Hypertonic Saline for Treatment of Hyponatremic Encephalopathy 1) 100 ml bolus of 3%

Hyponatremia Correction 1. Indications for Hypertonic Saline: seizure, coma, focal findings - typically occurs with Na 100-110 - Symptoms improve with increasing Na ~5mEq 2. Goal correction of 0.5-1 mEq/hr - not to exceed 10-12 mEq/day 3. Overcorrection of Hyponatremia → Osmotic Demyelination Syndrome - Tx with 5% Dextrose in water @ 3cc/kg/h, loop diuretics, desmopressin MH/CCF/CWRU EM Res @MetroHealth_EM #Hyponatremia #Correction #goal #rate #management #nephrology

Management of Hyponatremia Hypertonic Saline - Only indicated if patient has severe symptoms + Na < 125 Give a Bolus of 150mL of 3% NaCl over 30 min. Dicsuss with a senior. (Max of 3 doses) • Target rise of 4-6 mmol/L over 3-4 hours • Check levels after infusion of Hypertonic Saline • If still symptomatic after 3 doses - consider ITU review • The target for correction over 24 hours including the hypertonic saline correction is 10 mmol/L Raised ECF volume • Offer Fluid Restriction for all • Heart Failure - Add Diuretics. • Cirrhosis - Correct K & Albumin. Add Diuretics, Consider K-opoid agonists • Discuss with endocrinology consultant about use of Tolvaptan if not improving adequately Normal ECF Volume • Consider Fluid restriction for all FEUrate > 11% • If not improving in 24 hours — discuss with endocrinology about adding Tolvaptan • Rpt. FE Urate post correction - Normalizes in SIADH • IF SIADH — look for cause Reduced ECF Volume • Consider correction with N. Saline • Calculate water deficit + ongoing losses • Calculate correction rate for Na • Check Na levels 6 hourly • Identify Cause and give specific treatment • Additional considerations: Addison's, Renal Tubular Acidosis. TFT - Dr. Jonny Wilkinson @Wilkinsonjonny #Hyponatremia #Management #algorithm #treatment #sodium

Hyponatremia with Severe Symptoms - Management Algorithm with Hypertonic Saline The goal of acute management is to raise the Na by 5 or stop the symptoms, whichever is quicker. If you have raised the Na by 5 and they are still seizing, then it is probably not the low Na causing the seizure and you need to look deeper. - Joel M. Topf, MD FACP @kidney_boy #Hyponatremia #Severe #Management #Algorithm #treatment #Hypertonic #Saline #nephrology

Goals and limits for treatment of Hyponatremia Stratified by duration and risk of Osmotic Demyelination Syndrome (ODS) Acute Hypotonic Hyponatremia (duration verified to be <48h) Severe symptoms • Goal: Rapid increase by 4—6 mEq/L. then gradual increase to normalization • Rapidly increase serum Na by 4—6 mEg/L with up to three 100 mL boluses of hypertonic saline given over 10 min at a time, followed by hypertonic saline at 1 mL/kg/h until substantial normalization Mild or moderate symptoms • Goal: Normalization • Fluid restriction alone if etiology rapidly reversible. Otherwise, hypertonic saline at 1 mL/kg/h until substantial normalization Chronic Hypotonic Hyponatremia (duration known to be >48h or duration uncertain) Severe, moderate, or mild symptoms • Goal: 4-6 mEq/L in 24h • Limit: 8 mEq/L in any 24h period Moderate or mild symptoms • Goal: Normalization • Limit: Normalization #Osmotic #Demyelination #Syndrome #ODS #goals #limits #management #hyponatremia

DDAVP Clamp Protocol in Hyponatremia • Stop any maintenance fluids. • Start DDAVP 2 mcg IV q8h • Start 3% NaCl (1-1.5 ml/kg over 6 hours) • Fluid restrict patient to 1.2 liters per day • Monitor sodium every 2 hours initially. Once the sodium is rising predictably, decrease frequency to every 4-6 hours. • Adjust 3% NaCl infusion rate to achieve correction of less than 8 mmol/L per day. Try to avoid adjusting the rate more than every 6 hours. Look at the sodium trend rather than the latest value. • Continue 3% and DDAVP until the sodium is 125-130 #DDAVP #Clamp #Protocol #Hyponatremia #management #nephrology

