Hypernatremia

Last updated
Hypernatremia
Other namesHypernatraemia
Na-TableImage.svg
Sodium
Specialty Hospital medicine
Symptoms Feeling of thirst, weakness, nausea, loss of appetite [1]
Complications Cardiac arrest, confusion, muscle twitching, bleeding in or around the brain [1] [2]
TypesLow volume, normal volume, high volume [1]
Diagnostic method Serum sodium > 145 mmol/L [3]
Differential diagnosis Low blood protein levels [4]
Frequency~0.5% in hospital [2]

Hypernatremia, also spelled hypernatraemia, is a high concentration of sodium in the blood. [3] Early symptoms may include a strong feeling of thirst, weakness, nausea, and loss of appetite. [1] Severe symptoms include confusion, muscle twitching, and bleeding in or around the brain. [1] [2] Normal serum sodium levels are 135–145  mmol/L (135–145 mEq/L). [5] Hypernatremia is generally defined as a serum sodium level of more than 145 mmol/L. [3] Severe symptoms typically only occur when levels are above 160 mmol/L. [1]

Contents

Hypernatremia is typically classified by a person's fluid status into low volume, normal volume, and high volume. [1] Low volume hypernatremia can occur from sweating, vomiting, diarrhea, diuretic medication, or kidney disease. [1] Normal volume hypernatremia can be due to fever, extreme thirst, prolonged increased breath rate, diabetes insipidus, and from lithium among other causes. [1] High volume hypernatremia can be due to hyperaldosteronism, excessive administration of intravenous normal saline or sodium bicarbonate, or rarely from eating too much salt. [1] [2] Low blood protein levels can result in a falsely high sodium measurement. [4] The cause can usually be determined by the history of events. [1] Testing the urine can help if the cause is unclear. [1] The underlying mechanism typically involves too little free water in the body. [6]

If the onset of hypernatremia was over a few hours, then it can be corrected relatively quickly using intravenous normal saline and 5% dextrose in water. [1] Otherwise, correction should occur slowly with, for those unable to drink water, half-normal saline. [1] Hypernatremia due to diabetes insipidus as a result of a brain disorder, may be treated with the medication desmopressin. [1] If the diabetes insipidus is due to kidney problems the medication causing the problem may need to be stopped or the underlying electrolyte disturbance corrected. [1] [7] Hypernatremia affects 0.3–1% of people in hospital. [2] It most often occurs in babies, those with impaired mental status, and the elderly. [2] Hypernatremia is associated with an increased risk of death, but it is unclear if it is the cause. [2]

Signs and symptoms

The major symptom is thirst. [8] [9] The most important signs result from brain cell shrinkage and include confusion, muscle twitching or spasms. With severe elevations, seizures and comas may occur. [8]

Severe symptoms are usually due to acute elevation of the plasma sodium concentration to above 157 mmol/L [10] (normal blood levels are generally about 135–145 mmol/L for adults and elderly). [10] Values above 180 mmol/L are associated with a high mortality rate, particularly in adults. [11] However, such high levels of sodium rarely occur without severe coexisting medical conditions. [12] Serum sodium concentrations have ranged from 150 to 228 mmol/L in survivors of acute salt overdosage, while levels of 153–255 mmol/L have been observed in fatalities. Vitreous humor is considered to be a better postmortem specimen than postmortem serum for assessing sodium involvement in a death. [13] [14]

Cause

Common causes of hypernatremia include: [8]

Low volume

In those with low volume or hypovolemia:

Normal volume

In those with normal volume or euvolemia:

High volume

In those with high volume or hypervolemia:

Diagnosis

Hypernatremia is diagnosed when a basic metabolic panel blood test demonstrates a sodium concentration higher than 145 mmol/L.[ citation needed ]

