Sunday, February 28, 2021

Medicine department project on resolving diagnostic and therapeutic uncertainty in patients with hyponatremia

Project OUTCOMEs from 2018-2021 documented by Dr Manasa, MD medicine Resident from 2018


For more Medicine department projects please click here: https://medicinedepartment.blogspot.com/2021/02/medicine-department-projects.html?m=0





                               

         


– DISTRIBUTIUON OF HYPONATREMIA CASES IN 

                   IN DIFFERENT AGE GROUPS



Age group

(in years)

No. of cases

(n=60)

Percentage

13 -39

4

7

40 – 59

28

46

60 -79

24

40

80 – 99

4

7

Total

60

100






DISTRIBUTION OF HYPONATREMIA CASES BASED ON SERUM SODIUM LEVEL  

Serum Sodium (in meq/l)

No. of cases

n=60

Percentage

100 – 109

2

3

110 – 119

19

32

120  - 129

39

65

TOTAL

60

100

                                      


FIGURE 9 – PERCENTAGE DISTRIBUTION OF HYPONATREMIA CASES BASED ON SERUM SODIUM LEVEl







FIGURE 10 – FREQUENCY DISTRIBUTION OF HYPONATREMIA CASES BASED ON SERUM SODIUM LEVEL



Out of the 60 hyponatremia patients studied, only 2 patients have severe

Hyponatremia, majority of patients have mild asympomatic hyponatremia.

Most of the cases of mild hyponatremia are secondary to chronic kidney 

Disease.






                  TABLE 4 – ETIOLOGY OF HYPONATREMIA


ETIOLOGY  OF HYPONATREMIA

NO.OF CASES (n=60)

percentage

Vomitings + loose stools

4

6

Dehydration secondary to vomitings

7

12

Diarrhoea

1

2

Chronic liver disease

1

2

Cerebral salt wasting syndrome

4

6

Chronic kidney disease

13

22

Hyperglycemia

2

3

Dehydration

3

5

Dialated cardiomyopathy

2

3

Diuretics

6

10

Post TURP hyponatremia

1

2

SIADH

9

15

Anti psychotic drugs

1

2

Mixed causes

6

10

TOTAL

60

100




FIGURE 11 – ETIOLOGY OF HYPONATREMIA




TABLE 5 – MIXED CAUSES OF HYPONATREMIA


Mixed causes of hyponatremia

No.of cases

CCF + CLD + CKD

1

Hypothyroidism +thiazides

2

Hypothyroidism + vomitings

1

Vomitings+ thiazides+ hypothyroidism

1

CKD + thiazides

1

Total

6



FIGURE 12 – FREQUENCY DISTRIBUTION OF MIXED CAUSES OF HYPONATREMIA



Most common cause of hyponatremia in present study is 

Hypervolumic hyponatremia secondary to chronic kidney 

Disease. Second most common cause being SIADH followed by 

Hypovolemia which is secondary to vomitings,loose stools and 

Dehydration. 

Hypothyroidism alone rarely causes hyponatremia. Hypothyroidism

Need to be severe (myxedema coma) to cause hyponatremia.

 Most of the mixed Causes of hyponatremia are associated 

with hypothyroidism. In most of the mixed causes of hyponatremia 

which one actually lead to hyponatremia remains Unclear.














TABLE 6 – PRIMARY DISEASES ASSOCIATED WITH HYPONATREMIA


Primary diseases associated with hyponatremia

No. of cases

Percentage (%)

