1. Hypernatremia
Govind Benakatti

2. Hypernatremia
Rise in serum sodium concentration > 145 meq/l

3. Why sodium imbalances are important ?

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

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

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

7. Magnitude is more than two times than that of ECF

10. Compartmentalisation of effective osmoles

11. Sodium imbalances are in reality….a water problem…

12. 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.

13. Osmolaity and tonicity are not the same

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

15. 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)

16. 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

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

18.  Effects of selected drugs and electrolytes on vasopressin release and action

19. Independent Morality marker/predictor ?

21. Regulatory factors…..in (neuro)critical patients

23. Why brain is the most sensitive organ to hyponatremia?

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

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

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

29. Management-Basic principles
sodium and water retention

30. Management-Basic principles

33. Case

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

35. 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

36. 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

37. 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

38. 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

39. Thanks