Treatment

The cornerstone of treatment is administration of free water to correct the relative water deficit. Water can be replaced orally or intravenously. Water alone cannot be administered intravenously (because of osmolarity issues leading to rupturing of red blood cells in the bloodstream), but rather can be given intravenously in solution with dextrose (sugar) or saline (salt). However, overly rapid correction of hypernatremia is potentially very dangerous. The body (in particular the brain) adapts to the higher sodium concentration. Rapidly lowering the sodium concentration with free water, once this adaptation has occurred, causes water to flow into brain cells and causes them to swell. This can lead to cerebral edema, potentially resulting in seizures, permanent brain damage, or death. Therefore, significant hypernatremia should be treated carefully by a physician or other medical professional with experience in treatment of electrolyte imbalance. Specific treatments such as thiazide diuretics (e.g., chlorthalidone) in congestive heart failure or corticosteroids in nephropathy also can be used. [19]

See also

Related Research Articles

<span class="mw-page-title-main">Diabetes insipidus</span> Condition characterized by large amounts of dilute urine and increased thirst

Diabetes insipidus (DI) is a condition characterized by large amounts of dilute urine and increased thirst. The amount of urine produced can be nearly 20 liters per day. Reduction of fluid has little effect on the concentration of the urine. Complications may include dehydration or seizures.

<span class="mw-page-title-main">Diabetic ketoacidosis</span> Medical condition

Diabetic ketoacidosis (DKA) is a potentially life-threatening complication of diabetes mellitus. Signs and symptoms may include vomiting, abdominal pain, deep gasping breathing, increased urination, weakness, confusion and occasionally loss of consciousness. A person's breath may develop a specific "fruity" smell. The onset of symptoms is usually rapid. People without a previous diagnosis of diabetes may develop DKA as the first obvious symptom.

<span class="mw-page-title-main">Dehydration</span> Deficit of total body water

In physiology, dehydration is a lack of total body water that disrupts metabolic processes. It occurs when free water loss exceeds free water intake. This is usually due to excessive sweating, disease, or a lack of access to water. Mild dehydration can also be caused by immersion diuresis, which may increase risk of decompression sickness in divers.

Hyponatremia or hyponatraemia is a low concentration of sodium in the blood. It is generally defined as a sodium concentration of less than 135 mmol/L (135 mEq/L), with severe hyponatremia being below 120 mEq/L. Symptoms can be absent, mild or severe. Mild symptoms include a decreased ability to think, headaches, nausea, and poor balance. Severe symptoms include confusion, seizures, and coma; death can ensue.

<span class="mw-page-title-main">Thirst</span> Craving for potable fluids experienced by animals

Thirst is the craving for potable fluids, resulting in the basic instinct of animals to drink. It is an essential mechanism involved in fluid balance. It arises from a lack of fluids or an increase in the concentration of certain osmolites, such as sodium. If the water volume of the body falls below a certain threshold or the osmolite concentration becomes too high, structures in the brain detect changes in blood constituents and signal thirst.

Polydipsia is excessive thirst or excess drinking. The word derives from Greek πολυδίψιος (poludípsios) 'very thirsty', which is derived from Ancient Greek πολύς (polús) 'much, many' and δίψα (dípsa) 'thirst'. Polydipsia is a nonspecific symptom in various medical disorders. It also occurs as an abnormal behaviour in some non-human animals, such as in birds.

<span class="mw-page-title-main">Electrolyte imbalance</span> Abnormality in the concentration of electrolytes in the body

Electrolyte imbalance, or water-electrolyte imbalance, is an abnormality in the concentration of electrolytes in the body. Electrolytes play a vital role in maintaining homeostasis in the body. They help to regulate heart and neurological function, fluid balance, oxygen delivery, acid–base balance and much more. Electrolyte imbalances can develop by consuming too little or too much electrolyte as well as excreting too little or too much electrolyte. Examples of electrolytes include calcium, chloride, magnesium, phosphate, potassium, and sodium.

