Which manifestations should a nurse identify as the most serious complications associated with hypernatremia?
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Not a Subscriber?HOSPITAL nursing Hayes, Denise D. RN, CRNP, MSN Denise D. Hayes is a senior clinical editor on Nursing2007, an adjunct faculty member at Holy Family University in
Philadelphia, Pa., and a nurse practitioner for Nightingale Health and Wellness Services in Norristown, Pa. doi: 10.1097/01.NURSE.0000302559.47850.bf Nursing Quick LinksRelated Articles AbstractObjective : To study clinical manifestations and outcome of hyponatremia and hypernatremia in children with diarrhea. Method : We compared children aged 0–59 months hospitalized from 1 January to 31 December 2013 with hyponatremia (serum sodium <130 mmol/l), hypernatremia (serum sodium >150 mmol/l) and normonatremia (serum sodium 135–145 mmol/l). Results : The case fatality was significantly higher among the children with hypernatremia and hyponatremia than normonatremia. A logistic regression analysis adjusting for potential confounders revealed that children with hyponatremia are more likely to have convulsions, have severe acute malnutrition and be of older age compared with children with normal serum sodium. Children with hypernatremia are more likely to have convulsions and dehydration than normonatremic children (for all p < 0.05). Conclusion : Early diagnosis and prompt management of hypo- and hypernatremia by identifying simple clinical predicting factors of these two conditions in diarrheal children <5 years of age is critically important to prevent deaths in such children, especially in resource-limited settings. INTRODUCTIONDiarrheal disease is the second leading cause of death and accounts for nearly 9% of 6.3 million global deaths in children <5 years of age, and 6% of deaths in children <5 years of age in Bangladesh [ 1 ]. Most of these deaths are associated with diarrheal complications and/or associated problems [ 2 , 3 ]. A standardized management protocol for severe malnutrition, a common problem associated with diarrhea, was implemented in our hospital in 1996. This management protocol reduced the death rate among severely malnourished children by 47% [ 2 ]. Despite this achievement, hyponatremia (serum sodium <130 mmol/l) and hypernatremia (serum sodium >150 mmol/l), two main complications of diarrhea, are still important causes of death both in well-nourished and malnourished children [ 3 , 4 ]. Moreover, globally hyponatremia and hypernatremia are also considered as common problems in children with diarrhea [ 5 ]. They are known to contribute to morbidity and often other morbid conditions including seizures and encephalopathy [ 4 ]. Clinical manifestations of hyponatremia include lethargy, disorientation and depressed motor reflexes, which often overlap with manifestations of hypernatremia [ 6 ]. Severe hypernatremia (>170 mmol/l) may present with hyperthermia, seizures and coma [ 7 ]. If not identified early and managed properly, children may develop neurological sequelae [ 8 ]. Owing to a wide range of overlapping manifestations, hyponatremia and hypernatremia are often underdiagnosed, and timely intervention is delayed [ 8 ]. Children with malnutrition and diarrhea are more prone to develop hyponatremia and have a higher mortality rate [ 4 ]. On the other hand, most studies revealed that hypernatremia occurs primarily in dehydration associated with diarrhea [ 9 , 10 ]. Improperly prepared oral rehydration salt (ORS) solution, excessive intake of the same and rotaviral infection are thought to be the major causes of hypernatremia in diarrhea and are associated with life-threatening complications [ 9 ]. Thirty years ago, the consequences of hyponatremia and hypernatremia with acute diarrhea were evaluated in Bangladesh [ 5 ], which reported a high-case fatality rate with hyponatremia (>10%). A correlation of malnutrition and dehydration was also demonstrated [ 5 ]. However, there is an obvious change in the trend of the consequences of these two fatal conditions. Since the earlier study, no further research on the pattern of hyponatremia and hypernatremia has been undertaken in this specialized setting of diarrhea and malnutrition. Our study aimed to evaluate the associated factors of hyponatremia and hypernatremia and outline the characteristics of such children in the setting of diarrheal disease. MATERIALS AND METHODSStudy site and populationThis study was conducted in the Dhaka hospital of International Centre for Diarrheal Disease Research, Bangladesh (icddr,b). This is the largest diarrheal treatment center