1. Acute gastroenteritis

5

8

2.Chronic kidney disease

9

15

3. Cerebro vascular accident

4

7

4. surgical causes of vomitings 

4

12

5.food poisoning

4

12

5. Hypertention on thiazide diuretics

6

10

6. Pulmonary tuberculosis

3

5

7. Meningitis

4

7

8. Uncontrolled diabetes

2

3

9. AKI with hyponatremia

2

3

10. Heart failure

3

5

11. CCF + CKD + CLD

1

2

12. Hypothyroidism 

2

3

13. Miscellaneous

11

18s

14. TOTAL

60

100



FIGURE 13 – PERCENTAGE DISTRIBUTION OF PRIMARY DISEASES ASSOCIATED WITH HYPONATREMIA

Primary cause of hyponatremia in most of the cases chronic kidney 

Disease followed by SIADH .Dehydration Secondary to vomitings, loose 

stools and sepsis also contributed to large number of hyponatremia 

cases. Surgical causes like Renal colic, appendicitis, intestional  

obstruction and pyloric stenosis are the causes of vomiting which lead to 

hyponatremia in the study group


TABLE 7 – MISCELLANEOUS PRIMARY DISEASES ASSOCIATED WITH HYPONATREMIA

Primary diseases associated with hyponatremia

No. of cases ( n = 12 )

1. Septic arthritis with dehydration

1

2. Dengue shock syndrome

1

3. Acute subarchnoid hemorrage

1

4. Encephalitis

1

5. Necrotising fasciitis with pyogenic brain abscess

1

6. CLD with hepatorenal syndrome

1

7. Schzophrenia

1

8. SIADH secondary to antidepressants

1

9. Post TURP hyponatremia

1

11. CVA with hypertention and hypothyroidism

1

12. CVA causing SIADH

1

TOTAL

12



TABLE 8 – DISTRIBUTION OF CASES BASED ON TONICITY OF    HYPONATREMIA

Tonicity

No. of cases(n=60)

percentage

Hypertonic

3

5

Isotonic

0

0

Hypotonic

57

95

Total

60

100


Most of the cases of hyponatremia are hypotonic which includes 

Hypovolemic, euvolemic and hypervolemic causes of hyponatremia. 

Isotonic hyponatremia is considered as pseudohyponatremia. Hypertonic 

Causes of hyponatremia are secondary to hyperglycemia.







FIGURE 14 – PERCENTAGE DISTRIBUTION OF HYPONATREMIA CASES BASED ON TONICITY



FIGURE 15 – FREQUENCY DISTRIBUTION OF HYPONATREMIA CASES BASED ON TONICITY


TABLE 9 – DISTRIBUTION OF HYPONATREMIA CASES BASED ON VOLUME STATUS


Volume Status

No. Of  Cases( n=60)

percentage

Hypervolemic

22

37

Euvolemic

9

15

Hypovolemic

26

43

Hypertonic Hyponatremia

3

5

TOTAL

60

100


FIGURE 16– PERCENTAGE DISTRIBUTION OF HYPONATREMIA CASES BASED ON VOLUME STATUS



FIGURE 17 – FREQUENCY DISTRIBUTION OF HYPONATREMIA CASES BASED ON VOLUME STATUS


Hypovolumic and hypervolumic hyponatremia cases are much higher 

Compared to euvolemic cases










TABLE 10– DISTRIBUTION OF HYPONATREMIA CASES BASED ON CHRONICITY


Chronicity of hyponatremia

No. of cases

n=60

percentage

Acute Hyponatremia

20

33

Chronic Hyponatremia

40

67

TOTAL

60

100




FIGURE 18 – PERCENTAGE DISTRIBUTION OF HYPONATREMIA CASES BASED ON CHRONICITY

FIGURE 19 – FREQUENCY DISTRIBUTION OF HYPONATREMIA CASES BASED ON CHRONICITY


Out of the 60 hyponatremia patients studied, 40 are chronic hyponatremia 

Patients and 20 are acute hyponatremia cases.











