Prevalence of Hyponatremia in Neurosurgical Patients in South India – An Institution-Based Observational Study

BACKGROUND Hyponatremia is the most frequently encountered electrolyte abnormality in hospitalized patients, especially those with neurological injury. Acute onset hyponatremia is common in patients with any type of cerebral insult including traumatic brain injury (TBI), subarachnoid haemorrhage (SAH) and brain tumours. Also seen as a complication of intracranial procedures, contributing to increased morbidity and mortality. Early diagnosis and effective management can reduce mortality associated with this condition. This study was done to estimate the prevalence of hyponatremia in neurosurgical patients in our institution. METHODS This is an observational study that analysed the adult patients admitted to the neuro intensive care unit (ICU) after having undergone the neurosurgical procedure from January 2019 to July 2019. A structured questionnaire was used for data collection. The prevalence of hyponatremia was calculated with preoperative serum sodium levels in the study population. RESULTS In this study with 61 patients undergoing neurosurgical procedures, the prevalence of hyponatremia was 34.4 %. The majority of patients for surgery comes between 41 to 50 years. 57.4 % cases were with traumatic brain injury, 11.5 % cases were with sub arachnoid haemorrhage and 31.1 % were with intracranial tumour. 26 % of hyponatremia patients belonged to mild grade while 8 % to moderate grade. 62.5 % of patients above 70 years, 44.4 % of patients between 51 to 60 years and 40 % of patients between 61 and 70 years presented with mild hyponatremia. 37.5 % of patients above 70 years and 10 % of patients between 61 and 70 years presented with moderate hyponatremia. CONCLUSIONS Our study showed an increased prevalence of hyponatremia in neurosurgical patients which demand effective approaches for an accurate and timely diagnosis of this electrolyte disorder. Hyponatremia frequently occurs in patients with TBI, SAH and intracranial tumours. It is also essential to differentiate between syndrome of inappropriate antidiuretic hormone (SIADH) and cerebral salt wasting syndrome (CSW) as the treatment modalities are entirely different for these two entities. Early detection, close monitoring, etiological evaluation and prompt treatment based on aetiology can reduce the complications and improve patient’s outcomes. KEYWORDS Electrolyte Abnormality; Brain Injury, Morbidity

Approach to Hyponatremia

Hyponatremia is a common laboratory finding in numerous patients. It is defined as a serum sodium concentration <135 mmol/L and represents an excess of water in the extracellular compartment. The severity of this electrolyte abnormality ranges from asymptomatic to seizures, coma and death as a consequence of cerebral swelling. There are multiple medical conditions, medications and disease states that can cause hyponatremia. This article summarizes the important pathophysiological pathways involved in the development of hyponatremia, describes an approach to common causes and reviews the initial steps in management.

Dyselectrolemia in patients with dengue fever in tertiary care hospital

Background: Dengue is a mosquito borne acute febrile illness caused by viruses belonging to group flaviviridea. Primarily this disease is transmitted by Aedes aegypti and Aedes albopictus. There are 4 serotypes of dengue virus i.e. DENV 1, 2, 3, and 4. According to World Health Organization (WHO) report in 2009, globally around 2.5 billion people live in dengue endemic areas and more than 50 million people are infected with dengue fever annually. Dyselectrolemia is very common among dengue patients. Many studies found that hyponatremia is common in Dengue, DHF and especially in dengue shock patients. The purpose of this study was to evaluate serum sodium as the predictor of prognosis in dengue fever.Methods: Present study was longitudinal in nature conducted on 100 dengue patients. All patients fulfilling inclusion criteria and exclusion criteria were taken up for the study. Study was carried from August to October 2020. Serum electrolyte kit was used to analyze electrolytes.Results: Majority (39%) of the dengue patients was in the age group of 18-35 years and most of them were male. Fever was the most common complaint, present in all (100%) the patients followed by myalgia (96%), headache (89%), retro-orbital pain (88%), rash (73%) and joint pain (71%). Hyponatremia was the chief electrolyte abnormality, present among 61% dengue patients and it was associated with poor prognosis.Conclusions: We have found that hyponatremia was the chief electrolyte abnormality among dengue patients and prognosis was inversely related to hyponatremia.