in the world, providing care and treatment to >140,000 patients of all ages annually. Patients often come with diarrheal illnesses and/or other associated problems, including pneumonia, malnutrition, sepsis and electrolyte abnormalities. In the year 2013, the total number of children <5 years of age admitted was 98,506; those who had serum electrolytes measured during hospitalization were included in our study, and their medical data were extracted from the hospital electronic medical record system. The majority of the care seekers were from a poor socioeconomic background and lived in urban and pre-urban Dhaka. Care is provided by a professional team, which includes junior and consultant physicians, nurses, counselors and dietary workers in a multidisciplinary approach. Patients were treated according to the written protocolized hospital management plan for severe acute malnutrition (SAM), and treatment for hyponatremia and hypernatremia was provided when required [ 11 , 12 ]. During hospitalization, all treatment is provided free of cost, which includes drugs, food, laboratory investigations and other logistic support. Study designThis study was an unmatched retrospective medical record analysis with a case control design. We studied children of either sex, aged 0–59 months, who attended the Dhaka hospital during 1 January to 31 December 2013, and had serum electrolytes measured during hospitalization. Patients’ medical records were stored in a computerized hospital management system, which is access guarded. The data were collected anonymously, and children were organized into three groups: normonatremia (serum sodium 135–145 mmol/l), hyponatremia (serum sodium <130 mmol/l) or hypernatremia (serum sodium >150 mmol/l). Children with hyponatremia and hypernatremia were compared separately from normonatremic children. Data management and analysisAll data were entered into a database (SPSS version 17.0; Chicago, IL, USA). Differences in proportions were compared by the Chi-square test or Fisher-Exact test, as appropriate. Differences in means were compared by t -test (for normally distributed data), and differences in medians were compared by Mann–Whitney test (for data that were not normally distributed). p -values <0.05 were considered statistically significant. Strength of association was determined by calculating odds ratios and their 95% confidence intervals. In univariate models, characteristics analyzed included age, diarrhea after admission, fever on arrival, convulsion on presentation, no rehydration fluid intake before hospitalization, abnormal mentation (either lethargic or irritable), dehydration on arrival, edema, association of SAM, association of sepsis, development of septic shock, association of pneumonia and death in hospital. Finally, we performed logistic regression analysis to identify characteristics that were significantly associated with hyponatremia and hypernatremia after adjusting for the covariates. In the regression model, characteristics that were significantly associated with hyponatremia or hypernatremia by univariate analyses were considered as independent variables, whereas hyponatremia and hypernatremia acted as dependent variables in two different models. Ethical approval statementThe study (protocol number: PR-14063) was approved by icddr,b’s Research Review and Ethical Review Committees. All the data collected were kept confidential. RESULTSWe reviewed 1224 medical records of children admitted from January to December 2013 who fulfilled our inclusion criteria. Of these children, 693 (56.6%) were normonatremic, 292 (23.8%) were hyponatremic and rest 239 children (19.5%) were hypernatremic. Mean serum sodium levels among children with normonatremia, hyponatremia and hypernatremia were 138.7 ± 2.8, 125.8 ± 4.2 and 165.2 ± 13.4, respectively. The median ages of children with normonatremia, hyponatremia and hypernatremia with their differences are shown in Table 1 . The case-fatality rate was significantly higher among both the groups of hyponatremia and hypernatremia compared with normonatremia group ( Fig. 1 ). In univariate analyses, children with hyponatremia more often presented at an older age, with convulsion, abnormal mental status, dehydration, SAM, septic shock and pneumonia. Similarly, children with hypernatremia more often presented with fever, convulsion, abnormal mental status, dehydration, septic shock and pneumonia. Distribution of diarrhea, no rehydration fluid intake at home, edema and sepsis among the groups were statistically insignificant ( Table 1 ). Fig. 1. Association of death with different levels of serum sodium. Table 1. Comparison of baseline characteristics among the under-five children with normonatremia, hyponatremia and hypernatremia on admission