TABLE 11 – TREATMENT OF HYPONATREMIA


TREATMENT  GIVEN

NO.OF CASES(n=60)

percentage

0.9% NaCl

8

13

0.9% NaCl  and 3% NaCl

11

18

Fluid restriction + diuretics

11

18

Fluid restriction  + Tolvaptan

5

8

Fluid restriction +  increase dialysis ultrafiltrate

6

10

I.V  insulin

2

3

Stop thiazides

11

18

3% NaCl + T.Tolvaptan + fluid restriction

3

6

T.TYROXINE + i.v fluids/diuretics

3

6

TOTAL

60

100






FIGURE 20 – TREATMENT OF HYPONATREMIA


Fluids like 0.9% NaCl were given to patients with hypovolumic 

Hyponatremia who have signs of dehydration. 3% NaCl was given to 

Patients with severe  hypovolemic hyponatremia who have neurological 

Symptoms. Diuretics were given to patients with hypervolumic 

Hyponatremia. Fluid restriction and vaptans were used in SIADH.

Insulin and thyroxine supplementation were used in hyperglycaemia and

Hypothyroidism respectively.



TABLE 12 – DISTRIBUTION OF HYPONATREMIA CASES BASED ON OUTCOME


Outcome

No. of cases

n=60

Percentage

Symptomatically better

36

60

Same status

8

13

Asymptomatic

15

25

Died

1

2

TOTAL

60

100









FIGURE 21 – PERCENTAGE DISTRIBUTION OF HYPONATREMIA CASES BASED ON OUTCOME





                       DISCUSSION

The present study included patients with serum sodium less than 

130meq/l. there were 42 males and 18 females with ratio of 2.3 : 1 .

In general, more number of males were admitted in KIMS, Narketpally 

When compared to females . so no conclusion was made on this 

Difference in incidence.


In present study, hyponatremia was seen more commomly in patients

 above 45 years of age than in younger patients. youngest patient with 

hyponatremia in our study is of 25 years age. Eldest patient is of 87 years 

age. Incidence of hyponatremia is higher in elderly patients similar 

trend was also observed by Hochman (9) and Vurgese (10) in their study


The hydration status in the present study was noted based on clinical 

Examination like capillary refilling time, jugular venous pulse, blood 

Pressure, pressure or absence of pedal edema and IVC (inferior vena 

Cava diameter) .Hydration status was divided into euvolumic, 

Hypovolemic and hypervolemic states. In the present study 26 patients 

Were hypovolemic, 22 patients were hypervolemic and 9 patients were

Euvolumic representing 43%, 37% and 15% respectively.





TABLE : 13

Hyponatremia

Hochman( %)

Anderson (%)

Present study(%)

Euvolumia

50

34

15

Hypovolumia

30.5

35

43

Hypervolumia

19.5

31

37



In the present study hypervolumic cases are more compared to Hochman 

Study. Most of them are secondary to chronic kidney disease as in our 

Hospital locality (Nalgonda district) renal failure is commonly which was 

Thought to be due to fluorosis. Hypovolemia cases slightly higher than 

Both the studies. Most of the hypovolemic cases are due to vomitings, 

Loose stools and dehydration. Study also includes surgical causes of 

Vomiting which leads to hyponatremia.

Euvolumic cases are less compared to Hochman and Anderson studies

In the present study may due to underdiagnosis of adrenal insufficiency 

In our hospital setting and also relatively more cases of ESRD (end stage

Renal disease) which contribute to hypervolumic hyponatremia. 


The mean age was 58.4 years. The commonest age group affected was

40 to 79 years. The commonest cause of hyponatremia was chronic 

Kidney disease and vomitings,loose stools and dehydration. Next 

Common cause was SIADH which was secondary to pneumonia,

Pulmonary tuberculosis and sub arachnoid hemorrhage.


In study done by vurgese, the incidence of hyponatremia was 3.6%

With the defnation of hyponatremia as serum sodium levels less than

Or equal to 130meq/l. the study population consisted of 66 patients with

56% 

males and 44 % females. The mean age was 57.07 years. The 

Commonest age group affected was 45 to 64 years (72.8 %) and the least

Affected group was 12 to 25 years.