<span class="mw-page-title-main">Hypokalemia</span> Insufficient potassium in the blood

Hypokalemia is a low level of potassium (K+) in the blood serum. Mild low potassium does not typically cause symptoms. Symptoms may include feeling tired, leg cramps, weakness, and constipation. Low potassium also increases the risk of an abnormal heart rhythm, which is often too slow and can cause cardiac arrest.

The syndrome of inappropriate antidiuretic hormone secretion (SIADH), also known as the syndrome of inappropriate antidiuresis (SIAD), is characterized by a physiologically inappropriate release of antidiuretic hormone (ADH) either from the posterior pituitary gland, or an abnormal non-pituitary source. Unsuppressed ADH causes a physiologically inappropriate increase in solute-free water being reabsorbed by the tubules of the kidney to the venous circulation leading to hypotonic hyponatremia.

Hyperchloremia is an electrolyte disturbance in which there is an elevated level of chloride ions in the blood. The normal serum range for chloride is 96 to 106 mEq/L, therefore chloride levels at or above 110 mEq/L usually indicate kidney dysfunction as it is a regulator of chloride concentration. As of now there are no specific symptoms of hyperchloremia; however, it can be influenced by multiple abnormalities that cause a loss of electrolyte-free fluid, loss of hypotonic fluid, or increased administration of sodium chloride. These abnormalities are caused by diarrhea, vomiting, increased sodium chloride intake, renal dysfunction, diuretic use, and diabetes. Hyperchloremia should not be mistaken for hyperchloremic metabolic acidosis as hyperchloremic metabolic acidosis is characterized by two major changes: a decrease in blood pH and bicarbonate levels, as well as an increase in blood chloride levels. Instead those with hyperchloremic metabolic acidosis are usually predisposed to hyperchloremia.

<span class="mw-page-title-main">Water intoxication</span> Potentially fatal overhydration

Water intoxication, also known as water poisoning, hyperhydration, overhydration, or water toxemia, is a potentially fatal disturbance in brain functions that can result when the normal balance of electrolytes in the body is pushed outside safe limits by excessive water intake.

<span class="mw-page-title-main">Saline (medicine)</span> Saline water for medical purposes

Saline is a mixture of sodium chloride (salt) and water. It has a number of uses in medicine including cleaning wounds, removal and storage of contact lenses, and help with dry eyes. By injection into a vein, it is used to treat hypovolemia such as that from gastroenteritis and diabetic ketoacidosis. Large amounts may result in fluid overload, swelling, acidosis, and high blood sodium. In those with long-standing low blood sodium, excessive use may result in osmotic demyelination syndrome.

Nephrogenic diabetes insipidus, recently renamed arginine vasopressin resistance (AVP-R) and previously known as renal diabetes insipidus, is a form of diabetes insipidus primarily due to pathology of the kidney. This is in contrast to central or neurogenic diabetes insipidus, which is caused by insufficient levels of vasopressin. Nephrogenic diabetes insipidus is caused by an improper response of the kidney to vasopressin, leading to a decrease in the ability of the kidney to concentrate the urine by removing free water.

<span class="mw-page-title-main">Primary polydipsia</span> Medical condition

Primary polydipsia and psychogenic polydipsia are forms of polydipsia characterised by excessive fluid intake in the absence of physiological stimuli to drink. Psychogenic polydipsia caused by psychiatric disorders—oftentimes schizophrenia—is frequently accompanied by the sensation of dry mouth. Some conditions with polydipsia as a symptom are non-psychogenic. Primary polydipsia is a diagnosis of exclusion.

<span class="mw-page-title-main">ROHHAD</span> Medical condition

Rapid-onset obesity with hypothalamic dysregulation, hypoventilation, and autonomic dysregulation (ROHHAD) is a rare condition whose etiology is currently unknown. ROHHAD mainly affects the endocrine system and autonomic nervous system, but patients can exhibit a variety of signs. Patients present with both alveolar hypoventilation along with hypothalamic dysfunction, which distinguishes ROHHAD from congenital central hypoventilation syndrome (CCHS). ROHHAD is a rare disease, with only 100 reported cases worldwide thus far.