Hyponatremia - Diagnosis and Treatment Hyponatremia is usually caused by the inability to excrete water normally. In the vast majority of cases, ADH (appropriately or inappropriately secreted) is the culprit. Always start with a good history and exam, paying particular attention to volume status. Then, ask 3 questions to work through a physiologic approach to the differential! 1) Is it hypotonic? Calculate serum osmolality! 2) Is ADH elevated? Measure urine osmolality! 3) Is it appropriate? Assess volume status (EABV)! Treatment: Treatment of hyponatremia is a complex issue which varies based on chronicity and severity. Generally, treat the underlying cause and avoid rapid correction (max rate of correction 8 mEq/L/day) Rapid correction of chronic hyponatremia puts patients at risk for osmotic demyelination syndrome. 3% saline can be administered (through a peripheral IV!) in 100 mL boluses over 10 minutes up to 3x in the setting of symptomatic (seizures. obtundation. coma. respiratory arrest) hyponatremia. Other options for severe/refractory hypoNa include vaptans (HF/liver disease) and augmentation with DDAVP may be required. Dr. Meredith Greer @EmmGeezee #Hyponatremia #Differential #Diagnosis #Treatment #management #nephrology #sodium

Treatment of Hyperkalemia Membrane Stabilization • Calcium Gluconate (10%) • Hypertonic (3%) Normal Saline Shifters: • Insulin (Short Acting) • Albuterol Excreters: • Furosemide • Sodium Bicarbonate • Sodium Polystyrene Sulfonate Definitive: • Hemodialysis #Hyperkalemia #Management #Treatment #Medications #Interventions #Table #Onset #RebelEM

Criteria for stopping insulin drip in DKA: Don't stop the drip until the following criteria are met 1) Resolution of ketoacidosis (anion gap < 10-12 mEq/L). 2) The patient isn't significantly acidotic (bicarbonate > 18-20 mEq/L). 3) The patient has received the full daily dose of long-acting insulin >2 hours previously. 4) Glucose is reasonably well controlled (e.g., <250 mg/dL or <14 mM) 5) The patient should ideally be hungry (this is an excellent sign suggesting that the ketoacidosis has resolved). #Management #DKA #Stopping #Insulin #Drip #GTT #Criteria

Hypernatremia - Differential Diagnosis and Treatment Hypernatremia is almost always due to unreplaced water loss (free water deficit). The differential can be broadly placed into 4 categories. Diagnosis is primarily based on history, exam, and urine osm (in DI; high dilute urine output is a clue). 1) ↓ Water Intake, Dehydration: neurologic disease, water unavailable 2) Osmotic Diuresis: HHS, post-obstructive 3) Diabetes Insipidus: neurogenic, nephrogenic 4) ↑ Salt Intake: salt water, hyper/isotonic saline Treatment: Treatment of hypernatremia can also be complex and varies with chronicity and severity. • Start by calculating the free water deficit (FWD) = Total Body Water (TBW) x (([Na] / 140) - 1) • Total body water is 50-60% of patient weight (eg 0.5-0.6 x pt weight). • Generally, the treatment will involve resuscitation with isotonic fluids followed by free water. • Free water can be delivered with D5 fluids or enteral free water flushes. • Rapid correction of chronic hypernatremia puts patients at risk for cerebral edema and herniation. • The maximum rate of correction should not exceed 12 mEq/L in a 24-hour period. Dr. Meredith Greer @EmmGeezee #Hypernatremia #Differential #Diagnosis #Treatment #management #nephrology #sodium

SIADH Treatment Options 1. Treat underlying cause of SIADH: Pain, Primary lung pathology, Post-operative phenomenon, Medications, Basically anything 2. Free water restriction • All food has water • Electrolyte Free Water Clearance (EFWC) Equation • For practical purposes, restrict to 1 to 1.5L per day (if you plan on using this as a long-term solution, you should prove feasibility during hospitalization) 3. Salt tabs • Start with lg NaCl PO TID • With lower Na, you should increase the number and frequency of salt tablets administered • This can cause volume overload 4. Urea powder • Induces osmotic water elimination by promoting passive sodium reabsorption in the ascending limb of the loop of Henle • Contraindicated in cirrhosis given the potential for it to be metabolized into ammonium by urease-producing bacteria in the colon 5. 0.9% NS • If Urine osmolality < 538 AND UNa + UK < 154, can try giving 0.9% NS • Give 250 cc NS boluses at a time • Re-check the serum Na+ in 2-4 hours and decide before giving more 6. Vasopressor receptor antagonists (-vaptans) • Blocks ADH receptor • Major side effects: Thirst, Nausea, Hypotension, Increased urine output Satya Patel, MD @SatyaPatelMD #SIADH #Management #hyponatremia #nephrology #treatment