TABLE 14 


Vurgese

Present study

Study population



Male

56%

70 %

Female

44%

30 %

Mean age

57.95 years

58.4 years

>45 years with hyponatremia

72.8 %

83 %

Common causes

SIADH

Chronic kidney disease

Other causes

Renal failure

CCF

SIADH



Hyponatremia cases in the present study were also distributed based on 

serum sodium level. Most of the cases of hyponatremia are with the 

serum sodium level between the range of 120 to 129 meq/l (39 patients 

out of 60 ). most of the cases with mild hyponatremia are hypervolemic 

secondary to chronic kidney disease.



In the present study, In patients with euvolumic hyponatremia, 9 patients 


satisfied the criteria to diagnose SIADH. They had low serum osmolality, 


high urine osmolality and high urine sodium. However, in brain injury


cases like cerebral sinus venous thrombosis (CSVT) if patient presents 


with hyponatremia probable diagnosis of hyponatremia can be kept as 


SIADH or cerebral salt wasting syndrome. Clear cut differentiation


Between SIADH and cerebral salt wasting syndrome will be very difficult 


In the first 24 hours as important differentiating feature between SIADH 


And cerebral salt wasting syndrome is urine output.



Hypovolemic cases of hyponatremia are secondary to acute 


Gastroenteritis mostly due to Ecoli, salmonella and staph aureus.


Surgical causes of vomiting like intestional obstruction, pyloric stenosis,


Appendicitis and renal colic also contributed to hypovolemic causes of 


Hyponatremia. Thiazide diuretics usuage in patients with hypertention 


And chronic renal disease also contributed to hypovolemic 


hyponatremia.


Hyponatremia secondary to anti psychotic drugs presented with 


increased thirst, patient drank 6 to 7 litres of water for 2 days and 


passed only 1 to 2 litres of urine each day for 2 days.



Thyroid function tests and adrenal function


Thyroid function tests and random serum cortisol test was done in all

 

this patients. There are 2 cases of hypothyroidism, in both the patients


 cause of hypothyroidism is mixed. In one patient cause of hyponatremia 


 is both hypothyroidism and thiazide diuretics volume status in this


patient is hypovolemic. In another case cause of cause of hyponatremia 

is both hypothyroidism and vomitings secondary to acute illness like 


dengue. 


Patients with hypovolemic hyponatremia are 26 patients (43 %) among 


60 Patients of hyponatremia. Cause of hypovolemic hyponatremia is 


Mostly dehydration. Other cause of hypovolemic hyponatremia is 


Cerebral salt wasting syndrome. In present study there are 4 cases of


Hypovolemic hyponatremia are cerebral salt wasting syndrome.