Note . Figures represent n (%), unless specified. OR = odds ratio; CI = confidence interval; IQR = interquartile range. Legend: SAM = severe acute malnutrition; WLZ = weight for length Z-score. Table 1. Comparison of baseline characteristics among the under-five children with normonatremia, hyponatremia and hypernatremia on admission
Note . Figures represent n (%), unless specified. OR = odds ratio; CI = confidence interval; IQR = interquartile range. Legend: SAM = severe acute malnutrition; WLZ = weight for length Z-score. In logistic regression analyses, after adjusting for likely confounders ( Table 2 ), children with hyponatremia were significantly more likely to present at an older age, with convulsion, and SAM ( Table 2 ). For children with hypernatremia, the significant associations found after logistic regression analysis were convulsion and dehydration ( Table 3 ). Table 2. Independent predictors of hyponatremia in under-five diarrheal patients
Note . Exclusion variables: Septic shock and pneumonia variables were excluded from the regression model, as in 2/2 table, one cell value was 0. Adjustment variables: Abnormal mental status and presence of dehydration. Table 2. Independent predictors of hyponatremia in under-five diarrheal patients
Note . Exclusion variables: Septic shock and pneumonia variables were excluded from the regression model, as in 2/2 table, one cell value was 0. Adjustment variables: Abnormal mental status and presence of dehydration. Table 3. Independent predictors of hypernatremia in under-five diarrheal patients
Note . Exclusion variables: Association of pneumonia variable were excluded from the regression model, as in 2/2 table, one cell value was 1. Adjustment variables: Abnormal mental status and fever on admission. Table 3. Independent predictors of hypernatremia in under-five diarrheal patients
Note . Exclusion variables: Association of pneumonia variable were excluded from the regression model, as in 2/2 table, one cell value was 1. Adjustment variables: Abnormal mental status and fever on admission. DISCUSSIONOur study evaluates children suffering from hyponatremia and hypernatremia, which are serious complications of diarrhea in developing countries with a high burden of diarrhea and malnutrition [ 4 , 5 ]. Thirty years ago, Samadi et al. [ 5 ] described the consequences of hyponatremia and hypernatremia in children with diarrhea in Bangladesh. Hyponatremia was associated with a high case fatality rate of >10%, whereas hypernatremia-associated deaths were only 1.2%. Our study suggests that the scenario has now changed, with case fatality in hypernatremia being 12% and in hyponatremia only 5%. Malnourished children are typically hyponatremic despite having excess total body sodium because of an intracellular shift of sodium related to an inefficient Na + /K + pump [ 13 ]. During states of volume depletion, using fluids containing large quantities of sodium may lead to a high mortality rate [ 5 ]. In view of this fact, World Health Organization has revised the formulation of standard rehydration salt (ORS) with a new low-sodium-containing ORS (the hypo-osmolar ORS) for the past two decades, which may have an impact in reducing the mortality related with volume overload in hyponatremic children [ 14 ]. There has been a reduction in the incidence of invasive diarrhea owing to Shigellosis in Bangladesh, which could have resulted in a reduced prevalence of hyponatremia. This may have an impact in reduced mortality from hyponatremia [ 15 ]. Moreover, diagnosis of hypernatremia is still underestimated by the clinicians owing to lack of overt clinical signs of dehydration in hypernatremia children [ 16 ]. The prevalence of hypernatremia among hospitalized patients has been reported to be 2.5–12%, while mortality rates vary between 24% and 60% [ 17 , 18 ]. Death can occur either owing to the consequence of hypernatremia itself or as a result of complications during correction of dehydration [ 18 ]. In our study, case fatality associated with hypernatremia seems to be increasing compared with previous reports [ 5 ]. Several factors may contribute to the situation, such as change in the etiology of diarrhea [ 19 ] and the concept of preparation of ORS solution for managing dehydration [ 20 ]. This is an important aspect to reduce diarrhea-related deaths and further research, particularly qualitative, needs to be undertaken. We observe a significant association between serum sodium