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Disorders of Sodium and Water Balance in Hospitalized Patients Les Troubles De L’E´Quilibre Hydrosode´ Chez Les Patients Hospitalise´S

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Disorders of Sodium and Water Balance in Hospitalized Patients Les Troubles De L’E´Quilibre Hydrosode´ Chez Les Patients Hospitalise´S Can J Anesth/J Can Anesth (2009) 56:151–167 DOI 10.1007/s12630-008-9017-2 REVIEW ARTICLE Disorders of sodium and water balance in hospitalized patients Les troubles de l’e´quilibre hydrosode´ chez les patients hospitalise´s Sean M. Bagshaw, MD Æ Derek R. Townsend, MD Æ Robert C. McDermid, MD Received: 21 August 2008 / Revised: 10 November 2008 / Accepted: 18 November 2008 / Published online: 31 December 2008 Ó Canadian Anesthesiologists’ Society 2008 Abstract irrigation with hypotonic solutions). Hypernatremia is most Purpose To review and discuss the epidemiology, con- commonly due to unreplaced hypotonic water depletion tributing factors, and approach to clinical management of (impaired mental status and/or access to free water), but it disorders of sodium and water balance in hospitalized may also be caused by transient water shift into cells (from patients. convulsive seizures) and iatrogenic sodium loading (from Source An electronic search of the MEDLINE, Embase, salt intake or administration of hypertonic solutions). and Cochrane Central Register of Controlled Trials data- Conclusion In hospitalized patients, hyponatremia and bases and a search of the bibliographies of all relevant hypernatremia are often iatrogenic and may contribute to studies and review articles for recent reports on hyponat- serious morbidity and increased risk of death. These dis- remia and hypernatremia with a focus on critically ill orders require timely recognition and can often be reversed patients. with appropriate intervention and treatment of underlying Principal findings Disorders of sodium and water bal- predisposing factors. ance are exceedingly common in hospitalized patients, particularly those with critical illness and are often Re´sume´ iatrogenic. These disorders are broadly categorized as Objectif Passer en revue et discuter l’e´pide´miologie, les hypo-osmolar or hyper-osmolar, depending on the balance facteurs contributifs et l’approche a` la prise en charge des (i.e., excess or deficit) of total body water relative to total troubles de l’e´quilibre hydrosode´ chez les patients body sodium content and are classically recognized as hospitalise´s. either hyponatremia or hypernatremia. These disorders Source Nous avons effectue´ une recherche e´lectronique may represent a surrogate for increased neurohormonal des bases de donne´es MEDLINE, Embase et de Cochrane activation, organ dysfunction, worsening severity of illness, Central Register of Controlled Trials et une recherche des or progression of underlying chronic disease. Hyponatre- bibliographies de toutes les e´tudes pertinentes et articles mic disorders may be caused by appropriately elevated de synthe`se pour les comptes-rendus re´cents traitant de (volume depletion) or inappropriately elevated (SIADH) l’hyponatre´mie et de l’hypernatre´mie, en concentrant notre arginine vasopressin levels, appropriately suppressed attention sur les patients en phase critique. arginine vasopressin levels (kidney dysfunction), or alter- Constatations principales Les troubles de l’e´quilibre ations in plasma osmolality (drugs or body cavity hydrosode´, excessivement communs chez les patients hospitalise´s, et particulie`rement ceux en phase critique, sont en ge´ne´ral iatroge´niques. Ces troubles sont ge´ne´ralement S. M. Bagshaw, MD (&) Á D. R. Townsend, MD Á cate´gorise´s comme hypo-osmolaires ou hyper-osmolaires, R. C. McDermid, MD selon l’e´quilibre (c.-a`-d. l’exce`soulede´ficit) d’eau corpo- Department of Anesthesiology and Pain Medicine, Division of relle totale par rapport au contenu sode´ corporel total. Les Critical Care Medicine, University of Alberta Hospital, 3C1.16 troubles sont traditionnellement reconnus en tant que soit Walter C. Mackenzie Centre, 8440-112 Street, Edmonton, AB, Canada T6G 2B7 hyponatre´mie ou hypernatre´mie. Ces troubles pourraient e-mail: [email protected] eˆtre la manifestation d’une activation neurohormonale 123 152 S. M. Bagshaw et al. accrue, d’un dysfonctionnement organique, d’une e´volution (inception through August 2008), and Cochrane Central de´favorable de la maladie ou de la progression d’une Register of Controlled Trials (inception through August maladie chronique sous-jacente. Les troubles hyponatre´m- 2008) databases for recent and relevant articles. We also iques peuvent eˆtre provoque´s par des niveaux d’arginine- searched the bibliographies of all relevant studies and vasopressine ade´quatement e´leve´s (de´ple´tion volumique) ou review articles. Search terms (water balance OR sodium inade´quatement e´leve´s (syndrome d’antidiure`se inappro- OR hyponatremia OR hypernatremia) were