Majority of cases in  present study are of hypervolumic hyponatremia


Chronic kidney disease is the major cause of hypervolumic 


Hyponatremia. Other causes are dilated cardiomyopathy, chronic liver 


Disease and mixed causes like CCF + CLD +CKD. Patients with mild 


hyponatremia are almost always asymptomatic. Severe hyponatremia is 


usually associated with central nervous system symptoms and can be 


life-threatening. Diagnostic evaluation of patients with hyponatremia is


 directed toward identifying the extracellular fluid volume status, the 


neurological symptoms and signs, the severity and duration of 


hyponatremia, the rate at which hyponatremia developed. The first step


 to determine the probable cause of hyponatremia is the differentiation of 


the hypervasopressinemic and non-hypervasopressinemic 


hyponatremias with measurement of plasma osmolality, glucose, lipids 


and proteins. For further differential diagnosis of hyponatremia, the


 determination of urine osmolality, the clinical assessment of 


extracellular fluid volume status and the measurement of urine sodium 


concentration provide important information. The most important


 representative of euvolemic hyponatremias is SIADH. The diagnosis of 


SIADH is based on the exclusion of other hyponatremic conditions; low 


plasma osmolality (<275 mosmol/kg) and inappropriate urine 


concentration (urine osmolality >100 mosmol/kg) are of pathognomic 


value. Acute (<48 hrs) severe hyponatremia (<120 mmol/l) necessitates 


emergency care with rapid restoration of normal osmotic milieu


 (1 mmol/l/hr increase rate of serum sodium). Patients with chronic 


symptomatic hyponatremia have a high risk of osmotic demyelination 


syndrome in brain if rapid correction of the plasma sodium occurs 


(maximal rate of correction of serum sodium should be 0.5 mmol/l/hr or


 less). The conventional treatments for chronic asymptomatic 


hyponatremia (except hypovolemic patients) include water restriction 


and/or the use of demeclocycline or lithium or furosemide and salt 


supplementation. Vasopressin receptor antagonists have opened a new


 forthcoming therapeutic era. V2 receptor antagonists, such as 


lixivaptan, tolvaptan, satavaptan and the V2+V1A receptor antagonist 


conivaptan promote the electrolyte-sparing excretion of free water and 


lead to increased serum sodium






TREATMENT AND MONITORING


Monitoring of sodium was done on a 6 hourly to12 hourly basis in most 


Of the patients with symptomatic and severe hyponatremia. 


Fluid correction depended on the type, cause and presence of 


symptoms.


The mean rate of correction was adequate and comparable with most of 


The international studies. Normal saline alone, 3% saline, fluid 


restriction, + duration, dialysis, steroids alone and in combination were 


used to treat symptomatic and severe hyponatremia.


 Excessive antidiuretic hormone and continued fluid intake are the 


pathogenetic causes of these hyponatremias. Whereas hypovolemic 


hyponatremia is best corrected by isotonic saline, conventional 


proposals for euvolemic and hypervolemic hyponatremia consist of the 


following: fluid restriction, lithium carbonate, demeclocycline, urea and 


loop diuretic. None of these nonspecific treatments is entirely 


satisfactory. Recently a new class of pharmacological agents -orally 


available vasopressin antagonists, collectively called vaptans- have 


been described. A number of clinical trials using vaptans have been 


performed already. They showed vaptans to be effective, specific and 


safe in the treatment of euvolemic and hypervolemic hyponatremia.  


vaptans generally had favorable effects on fluid balance


 also. To date two vaptans, ie, conivaptan and tolvaptan, have been 


marketed in the United States for the treatment of euvolemic and 


hypervolemic hyponatremia, whereas tolvaptan has been marketed in 


Europe with the limitation of euvolemic hyponatremia. Although these 


drugs have a good safety profile, caution should be used, and treatment 


should be initiated in a hospital setting in order to closely monitor


 patients and avoid overly rapid correction or overcorrection. Vaptans 


can be considered a new effective tool for the treatment of euvolemic 


and hypervolemic hyponatremia. Nevertheless, more comparative 


research of vaptans vs other therapies on clinical grounds is needed to 


more accurately assess the value of these drugs in the treatment of 


hyponatremia. Acute hyponatremia causes serious brain swelling that 


can lead to permanent disability or death. A 4-6 mEq/l increase in serum


 sodium is sufficient to reverse impending herniation. Brain swelling is 


minimal in chronic hyponatremia, and to avoid osmotic demyelination,


 correction should not exceed 8 mEq/l/day. In high-risk patients, 


correction should not exceed 4-6 mEq/l/day. Inadvertent overcorrection


 of hyponatremia is common and preventable by controlling unwanted 


urinary water losses with desmopressin. Even mild chronic 


hyponatremia is associated with increased mortality, attention deficit, 


gait instability, osteoporosis, and fractures, but it is not known if the 


correction of mild hyponatremia improves outcomes.


