HYPERNATREMIA
Introduction:
An intact thirst mechanism usually prevents
hypernatremia ( 145 meq/L).
Whatever the underlying disorder, excess water loss can
cause hypernatremia only when adequate water intake is
not possible, as with unconscious patients.
Symptoms and Signs
When dehydration exists, orthostatic hypotension and
oliguria are typical findings.
Hyperthermia, delirium, and coma may be seen with
severe hyperosmolality.
Laboratory Findings
1. Urine osmolality 400 mosm/kg: Renal water-
conserving ability is functioning.
a. Nonrenal losses: Hypernatremia will develop if water
ingestion fails to keep up with hypotonic losses from
excessive sweating, exertional losses from the
respiratory tract, or through stool water. Lactulose
causes an osmotic diarrhea with loss of free water.
b. Renal losses: While diabetic hyperglycemia can cause
pseudohyponatremia, progressive volume depletion from
the osmotic diuresis of glycosuria can result in true
hypernatremia. Osmotic diuresis can occur with the use
of mannitol or urea
2. Urine osmolality < 250 mosm/kg: dilute urine with
osmolality less than 250 mosm/kg with hypernatremia is
characteristic of central and nephrogenic diabetes
insipidus.
Treatment
Treatment of hypernatremia is directed toward correcting
the cause of the fluid loss and replacing water and, as
needed, electrolytes.
If hypernatremia is too rapidly corrected, the osmotic
imbalance may cause water to preferentially enter brain
cells, causing cerebral edema and potentially severe
neurologic impairment.
Fluid therapy should be administered over a 48-hour
period, aiming for a decrease in serum sodium of 1
meq/L/h (1 mmol/L/h).
Potassium and phosphate may be added as indicated by
serum levels; other electrolytes are also monitored
frequently.
A. Choice of Type of Fluid for Replacement
1. Hypernatremia with hypovolemia:
Severe hypovolemia should be treated with isotonic
(0.9%) saline to restore the volume deficit and to treat the
hyperosmolality, since the osmolality of isotonic saline
(308 mosm/kg) is often lower than that of the plasma.
This should be followed by 0.45% saline to replace any
remaining free water deficit.
Milder volume deficit may be treated with 0.45% saline
and 5% dextrose in water.
2. Hypernatremia with euvolemia:
Water drinking or 5% dextrose and water intravenously
will result in excretion of excess sodium in the urine.
If GFR is decreased, diuretics will increase urinary sodium
excretion but may impair renal concentrating ability,
increasing the quantity of water that needs to be
replaced.
3. Hypernatremia with hypervolemia:
Treatment consists of providing water as 5% dextrose in
water to reduce hyperosmolality, but this will expand
vascular volume.
Thus, loop diuretics such as furosemide (0.5-1 mg/kg)
should be administered intravenously to remove the excess
sodium.
In severe renal insufficiency, hemodialysis may be
necessary.
B. Calculation of Water Deficit
When calculating fluid replacement, both the deficit and
the maintenance requirements should be added to each
24-hour replacement regimen.
1. Acute hypernatremia:
In acute dehydration without much solute loss, free water
loss is similar to the weight loss.
Initially, 5% dextrose in water may be employed.
As correction of water deficit progresses, therapy should
continue with 0.45% saline with dextrose
2. Chronic hypernatremia
Water deficit is calculated to restore normal osmolality for
total body water.
Volume to be replaced (in L) = Current TBW - 140
140
