Abnormal Sodium,National Pediatric Nighttime Curriculum Written by Julia Aquino, MD Floating Hospital for Children at Tufts Medical Center,Learning objectives,After this module learners will be able to: Describe principles of acute fluid management in the correction of hypernatremia and hyponatremia Recognize the signs and symptoms that require immediate attention in patients with disordered sodium Consider the level of care appropriate for patients requiring correction of hypernatremia and hyponatremia,Case #1 (intern),You have just finished sign out and you are reviewing your patient list to prioritize the most ill patients when your pager goes off: “Lab called with critical value for patient in 735: sodium 160. Please advise. Kevin”,You review your sign out,7 month old otherwise healthy male admitted directly from clinic in the late afternoon with gastroenteritis and dehydration. He has had minimal PO intake and decreased urine output. Tachycardic and febrile when the admitting team saw him but otherwise stable. Overnight plan: floor staff is placing an IV, giving a 20cc/kg NS bolus and will call night team to reassess when complete.,You head to room 735,As you go to the bedside to assess the patient, you review some questions: What are possible etiologies of hypernatremia? What about in this patient specifically? What do I need to worry about immediately? Should I call my senior? Can I take care of this patient on the floor or does he need a higher level of care?,At the bedside,VS: T 38.5, HR 120, RR 30, BP 90/60, O2 sat 99% RA His nurse, Kevin, tells you that the NS bolus is almost complete and that the patient has been irritable since arriving to the floor Physical exam: General: irritable infant; HEENT: mucous membranes dry, anterior fontanelle slightly sunken; Chest: clear; CV: tachycardic, regular rhythm, II/VI systolic ejection murmur; Abdomen: soft, hyperactive bowel sounds; Extremities: normal skin turgor, cap refill 3 seconds What is your overall assessment of this patient?,What is your next step? Stop the bolusthis patient is hypernatremic and NS is an inappropriate fluid choice Give another 20cc/kg bolus of NS Call a renal consult,Next steps,You give another normal saline bolus and the patients perfusion, heart rate and mental status start to normalize Kevin asks you what fluids you want to hang now. What do you need to consider when correcting the sodium in hypernatremic dehydration? What do you need to worry about if correcting too fast?,Calculating free water deficit,Free water deficit is the minimum amount of fluid necessary to correct serum sodium Estimate of free water deficit: 4mL x body weight x desired change in sodium Goal is to correct sodium at a rate no faster than 0.5 mEq/L/hour Add maintenance fluid needs and account for any ongoing losses,Ongoing management,What fluid should you choose? When should you recheck a sodium?,Hypernatremia,Defined as serum sodium /= 145mEq/L Causes:,Clinical Manifestations and Evaluation of Hypernatremia,Early neurologic signs include agitation and irritabilitycan progress to seizure and coma Neurologic exam can reveal increased tone, brisk reflexes and nuchal rigidity Lab evaluation can include: Serum osmolarity Serum glucose Urine osmolarity and specific gravity,Neurologic Sequelae,In acute phase: Intracellular fluid moves to extracellular space-volume loss in brain separation from meninges If hypernatremia has existed for 2-3 days: Neurons protect themselves by making osmolytes to maintain gradient With rapid correction, neurons can swell leading to cerebral edema Mortality estimated at 10-16% despite correct rate of rehydration,Case #2 (senior),You are doing your late evening rounds on the ward when one of the nurses pulls you aside: “One of the post-op orthopedic patients has a sodium of 115 and I cant reach the primary team. Can you help me?”,His nurse gives you more info,Patient is a 16yo with cerebral palsy and global developmental delay who is post-operative day #2 from posterior spinal fusion. He has been wretching and not tolerating g-tube feeds so has been on maintenance IV fluids of D5 NS + 20mEq/L KCl all day. His mother is at the bedside and feels he is not himself.,At the bedside,VS: T 38.0, HR 90, BP 100/75, RR 20, O2 98%RA General: neurologically impaired child moaning in bed, less responsive to voice/touch per mother; HEENT: lips dry, mucous membranes slightly dry; Chest: CTAB; CV: RRR, nl S1, S2; Abdomen: g-tube intact, hypoactive bowel sounds; Extremities: well perfused; Neuro: increased tone and spasticity in extremities, responds to voice with a moan, responsive to painful stimuli,Next steps,You initiate a rapid response and transfer to the PICU should happen shortly. Your immediate next step should be: Prompt administration of hypertonic saline (3%) Emergent head CT Fluid restriction due concern for SIADH,Your patient stabilizes,Your patient is returning to baseline mental status and you stop the hypertonic sa