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    Hypernatremia

    Hypernatremia is a topic covered in the 5-Minute Emergency Consult.

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    Basics

    Description

    Hypernatremia definition: Sodium >145 mEq/L:
    • Mild hypernatremia: Serum sodium 146–155 mEq/L
    • Severe hypernatremia: Serum sodium >155 mEq/L

    Etiology

    Divided into 3 categories

    Hypovolemic Hypernatremia
    • Most common
    • Loss or deficiency of water and sodium with water losses being greater than sodium losses
    • Examples:
      • Renal failure
      • Medications (e.g., diuretics, lactulose)
      • Osmotic diuresis (mannitol, glucosuria, high protein feedings)
      • Insensible losses (burns, sweating)
      • Respiratory loss
      • Defective thirst mechanism
      • Lack of access to water
      • Diarrhea/vomiting
      • Intubated patients

    Isovolemic Hypernatremia
    • Water deficiency without sodium loss; free water loss
    • Examples:
      • Fever
      • Hypothalamic diabetes insipidus (DI):
        • Head trauma
        • Tumor
        • Congenital
        • Infection (TB, syphilis, mycoses, toxoplasmosis, encephalitis)
        • Granulomatous disease (sarcoid, Wegner)
        • Cerebrovascular accident
        • Aneurysm
      • Nephrogenic DI:
        • Congenital
        • Drugs (lithium, amphotericin B, foscarnet, demeclocycline)
        • Obstructive uropathy
        • Chronic tubulointerstitial disease (sickle cell nephropathy, multiple myeloma, amyloidosis, sarcoidosis, systemic lupus erythematosus, polycystic kidney)
        • Electrolyte disorders (hypercalcemia, potassium depletion)

    Hypervolemic Hypernatremia
    • Gain of water and sodium, with sodium gain greater than water gain.
    • Examples:
      • Iatrogenic—most common cause:
        • Sodium bicarbonate administration
        • NaCl tablets
        • Hypertonic parenteral hyperaliment
        • Hypertonic IV fluid (IVF)
        • Hypertonic dialysis
      • Hypertonic medicine preparations such as ticarcillin and carbenicillin
      • Cushing disease
      • Adrenal hyperplasia
      • Primary aldosteronism
      • Sea water drownings

    Pediatric Considerations
    • More prone to iatrogenic causes
    • More likely to die or to have permanent neurologic sequelae
    • Morbidity ranges from 25% to 50%.
    • May present with high-pitched cry, lethargy, irritability, muscle weakness
    • Poor breast feeding and inappropriate formula preparations are a potential cause in neonates
    • If hypernatremia is due to DKA, follow pediatric DKA protocols for fluid resuscitation
    • DDAVP dose for 3 mo–12 yr is 5–30 μg/day intranasally
      • Consider NG hydration


    Geriatric Considerations
    • Most commonly affected group due to impaired renal concentrating ability and reduced thirst mechanism
    • Consider neglect if underlying etiology is dehydration alone


    Pregnancy Considerations
    • May encounter transient DI of pregnancy
    • Vasopressin and desmopressin are category B drugs in pregnancy
    • Hydration status much more difficult to evaluate accurately by exam

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    Citation

    Rosen, Peter, et al., editors. "Hypernatremia." 5-Minute Emergency Consult, 5th ed., Lippincott Williams & Wilkins, 2016. Emergency Central, emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307047/all/Hypernatremia.
    Hypernatremia. In: Rosen P, Shayne P, Barkin AZ, et al, eds. 5-Minute Emergency Consult. 5th ed. Lippincott Williams & Wilkins; 2016. https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307047/all/Hypernatremia. Accessed April 26, 2019.
    Hypernatremia. (2016). In Rosen, P., Shayne, P., Barkin, A. Z., Wolfe, R. E., Hayden, S. R., Barkin, R. M., & Schaider, J. J. (Eds.), 5-Minute Emergency Consult. Available from https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307047/all/Hypernatremia
    Hypernatremia [Internet]. In: Rosen P, Shayne P, Barkin AZ, Wolfe RE, Hayden SR, Barkin RM, Schaider JJ, editors. 5-Minute Emergency Consult. Lippincott Williams & Wilkins; 2016. [cited 2019 April 26]. Available from: https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307047/all/Hypernatremia.
    * Article titles in AMA citation format should be in sentence-case
    TY - ELEC T1 - Hypernatremia ID - 307047 ED - Rosen,Peter, ED - Shayne,Philip, ED - Barkin,Adam Z, ED - Wolfe,Richard E, ED - Hayden,Stephen R, ED - Barkin,Roger M, ED - Schaider,Jeffrey J, BT - 5-Minute Emergency Consult UR - https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307047/all/Hypernatremia PB - Lippincott Williams & Wilkins ET - 5 DB - Emergency Central DP - Unbound Medicine ER -