Hiponatremia

Hiponatremia na UTI Paulo Novis Rocha Professor Adjunto do Depto de Medicina Faculdade de Medicina da Bahia - 200 anos Nefrologista Congresso Brasileiro de Medicina Intensiva Salvador – Bahia, 2008

Hiponatremia ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],1. Upadhyay A et al: Incidence and prevalance of hyponatremia. Am J Med 119:S30–S35, 2006 2. Patel GP et al. Recognition and treatment of hyponatremia in acutely ill hospitalized patients. Clin Ther. 2007 Feb;29(2):211-29. 3. DeVita MV et al.: Incidence and etiology of hyponatremia in an intensive care unit. Clin Nephrol 34:163–166, 1990 4. Asadolahi K et al. Laboratory risk factors for hospital mortality in acutely admitted patients. QJM. 2007 Aug;100(8):501-7.

[Na + ] = meq /L Combinações que podem gerar HIPONATREMIA :    H 2 0 corporal total Aumentado Normal Reduzido Volume extra-celular SIADH Normal ICC  Diarréia   Exemplos Na + corporal total

[object Object],[object Object],[object Object],[object Object],“ Excess Disorders” Burton D. Rose, Clinical Physiology of Acid Base & Electrolyte Disorders COMMON FACTOR: impaired renal ability to excrete the retained solute or water

Hiponatremia ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Pergunta (do nefrologista) frente ao paciente hiponatrêmico: Porque os rins não conseguem excretar o excesso de água ?

Principais motivos pelos quais os rins não conseguem excretar o excesso de água livre ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Nephrogenic Syndrome of Inappropriate Antidiuresis Brian J. Feldman, M.D., Ph.D., Stephen M. Rosenthal, M.D., Gabriel A. Vargas, M.D., Ph.D., Raymond G. Fenwick, Ph.D., Eric A. Huang, M.D., Mina Matsuda-Abedini, M.D., Robert H. Lustig, M.D., Robert S. Mathias, M.D., Anthony A. Portale, M.D., Walter L. Miller, M.D. and Stephen E. Gitelman, M.D. N Engl J Med Volume 352;18:1884-1890 May 5, 2005

Study Overview ,[object Object],[object Object],[object Object],[object Object]

Nucleotide Sequence of the Wild-Type and Two Mutant AVPR2 Genes in the Affected Region (Panel A) and Diagram of V2R (Panel B) Feldman, B. et al. N Engl J Med 2005;352:1884-1890

Exceções: ,[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Hiponatremia com urina diluída

Causas comuns de hiponatremia em terapia intensiva ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Cerebral Salt Wasting Versus SIADH: What difference? Sterns RH & Silver SM. Cerebral Salt Wasting Versus SIADH: What difference? JASN 19: 194–196, 2008 Low Normal / High ECBV 3% saline 3% saline Treatment Supressed Supressed RAAS High High Serum ANP Low Low Uric acid High High Serum AVP High High Urine Na Low Low Serum Na CSWS SIADH

Hiponatremia em pacientes neurológicos: CSWS ou SIADH ? Brimioulle S et al. Hyponatremia in neurological patients: cerebral salt wasting versus inappropriate antidiuretic hormone secretion. Intensive Care Med (2008) 34:125–131 37  6 37  6 Volume plasmático (ml /kg) 54  8 54  9 Volume sanguíneo (ml /kg) 18  4 17  5 Volume hemácias (ml /kg) 127  3 139  2 [Na + ] sérico  [Na + ] (N = 20) Controle (n= 20)

Manifestações Clínicas ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Adrogue H and Madias N. N Engl J Med 2000;342:1581-1589 Effects of Hyponatremia on the Brain and Adaptive Responses

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Velocidade de Correção

Método de Correção Depende do diagnóstico...

Método de Correção: I. Hipovolemia ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Método de Correção: II. Hipervolemia ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Vasopressin Receptor Antagonists Ellison D, Berl T. N Engl J Med 2007;356:2064-2072

Método de Correção: III. Normovolemia ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Fórmulas para correção do Na + sérico ,[object Object],[object Object],(Na + + K + solução - Na + sérico) ÷ (A.C.T. + 1) Adrogué HJ, Madias NE. Aiding fluid prescription for the dysnatremias. Intensive Care Med 1997;23:309-16. Adrogué HJ, Madias NE. Hyponatremia. N Engl J Med 2000;342(21):1581-89

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Hyponatremia: Accuracy of formulas for calculating initial infusion rates Ellison D, Berl T. N Engl J Med 2007;356:2064-2072

Problemas com as fórmulas ,[object Object],[object Object],[object Object],[object Object],[object Object]

Conclusões ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Hiponatremia

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Hiponatremia