concentration and abnormal mental status that includes lethargy, irritability or convulsions. Most importantly, commonly associated conditions of hypernatremia in developing countries such as diarrhea and vomiting cause excess loss of water that may exceed electrolyte loss and lead to an increase in the osmolarity of body fluids. As a result, there is movement of water from the cells to the extracellular fluid compartment. This results in intracellular dehydration, subsequently resulting in brain shrinkage, which predisposes the child to petechial brain hemorrhages that may manifest convulsion [ 16 ]. Alternatively, convulsion in hyponatremia occurs owing to brain cell swelling as a result of Na + deficit in the extracellular fluid compartment, which is sufficient to lead to a devastating neurological outcome [ 21 ]. From our study, it can be postulated that convulsion on presentation can be used as a screening tool for sodium disorders, and should be managed immediately to prevent future neurological complications. Our study describes an association between hyponatremia with SAM and pneumonia. A number of studies have reported the association of hyponatremia with SAM [ 22 , 23 ]. Children with pneumonia may often present with syndrome of inappropriate Antidiuretic Hormone (ADH) secretion resulting in hyponatremia. Moreover, co-existence of pneumonia and hyponatremia often occurs in SAM children with minimum clinical manifestation of pneumonia owing to poor inflammatory response and hypokalemia in SAM children [ 24–26 ]. We observed the association of dehydration with hypernatremia. Clinical signs such as restlessness and thirst are common signs of dehydration and hypernatremia. This may have led to an association of dehydration with hypernatremia [ 6 , 7 , 27 ]. The main limitation of this study is the retrospective nature of the study that may restrain interpretation of information. Moreover, the data on rehydration fluid used at home could not be retrieved, which could contribute more to the findings. Finally, this report reflects the experience of just one urban hospital that primarily provides care for children with diarrheal disease and so this may not be generalizable to all patients admitted elsewhere. In conclusion, both hyponatremia and hypernatremia are common diarrheal-associated complications in developing countries that have high-case fatality. The findings of our study have significant clinical importance to generate future research hypotheses for targeted identification of hyponatremia and hypernatremia and early interventions to reduce diarrhea-related deaths in developing countries. ACKNOWLEDGEMENTSWe gratefully acknowledge these donors for their support and commitment to the Centre’s research efforts. FUNDINGThis research protocol was funded by the icddr,b and its donors who provide unrestricted support to this organization for its infrastructure (such as Dhaka Hospital) and research. Current donors providing unrestricted support include the following: Australian Agency for International Development (AusAID), Government of the People’s Republic of Bangladesh, Canadian International Development Agency (CIDA), Embassy of the Kingdom of Netherlands, Swedish International Development Cooperation Agency (Sida), Swiss Agency for Development and Cooperation and Department for International Development, UK (DFID). We also acknowledge the support of Bill and Melinda Gates Foundation. REFERENCES1 UNICEF. Committing to child survival: a promise renewed. Progress Report . New York, NY : United Nations Children’s Fund (UNICEF) , 2014 . 2 et al. . Mortality in severely malnourished children with diarrhoea and use of a standardised management protocol . Lancet 1999 ; 353 : 1919 – 22 . 3 et al. . Predictors of death in under-five children with diarrhoea admitted to a critical care ward in an urban hospital in Bangladesh . Acta Paediatr 2011 ; 100 : e275 – 9 . 4 et al. . Predictive factors of hyponatremia in under-five severely malnourished children with pneumonia admitted to a large urban hospital in Dhaka, Bangladesh: a nested case-control design . Food Nutr Sci 2013 ; 4 : 398 – 404 . 5 et al. . Consequences of hyponatraemia and hypernatraemia in children with acute diarrhoea in Bangladesh . Br Med J (Clin Res Ed) 1983 ; 286 : 671 – 3 . 6 . Pathogenesis and pathophysiology of hypertonic dehydration with diarrhea: a clinical study of 59 infants with observations of respiratory and renal water metabolism . Arch Pediatr Adolesc Med 1968 ; 115 : 122 – 4 . 7 . Hypernatremia . N Engl J Med 2000 ; 342 : 1493 – 9 . 