Hypernatremia_case_Presentation

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Clinical Meeting:

Clinical Meeting Presented by: Dr. Laila Registrar, Paediatrics Apollo Hospitals, Dhaka

Particulars of the patient:

Particulars of the patient Name : Hamim Age : 10 months Sex : Male Religion : Islam Address : Dhaka, Bangaladesh DOA : 21 January, 2011

Chief Complaints:

Chief Complaints Loose motion for 5 days Decreased urine output for 3 days Fever and lethargy for last 1 day H/O vomiting 3 days back for initial 2 days

H/O Present illness:

H/O Present illness According to mother’s statement, her child was reasonably well 5 days back. Then he developed loose motion which was watery, not mixed with blood and occurred for 3-4 times a day for the initial two days, which was associated with vomiting. Later on, the loose motion became more frequent ( 10-15 times a day) & he developed decreased urine output for which he was taken to local doctor & was treated with ORS as per advice. Mother also complained of low grade fever and lethargy for last one day. He had no H/O convulsion prior admission.

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H/O past illness : Nothing significant Birth history : Delivered by LUCS at term, B.W- 3 kg , no post natal complications Feeding history : BF + Formula milk up to 6 months of age. Then started cerelac , khichuri & suji Immunization : Completed as per EPI schedule Developmental milestones : A ge appropriate Family history: 2 nd issue of non-consanguineous parents. His elder sister is healthy Medication history: 12 packs of ORS in 3 days

General Examination:

General Examination Appearance : Lethargic Fontanelle : Depressed Eyes : Sunken Pallor : Mild Dehydration : Severe with acidodic breathing Skin Survey : Skin pinch goes back very slowly

General Examination:

General Examination Pulse : 180 /min BP(mm Hg) : 60/35 Temperature (⁰ F) : 101 RR : 80 / min Weight (kg) : 8.5 No cyanosis, jaundice or oedema No sign of meningeal irritation No lymphadenopathy

General Examination:

General Examination Dehydration : Severe with acidodic breathing Skin Survey : Skin pinch goes back very slowly Neck vein : Not engorged Lymph Nodes : Not palpable Bony tenderness : Absent ENT : NAD Signs of meningeal irritation : Absent

Systemic Examination:

Systemic Examination CVS : S1 & S2 audible, No added sound Respiratory : Vesicular breath sound, no added sound Abdominal : Soft, mildly distended, no organomegaly, B/S - Hyperactive

Systemic Examination:

Systemic Examination Nervous System: Conscious but lethargic Muscle Tone – Normal DTRs – Knee jerks were exaggerated Planter – Equivocal

Salient Features:

Salient Features Hamin, a 10 months old male baby, weighing 8.5 kg, 2 nd issue of non-sanguineous parents was admitted in Apollo with the complaints of loose motion for 5 days, which was watery in nature, 3-4 times a day and was not mixed with blood but was associated with vomiting. Later on loose motion became more frequent (10-15 times a day) along with decreased urine output. He also developed fever & lethargy for last one day. He had no H/O convulsion prior to admission

Salient Features:

Salient Features He was treated at home with 12 packs of properly diluted ORS within 3 days. On examination, he was febrile, mildly pale, lethargic, severely dehydrated with acidotic breathing, tachypnoea and tachycardia. His abdomen was mildly distended with hyperactive B/S and no organomegaly . His knee jerks were exaggerated

Provisional Diagnosis:

Provisional Diagnosis Acute watery Diarrhea Severe dehydration Dyselectrolytemia Differential Diagnosis Septicemia

Investigations:

Investigations CBC: Hb – 10.6 gm / dl, MCV – 66, MCH – 21, TLC – 19, 000, N- 67%, L- 26%, Platelet – 3.81 lacs CRP: <0.6 mg / dl RBS: 11.2 mmol/ L S. Creatinine: 1.75 mg / dl

Investigations:

Investigations Serum Electrolytes (mmol / L): 200 / 3.6 / 176 / 15 S. Ca: 5.2 mg /dl SGPT: 27 IU /L Urine R/E: Normal Stool R /E: Numerous pus cells, 3-5 RBCs, Macro.(+) Stool C/S : E. coli Rota Ag : Negative Blood C/S: Staph. Aureus Urine C/S: Enterococcus

Investigations:

Investigations Urinary Osmolality: 651 m Osmol/ kg S. Osmolality: 319 m Osmol /kg Spot Urinary Sodium: 74 mmol / L ABG: P H – 7.13 PCO 2 – 51.8 PO 2 - 84.1 HCO 3 – 17.15

Final Diagnosis :

Final Diagnosis Dysentery with severe dehydration Severe hypernatraemia Pre renal azotaemia Sepsis (Staph. aureus) UTI (Enterococcus) Microcytic hypochromic anaemia

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Treatment NPO 10% dehydration correction with cholera saline + 0.9% NaCl then maintenance with 0.45% NaCl Inj. Ceftriaxone Inj. Ranitidine Paracetamol for fever Inj. NaHCO3 , I/V stat Inj. KT in IV drip Inj. Frusemide IV stat

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Treatment After about 10 hours of admission Sudden development of GTC convulsion which was managed with- O 2 inhalation P/R Diazepam Inj. Midazolam I/V stat

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Treatment Day – 2 I/V fluid changed to 5% D/A Tab. Potassium Citrate Tab. Metolazone As per Nephrologist consultation N.B. Ceftriaxone and Paracetamol were continued

