嚴重低血鈉 Severe hyponatremia

日期：



<臨床情境>

一位53歲女性被家人發現今天早上倒在浴室意識狀況不清 

家人表示病患本來預計做大腸鏡檢查 所以昨天下午有服用PEG 進行清腸

檢傷Vital signs: T/P/R: 36.4/67/20, BP: 108/74, E1V1M5 SpO2: 99%

理學檢查: coma, E1V1M3, pupil 3+/3+

過去病史: HBV carrier

目前用藥史: zolpidem, alprazolam, carisoprodol, duloxetine, gabapentin

  • First order: finger sugar, on monitor, mask 6L/min, CBC/DC, Na, K, BUN, Cr, ALT, VBG, Ammonia, Troponin I, PT, APTT, EKG, CXR, Brain CT


  • 病人來診45分鐘時突然GTC s/p valium -> subside 


  • Brain CT: no ICH, CXR: no pneumonia patch, EKG: no STT change, no QTc prolong


  • Lab data: 

WBC

Hb

PLT

PT

aPTT

Troponin I

14300

12

216000


12.8

26.5

Na

K

BUN

Creatinine

ALT

Ammonia

109

3.0

4.9

0.46

101

74

PH

PaCO2

HCO3




7.24

38.3

16.3





  • Management: 3 % NaCl run 20ml/hr, 30ml challenge, arrange admission 

  • Seizure recurrence s/p valium in vain, subside after NaCl 3% 30cc -> intubation, loading AED, Na: 114 

  • 3th seizure attack, subsided by Ativan -> admission to ICU care unit 

  • Impression: Status epilepticus, favor severe hyponatremia related with respiratory failure s/p ETT + MV


<Hyponatremia> Reference: Diagnosis and Management of Hyponatremia A Review 2022, JAMA

2022 JAMA review definition: 血清鈉 <135-138 mEq/L

  • 流行病學:  5% 住院病人合併低血鈉, 超過65歲的老人約20%有低血鈉問題

  • 急性/慢性: 時間定義切48小時, 主要差別是腦細胞的適應能力, 急性比較容易產生神經學症狀

  • 臨床症狀: 來自於brain osmolarity effect ( brain injury may become irreversible)

  1. Moderately severe: often start when a plasma [Na+] is <130 mEq/L and consist of headache, nausea, disorientation, confusion, agitation, ataxia, and areflexia 

  2. severe: When [Na+] <120 mEq/L, including intractable vomiting, seizures, coma, and ultimately respiratory arrest due to brainstem herniation

  • 診斷低血鈉的流程圖如下





  1. 確認為hypotonic hyponatremia 

  2. 區分病人的fluid status 

  3. 排除鑑別診斷




Reference: NEJS from web blog

  1. 鑑別Isotonic hyponatremia and Hypertonic hyponatremia 的原因


  • 治療: 根據症狀可以分為Emergency and non- Emergency

  1. Emergency: seizures, coma, cardiac arrest




Reference: Tintinalli’s


 

Reference: NEJS from web blog and JAMA 2022: 328:280291




Reference: NEJS from web blog and JAMA 2022: 328:280291


  1. Non- Emergency

  • 血清鈉<120 mEq/L 需要住院觀察(initially at least Q8H)

  • Hypovolemic hyponatremia -> Isotonic saline or other crystalloid solution is used for parenteral volume repletion

  • Euvolemia hyponatremia for SIAD include fluid restriction, increased solute intake (sodium chloride, protein, urea), and vaptans

  • Hypervolemic hyponatremia: treat underlying ex liver cirrhosis 

  • SIADH diagnosis by exclusion 



  • Osmotic Demyelination Syndrome: 發生在鈉離子校正太快(Correction>12mEq/L/24h)

  • 症狀: Dysarthria, dysphagia, lethargy, paraparesis or quadriparesis, seizures, and coma

  • 治療: giving 5% dextrose in water at 3 mL/kg/h, loop diuretics, and desmopressin 


<Hyponatremia with seizure>

  • 有研究顯示, Using120–124mM as reference, 勝算比 Odds ratio for having seizures at serum sodium levels of 115–119 mM was 3.85, 8.43 , at 110–114mM, and 18.06 at <110 mM

(Hyponatremia and risk of seizures: a retrospective cross-sectional study)


Edited by Hsin-Tzu, Yeh

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