 286 patients, we studied acute kidney injury (AKI) and related biomarkers in severe COVID-19. AKI developed in 38% of the patients and a higher mortality was seen in the group with AKI. Discrepant results between eGFR creatinine (eGFRCR) and eGFR Cystatin C (eGFRCYS) was common, especially in the ICU patients, and the development of a pronounced discrepancy was related to poor outcome. To conclude, during hospitalization for severe COVID-19 the biomarker pattern fluctuates depending on improvement or worsening of the disease. In this thesis we describe the changes in some of our common blood tests and how they associate with outcome. Therefore, an evaluation of the dynamics of the biomarkers is an important part in the assessment of disease development, treatment and prognosis

A study of serum sodium levels in decompensated chronic liver disease and its clinical significance.

Decompensated Chronic Liver Disease is associated with disturbances in regulation of water balance leading on to abnormalities in serum sodium. Various studies have established a correlation between serum sodium levels and survival in these patients. Dilutional Hyponatremia due to impaired free water clearance is the most common dysnatremia while hypernatremia due to cathartic use has also been reported in few studies. The aim of this study was to study the serum sodium levels in patients with DCLD and to establish its significance. Hyponatremia is more common in DCLD and low serum sodium levels are associated with increased frequency of complications such as hepatic encephalopathy, hepatorenal syndrome, spontaneous bacterial peritonitis and GI bleeding. Lower serum sodium levels were associated with increased MELD CPS score and mortality indicating the inverse relationship between serum sodium levels and severity of the disease