8 . Hypernatremia and hyponatremia: current understanding and management . Clin Pediatr Emerg Med 2009 ; 10 : 272 – 8 . 9 . Hypernatremic dehydration of infancy: an epidemiologic review . Am J Dis Child 1980 ; 134 : 785 – 92 . 10 et al. . Oral rehydration therapy of infantile diarrhea: a controlled study of well-nourished children hospitalized in the United States and Panama . N Engl J Med 1982 ; 306 : 1070 – 6 . 11 et al. . Mortality in severely malnourished children with diarrhoea and use of a standardised management protocol . Lancet 1999 ; 353 : 1919 – 22 . 12 World Health Organization. Pocket book for hospital care of children: guidelines for the managemnet of common illness with limited resources . Geneva , 2013 . . 13 et al. . Efficacy and safety of a modified oral rehydration solution (ReSoMaL) in the treatment of severely malnourished children with watery diarrhea . J Pediatr 2003 ; 143 : 614 – 19 . 14 . Management of severe malnutrition: efficacious or effective? J Pediatr Gastroenterol Nutr 2001 ; 32 : 521 – 2 . 15 . Effect of washing hands with soap on diarrhoea risk in the community: a systematic review . Lancet Infect Dis 2003 ; 3 : 275 – 81 . 16 . Pathogenesis of lesions in the nervous system in hypernatremic states II. Experimental Studies of Gross Anatomic Changes and Alterations of Chemical Composition of the Tissues . Paediatrics 1959 ; 23 : 46 – 53 . 17 . Are patients admitted to hospitals from care homes dehydrated? A retrospective analysis of hypernatraemia and in-hospital mortality . J R Soc Med 2015 ; 108 : 259 – 65 . 18 et al. . Undercorrection of hypernatremia is frequent and associated with mortality . BMC Nephrol 2014 ; 15 : 37 . 19 et al. . Etiological diversity of diarrhoeal disease in Bangladesh . J Infect Dev Ctries 2013 ; 7 : 900 – 9 . 20 et al. . Impact of educational intervention on knowledge of mothers regarding home management of diarrhoea . Indian J Pediatr 2001 ; 68 : 393 – 7 . 21 et al. . Hyponatremia as the cause of seizures in infants: a retrospective analysis of incidence, severity, and clinical predictors . Ann Emerg Med 1995 ; 26 : 42 – 8 . 22 et al. . Diarrhoea complicating severe acute malnutrition in Kenyan children: a prospective descriptive study of risk factors and outcome . PloS One 2012 ; 7 : e38321 . 23 . Critical appraisal of the management of severe malnutrition: 3. Complications . J Paediatr Child Health 2006 ; 42 : 583 – 93 . 24 et al. . Pneumonia in severely malnourished children in developing countries–mortality risk, aetiology and validity of WHO clinical signs: a systematic review . Trop Med Int Health 2009 ; 14 : 1173 – 89 . 25 et al. . Influences of dehydration on clinical features of radiological pneumonia in children attending an urban diarrhoea treatment centre in Bangladesh . Ann Trop Paediatr 2010 ; 30 : 311 – 16 . 26 et al. . Clinical signs of radiologic pneumonia in under-five hypokalemic diarrheal children admitted to an urban hospital in Bangladesh . PloS One 2013 ; 8 : e71911 . 27 et al. . Use of only oral rehydration salt solution for successful management of a young infant with serum sodium of 201 mmol/l in an urban diarrhoeal diseases hospital, Bangladesh . J Health Popul Nutr 2012 ; 30 : 371 . © The Author [2016]. Published by Oxford University Press. All rights reserved. For Permissions, please email: © The Author [2016]. Published by Oxford University Press. All rights reserved. For Permissions, please email: Which manifestation should a nurse identify as the most serious complication associated with hypernatremia?Hypernatremia typically causes thirst. The most serious symptoms of hypernatremia result from brain dysfunction. Severe hypernatremia can lead to confusion, muscle twitching, seizures, coma, and death.
Which clinical manifestation is associated with hypernatremia?Symptoms of hypernatremia tend to be nonspecific. Anorexia, restlessness, nausea, and vomiting occur early. These symptoms are followed by altered mental status, lethargy or irritability, and, eventually, stupor or coma. Musculoskeletal symptoms may include twitching, hyperreflexia, ataxia, or tremor.
What is the most severe complication of hyponatremia?In acute hyponatremia, sodium levels drop rapidly — resulting in potentially dangerous effects, such as rapid brain swelling, which can result in a coma and death. Premenopausal women appear to be at the greatest risk of hyponatremia-related brain damage.
Which complication may result from the treatment of hypernatremia?It is important to remember that hypernatremia should be corrected over 48 hours. Rapid correction can lead to cerebral edema and seizures.
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