Eggplant: The Story of Sodium in Neurocritical Care

Transcription

1 Eggplant: The Story of Sodium in Neurocritical Care Larry Burris, DO Medical Director NCC - Sanford Health Medical Director Renal Transplant - Sanford Health Assistant Professor of Medicine SSOM

2 NaCl Facts First Harvested and used as a spice in 6050 BC by Neolithic Precucuteni culture 210 metric tons of NaCl produced annually, China is the biggest Plays a role in most religions

3 Sodium Range mEq/l in extracellular space Volume of distribution of that of water Plasma Na = 154mEq/l Major Contributor to Osmolarity 2[Na] + [BUN]/2.8 + [Glu]/18 or 2[Na] + 10

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5 Sodium Balance More Na Hypertonic Saline Hypernatremia Less Na Sweating Hypotonic Saline Salt wasting Hyponatremia 140 meq liter More Water Free Water IVF SIADH DDAVP/Vasopressin Hyponatremia Less Water Diarrhea NGT Suction Insensible losses DI Hypernatremia

6 Sodium Balance Almost all derangement in Na are related to water Less Na Salt wasting Hyponatremia 140 meq liter More Water SIADH Hyponatremia Less Water DI Hypernatremia

7 Arginine Vasopressin aka: AVP, ADH, Vasopressin, Argipressin

8 Aquaporin QuickTime and a YUV420 codec decompressor are needed to see this picture. Tajkhorshid, Norbert, Jensen, Miercke, O Connell, Stroud, Shulten Science 296, , 2002

9 Increased ADH Appropriate - SAADH Increase Osmolality Hypoperfusion Inappropriate - SIADH Increase ICP Lung Injury Nausea Pain Data from Robertson, GL, Aycinena, P, Zerbe, RL, Am J Med 1982; 72:339. Morphine

10 Decreased ADH Pituitary Failure - DI Pregnancy Sepsis Liver failure Nephrogenic DI*

11 ADH Increase ADH = Hyponatremia Decrease ADH = Hypernatremia

12 How to Determine ADH Increase ADH Aquaporin channels are closed Decrease free water loss Urine is concentrated Urine Osmolality is great than Serum Osmolality Decrease ADH Aquaporin channels are open Increase free water loss Urine is dilute Urine Osmolality is less than Serum Osmolality

13 Other factors in NCC that Effects Na Osmolar agents Mannitol Increased Glucose (200mg/dl) Bulk Lipids Paraproteins

14 Pseudohyponatremia A B Na Na Na Na Na Na Na Na Na Na 1 cc of blood with the same Hgb and Na concentration. The lipid content B>A

15 Cerebral Salt Wasting aka Renal Salt Wasting Maesaka,Imbriano,Ali,Ilamathi, KI, 2009,76,

16 Effect of Sodium imbalance Hyponatremia Acute (< 2days) Seizures Coma Lethargy Increase ICP Chronic (> 2 days) Confession Nausea Lethargy Gait Disturbance Hypernatremia Lethargy

17 Increases in ADH/Hyponatremia in NCC Increase ICP TBI with Pituitary Damage Pain Nausea and Vomiting Stress Hypoperfusion Increase Osmolality Drugs Morphine Haloperidol Cipro Carbamazepine TCA NSAIDS HCTZ DDAVP/Vasopressin

18 Acute Hyponatremia 7yr JRA admitted with L ICH. 0.9% NaCl started to keep Na > 140mEq/l. Had angiogram and developed acute change in mental status. Na had dropped to 128mEq/l and 3% NaCl has given to correct Na Carpenter, Weinstein, Myseros, Vezina, Bell, NCC,2007,6,

19 Hyponatremia - Outcomes If admitted with Na < 130mEq/l 60 fold increase in death If admitted with Na < 120mEq/l death rate is 25% 21% present of patients found to have Na < 135mEq/l present with falls, compare to 5% with Na> 135mEq/l Persistent or acquiring hyponatremia increase hospital, 1 yr and 5 yr death rates Correction of hyponatremia improves short and long term outcomes In SAH hyponatremia is associated with worse 3 month outcomes Rahman, Friedman, Neurosurgery, 2009,56,