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Treatment Day – 3 Developed convulsion once again Managed with – P/R Diazepam Inj. Phenytoin O 2 inhalation Shifted to ICU I/V fluid changed to 0.225% Inj. Ceftriaxone was replaced by Inj. Meropenem Stopped Metolazone Added Inj. Calcium Gluconate

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Treatment Day – 4 Inj. NaHCO 3 I/V stat Frusemide to increase urine output N.B. Other treatment of Day – 3 was continued Day – 5 Sudden bradycardia, desaturation, VT followed by asystole Unfortunately, the baby passed away despite trying all the resuscitation measures

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Follow up Clinical Vitals Dehydration status Level of consciousness Strict I/O chart Laboratory Serum electrolytes, and Calcium Blood Urea & Creatinine RBS

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Follow up Serum Electrolytes status over the follow up period – Unit: mmol/ L Na + K + Cl - HCO 3 Day 1 Morning 200 3.6 176 15 Evening 200 3 165 19 Day 2 Morning 189 3.2 149 17 Evening 190 3.3 154 13 Day 3 Morning 167 5.1 133 17 Evening 164 3.1 128 20 Day 4 Morning 164 2.7 124 26 Evening 164 3.6 125 27

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HYPERNATRAEMIA

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Introduction Disorders of serum sodium are the most common & poorly understood electrolyte disorder Hypernatraemia is defined as a serum Sodium of ≥ 150 mmol / L Moderate :150 – 169 mmol /L Severe : >169 mmol / L

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Hypernatraemia may exist with Hypovolemia: Water loss > Na loss Euvolemia: Normal total body Na BUT pronounced pure water loss Hypervolemia: High total body Na

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Pathophysiology Three mechanisms – Pure water depletion Water depletion exceeding Na + depletion Na + excess

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Incidence In developing countries : 1.5 – 2 % Race No predilection Sex No sex difference Age Elderly people and children are most commonly affected

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Causes Water and Na deficits: GIT loss Diarrhoea Vomiting Fistula Cutaneous loss Burn Excessive sweating Renal Loss Osmotic diuretics CKD ; e.g. dysplasia, obstructive uropathy Polyuric phase of ATN Post obstructive diuresis

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Causes Water deficit: Nephrogenic DI Central DI Increased insensible loss Prematurity Radiant warmer Phototherapy Inadequate intake Ineffective BF Adipsia (lack of thirst)

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Causes Excess Na + Ingestion of large quantities of Na + Improperly mixed ‘formula’ ORS (concentrated / excessive intake) Iatrogenic Hypertonic saline Excess NaHCO 3 administration Sea water ingestion Hyperaldosteronism

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Clinical Features Increased thirst Nausea & vomiting Hypotension, Tachycardia & Tachypnoea Dehydration Doughy skin Irritability, lethargy Altered sensorium Convulsion Muscle twitching, spasticity Hyperreflexia

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Investigations S. electrolytes RBS S. calcium Blood Urea S. Creatinine S. osmolarity U. osmolarity U. Na +

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Investigations Imaging studies CT brain MRI brain Special Tests Water deprivation test ADH stimulation test

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Treatment Principles Treat hypovolemia first then hypernatraemia Rehydrate slowly over 48 – 72 hours Serum Na should not drop by >12 mmol / L in 24 hrs. (0.5 ml / kg/hour) Oral rehydration is preferable to I/V Identification & treatment of underlying cause

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Hypernatraemic dehydration Volume resuscitation with Isotonic fluid Replace the remaining deficit with hypotonic fluid Add Inj. Potassium chloride after urine passes Add Inj. 10% Calcium Gluconate If associated hyperglycemia, 5% Dextrose changed to 2.5% Insulin is NOT recommended Correct acidosis Treat all co-morbidities

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Estimation of Replacement Fluid: Calculate TBW deficit: 0.6 x Weight in kg Calculate the effect of 1 L of selected fluid on serum sodium using Adrogue – Madias formula - Divide 10 by the number obtained from A-M formula and Add the ongoing loss Convert to ml and divide by 24 to obtain ml / hr volume (TBW +1) Change in Serum Na (Infusate Na - Serum Na ) = (TBW +1) Change in Serum Na (Infusate Na + Infusate K - Serum Na ) = OR

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Add Inj. Potassium chloride after urine passes Add Inj. 10% Calcium Gluconate If associated hyperglycemia, 5% Dextrose changed to 2.5% Insulin is NOT recommended Correct acidosis Treat all co-morbidities Hypernatraemic dehydration

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Euvolemic : Give 5% D/A or 0.45% NaCl or o.225% NaCl Hypervolemic: Loop diuretics – to increase sodium excretion Replace with 5% D/A to correct hypertonicity In Euvolemic and Hypervolemic Patients

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Hypernatraemia in the setting of volume overload Renal failure Indications for Dialysis Daily body weight Vitals Dehydration status Intake and output Frequent serum electrolytes S. Calcium & RBS Renal function Monitoring

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Complications Intracranial Haemorrhage Cerebral Infarction Cerebral Oedema; especially during treatment Hypocalcaemia Hypergluycaemia

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Prognosis Acute hypernatraemia: Mortality is as high as 20% Chronic hypernatraemia: Mortality is 10% Neurological complications occur in 15% cases Neurological sequelae develop in patients with recurrent hypernatraemia

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Thank You

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