The Management of Very Severe Hypernatremia with Hemodialysis
Dilek Hündür, Gökçe Aliş, Özlem Polat, Figen Esen
İstanbul Üniversitesi İstanbul Tıp Fakültesi Anesteziyoloji ve Reanimasyon Anabilim Dalı
Giriş:
Hypernatremia frequently develops in hospitalized patients. Nephrogenic diabetes insipidus (NDI) is a relatively rare cause of hypernatremia caused by urinary losses. NDI is the most common adverse effect of lithium which occurs in up to 40% of patients. We report a patient with unrecognized lithium-induced nephrogenic diabetes insipidus, who developed severe hypernatremia during an emergency surgery.
Olgu: 41 years old woman admitted the emergency service with complaints of numbness and pallor in her left hand. She had bipolar disorder that was treated with lithium of 15 years duration. The patient was taken to emergency operation with the diagnosis of brachial artery embolism. During the operation, she had normal urine output and electrolyte values.
On the first day after the operation, the patient needed a reoperation because of stenosis. At the 2nd hour of the operation, we noticed polyuria. Meanwhile, arterial blood gas analysis results; Na: 155 mmol/L and metabolic acidosis. Following, urine density was 1004 and urine Na level was 22 mmol/L (Table 1). The first lithium level seen in the blood was 0.4 mmol/L (range 0.5-1.0 mmol/L). Based on the medical history and laboratory results, the patient was diagnosed with lithium-induced nephrogenic diabetes insipidus. After the patient admitted to ICU, intravenous fluids were rapidly administered for dehydration and hypernatremia. Therefore, treatment of the i.v. high dose desmopressin was started.
On the 2nd day of admission to intensive care, sodium value reached 194 mmol/L. So, continuous veno-venous hemodiafiltration (CVVHDF) was started for sodium regulation. After 24 hours with CVVDHF, control sodium was 164mmol/L. Then, CVVHDF stopped. During all the follow-up she didn't have any neurological symptoms.
Tartışma ve Sonuç: Hypernatremia due to NDI can be a major cause of morbidity and mortality in the postoperative period. With this case, we have demonstrated successful treatment of acute hypernatremia by CVVHDF before neurological complications occurred.
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