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Approach to the Management of Sodium Disorders in the Neuro Critical Care Unit
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Purpose of Review To present an overview of the current diagnostic and therapeutic approaches for patients with hyponatremia and hypernatremia in the neurocritical care unit (NCCU). Recent Findings Dysnatremias are associated with poor neurological outcomes and mortality in neurocritically ill patients. Volume status determination, although challenging, is critical in differentiating between the two most common etiologies of hyponatremia in the NCCU: SIADH and salt wasting.
Central diabetes insipidus (CDI) is common in post trans-sphenoidal surgery patients and in severe brain injuries where it portends a poor prognosis. Summary Treatment of dysnatremia should take into account severity of symptoms, rapidity of onset, and presence and extent of underlying brain injury. Severe acute hyponatremia is an emergency that should be treated with intravenous hypertonic saline. Controlled speed of correction is crucial in preventing osmotic demyelination syndrome in the most vulnerable patients in patients with chronic hyponatremia. SIADH is the most common cause of hyponatremia in the NCCU and is usually treated with fluid restriction, vaptans, oral salt, urea, and occasionally saline and loop diuretics. Salt wasting is a common cause of hypovolemic hyponatremia in severe brain injuries and should be managed with fluid and salt repletion ± fludrocortisone. Hypernatremia is treated with hypotonic solutions after correcting volume status as needed with isotonic solution, with the addition of desmopressin or vasopressin in cases of CDI.
Purpose of Review To present an overview of the current diagnostic and therapeutic approaches for patients with hyponatremia and hypernatremia in the neurocritical care unit (NCCU). Recent Findings Dysnatremias are associated with poor neurological outcomes and mortality in neurocritically ill patients. Volume status determination, although challenging, is critical in differentiating between the two most common etiologies of hyponatremia in the NCCU: SIADH and salt wasting.
Central diabetes insipidus (CDI) is common in post trans-sphenoidal surgery patients and in severe brain injuries where it portends a poor prognosis. Summary Treatment of dysnatremia should take into account severity of symptoms, rapidity of onset, and presence and extent of underlying brain injury. Severe acute hyponatremia is an emergency that should be treated with intravenous hypertonic saline. Controlled speed of correction is crucial in preventing osmotic demyelination syndrome in the most vulnerable patients in patients with chronic hyponatremia. SIADH is the most common cause of hyponatremia in the NCCU and is usually treated with fluid restriction, vaptans, oral salt, urea, and occasionally saline and loop diuretics. Salt wasting is a common cause of hypovolemic hyponatremia in severe brain injuries and should be managed with fluid and salt repletion ± fludrocortisone. Hypernatremia is treated with hypotonic solutions after correcting volume status as needed with isotonic solution, with the addition of desmopressin or vasopressin in cases of CDI.
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