PUSHING THE LIMIT: SEVERE HYPONATREMIA IN THE SETTING OF SEPSIS AND LIVER FAILURE

Abstract

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Hyponatremia, a serum sodium < 135 mEq/L, is the most common electrolyte disorder in hospitalized patients. Most hyponatremia is asymptomatic or mild, but severe hyponatremia (< 120 mEq/L) may cause stupor, cerebral edema, seizures, coma, or death. Hyponatremia must be slowly corrected to avoid risk of osmotic demyelination syndrome (ODS), occurring within a few days after overcorrection leading to altered mental status, quadriplegia, coma, or seizures. We describe a case of severe, symptomatic hyponatremia with an initial sodium (Na) of 96 mEq/L to discuss treatment strategies that were applied. CASE PRESENTATION: We present a case of a 30 year-old female with a history of alcohol use presenting via ambulance after three witnessed seizures. Febrile to 101 F in the ED, tachypneic, tachycardic, and hypotensive. On exam, she was icteric with hepatosplenomegaly, the remaining exam was unremarkable. Significant labs include Na 96, chloride 50, total bilirubin 27.1, serum osmolality 214, and lactate 6.8. Ultrasound revealed a cirrhotic liver, sepsis criteria met and initial lactated ringers bolus given. Normal saline (NS) initiated on hospital day 2 (HD2) with an initial goal of 102. Switched to hypertonic saline with D5W on HD3 with Na goal 108. HD4 and HD5 goals were 112 and 117. D5W discontinued on HD6 with Na goal 126. Hypertonic saline switched to NaCl tablets on HD7 after achieving Na of 126. Three weeks later the patient was alert, active, and able to participate in therapy and feed herself. DISCUSSION: Identifying causes of hyponatremia is a crucial step in providing the appropriate treatment plan. In addition, the timeline of hyponatremia is a major determinant of the treatment and the severity of symptoms. A detailed history provides clues for the cause of hyponatremia but can be challenging due to the neurological symptoms associated with it. Physical exam is important in assessing the volume status and evaluation of possible complications. Laboratory tests are always required to establish the diagnosis and monitoring the Na levels during the treatment. We believe that our patient's presentation of severe hyponatremia is to the best of our knowledge the lowest recorded in the current literature. She made a gradual and full recovery with slow correction of her sodium levels over her hospitalization course without any permanent neurological damage. CONCLUSIONS: Clinicians should consider a methodical approach to managing correction of hyponatremia. Prevention of ODS is vital for favorable patient outcomes and may be avoided through close monitoring of daily goals and layered treatments to avoid overcorrection. REFERENCE #1: Verbalis JG, Goldsmith SR, Greenberg A, et al. Diagnosis, evaluation, and treatment of hyponatremia: expert panel recommendations. Am J Med. 2013;126:S1-S42. REFERENCE #2: Thaofiq I, Sandhya M, Kameswari L,"Therapeutic Approach to the Management of Severe Asymptomatic Hyponatremia", Case Reports in Nephrology, vol. 2017, Article ID 1371804, 4 pages, 2017. REFERENCE #3: Rondon-Berrios, H., Agaba, E.I. & Tzamaloukas, A.H. Hyponatremia: pathophysiology, classification, manifestations and management. Int Urol Nephrol 46, 2153–2165 (2014). DISCLOSURES: No relevant relationships by Yazan Addasi, source=Web Response No relevant relationships by Venkata Andukuri, source=Web Response No relevant relationships by Keith Christensen, source=Web Response No relevant relationships by Shannon DeVries, source=Web Response No relevant relationships by Taylor Lenz, source=Web Response No relevant relationships by Mark Malesker, source=Web Response