Let me tell you about a patient. He was an elderly man with a severe intracranial hemorrhage. He was treated with hypertonic saline for a while, pushing his sodium to the 150s. Following intubation and some days in the ICU, it became clear that he wasn't going to recover. Discussions occurred with his family and the decision was reached to transition to comfort-directed care. Following extubation, he was only able to say a single word: water. He moaned “water” over and over again. We gave him sips of water, ice chips, and intravenous D5W. He felt better, and eventually passed on.
He illustrates the enormous misery we inflict on patients by ignoring hypernatremia. The man's brain was severely injured, barely able to construct language. The only word he could muster up the strength for was “water.” He had probably been suffering from intense thirst for days, as we infused him with 3% saline.
Treating hypernatremia in the ICU isn't exciting or particularly difficult. However, it's enormously important to provide patients with comfort. We talk a lot on treating pain, but usually forget about the discomfort caused by thirst. Remember: when you intubate a patient and take control of their airway, you're also taking responsibility to provide them with water.
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hey brother,wouldn’t marked hyperglycemia cause hyponatremia?
Yes it can, absolutely. I think hyperglycemia can cause either hypernatremia or hyponatremia depending on the context & chronicity:
#1) Acute hyperglycemia will tend to suck glucose out of the cells osmotically, this will cause hyponatremia (probably most common scenario)
#2) Chronic hyperglycemia will cause an ongoing osmotic diuresis which eventually causes hypernatremia (e.g. really severe hyperosmolar hyperglycemic nonketotic syndrome a.k.a. HHNS or HONK).
#3) You can have #1 & #2 coexisting to a certain extent, to make things even more confusing.
We will eventually go down this rabbit hole in the chapter on hyperosmolar hyperglycemic nonketotic syndrome.
Can’t wait to read it. If you mean after correction, then absolutely agree, but it sounds like you are positing a frank lab hypernatremia rather than one seen after lab correction.
I had this exact scenario recently with a new diagnosed DM with HHNS whose glucose was 1800 and Na 160 (not corrected for the glucose) who was receiving an insulin gtt at 20 units/hr. The intensivist and I chose 0.2% saline @120ml/hr to avoid giving more glucose with D5. Checked BMPs q6, he responded well. Looking forward to hearing that HHNS post.
Any idea at what point patients start having thirst? Any specific value we can strive for to be reasonably certain patients are comfortable?
At this year’s fluid academy days conference I heard of one intensivist who provides awake ventilated patients with a PCA catheter so they can push a button and bolus themselves a small amount of water (I guess about 200 ml?). This sounds like a great approach, assuming adequate oversight and patient selection.
Most studies have looked at serum osmolarity rather than sodium level, so it’s hard to say exactly. Small shifts in osmolarity can cause thirst (e.g. 2% changes), so it may be a fair guess that any degree of hypernatremia could cause thirst. Drinking is a really important survival mechanism, so we are hard wired to seek out water early and aggressively.
Giving an intubated patient control over their own water intake is a really neat idea.
As an ICU nurse we encourage frequent oral cares; and we treat them like they are getting their teeth cleansed at the dentist. Soft suction in the back corner of mouth and moderately moist cool sponge in the mouth. It is what I would want – I am also a stickler for lip moisturizing as often as necessary. When we extubate it is usually the first thing our patients want – we even had a sweet young patient using her own “sign language” to ask her father for water. I do not believe there is a specific number you will… Read more »
oh, and 1 more– how would you vary your Rx if the patient is hypovolemic in addition to the profound dehydration
There’s tons of perfectly fine ways of doing this, the following is how I’d play it. (1) Give an infusion of D5W or enteral free water – in the same exact fashion & dose that you would do for any hypernatremic patient (calculations above). (2) Treat hypovolemia with an infusion of isotonic crystalloid (e.g. LR, plasmalyte etc). You want to dose-reduce the isotonic crystalloid a bit. Compared to what you would otherwise give for volume resuscitation, reduce the volume by an amount equal to ~1/3 of the volume of free water that you’re giving. The free water will distribute throughout… Read more »
Can we use distilled water intravenously for free water correction…?
Infusing “pure water” would make the pharmacy staff go nuts. Due to the hypotonicity (ZERO mOsm/L), infusing sterile water results in hemolysis and in one particular case the death of a patient after receiving ~500 mL of sterile water. See the link for a warning from ISMP about infusing sterile water intravenously (https://www.ismp.org/resources/water-water-everywhere-please-dont-give-iv). Otherwise, great post!
Lauren,
Sterile water can absolutely be administered as long as it is done via central line with a pump. You can see this article for a discussion:
Anaesthesia and Intensive Care 2014;42(2):258-62
Agree 100% with Scott.
I’ve infused hydrochloric acid via central line. Water is less irritating than hydrochloric acid. Therefore, infusing water via central line really ought to be safe!
The limitations are really just logistic, primarily getting folks over the fear of doing this. Many pharmacists will refuse to infuse water and it’s not a hill that’s worth dying on.
How to treat patient with brain injury with brain edema who is also hyponatremic. Can we give D5W in such patients as D5W is generally avoided in patients with brain edema.
Please see the article below for an opinion favoring not too rapidly correcting hypernatremia caused by massive sodium ingestion if ingestion happened more than 3 hours before treatment can be started. This is a case report on a 40-year-old schizophrenic patient ingesting too much soy sauce:
Fatal acute hypernatremia resulting from a massive intake of seasoning soy sauce. Acute Med Surg. 2020 Aug 20;7(1):e555. doi: 10.1002/ams2.555