20 Hypernatremia in NCC Diabetes Insipitus Increase Insensible Free water losses Diarrhea Fever Medications Lasix Mannitol IV fluid

21 Hypernatremia - Outcomes Pulmonary Edema Central Pontine Lysis Worse outcomes 3 months after SAH Acute hypernatremia in adult associated with mortality of 75% Acute hypernatremia in children is associated with an increase of mortality of 10-70%

22 The Brain is like an Eggplant? Has a Stem Covered by a tough membrane Contains lots of water Osmotic agents can be used to remove the water

23 Eggplant and Salt There are as many variations on the reasons for using salt on eggplant as there are celebrity chefs. First and foremost, there is only one reason to use salt on eggplant and that is because it has a very high moisture content. When eggplant is broiled or cooked in a pan, it will usually steam and end up being mushy. The solution is to draw the moisture out. By sprinkling salt on the eggplant, water is drawn to the surface. I have seen recommendations for using kosher salt. The only difference between kosher salt and regular table salt is the size of the granules. Crystals of salt (no matter what the size) dissolve in the moisture on the surface of the eggplant and form a concentrated salt solution. The high concentration of salt then pulls moisture from inside the fruit. Rinsing and patting the eggplant dry won't result in it absorbing a significant amount of water (it is porous but not a sponge). The more salt you use or the longer it is on the eggplant, the more effective this technique will be.

24 IVF in the NICU 0% NaCl 0.9% NaCL 3% NaCl 0.45% NaCl 1.5% NaCl

25 Na Goal At Sanford s NICU All patients or Osmolar Therapy: Any intraparenchymal process: NCC Sodium Scale Adult Only Medications: NCC Sodium Scale Na Goal: Goal IVF: 100cc/hr 3. Na/K every: 6hr 4. Total IVF = 0.9% NaCl + 3% NaCl 5. Start 0.9% NaCl at 85cc/hr 6. Start 3% NaCl at 15cc/hr 7. Adjust rate of 0.9% NaCl to achieve IVF Rate Goal 8. Adjust 3% NaCl based on Na, as follows 8.1. If Na increase 3% NaCl by 30cc/hr 8.2. If Na increase 3% NaCl by 20cc/hr 8.3. If Na increase 3% NaCl by 10cc/hr 8.4. If Na no change 8.5. If Na decrease 3%NaCL by 10cc/hr 8.6. If Na decrease 3%NaCL by 20cc/hr 8.7. If Na decrease 3%NaCL by 30cc/hr 9. If Na < 135 or > 160 Call 10. If Na > 150 and not on 3% NaCl, call 11. If Na < 145 and on only 3% NaCl, call 12. Do not call critical chlorides 13. Do not interrupt either the 0.9% NaCl or the 3% NaCl 14. Use K Sliding scale to correct K 15. If no adjustment in 3% NaCl for > 24hrs, decrease 3% NaCl by 10cc/hr daily and follow above scale 16. If off 3% NaCl for > 48hrs, stop Sodium Scale 17. Must be given through central line 18. Only to be used in Neuroscience patients 19. Only to be used by NCC (Drs Burris and Miller) and Nephrology 20. Only used in ICU, Neuroacute, Neuro and Rehab Floors DATE: 5/9/2010 TIME: 2:09 PM SIGNATURE

26 Mannitol vs 3% NaCl Mannitol Dose gm/kg Osmolarity 1376 mosol/l Onset 15 minutes Half Life minutes Side Effects Hypotension Hypernatremia Hyperkalemia Renal Failure 3% NaCL Bolus 200cc or drip

27 Na Scale: Our experience > 100 patients Na is in range within 18 hours Na remain with in range without additional orders As brain improves (decrease ADH) the Na Scale self adjust IVF rate is a set variable Adjustments for Acidosis Has been used in ICU, NACU, Pulm Acute, Neuro Floor and Rehab

28 Weaning patients off NaCl Scale Patient improve physically faster the ADH secretion normalizes Patient can t go home ion 3% NaCl drip Rapid decrease in Na will lead to increase ICP Tried Fludrocortisone and NaCl Tablets Currently using Demeclocycline and NaCl Tablets

29 Questions? Yes I have one...