Cerebral Salt Wasting

Transcription

1 Cerebral Salt Wasting Heather A Martin MSN, RN, CNRN, SCRN Swedish Medical Center 1

2 Disclosures none 2 2

3 The problem Hyponatremia is the most common disorder of electrolytes encountered in medical practice and occurs in 15-30% of hospitalized patients(na<135 meq/l) 1-4% of hospitalized patients(na<130meq/l) Acute/severe hyponatremia can cause substantial morbidity and mortality Rapidly overcorrecting- esp in chronic hyponatremia can cause severe neurological deficits and death Verbalis, Goldsmith, Greenberg, Korzelius, Schrier, Sterns, & Thompson. (2013) 3 3

4 Cerebral Salt Wasting Incidence 2-4% of neuro cases with hyponatremia Potential Pathophysiology Sympathetic Nervous System: loss of adrenergic tone to nephron>> decrease in renin secretion by juxtaglomerular cells causing decreased aldosterone and decreased sodium reabsorption Natriuretic Peptide Theory: a release of brain natriuretic factors(c-type) by the injured brain causes decreased sodium reabsorption and inhibits renin 4

5 Common Patients with CSW Subarachnoid hemorrhage Head trauma Intracranial neoplasm Metastatic neoplasm Cranial/Spine infections Encephalitis 5 5

6 Cerebral Salt Wasting Diagnosis: Evidence of volume depletion near hyponatremia event Increased urine output Abnormal lab findings Treatment: 0.9% NaCl 3% NaCl is sometimes warranted Mineralcorticoid Verbalis, Goldsmith, Greenberg, Korzelius, Schrier, Sterns, & Thompson. (2013 ), Yee, Burns, & Wijdicks. (2010). 6 6

7 SIADH-Syndrome Of Inappropriate Antidiuretic Hormone Yee, Burns, & Wijdicks. (2010). 7 7

8 Accurate Intake and Output An accurate I/O is essential Difficult with neuro patients due to incontinence and our drive to have fewer foley related to CAUTI WEIGH your patientslikely most 1kg = 1 liter of fluid 1 Liter 1 Liter 8 8

9 Other Clinical signs of Volume status Hypovolemia Hypotension Orthostatic hypotension Tachycardia Skin turgor Prolonged Capillary refill Increased thirst Dry mucous membranes Hypervolemia Jugular vein distension Peripheral Edema Ascites Technology Bedside ECHO CVP Non invasive fluid monitoring 9 9

10 Rate of Correction Correcting too fast could case central pontine myelinolysis Altered mental status Flaccid quadriplegia Cranial nerve abnormalities Coma Highest risk patients for osmotic demyelination syndrome Serum NA <105 meq/l Hypokalemia Alcoholism Malnutrition Advanced liver disease 10 10

11 Rate of Correction Consider whether Chronic Hyponatremia vs Acute Hyponatremia(occurred hours) Chronic- 4-8 meq/l in a 24 hour period Acute ~ 12 meq/l in 24 hours. First 4-6mEq bump typically corrects the most Verbalis, Goldsmith, Greenberg, Korzelius, Schrier, Sterns, & Thompson. (2013 ), Yee, Burns, & Wijdicks. (2010)

12 Treatment of CSW Vs SIADH CSW Replace Fluid deficit to Euvolemia with isotonic Mineralcorticoid- some patient may also require glucocorticoid replacement as well(acth testing) 2%-3% Saline SIADH Fluid Restriction Vasopressin Receptor Antagonists(VAPTANS) if NA resistant to conservative measures 2%-3% Saline Watch NA Closely- Can Change quickly 12 Verbalis, Goldsmith, Greenberg, Korzelius, Schrier, Sterns, & Thompson. (2013 ), Yee, Burns, & Wijdicks. (2010). 12

13 Case Study SIADH 13 13

14 Case Study CSW 14 14

15 References Garg, R., & Bar, B. (2017). Systemic Complications Following Aneurysmal Subarachnoid Hemorrhage. Current Neurology and Neuroscience Reports, 17(1), 1-7. Hannon, Behan, O'Brien, Tormey, Ball, Javadpour,... Thompson. (2014). Hyponatremia following mild/moderate subarachnoid hemorrhage is due to SIAD and glucocorticoid deficiency and not cerebral salt wasting. The Journal of Clinical Endocrinology and Metabolism, 99(1), Harring, Deal, & Kuo. (2014). Disorders of Sodium and Water Balance. Emergency Medicine Clinics of North America, 32(2), Hickey, J. (2014). The clinical practice of neurological and neurosurgical nursing (Seventh ed.). Philadelphia, Pennsylavania: Wolters Klower Health/Lippincott Williams & Wilkins Verbalis, Goldsmith, Greenberg, Korzelius, Schrier, Sterns, & Thompson. (2013). Diagnosis, Evaluation, and Treatment of Hyponatremia: Expert Panel Recommendations. The American Journal of Medicine, 126(10), S1-S42 Verbalis, J. (2014). Hyponatremia with intracranial disease: Not often cerebral salt wasting. The Journal of Clinical Endocrinology and Metabolism, 99(1), Yee, Burns, & Wijdicks. (2010). Cerebral Salt Wasting: Pathophysiology, Diagnosis, and Treatment. Neurosurgery Clinics of North America, 21(2),