A rare case of hypokalaemia and hypophosphataemia secondary to geophagia

We report a case of severe hypokalaemia and moderate hypophosphataemia from clay ingestion. A 60-year-old woman presented with flaccid paralysis. Investigations revealed a serum potassium level of 1.8 mmol/L, phosphate level of 0.56 mmol/L and creatine kinase level of 30 747 IU/L. She had marked proximal and distal muscle weakness due to severe hypokalaemia and concurrent hypophosphataemia, which likely contributed to the onset of rhabdomyolysis. The patient subsequently admitted to significant pica, most likely secondary to an associated iron deficiency. We conclude that the ingested clay acted as a potassium and phosphate binder. Although we did not investigate the content of the clay in this case, it has been reported that clay can bind potassium in vitro and is rich in minerals such as aluminium that could play a role in the binding of phosphate, although the exact mechanism remains unclear. The patient recovered fully and outpatient follow-up at 6 months and again at 40 months confirmed no electrolyte abnormality, myopathy nor any further geophagia.

RELATION OF GRADES OF HYPONATREMIA ON SEVERITY OF BRONCHIOLITIS

Background and objectives: Hyponatremia often occurs among children with bronchiolitis. It is the most common electrolyte abnormality associated with severe disease course. Aim was to study relation between sodium levels and severity of bronchiolitis Methodology: Cross-sectional study was conducted on 72 infants admitted with bronchiolitis to Pediatrics ward/ICU, JMMC. Infants with recurrent respiratory or super added bacterial infections, born <34weeks gestation, any chronic disorder or medications that can influence electrolyte levels or parents unwilling for consent were excluded. Severity of bronchiolitis was scored and classified into mild, moderate, severe. Sodium levels were determined and grouped (in mmol/L) into normonatremia (135-145) and hyponatremia (mild (130-134), moderate (125-129) and severe (≤124). The grade of hyponatremia with severity of bronchiolitis was compared. Chi square test was used to test the association of severity of bronchiolitis and category of hyponatremia. ANOVA test was done to compare the severity of bronchiolitis with sodium levels. Results: Hyponatremia was seen in 50% of cases admitted with severe bronchiolitis, which when compared to mild and moderate bronchiolitis, was statistically significant (p<0.001). ANOVA showed mean sodium levels of mild, moderate and severe bronchiolitis were 138.44±1.81, 137.37±1.76 and 135.43±3.93 respectively; these were statistically significant (p<0.001). A pairwise comparison between mild and moderate bronchiolitis with hyponatremia was not found to be statistically significant (p-0.769) but comparison between mild and severe bronchiolitis with hyponatremia was statistically significant (p<0.001) Conclusion: There is statistically significant relation between hyponatremia and severity of bronchiolitis. Hyponatremia could be considered as a marker to assess the severity of bronchiolitis. Keywords: Bronchiolitis, Hyponatremia, Respiratory distress

STUDY OF MORTALITY IN CHILDREN WITH ELECTROLYTE ABNORMALITIES IN PEDIATRIC INTENSIVE CARE UNIT

Background: Electrolyte abnormalities are common in ill children requiring the intensive care. As the electrolytes play an important role to maintain homeostasis and has impact on the final outcome of the patient, the present study was undertaken. The aims of this study was to determine the prevalence of electrolyte abnormalities in children admitted in Pediatric Intensive Care Unit at the time of admission, primary organ involvement seen and the mortality associated with it. Methods: The study enrolled all the patients from 1 month to 12 years admitted in PICU of a tertiary care hospital during January 2019 to June 2020 (18 months). The children were divided according to the presence or absence of electrolyte abnormality. The organ system involved was analyzed in each group. Results: The prevalence of electrolyte abnormality in terms of sodium and potassium in the present study was 55.56% (100 of 180). The most common electrolyte abnormality was hyponatremia (30.6%) followed by hypokalemia (20.6%). The mortality in children with electrolyte abnormality was significantly higher than mortality in those without electrolyte abnormality and was found to be 51.7% in the present study. Maximum children with hyponatremia had infections (23.6%) and those with hypernatremia had gastrointestinal involvement (17.6%). Hypokalemia was most frequently seen in cases of respiratory involvement (27%) and hyperkalemia seen in renal involvement (25%). Conclusion: There is significant association of the electrolyte abnormalities at admission in PICU with mortality and primary system involvement, which was seen in the present study. Close monitoring and correction of electrolyte abnormalities reduces the mortality in ill children.