 Controlled trials are needed to identify affordable treatments for 


hyponatremia that reduce the need for hospitalization, decrease hospital


 length of stay, and decrease morbidity. Such trials could also help


 answer the question of whether hyponatremia causes excess mortality


 or whether it is simply a marker for severe, lethal, underlying disease




                               CONCLUSIONS


  1. Asymptomatic hyponatremia is more common than symptomatic 


         Hyponatremia


  1. Renal failure,dehydration and SIADH formed the largest subgroup in the study


  1. Drugs, especially thiazide diuretics are common cause of 


Hyponatremia


  1. Incidence of hyponatremia is higher in patients aged above 


45years 


  1. Symptoms of hyponatremia increased with severity of 


Hyponatremia


  1. Neurological symptoms like headache, seizures and altered 


Sensorium are commonly seen in severe hyponatremia patients


  1. To distinguish between SIADH and cerebral salt wasting syndrome


In patients of hyponatremia with head injury is difficult  


                       REFERENCES


  1. Rafat, C., Flamant, M., Gaudry, S. et al. Hyponatremia in the intensive care unit: How to avoid a Zugzwang situation?. Ann. Intensive Care 5, 39 (2015).


  1. Sahay M, Sahay R. Hyponatremia: A practical approach. Indian J Endocrinol Metab. 2014;18(6):760-771.


  1. Rondon H, Badireddy M. Hyponatremia. [Updated 2020 Sep 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan


  1. Zieg J. Pathophysiology of Hyponatremia in Children. Front Pediatr. 2017;5:213. Published 2017 Oct 16. 


  1. Lee JJ, Kilonzo K, Nistico A, Yeates K. Management of hyponatremia. CMAJ. 2014;186(8):E281-E286.


  1. Schrier RW, Bansal S. Diagnosis and management of hyponatremia in acute illness. Curr Opin Crit Care. 2008;14(6):627-634.


  1. Weismann D, Schneider A, Höybye C. Clinical aspects of symptomatic hyponatremia. Endocr Connect. 2016;5(5):R35-R43. 


  1. Dineen R, Thompson CJ, Sherlock M. Hyponatraemia - presentations and management. Clin Med (Lond). 2017;17(3):263-269.


  1. Hochman I, Cabili S, Peer G. Hyponatremia in internal medicine ward patients: cause, treatment and prognosis. Isr J Med Sci 1989; 25: 73 – 6.


  1. Vurgese TA,Radakrishnan ,Mapkar .Frequency and etiology of hyponatremia in adult hospitalised patients in medical wards of a general hospital in Kuwait.kuwait medical journal 2006:38(3):211-213


  1. Gross P. Treatment of hyponatremia. Intern Med. 2008;47(10):885-91. doi: 10.2169/internalmedicine.47.0918. Epub 2008 May 15. PMID: 18480571. Peri A. 


  1. Clinical review: the use of vaptans in clinical endocrinology. J Clin Endocrinol Metab. 2013 Apr;98(4):1321-32.


  1. Laczi F. A hyponatraemiás állapotok etiológiája, diagnosztikája és terápiája


  1. Burst V. Etiology and Epidemiology of Hyponatremia. Front Horm Res. 2019;52:24-35. doi: 10.1159/000493234. Epub 2019 Jan 15.


  1. Lu X, Wang X. Hyponatremia induced by antiepileptic drugs in patients with epilepsy. Expert Opin Drug Saf. 2017 Jan;16(1):77-87. doi: 10.1080/14740338.2017.1248399. Epub 2016 Oct 27. 


  1. Adrogué HJ, Madias NE. The challenge of hyponatremia. J Am Soc Nephrol. 2012 Jul;23(7):1140-8.


  1. Sterns RH, Nigwekar SU, Hix JK. The treatment of hyponatremia. Semin Nephrol. 2009 May;29(3):282-99.


  1. George JC, Zafar W, Bucaloiu ID, Chang AR. Risk Factors and Outcomes of Rapid Correction of Severe Hyponatremia. Clin J Am Soc Nephrol. 2018 Jul 6;13(7):984-992.


  1. John S, Thuluvath PJ. Hyponatremia in cirrhosis: pathophysiology and management. World J Gastroenterol. 2015 Mar 21;21(11):3197-205.



