Abstract: FR-PO583
Management of Critical Hypernatremia During Continuous Renal Replacement Therapy and Septic Shock
Session Information
- Dialysis and Vascular Trainee Case Reports
November 08, 2019 | Location: Exhibit Hall, Walter E. Washington Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Trainee Case Report
- 902 Fluid and Electrolytes: Clinical
Authors
- Valenzuela, Harol S., Medical University of South Carolina, Charleston, South Carolina, United States
- Fulop, Tibor, Medical University of South Carolina, Charleston, South Carolina, United States
- Marshall, Anna, Medical University of South Carolina, Charleston, South Carolina, United States
Introduction
The concept of osmotic stability in the critically ill during continuous renal replacement therapy is insufficient explored. Herewith, we are reporting a case of extreme hypernatremia (serum sodium [SeNa+] 182 mEq/L) with septic shock and acute kidney injury addressed with continuous renal replacement therapy (CRRT) and simultaneous hypertonic saline (HTS) administration.
Case Description
A 52-year-old male suffered a motor bicycle accident with subarachnoid hemorrhage and traumatic right below-the-knee amputation[FT1] . On the 17th day of hospitalization he suffered acute decompensation with increased work of breathing and decreased alertness. He required emergency intubation with mechanical ventilation and 3 pressor agents to maintain acceptable BPs. Initial laboratory studies revealed acute kidney injury with serum creatinine (SeCr) 3.6 mg/dL (normal baseline), BUN 142 mg/dL and sodium 177 mEq/L. With intravenous fluids, SeCr improved to 3 mg/dL while SeNa+ rose to 182 mEq/L. Due to subsequent anuria, resistant hypoxia and escalating vasopressor requirements, a decision was made to start CRRT in continuous hemofiltration modality. To address co-morbid hyperosmolar state, HTS with 3% saline was added to ensure a predictable rate of SeNa+ correction; correction for serum protein content (5 mg/dL) was achieved by multiplying predicted SeNa+ by 0.95 to calculate in vivo SeNa+.
Recovery was complicated by hypotonic polyuria and central diabetes insipidus (DI), attributable to subarachnoid hemorrhage.
Discussion
While presence of DI was difficult to recognized with anuria and AKI but undoubtedly was responsible for hypernatremia on presentation. Premixed CRRT fluids are hypotonic (Na+ 140 mEq/L) by default, when considering the presence of serum protein content. Excessive drops of SeNa+ and BUN likely would have caused harm in our index case without concurrent HTS administration. Management of dysnatremic CRRT protocols represent an important and emerging field of critical care nephrology.
CVVHD and Electrolytes
| Days on CVVHD | BFR/Therapy fluid dose | Hypertonic (3%) saline infusion | SeNa+ | SeOsm | SeCr | BUN | UOsm | UNa+ |
| Day-1 | 250 mL/min 4L/hrs | 250 mL/hr | 182 mEq/L | 443 Mosm/kg | 3 mg/dL | 139 mg/dL | Anuric | Anuric |
| Day-2 | 250 mL/min 4L/hrs | 200 mL/hr | 169 mEq/L | 372 Mosm/kg | 2.9 mg/dL | 119 mg/dL | Anuric | Anuric |
| Day-3 | 250 mL/min 4L/hrs | 150 mL/hr | 160 mEq/L | 343 Mosm/kg | 2.6 mg/dL | 93 mg/dL | Anuric | Anuric |
| Day-4 | 250 mL/min 4L/hrs | 100 mL/hr | 152 mEq/L | 312 Mosm/kg | 0,8 mg/dL | 21 mg/dL | Oliguric | Oliguric |
| Day-5 | CRRT stop | 3% saline stop | 144 mEq/L | 318 Mosm/kg | 0.6 mg/dL | 11 mg/dL | 122 mOsm/kg | <20 mmol/L |
| Day-6 | DDAVP 1 mcg Q12 hrs | D5W 100 mL/hr | 149 mEq/L | 320 Mosm/kg | 0.6 mg/dL | 9 mg/dL | 544 mOsm/kg | 130 mmol/L |