Frequency of hyponatremia in community acquired pneumonia.

Objectives: Community acquired pneumonia (CAP) is frequent amongst pediatric population all over the world while hyponatremia is a common electrolyte abnormality in hospitalized patients that has been shown to be associated with considerable morbidity and mortality. We aimed to determine the frequency of hyponatremia in children with community acquired pneumonia (CAP). Study Design: Cross Sectional study. Setting: Pediatrics Department, Services Hospital, Lahore. Period: July 2018 to January 2019. Material & Methods: A total of 100 cases up to 2 years of age of either gender, diagnosed cases of CAP during the last 72 hours, were enrolled. Demographic profile, age and gender were recorded. Every child with CAP was evaluated for the presence of hyponatremia. Mean and standard deviation were calculated for age. Frequency and percentages were noted for categorical variable like gender and presence/absence of hyponatremia. Results: Out of 100 cases of CAP, 57 (57.0%) were male and 43(43.0%) female. There were 45 (45.0%) cases who were less than 1 year of age while 55 (55.0%) were between 1-2 years of age. Mean age was calculated as 1.55 years with standard deviation of 0.52 years. Frequency of hyponatremia in children with CAP was recorded in 24 (24.0%) whereas 76 (76.0%) had no findings of the morbidity. Conclusion: Frequency of hyponatremia was high (24.0%) among children with CAP. Every patient who present with CAP should be evaluated for hyponatremia.

Prevalence of hyponatremia in pulmonary tuberculosis

Background: Tuberculosis is one of the most common infection in India and is associated with high mortality. India ranks 14th out of top 22 countries who are burdened with TB infections.Methods: It is a prospective study after getting the ethical committee clearance from the institute. The patients admitted to Chest and TB, Medicine Department of SLN medical college and Hospital, Koraput, Odisha from Jan 2019 to December 2019 with pulmonary tuberculosis were included in the study.Results: A total of 65 adult patients with active PTB were included in this study with age ranging from 15 to 69 years. The mean age of patients was 38.80 + 15.03 years. The total mean serum sodium levels among the subjects was 135.5+7.23. Among 65 patients, 26 (40%) patients had low sodium levels which was less than 135mmol/l out of which 21 (42%) were males and 5 (33%) were females. In all the groups of hyponatremias, majority were found to be males when compared to the females in their respective groups.Conclusions: Hence patients with PTB have to be evaluated for hyponatremia as early detection and treatment of underlying electrolyte abnormality can potentially reduce mortality and morbidity associated with tuberculosis and also can shorten the duration of hospitalization.

Reset Osmostat: A Challenging Case of Hyponatremia

Hyponatremia is the most common electrolyte abnormality seen in hospitalised patients with up to 15–20% of patients having a sodium level of less than 135 mmol/L (Reddy and Mooradian, 2009). Cases of hyponatremia were first described in the 1950s (George et al., 1955). As the differential diagnosis for hyponatremia is broad, a systematic and logical approach is needed to identify the cause. We describe a case of a 30-year-old gentleman who was found to have chronic hyponatremia. After a thorough workup, he was diagnosed to have reset osmostat. Reset osmostat is an uncommon and under recognised cause of hyponatremia which does not require any treatment. This diagnosis needs to be considered when the hyponatremia workup suggests SIADH, but the hyponatremia is not amenable to fluid restriction, salt or urea supplementation, and diuretic treatment.

Idiopathic Hypertrophic Pyloric Stenosis

Idiopathic hypertrophic pyloric stenosis (IHPS) is a common cause of nonbilious, projectile vomiting in the infant. Progressive hypertrophy of the pyloric muscle leads to an obstruction of the gastric outlet. The condition is easily corrected with a pyloromyotomy. Mortality is <0.5% in most specialty centers when hydration and normal electrolyte status is restored prior to surgery, appropriate precautions are taken preoperatively, and the patient is carefully monitored for known postoperative complications. This chapter discusses the related epidemiology and etiology; clinical presentation; use of imaging studies; preoperative preparation; and anesthetic, surgical, nonsurgical, and postoperative management of these patients. Topics covered include metabolic alkalosis, electrolyte abnormality, dehydration, pulmonary aspiration, and pyloromyotomy.