Central diabetes insipidus, recently renamed arginine vasopressin deficiency (AVP-D), is a form of diabetes insipidus that is due to a lack of vasopressin (ADH) production in the brain. Vasopressin acts to increase the volume of blood (intravascularly), and decrease the volume of urine produced. Therefore, a lack of it causes increased urine production and volume depletion.

<span class="mw-page-title-main">Sodium in biology</span> Use of sodium by organisms

Sodium ions are necessary in small amounts for some types of plants, but sodium as a nutrient is more generally needed in larger amounts by animals, due to their use of it for generation of nerve impulses and for maintenance of electrolyte balance and fluid balance. In animals, sodium ions are necessary for the aforementioned functions and for heart activity and certain metabolic functions. The health effects of salt reflect what happens when the body has too much or too little sodium. Characteristic concentrations of sodium in model organisms are: 10 mM in E. coli, 30 mM in budding yeast, 10 mM in mammalian cell and 100 mM in blood plasma.

<span class="mw-page-title-main">Adipsia</span> Medical condition

Adipsia, also known as hypodipsia, is a symptom of inappropriately decreased or absent feelings of thirst. It involves an increased osmolality or concentration of solute in the urine, which stimulates secretion of antidiuretic hormone (ADH) from the hypothalamus to the kidneys. This causes the person to retain water and ultimately become unable to feel thirst. Due to its rarity, the disorder has not been the subject of many research studies.

Exercise-associated hyponatremia (EAH) is a fluid-electrolyte disorder caused by a decrease in sodium levels (hyponatremia) during or up to 24 hours after prolonged physical activity. This disorder can develop when marathon runners or endurance event athletes drink more fluid, usually water or sports drinks, than their kidneys can excrete. This excess water can severely dilute the level of sodium in the blood needed for organs, especially the brain, to function properly.

<span class="mw-page-title-main">Salt poisoning</span> Intoxication from excessive intake of sodium

Salt poisoning is an intoxication resulting from the excessive intake of sodium either in solid form or in solution. Salt poisoning sufficient to produce severe symptoms is rare, and lethal salt poisoning is possible but even rarer. The lethal dose of table salt is roughly 0.5–1 gram per kilogram of body weight.

