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    Hyponatremia

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    Assessment & Plan (short)

    # Hyponatremia, ***symptomatic
    Likely due to ***.
    - UOsm, UNa, Upotassium prior to additional lab workup or IV fluids
    - Level of care and lab check frequency based on severity and symptomatology

    Assessment & Plan (long)

    Patient's baseline Na ***. Duration likely ***. Patient appears to be hypo/hyper-volemic*** given physical exam***. Patient's urine output ***. Patient is on *** medications/IV infusions that could result in hyponatremia.

    Serum evaluation: Chem 10, osms, glucose, Corrected Na = measured Na + [(serum glucose - 100)/100]*1.6
    Consider total protein and/or lipids for pseudohyponatremia
    Consider uric acid, TSH, AM cortisol
    Urine studies: Urine lytes (Na, K), uUrea, uCr, uOsms, urine volume
    ------
    Determine if ADH is being secreted:
    - ADH present: uOsm > 150 (300-500) mosm, uNa <20-25
    - ADH absent: uOsm <100, uNa >20-40
    - Unsure: give small isotonic fluid challenge and recheck sNa

    If ADH present, determine if ADH secretion is appropriate:
    - Appropriate: Volume depletion (bleeding, GI and Renal fluid loss), or decreased effective circulating volume (CHF, cirrhosis, nephrotic syndrome)
    - Inappropriate: SIADH, pulmonary disease (pneumona, PE, lung Ca), pain, stress, nausea, spinal cord injury/CNS pathology, medications (SSRI, diuretics, ectasy, chemotherapy)
    -----
    Determine patient's capacity to excrete free water.
    - Ensure adequate osmole intake and generation to allow for free water intake (good intake, r/o polydipsia), assess thyroid and adrenal function
    -----
    SIADH is a diagnosis of exclusion: 1) Patient is euvolemic, 2) Normal thyroid and adrenal function with no recent diuretic use, 3) Labs with uOsm >150, sOsm <275, uNa >20-40 with normal dietary salt intake. Often sUric acid <4, BUN <10, FeNA >2% or FeUrea >45%.
    -----
    Treatment:
    - <48h: rapid correction appropriate.
    - >72h:
    HYPOVOLEMIC: volume expand with IVF

    EUVOLEMIC:
    - Asymptomatic: Use effective free water clearance:
    ECFW= urine volume * [1- (uNa +K)/ sNa]
    - If >0, is excreting free water. If free water intake is < output, hypoNa will correct
    - If <0, actively reabsorbing free water and osm supplementation is required
    --> Treatment = 500mg -2g PO 2-3x daily

    HYPERVOLEMIC:
    - Free water restrict (1-1.5L/day or less than calculated EFWC)
    - Loop diuretics
    - Emergent dialysis

    RATE OF CORRECTION:
    - Max rate 6-8/day
    - If neuro sx present: 1-2/hr until sx resolve
    - If hypertonic saline, check every 2-4h initially

    IF OVERCORRECTION:
    - IV D5 alone or with desmopressin
    - Do not use demopressin in volume overload or self-induced water intox

    Organ systems
    • Renal/Electrolytes
    Medical field
    • Internal medicine
    Setting
    • Inpatient
    Author
    Eric Lee
    Page info

    Originally created: March 3, 2020 by Eric Lee

    [xyz-ips snippet="lastupdated"] [xyz-ips snippet="sectioneditor"] [post-views]

    Number of revisions: [xyz-ips snippet="numrevisions"]

    References
    [xyz-ips snippet="easyfootnote"]
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