HYPERNATREMIA
BY,
BLESSY RACHAL BOBAN
PHARM D INTERN
04/26/2022 1
HYPERNATREMIA
• Hypernatremia is defined as a serum sodium
concentration of greater than 145 meq/l.
• Hypernatremia usually is associated with hypovolemia .
Definition Serum [Na+]
( mmol/l )
Hyponatraemia < 135
Normal 135 - 145
Mild Hypernatremia 146 - 149
Moderate Hypernatraemia 150 - 169
Severe Hypernatraemia ≥ 170
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CLASSIFICATION
• Hypovolemic hypernatremia- occurs with low ECF
volume and caused by water losses exceeding sodium
[Link] causing this condition are osmotic
diuretics,laxatives.
• Isovolemic hypernatremia- associated with an isolated
pure water loss and total body sodium content is
[Link], insufficient fluid intake are the causes.
• Hypervolemic hypernatremia- results from an increase in
total body sodium and water.
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ETIOLOGY
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PATHOPHYSIOLOGY
• Sodium is important to maintain ECF volume.
• Changes in the ECF volume provide feedback to
maintain total sodium content by increasing or
decreasing sodium excretion in the urine.
• Sodium excretion also involves regulatory mechanisms
such as the renin-angiotensin-aldosterone systems.
• When serum sodium increases, the plasma osmolality
increases and triggers an increase in thirst response
and ADH secretion, leading to renal water conservation
and concentrated urine.
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CLINICAL PRESENTATION
Symptoms related to the
Characteristics of
characteristics of
hypernatremia
hypernatremia
Cognitive dysfunction and Lethargy, obtundation, confusion,
symptoms associated with abnormal speech, irritability, seizures,
neuronal cell shrinkage nystagmus, myoclonic jerks
Orthostatic blood pressure changes,
Dehydration or clinical signs of
tachycardia, oliguria, dry oral mucosa,
volume depletion
abnormal skin turgor, dry axillae,
Other clinical findings Weight loss, generalized weakness
Nausea, vomiting, and falls and weakness are common symptoms of
severe hypernatremia in patients presenting to an emergency
department.
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Management
Too rapid reduction of the sodium in
hypernatraemia can cause cerebral oedema,
convulsions and permanent brain injury.
Close monitoring is critical.
Resuscitation:
If "shocked", resuscitate with boluses 20ml/kg of 0.9%
saline as required
Initial management and monitoring
Fluid management should then be based on the initial
serum sodium
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Rate to lower sodium:
Aim to lower the serum sodium slowly at a rate
of no more than 12mmol/L in 24 hours,
(0.5mmol/L/hour).
An even slower rate will be required for children
with chronic hypernatraemia
The rate of rehydration, or sodium concentration of
fluids, may need to be changed if appropriate rate of
correction of serum sodium is not seen (too fast or
too slow).
Monitor other electrolytes and blood sugar
Measure ongoing losses (ie: vomiting or diarrhoea,
excluding urine) and replace ml for ml with normal
saline.
Careful neurological monitoring
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Rehydration: The following guide is for rehydration of
patients with excess water loss for the first 12 - 24hrs.
Mild hypernatraemic dehydration, [Na+] 146 - 149
mmol/L.
Rarely requires specific management. Manage
underlying cause. Repeat in 4-6 hours if clinically
indicated.
Moderate hypernatraemic dehydration, [Na+] 150 -
169 mmol/L.
After initial resuscitation, replace the deficit plus
maintenance slowly at a uniform rate over 48 hours.
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Nasogastric rehydration is preferred. Use oral solution
([Link]).
If the serum sodium falls too rapidly (>0.5mmol/L/hr) slow
the rate of rehydration (for example, by 20%) or change
to intravenous fluids.
If needing intravenous rehydration use Plasma-Lyte 14
and 5% Glucose OR 0.9% sodium chloride (normal
saline) and 5% Glucose. Add maintenance KCl once
urine output established.
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Severe hypernatraemic dehydration [Na+] ≥ 170
After initial resuscitation, aim to replace deficit and
maintenance with Plasma-Lyte 148 and 5%
Glucose OR 0.9% sodium chloride (normal saline) and
5% Glucose over 72 - 96 hours.
Care should be taken not to correct blood [Na+ ] too rapidly or
overcorrect, as cerebral and non-cardiogenic pulmonary edema
may result.
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Calculation of water deficit in a patient with
hypernatremia
Volume of distribution is total body water (TBW).
Water deficit = normal body water (NBW) – current body
water (CBW).
Water deficit = CBW x ([Link]
140 – 1)
TBW calculated as fraction of body weight:
Men - 0.6
Elderly men -0.5
Women- 0.5
Elderly women- 0.45
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Hypovolemic hypernatremia – treated with isotonic 0.9%
NaCl solution for 30-45 [Link] intravascular
volume is replaced, free water deficit can be replaced
with 5% dextrose or 0.45% [Link] greater
than 175mEq/L should not be corrected by more than
15mEq/L during the first 24 hours.
Isovolemic hypernatremia – corrected by replacing water
deficit with 5%dextrose or 0.45% NaCl solution.
Hypervolemic hypernatremia- treated by replacement of
water deficit in conjunction with diuretics to eliminate
excess sodium.
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CONCLUSION
• Hypernatremia is usually caused by limited access to water or an
impaired thirst mechanism, and less commonly by diabetes insipidus.
• Manifestations include confusion, neuromuscular excitability,
hyperreflexia, seizures, and coma.
• Patients who do not respond to simple rehydration or in whom there
is no obvious cause may need assessment of urine volume and
osmolality, particularly after water deprivation.
• Replace intravascular volume and free water orally or intravenously
at a rate dictated by how acutely (< 24 hour) or chronically (> 24
hour) the hypernatremia has developed, while watching other serum
electrolyte levels (especially potassium and bicarbonate) as well.
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reference
• Hypernatremia : Successful Treatment .Soo Wan Kim
electrolytes and blood pressure ; 2006 Nov; 4(2): 66.
• Pharmacotherapy handbook, ninth edition,
[Link], [Link], page no.955-956.
• Arampatzis S, Frauchiger B, Fiedler GM, Leichtle AB,
et al. Characteristics, symptoms, and outcome of
severe dysnatremias present on hospital admission.
Am J Med 2012;125:1125.
• Turk EE, Schulz F, Koops E, Gehl A, et al. Fatal
hypernatremia after using salt as an emetic--report of
three autopsy cases. Leg Med (Tokyo) 2005;7:47-50.
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THANK YOU
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