  1. Liamis G, Barkas F, Megapanou E, Christopoulou E, Makri A, Makaritsis K, Ntaios G, Elisaf M, Milionis H. Hyponatremia in Acute Stroke Patients: Pathophysiology, Clinical Significance, and Management Options. Eur Neurol. 2019;82(1-3):32-40.


  1. Gross P, Pusl T. Hyponatriämie [Causes, diagnosis and differential diagnosis of hyponatremia]. Dtsch Med Wochenschr. 2016 Oct;141(21):1543-1548. German. 


  1. Chen Z, Jia Q, Liu C. Association of Hyponatremia and Risk of Short- and Long-Term Mortality in Patients with Stroke: A Systematic Review and Meta-Analysis. J Stroke Cerebrovasc Dis. 2019 Jun;28(6):1674-1683.



  1. Dineen R, Thompson CJ, Sherlock M. Hyponatraemia - presentations and management. Clin Med (Lond). 2017 Jun;17(3):263-269.


  1. Tee K, Dang J. The suspect - SIADH. Aust Fam Physician. 2017 Sep;46(9):677-68



  1. Lunøe M, Overgaard-Steensen C. [Prevention of hospital-acquired hyponatremia]. Ugeskr Laeger. 2014 Sep 1;176(36):V03140182. 


  1. Braun MM, Barstow CH, Pyzocha NJ. Diagnosis and management of sodium disorders: hyponatremia and hypernatremia. Am Fam Physician. 2015 Mar 1;91(5):299-307. PMID: 25822386.


  1. Feld LG, Neuspiel DR, Foster BA, Leu MG, Garber MD, Austin K, Basu RK, Conway EE Jr, Fehr JJ, Hawkins C, Kaplan RL, Rowe EV, Waseem M, Moritz ML; SUBCOMMITTEE ON FLUID AND ELECTROLYTE THERAPY. Clinical Practice Guideline: Maintenance Intravenous Fluids in Children. Pediatrics. 2018 Dec;142(6):e20183083. 



  1. Jones DP. Syndrome of Inappropriate Secretion of Antidiuretic Hormone and Hyponatremia. Pediatr Rev. 2018 Jan;39(1):27-35.


  1. Tanındı A, Töre HF. Hiponatremi tedavisinde Vaptan kullanımı [Use of "Vaptans" in treatment of hyponatremia]. Turk Kardiyol Dern Ars. 2015 Apr;43(3):292-301. Turkish. 


  1. Rondon-Berrios H. Urea for Chronic Hyponatremia. Blood Purif. 2020;49(1-2):212-218. Epub 2019 Dec 18.


  1. Jang CM, Jung YK. [Hyponatremia in Liver Cirrhosis]. Korean J Gastroenterol. 2018 Aug 25;72(2):74-78. Korean. 


  1. Ackermann D. Therapie von Aszites, Hyponatriämie und hepatorenalem Syndrom bei der Leberzirrhose [Treatment of ascites, hyponatremia and hepatorenal syndrome in liver cirrhosis]. Ther Umsch. 2009 Nov;66(11):747-51. German. 


  1. Thomas DR, Cote TR, Lawhorne L, Levenson SA, Rubenstein LZ, Smith DA, Stefanacci RG, Tangalos EG, Morley JE; Dehydration Council. Understanding clinical dehydration and its treatment. J Am Med Dir Assoc. 2008 Jun;9(5):292-301. 


  1. Grant P, Ayuk J, Bouloux PM, Cohen M, Cranston I, Murray RD, Rees A, Thatcher N, Grossman A. The diagnosis and management of inpatient hyponatraemia and SIADH. Eur J Clin Invest. 2015 Aug;45(8):888-94. 


  1. Verbalis JG, Grossman A, Höybye C, Runkle I. Review and analysis of differing regulatory indications and expert panel guidelines for the treatment of hyponatremia. Curr Med Res Opin. 2014 Jul;30(7):1201-7.