References

  1. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Reynolds, RM; Padfield, PL; Seckl, JR (25 March 2006). "Disorders of sodium balance". BMJ (Clinical Research Ed.). 332 (7543): 702–5. doi:10.1136/bmj.332.7543.702. PMC   1410848 . PMID   16565125.
  2. 1 2 3 4 5 6 7 Lin, M; Liu, SJ; Lim, IT (August 2005). "Disorders of water imbalance". Emergency Medicine Clinics of North America. 23 (3): 749–70, ix. doi:10.1016/j.emc.2005.03.001. PMID   15982544.
  3. 1 2 3 Muhsin, SA; Mount, DB (March 2016). "Diagnosis and treatment of hypernatremia". Best Practice & Research Clinical Endocrinology & Metabolism. 30 (2): 189–203. doi:10.1016/j.beem.2016.02.014. PMID   27156758.
  4. 1 2 Kliegman, Robert M.; Stanton, Bonita M. D.; Geme, Joseph St; Schor, Nina F. (2015). Nelson Textbook of Pediatrics (20 ed.). Elsevier Health Sciences. p. 348. ISBN   9780323263528. Archived from the original on 2017-09-08.
  5. ↑ Kuruvilla, Jaya (2007). Essentials of Critical Care Nursing. Jaypee Brothers Publishers. p. 329. ISBN   9788180619205.[ permanent dead link ]
  6. ↑ Ranasinghe, Sudharma; Wahl, Kerri M.; Harris, Eric; Lubarsky, David J. (2012). Anesthesiology Board Review Pearls of Wisdom 3/E. McGraw Hill Professional. p. 6. ISBN   9780071773638.
  7. ↑ Khanna, A (May 2006). "Acquired Nephrogenic Diabetes Insipidus". Seminars in Nephrology (Review). 26 (3): 244–8. doi:10.1016/j.semnephrol.2006.03.004. PMID   16713497.
  8. 1 2 3 Lewis, J. L. (March 2013). "Hypernatremia". Merck Manual of Diagnosis and Therapy . Medical Library Association. Archived from the original on 27 December 2015. Retrieved 25 December 2015.
  9. ↑ Department of Health & Human Services, State Government of Victoria, Australia Better Health Channel: Salt Archived 2016-04-02 at the Wayback Machine Last updated: May 2014
  10. 1 2 Reynolds, R.; Padfield, P. L.; Seckl, J. R. (2006). "Disorders of sodium balance". BMJ . 332 (7543): 702–705. doi:10.1136/bmj.332.7543.702. PMC   1410848 . PMID   16565125.
  11. 1 2 3 Ofran, Y.; Lavi, D.; Opher, D.; Weiss, T. A.; Elinav, E. (2004). "Fatal voluntary salt intake resulting in the highest ever documented sodium plasma level in adults (255 mmol L−1) a disorder linked to female gender and psychiatric disorders". J. Intern. Med. 256 (6): 525–528. doi: 10.1111/j.1365-2796.2004.01411.x . PMID   15554954. S2CID   20446209.
  12. ↑ Shier, D.; Butler, J.; Lewis, R. (2006). Hole's Human Anatomy and Physiology (11th ed.). McGraw-Hill Companies. ISBN   9780073256993.
  13. ↑ Coe, J. I. (1993). "Postmortem chemistry update. Emphasis on forensic application". Am. J. Forensic Med. Pathol. 14 (2): 91–117. doi:10.1097/00000433-199306000-00001. PMID   8328447. S2CID   35536508.
  14. ↑ Baselt, R. C. (2014). Disposition of Toxic Drugs and Chemicals in Man (10th ed.). Seal Beach, Ca.: Biomedical Publications. pp. 1855–1856. ISBN   9780962652394.
  15. ↑ Leroy, C.; Karrouz, W.; Douillard, C.; Do Cao, C.; Cortet, C.; Wémeau, J. L.; Vantyghem, M. C. (2013). "Diabetes insipidus". Ann. Endocrinol. 74 (5–6). Paris: 496–507. doi:10.1016/j.ando.2013.10.002. PMID   24286605.
  16. ↑ Saunders, N.; Balfe, J. W.; Laski, B. (1976). "Severe salt poisoning in an infant". J. Pediatr. 88 (2): 258–61. doi:10.1016/s0022-3476(76)80992-4. PMID   1249688.
  17. ↑ Paut, O.; André, N.; Fabre, P.; Sobraquès, P.; Drouet, G.; Arditti, J.; Camboulives, J. (1999). "The management of extreme hypernatraemia secondary to salt poisoning in an infant". Paediatr. Anaesth. 9 (2): 171–174. doi:10.1046/j.1460-9592.1999.9220325.x. PMID   10189662. S2CID   3212802.
  18. ↑ Carlberg, D. J.; Borek, H. A.; Syverud, S. A.; Holstege, C. P. (2013). "Survival of Acute Hypernatremia Due to Massive Soy Sauce Ingestion". J. Emerg. Med. 45 (2): 228–231. doi:10.1016/j.jemermed.2012.11.109. PMID   23735849.
  19. ↑ Adrogué, H. J.; Madias, N. E. (2000). "Hypernatremia". N. Engl. J. Med. 342 (20): 1493–1499. doi:10.1056/NEJM200005183422006. PMID   10816188.
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