ReviewsTreatment of Symptomatic Hyponatremia
Section snippets
Brain Adaptation to Hyponatremia and Its Treatment
Understanding of the most appropriate therapeutic approach in the presence of hyponatremia requires a brief physiopathologic review. When blood tonicity diminishes, the brain will rapidly lower the electrolyte content of its interstitial fluid (Na+ and Cl−) within minutes; then, intracellular potassium and organic osmolytes such as amino acids (eg, taurine, glutamine, glutamate), polyols (myoinositol), methylamines (creatine, etc) decrease. This prevents excessive cerebral edema, 4 which could
Risk Factors for Myelinolysis (ODS)
The most important factor is the daily difference in serum sodium level. Furthermore, about 80% of cases of ODS reported in the literature are associated with hypokalemia (often induced by thiazides). 12 Most ODS observations were reported in patients presenting with an initial SNa below 120 mEq/L. 4 However, in malnourished patients (chronic alcohol abuse, liver cirrhosis, heavy burns, hypocorticism, etc), ODS cases were reported with less severe hyponatremia. 13
In animals, there is a good
Treatment of Acute Hyponatremia
The circumstances inducing hyponatremia are very important diagnostic clues to recognizing hyponatremia as acute or chronic. Acute hyponatremia occurs generally in hospitalized patients and is most frequently iatrogenic. The main causes are outlined in Table 1. Some symptoms suggest intracranial hypertension: headache, nausea, vomiting, seizures, and deep coma. Sometimes these symptoms may be explosive in nature.
Exercise-induced hyponatremia occurs in association with overwhelming physical
Treatment of Symptomatic Chronic Hyponatremia (> 48 to 72 Hours), Subacute Hyponatremia, or Hyponatremia of Undetermined Duration
The clinical context in which hyponatremia develops may be helpful in differentiating acute from chronic hyponatremia. Severe neurologic symptoms often reflect cerebral edema, but this is not always true. 21 Extrahospital acquired hyponatremia is generally chronic, except for polydipsia, marathon runners, and ecstasy. Chronic hyponatremia may have a superimposed acute component. Hyponatremia of undetermined duration, especially when it is symptomatic, needs treatment combining rapid decrease of
Relowering of the SNA in Case of Overcorrection of Hyponatremia
An excessive rate of correction of hyponatremia may be secondary to the excessive administration of salt (error in calculation of doses to administer), and we have to remember that the administration of potassium in the solution contributes to increase the serum sodium. Most often this is caused by a predictable or unpredictable increase in the excretion of electrolyte free water. 22., 23. Frequent monitoring of SNa should enable avoidance of this complication. Data obtained in animals suggest
General Recommendations
When hyponatremia is associated with severe neurologic symptoms (vomiting, headaches, seizures, coma, etc), rapid correction of hyponatremia during the first hours is mandatory (Table 4). However, there is no reason to increase SNa by more than 8 to 10%. If the acute nature of hyponatremia is obvious (postoperative, duration < 48 hours), normalization of SNa is theoretically possible without inducing cerebral lesions. In those patients in whom the duration of hyponatremia is not definitely
Urea as Alternative Treatment for Symptomatic Hyponatremia
Urea represents a valuable therapeutic alternative in hyponatremia 4 (Table 6). This endogenous diuretic is able to rapidly diminish cerebral edema without any risk of volume overload and without the risk of transitory worsening of hyponatremia (as seen with the administration of mannitol, caused by water translocation). 30 The osmotic diuresis caused by urea is accompanied by sodium retention that also plays a role in the correction of hyponatremia. 31 Urea may also be used as a long-term
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Many studies were supported by grants from the “Fonds National de la Recherche Scientifique” (1.5.228.90F/1.5.204.91F/1.5.175.94F/1.5.193.96F/1.5.198.97F/1.5.164.98F/1.5.141.00F/4574.01).