  1. Kitchlu A, Rosner MH. Hyponatremia in patients with cancer. Curr Opin Nephrol Hypertens. 2019 Sep;28(5):433-440. 


  1. Pfennig CL, Slovis CM. Sodium disorders in the emergency department: a review of hyponatremia and hypernatremia. Emerg Med Pract. 2012 Oct;14(10):1-26. Epub 2012 Sep 20. 


  1. Lee A, Jo YH, Kim K, Ahn S, Oh YK, Lee H, Shin J, Chin HJ, Na KY, Lee JB, Baek SH, Kim S. Efficacy and safety of rapid intermittent correction compared with slow continuous correction with hypertonic saline in patients with moderately severe or severe symptomatic hyponatremia: study protocol for a randomized controlled trial (SALSA trial). Trials. 2017 Mar 29;18(1):147. 


  1. Patterson JH. The impact of hyponatremia. Pharmacotherapy. 2011 May;31(5 Suppl):5S-8S. 


  1. McNab S. Intravenous maintenance fluid therapy in children. J Paediatr Child Health. 2016 Feb;52(2):137-40. 


  1. Aylwin S, Burst V, Peri A, Runkle I, Thatcher N. 'Dos and don'ts' in the management of hyponatremia. Curr Med Res Opin. 2015;31(9):1755-61.


  1.  Ball SG, Iqbal Z. Diagnosis and treatment of hyponatraemia. Best Pract Res Clin Endocrinol Metab. 2016 Mar;30(2):161-73.    



















                            PROFORMA

S.no                   sex Ipno.                 DOA

Age                                                                    DOD

Weight

Primary diagnosis

H/o present illness


SNO.

SYMPTOMS

STETUS

DURATION

1

Nausea

Y

N


2

Vomiting

Y

N


3

Headache

Y

N


4

Altered mineral status

Y

N


5

Hiccups

Y

N


6

Seizures

Y

N


7

Others

y

N



If others please specify


Diet habits:

         Fluid intake

         Decreased intake



SNO.s

comorbid conditions

status

duration

specify

1

Diabetis mellitus

Y

N



2

Hypertension

Y

N



3

cardiovascular

Y

N



4

Renal problems

Y

N



5

Endocrine 

Y

N



6

respiratory

Y

N



    7

neurological

   

    



      8

gastrointestinal





9

Others

y

N




CURRENT  MEDICATIONS


s.no

Drug name

duration

Dosage/day

Causes  hypontremia

1




Y

N

2




Y

N

3




Y

N

4




Y

N

5




Y

N

6




y

N


CLINICAL FINDINGS


Pulse rate

Blood pressure 

Volume status at the time of admission;  hypo/hyper/euvolumic   

Oedema      y/n

Dehydration                 y/n

Ascitis /paedal edema

Others


BIOCHEMICAL PARAMETERS(AT THE TIME OF ADMISSION)


Serum sodium level

Urine spot sodium

Serum osmolarity

Serum urea

Grbs

Random serum cortisol      done/not done

Tft:   done/not done

Tsh :   free t4 


TREATMENT GIVEN

Infusion plan

Diuretics       y/n

Fluid restriction       y/n

Specific  drugs if given

Other treatment


OUTCOME

Asymptomatic/symptomatically better/same status

Discharged/discharged at request/lama/reffered to higher centre

 hyponatremia cause:

  possible secondary cause





                             CONSENT FORM

Thesis title ; Etiology, management and outcome in patients with hyponatremia in ICU KIMS, Narketpally

I/We, relative of patient have read and understood the information provided in the “ patient information sheet “ and have been informed and explained the purpose and nature of the study in the language I understand.

Iam aware of the fact that I may not derive any benefit from the study and that I reserve the right to opt out of the study at any point of time

I willingly agree to participate in this study.


Patient’s sign / thumb impression                witness’s sign


Name;                                                          Name;

Date;                                                            Date;

Resident’s sign;

Resident’s name;

Date





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