HYPONATRAEMIA: NUH GUIDELINE FOR INITIAL ASSESSMENT AND MANAGEMENT.
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1 HYPONATRAEMIA: NUH GUIDELINE FOR INITIAL ASSESSMENT AND MANAGEMENT. HYPONATRAEMIA: SODIUM < 130 MMOL/L SIGNIFICANT. Symptoms/signs usually only occur when sodium < 125 mmol/l. Acute hyponatraemia is less well tolerated. Aetiology is often multifactorial in medical patients. ASSESSMENT IF THE PATIENT HAS SEVERE SYMPTOMS: SEIZURES, COMA, ALTERED GCS OR ENCEPHALOPATHY START URGENT TREATMENT (GO TO PAGE 3). HISTORY: symptoms include nausea and vomiting, headache, muscle cramps, confusion, lethargy, reduced GCS and seizures. o Consider the context e.g. known cancer or polydipsia. o Include accurate drug history. Common precipitants: Diuretics (predominantly thiazides, less with loop diuretics). Antidepressants, antipsychotics, antiepileptics. Smaller contribution from PPIs EXAMINATION: An accurate assessment of fluid status is vital to determine diagnosis and guide treatment. SCREENING BLOOD/URINE PANEL: o U&Es, glucose, plasma osmolality, LFTs, TFTs, lipids, cortisol. o Urine osmolality and urine Na + + K +. OTHER INVESTIGATIONS AS INDICATED: e.g. short synacthen test, CXR, CT head. 1
2 DIFFERENTIAL DIAGNOSIS BY VOLUME STATUS HYPOVOLAEMIC Reduced skin turgor, dry membranes, low BP or postural hypotension Renal losses - Osmotic diuresis - Diuretic therapy - Addison s disease - Salt-losing nephropathy - Cerebral salt wasting <20mmol/L Extra-renal losses - Diarrhoea - Vomiting - Burns - Fistulae - Pancreatitis EUVOLAEMIC - SIADH - Secondary adrenal insufficiency - Addison s disease (with secondary ADH response) - Hypothyroidism - Diuretic therapy - Drugs HYPERVOLAEMIC Oedema, raised JVP, ascites - Acute or chronic renal failure - Diuretic therapy for heart failure <20mmol/L - Nephrotic syndrome - Cirrhosis - Cardiac failure DIAGNOSTIC CRITERIA FOR SIADH Clinically euvolaemic Serum osmolality < 270 mosm/kg Inappropriately concentrated urine > 100 mosm/kg, usually > 300 mosm/kg Increased urine Na + (> 20 mmol/l) Absence of adrenal, thyroid, pituitary or renal insufficiency INTERPRET BIOCHEMISTRY WITH CAUTION IF PATIENT IS ON DIURETIC THERAPY. 2
3 GENERAL MANAGEMENT OF HYPONATRAEMIA MANAGEMENT IS DETERMINED BY 1. Severity of symptoms. 2. Chronicity of the hyponatraemia: Acute < 24 hours, chronic > 48 hours. Treat as chronic if unclear and no severe symptoms. 3. Patient s volume status. IN ALL PATIENTS 1. Stop any offending medications. 2. Review any IV fluids. 3. Treat the underlying cause. 4. Transfer to a Level 2 or ICU bed if severe symptoms are present. 5. Limit rise in sodium in first 24 hours to 10 mmol/l and 8 mmol/l in each following 24 hours. MANAGEMENT OF SEVERE HYPONATRAEMIA IF SEIZURES, COMA, ALTERED GCS OR ENCEPHALOPATHY START URGENT TREATMENT AS BELOW (REGARDLESS OF CHRONICITY) FIRST HOUR MANAGEMENT SUBSEQUENT MANAGEMENT 1. Manage in level 2/3 bed. 2. Senior input. 3. Give 150 mls IV 3% saline (hypertonic) over 20 mins. 4. Check sodium concentration. 5. Repeat 150 mls IV 3 % over 20 mins saline until sodium risen by 5 mmol/l. 1. Stop 3% saline. 2. Slow IV infusion 0.9% saline. 3. Start diagnosis specific treatment. 4. Limit rise in sodium in first 24 hours to 10 mmol/l and 8 mmol/l in each following 24 hours. 5. Recheck sodium at 6, 12, 24 and 48 hours. 3
4 MANAGEMENT OF ACUTE HYPONATRAEMIA (< 48 hours) without severe symptoms. Ensure there are no sampling or sample handling errors e.g. drip arm venepuncture. Recheck sodium. Stop any non-essential fluids or medication that could be contributing/provoking. Make diagnostic assessment and treat underlying cause. If hypovolaemic start IV 0.9% saline. Recheck sodium after 4 hours to determine trend. Limit rise in sodium in first 24 hours to 10 mmol/l and 8 mmol/l in each following 24 hours. MANAGEMENT OF CHRONIC HYPONATRAEMIA (> 48 hours or unclear duration) without severe features. Assess volume status Hypovolaemic Reduced skin turgor, dry membranes, low BP or postural hypotension Restore volume with IV 0.9% saline. If haemodynamic compromise the need for rapid fluid resuscitation overrides the risk of an overly rapid increase in sodium Euvolaemic Confirm hypotonic hyponatraemia. i.e. Plasma Osm < 275 mosm/kg, Urine Osm > 100 mosm/kg Review urine Na. Urine Na <20 reconsider hypo/hypervolaemia. Urine Na>20 see page 5 Hypervolaemic Oedema, raised JVP,ascites Treat the underlying cause. Consider fluid restriction to prevent further fluid overload 4
5 Euvolaemic hypotonic hyponatraemia Urine Na > 20 mmol/l Review thyroid function, cortisol, +/- short synacthen test. Normal Likely SIADH (see diagnostic criteria Page 2) Abnormal Treat underlying thyroid, adrenal or pituitary disease Investigate underlying cause: consider CT chest/abdo/pelvis/head Calculate electrolyte free water clearance with Furst formula: Urine Na + Urine K Serum Na < 0.5: commence 1.0 L fluid restriction 0.5 1: commence 0.5 L fluid restriction > 1.0: fluid restriction not advised Assess response at 24 and 48 hours. Seek specialist opinion (endocrinology) If poor response Consider demeclocycline 150mg tds and review Na or Tolvaptan 15 mg single dose and review- UNDER ENDOCRINE CONSULTANT ADVICE ONLY. Fluid restriction must be lifted Aim for target Na 130mmol/l References: Clinical practice guideline on diagnosis and treatment of hyponatraemia. G. Spasovski et al, Eur J Endocrinol 2014; 170: G1 G47. The diagnosis and management of inpatient hyponatraemia and SIADH. P Grant et al, Eur J Clin Invest 2015; 45 (8): Guidelines by: Dr G Argentesi, Dr S Jackson, Dr J Clayton & Dr M Glover. May Jenny.clayton@nuh.nhs.uk 5
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