Hypernatremia Govind Benakatti

Hypernatremia Rise in serum sodium concentration > 145 meq/l

Why sodium imbalances are important ?

Intracelluar osmolality Do we need U Osm, S Osm, UNa, FENa?

“As cell membranes are largely freely permeable to water, plasma osmolarity tends to guide intracellular osmolarity”

Intracellualr osmolality = intracellular osmolality = 300 mosm/l Osmotic equilibrium is maintained between intracellular and extracellular fluids Intracellualr osmolality = intracellular osmolality = 300 mosm/l

Magnitude is more than two times than that of ECF

Compartmentalisation of effective osmoles

Sodium imbalances are in reality….a water problem…

Sodium and water relations Total body sodium determines clinical volume status, but sodium concentration does not correlate with volume status. Both hypernatremia and hyponatremia occur in the presence of hypo-, eu-, and hypervolemia.

Osmolaity and tonicity are not the same

Model of renal water handling 1. Free water clearance 2. Electrolyte free water clearance

Dysnatremia in critically ill Prospective study – Enrolled 727 children (<12 years) attending Pediatric ER Hyponatremia – Serum Na < 130meq/l – 29.8% patients Summer 36 % (123/341); Winter 24% (94/386)

Hypernatremia in critically ill Mostly Iatrogenic Independent risk factor for mortality Only 20% admitted with Hypernatremia; and rest develops during hospital stay Impaired Renal fluid regulation Lack of Thirst sense

Therapy with Diuretics Osmotic diuresis Diabetes Insipidus/ Cerebral Salt wasting Oliguric ARF Non-Oliguric ARF

 Effects of selected drugs and electrolytes on vasopressin release and action

Independent Morality marker/predictor ?

Regulatory factors…..in (neuro)critical patients

Why brain is the most sensitive organ to hyponatremia?

Again effects of commonly used fluids and drugs used in sick children

Do all critically ill children require same quantity “water component” ?

What about Holiday-Segar Formula based approach- anniversary applied ?

Management-Basic principles sodium and water retention

Management-Basic principles

Case

Case Acute watery diarrhoea of 4 ddays duration AT admission, acidotic (7.021/110/12/4/-17/99%) 168/121/2.3

Case Severely acidotic 6.9/89/9/2/-26 158/91/4.3 Vomitings of few episodes, non bilious Neurodevelopemental delay present Acute crisis of IEM

Case Acute severe distress, previously healthy, afebrile child on enquiry Vomitings, 2 episodes yesterday Abdminal pain H/o passing frequntly, even at night present 6.9/90/12/3.1/-20/96% 165/100

Case Admitted in PICU, 5th dau of stay Primary diagnosis Pneumonia, sepsis and shock on ventilator Edematous, sedated, Hemodynamically stable urine output-normal On ryle’s tube feeding Serial sodium values 141/134/144/139/148/156/163/167

Case H/o facial puffiness for 4 days Reduced urine output (0liguria), Not responded to diuretic Observation and microscopy Hematuria RFT-80/2.1 ABG-7.2/90/22/10/-12/97% 155/100

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