combined with prie´e), des niveaux d’arginine-vasopressine ade´quatement key terms for ‘‘outcome’’ OR ‘‘mortality’’ OR ‘‘diagnosis’’ supprime´s (dysfonctionnement he´patique) ou des alte´rations OR ‘‘epidemiology’’. The search was limited to studies de l’osmolarite´ plasmatique (me´dicaments ou irrigation des conducted in humans and reported in English. cavite´s corporelles par des solutions hypotoniques). L’hy- pernatre´mie est la plupart du temps provoque´e par une de´ple´tion d’eau hypotonique non remplace´e(e´tat mental Overview of sodium and water homeostasis aggrave´ et/ou acce`s libre a` de l’eau), mais elle peut e´gale- ment eˆtre cause´e par une translation provisoire de l’eau Sodium [Na?] is the primary extracellular cation and the dans les cellules (a` partir de convulsions) et de charge sode´e most important osmotically active solute in the body. iatroge´nique (de l’apport sodique ou par l’administration Under normal circumstances, the serum [Na?] is preserved des solutions hypertoniques). within a fine physiologic range (138–142 mEq l-1) despite Conclusion Chez les patients hospitalise´s, l’hyponatre´- large variations in daily sodium and water intake. Sodium mie et l’hypernatre´mie sont souvent iatroge´niques et metabolism is tightly regulated by the kidney through the pourraient contribuer a` une morbidite´ grave et un risque interaction of numerous neurohormonal mechanisms, accrue de de´ce`s. Ces troubles ne´cessitent une identification including the renin–angiotensin–aldosterone system, the rapide et peuvent souvent eˆtre soigne´s graˆce a` une inter- sympathetic nervous system, and the presence of atrial vention adapte´e et au traitement des facteurs pre´disposants natriuretic and brain natriuretic peptides. Sodium regula- sous-jacents. tion is closely correlated with the body’s effective circulating volume (ECV), defined as the requisite intra- vascular volume to provide adequate tissue perfusion. As such, the major determinant of serum [Na?] is in fact the Introduction serum water content, and disturbances in sodium balance most often reflect abnormalities in the ECV and serum Disorders of sodium and water balance are commonly water content. encountered in critically ill patients.1 Critical illness, multi- Water metabolism, on the other hand, is predominantly organ dysfunction, fluid resuscitation, and the numerous regulated by arginine vasopressin (AVP) and is strongly additional interventions received routinely by patients influenced by water intake and output. Arginine vasopres- admitted to the intensive care unit can interfere with the sin is produced in the supraoptic and paraventricular complex mechanisms that maintain total body sodium and hypothalamic nuclei and stored in the posterior pituitary. water homeostasis.2 Arginine vasopressin secretion is tightly regulated by Disorders of sodium and water balance are generally changes in serum osmolality (i.e., as little as 1–2%) categorized as either hypo-osmolar or hyper-osmolar, detected by osmoreceptors in the anterior hypothalamus depending on the balance (i.e., excess or deficit) of total and also by changes in mean arterial pressure and/or blood body water relative to total body sodium content. As sodium volume detected by baroreceptors in the aortic arch and is the primary extracellular constituent of serum osmolality, carotid bodies. Arginine vasopressin controls the water disorders of sodium and water balance can classically be permeability of the kidney by directing the insertion of recognized as hyponatremia and hypernatremia. Both of aquaporin-2 (AQP-2) channels on the luminal surface of these disorders can contribute to substantial morbidity and the distal tubules and collecting duct. Arginine vasopressin mortality, and given their prevalence in critically ill patients, induces an increase in AQP-2 channels and acts to stimu- clinicians need to have a solid understanding of their path- late free water reabsorption and anti-diuresis. ophysiology, diagnosis, and management. Hyponatremia Search methodology Hyponatremia is commonly defined as a serum In August 2008, we conducted an electronic search of the [Na?] \ 135 mmol l-1; however, this definition may vary MEDLINE (inception through August 2008), Embase across different institutional laboratories. The presence of 123 Sodium and water abnormalities 153 hyponatremia most commonly indicates an underlying generally reflect neurologic dysfunction induced by cere- disorder of an excess in body water relative to body sodium bral edema. A reduction in serum [Na?] creates an osmotic content. Less commonly, it may result from a depletion of gradient that favours water movement into the brain. This body sodium content in excess of concurrent body water increase in brain intracellular volume contributes to cere- losses. bral edema and raised intracranial pressure and leads to the appearance of neurologic manifestations. Epidemiology Mild hyponatremia
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