Two memorable cases with hypernatremia
The first hypernatremia case is a gentleman in his mid sixties admitted for hypernatremia and Altered Mental Status 2/2 to lung cancer that had metastasized to the brain. He came in with a sodium of about 165. The hospitalists did calculations and replaced fluids slowly and brought him back to normal. This gentleman who was already on low dose Keppra ended up having a seizure and was transferred to the ICU where he was there for a few days. The hospitalists had a meeting with the oncology team and family to try to determine disposition: Whether to stop active chemotherapy and give comfort treatment to this patient who really wanted to go home.
– Nephrologist consultation was made, even though the hospitalist team was comfortable handling hypernatremia–simply to have a second opinion. By the time he came, the hypernatremia was almost resolved and he just blessed the ongoing treatment.
The second hypernatremia case is a 90 plus lady admitted for hypernatremia, AKI, and altered mental status 2/2 to Alzheimer’s disease. Sodium initially 164. Water deficit calculated and replaced.
Both Nephrology and Psychiatry were consulted for this patient.
** The key with hypernatremia is that it is almost impossible to develop hypernatremia unless you have some form of brain injury or altered mental status because the thirst mechanism is very strong. When sodium starts going up, thirst centers are stimulated to cause the patient to drink. The only time that doesn’t work is if: The patient has some form of brain malfunction so that the thirst stimulus is compromised, they are in a desert where they can’t find water, or they are given hypertonic saline in the hospital setting (iatrogenic).