Hypernatremia

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Hypernatremia
Classification and external resources
Na-TableImage.png
ICD-10 E87.0
ICD-9 276.0
DiseasesDB 6266
eMedicine emerg/263

Hypernatremia or hypernatraemia that is defined by an elevated sodium level in the blood.[1] Hypernatremia is generally not caused by an excess of sodium, but rather by a relative deficit of free water in the body. For this reason, hypernatremia is often synonymous with the less precise term, dehydration.

Water is lost from the body in a variety of ways, including perspiration, imperceptible losses from breathing, and in the feces and urine. If the amount of water ingested consistently falls below the amount of water lost, the plasma sodium level will begin to rise, leading to hypernatremia. Rarely, hypernatremia can result from massive salt ingestion,[2][3] such as may occur from drinking seawater or excessive amounts of a salty liquid like soy sauce.[4][5]

Ordinarily, even a small rise in the plasma sodium concentration above the normal range results in a strong sensation of thirst, an increase in free water intake, and correction of the abnormality. Therefore, hypernatremia most often occurs in people such as infants, those with impaired mental status, or the elderly, who may have an intact thirst mechanism but are unable to ask for or obtain water.

Signs and symptoms[edit]

Clinical manifestations of hypernatremia can be subtle, consisting of lethargy, weakness, irritability, neuromuscular excitability, and edema. With more severe elevations of the sodium level, seizures and coma may occur.

Severe symptoms are usually due to acute elevation of the plasma sodium concentration to above 157 mEq/L[6] (normal blood levels are generally about 135-145 mEq/L for adults and elderly) [6] Values above 180 mEq/L are associated with a high mortality rate, particularly in adults.[2] However such high levels of sodium rarely occur without severe coexisting medical conditions.

Cause[edit]

Management of hypernatremia

Common causes of hypernatremia include:

  • Hypovolemic
    • Inadequate intake of free water associated with total body sodium depletion. Typically in elderly or otherwise disabled patients who are unable to take in water as their thirst dictates and also are sodium depleted. This is the most common cause of hypernatremia.
    • Excessive losses of water from the urinary tract, which may be caused by glycosuria, or other osmotic diuretics - leads to a combination of sodium and free water losses.
    • Water losses associated with extreme sweating.
    • Severe watery diarrhea
  • Euvolemic
    • Excessive excretion of water from the kidneys caused by diabetes insipidus, which involves either inadequate production of the hormone vasopressin, from the pituitary gland or impaired responsiveness of the kidneys to vasopressin.[7]
  • Hypervolemic
    • Intake of a hypertonic fluid (a fluid with a higher concentration of solutes than the remainder of the body) with restricted free water intake. This is relatively uncommon, though it can occur after a vigorous resuscitation where a patient receives a large volume of a concentrated sodium bicarbonate solution. Ingesting seawater also causes hypernatremia because seawater is hypertonic and free water is not available. There are several recorded cases of forced ingestion of concentrated salt solution in exorcism rituals leading to death.[2]
    • Mineralcorticoid excess due to a disease state such as Conn's syndrome usually does not lead to hypernatremia unless free water intake is restricted.
    • Salt poisoning (this condition is most common in children).[8][9]

Treatment[edit]

The cornerstone of treatment is administration of free water to correct the relative water deficit. Water can be replaced orally or intravenously. Water alone cannot be administered intravenously (because of osmolarity issue), but rather can be given with addition to dextrose or saline infusion solutions. However, overly rapid correction of hypernatremia is potentially very dangerous. The body (in particular the brain) adapts to the higher sodium concentration. Rapidly lowering the sodium concentration with free water, once this adaptation has occurred, causes water to flow into brain cells and causes them to swell. This can lead to cerebral edema, potentially resulting in seizures, permanent brain damage, or death. Therefore, significant hypernatremia should be treated carefully by a physician or other medical professional with experience in treatment of electrolyte imbalance, specific treatment like ACE inhibitors in heart failure and corticosteroids in nephropathy also can be used.[10]

References[edit]

  1. ^ "Hypernatremia: Fluid and Electrolyte Metabolism: Merck Manual Professional". Retrieved 2009-05-09. 
  2. ^ a b c Ofran, Y., Lavi, D., Opher, D., Weiss, T. A. and Elinav, E. (2004), Fatal voluntary salt intake resulting in the highest ever documented sodium plasma level in adults (255 mmol L−1): a disorder linked to female gender and psychiatric disorders. Journal of Internal Medicine, 256: 525–528. doi:10.1111/j.1365-2796.2004.01411.x
  3. ^ http://dx.doi.org/10.1016/S0379-0738(98)00179-0
  4. ^ "Soy Sauce Overdose Sends Man Into Coma". Huffington Post. 7 June 2013. 
  5. ^ Survival of Acute Hypernatremia Due to Massive Soy Sauce Ingestion, The Journal of Emergency Medicine
  6. ^ a b Reynolds, Rebecca; Padfield PL; Seckl JR (25 March 2006). "Disorders of sodium balance". BMJ 332 (7543): 702–705. doi:10.1136/bmj.332.7543.702. PMC 1410848. PMID 16565125. Retrieved 15 September 2013. 
  7. ^ Leroy, C.; Karrouz, W.; Douillard, C.; Do Cao, C.; Cortet, C.; Wémeau, JL.; Vantyghem, MC. (Dec 2013). "Diabetes insipidus.". Ann Endocrinol (Paris) 74 (5-6): 496–507. doi:10.1016/j.ando.2013.10.002. PMID 24286605. 
  8. ^ Saunders, N.; Balfe, JW.; Laski, B. (Feb 1976). "Severe salt poisoning in an infant.". J Pediatr 88 (2): 258–61. doi:10.1016/s0022-3476(76)80992-4. PMID 1249688. 
  9. ^ Paut, O.; André, N.; Fabre, P.; Sobraquès, P.; Drouet, G.; Arditti, J.; Camboulives, J. (1999). "The management of extreme hypernatraemia secondary to salt poisoning in an infant.". Paediatr Anaesth 9 (2): 171–4. doi:10.1046/j.1460-9592.1999.9220325.x. PMID 10189662. 
  10. ^ Hypernatremia — NEJM

External links[edit]