Hypernatremia in Emergency Medicine
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Sodium levels are tightly controlled in a healthy individual by regulation of urine concentration and an intact thirst mechanism. Hypernatremia (defined as a serum sodium level >145 mEq/L) is rare in patients with preserved thirst mechanism. When hypernatremia does occur, it is associated with a high mortality rate (>50% in most studies).
Given this high mortality rate, the emergency physician must be able to recognize and treat this condition. This article discusses the patients in whom hypernatremia should be suspected and how to initiate workup and administer appropriate treatment.
In general, hypernatremia can be caused by derangement of the thirst response or altered behavioral response thereto (primarily psychiatric patients, and elderly patients who are institutionalized), impaired renal concentrating mechanism (diabetes insipidus [DI]) secondary to kidney pathology (nephrogenic DI) or difficulty with the neurohormonal control of this concentrating mechanism (central DI), or by losses of free water from other sources.
Assessment and treatment of a hypernatremic patient focuses on 2 important questions:
What is the patient’s volume status?
Is the problem acute or chronic?
Water homeostasis is maintained by a balance between water intake and the combined water loss from renal excretion, respiratory, skin, and GI sources. Under normal conditions, water intake and losses are matched. To maintain salt homeostasis, the kidneys similarly adjust urine concentration to match salt intake and loss. See the image below.
Hypernatremia results from disequilibrium of one or both of these balances. Most commonly, the disorder is caused by a relative free water loss, although it can be caused by salt loading. The various ways in which these equilibria can be disturbed are discussed in Causes.
When hypernatremia (of any etiology) occurs, cells become dehydrated. Either the osmotic load of the increased sodium acts to extract water from the cells or a portion of the burden of the body’s free water deficit is borne by the cell. (Sodium, primarily an extracellular ion, is actively pumped out of most cells and is the primary determinant of serum osmolarity.) Dehydrated cells shrink from water extraction.
Cells immediately respond to combat this shrinkage and osmotic force by transporting electrolytes across the cell membrane, thus altering rest potentials of electrically active membranes. After an hour of hypernatremia, intracellular organic solutes are generated in an effort to restore cell volume and to avoid structural damage. This protective mechanism is important to remember when treating a patient with hypernatremia. Cerebral edema ensues if water replacement proceeds at a rate that does not allow for excretion or metabolism of accumulated solutes.
The effects of cellular dehydration are seen principally in the CNS, where stretching of shrunken neurons and alteration of membrane potentials from electrolyte flux lead to ineffective functioning. If shrinkage is severe enough, stretching and rupture of bridging veins may cause intracranial hemorrhage.
United States
Hypernatremia occurs in approximately 1% of hospitalized patients. The condition usually develops after hospital admission. An incidence closer to 2% has been reported in debilitated elderly persons and in breastfed infants. [1, 2]
International
Pediatric patients in developing nations may be at increased risk for hypernatremia because infant feeding may be complicated by poor maternal milk production (secondary to nutritional status) and errors in reconstitution of powdered formula.
An Italian study, by Giordano et al, found that hypernatremia accounted for just 4.4% of all cases of electrolyte imbalance in the study’s emergency department (compared with 44% for hyponatremia). [3]
The mortality rate from hypernatremia is high, especially among elderly patients. Mortality rates of 42-75% have been reported for acutely evolving hypernatremia and 10-60% for chronic hypernatremia. Because patients with hypernatremia often have other serious comorbidities, precisely evaluating the degree of mortality directly due to hypernatremia is difficult. Morbidity in survivors is high, with many patients experiencing permanent neurologic deficits.
Most deaths are due to an underlying disease process, rather than the hypernatremia itself. Delay in treatment (or inadequate treatment) of hypernatremia increase mortality.
A study by Vedantam et al reported that in patients with severe traumatic brain injury (TBI), an independent association exists between the development of hypernatremia after hospital admission, whether mild, moderate, or severe, and an increased likelihood of early mortality. The investigators cited mortality hazard ratios for mild, moderate, and severe hypernatremia of 3.4, 4.4, and 8.4, respectively, in severe TBI. [4]
A study by Huang et al indicated that in patients with chronic kidney disease, hypernatremia is associated with an increased risk for all-cause mortality and for deaths unrelated to cardiovascular problems or malignancy. Hyponatremia was found to be associated with an increased risk for the same, as well as for cardiovascular- and malignancy-related mortality. The study included 45,333 patients with stage 3 or 4 chronic kidney disease, 9.2% of whom had dysnatremia. [5]
A Turkish study, by Ates et al, indicated that in patients presenting to emergency departments with severe hypernatremia, independent risk factors for mortality included low systolic blood pressure, low pH, Na+ level over 166 mmol/L, increased plasma osmolarity, a mean sodium reduction rate of -0.134 mmol/L/h or less, dehydration, and, pneumonia. The retrospective study included 256 patients. [6]
In hospitalized patients, persistent hypernatremia and protracted hypotension have been associated with a very poor prognosis. A study by Jung et al indicated that in patients with community-acquired hypernatremia, an independent association exists between admission to the hospital from the emergency department and hospital mortality, with the same being true for oral intake restriction, mean arterial pressure, and respiratory rate. Also with regard to hospital mortality, multivariate analysis revealed a peak sodium level in the moderate or severe range to be an independent risk factor. [7]
The aforementioned study by Giordano et al stated that the great majority of electrolyte imbalances encountered in the report were associated with other systemic diseases. Dividing the study population into young, middle aged, and elderly, the investigators found that in the young group, electrolyte imbalances were most commonly associated with gastrointestinal disease, while in the middle-aged group, they were most often associated with cardiovascular disease, and in the elderly group, with cardiovascular disorders and lung disease. [3]
Hypernatremia is diagnosed in males and females in equal numbers.
Patients who present to the hospital with hypernatremia tend to be at the extremes of age. Breastfed infants occasionally present with hypernatremia in the first weeks of life, and elderly patients who are institutionalized are especially heavily represented.
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Zina Semenovskaya, MD Resident Physician, Department of Emergency Medicine, Kings County Hospital, State University of New York Downstate Medical Center College of Medicine
Disclosure: Nothing to disclose.
Richard H Sinert, DO Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Vice-Chair in Charge of Research, Department of Emergency Medicine, Kings County Hospital Center
Richard H Sinert, DO is a member of the following medical societies: American College of Physicians, Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Steven L Stephanides, MD Attending Physician, Department of Emergency Medicine, Eisenhower Medical Center
Steven L Stephanides, MD is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, Society for Academic Emergency Medicine, Wilderness Medical Society
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
Howard A Bessen, MD Professor of Medicine, Department of Emergency Medicine, University of California, Los Angeles, David Geffen School of Medicine; Program Director, Harbor-UCLA Medical Center
Howard A Bessen, MD is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.
Romesh Khardori, MD, PhD, FACP Professor of Endocrinology, Director of Training Program, Division of Endocrinology, Diabetes and Metabolism, Strelitz Diabetes and Endocrine Disorders Institute, Department of Internal Medicine, Eastern Virginia Medical School
Romesh Khardori, MD, PhD, FACP is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Physicians, American Diabetes Association, Endocrine Society
Disclosure: Nothing to disclose.
Joseph J Sachter, MD, FACEP Consulting Staff, Department of Emergency Medicine, Muhlenberg Regional Medical Center
Joseph J Sachter, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Association for Physician Leadership, American Medical Association, Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, Richard Sinert, DO, to the development and writing of this article.
Hypernatremia in Emergency Medicine
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