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Hyponatremia: A Practical Approach

Dec 20, 1:30 PM

What happens when the sodium in the bloodstream reaches low levels? As a physician, how does one combat this condition? What are the warning signs? A wide-ranging variety of medical diseases, drugs, and disease states can lead to Hyponatremia. Hyponatremia is one of the most prevalent electrolyte abnormalities in critically ill patients, with about 30% of ICU admissions reporting it. With numerous treatment pathways at their disposal, residents and physicians can often get overwhelmed in treating the condition. Join the clinical expert Dr. Rohit Jacob live on Medflix as he deciphers this complicated topic with his real-world experiences!

[Music] i welcome you all on behalf of team netflix uh today we have with us dr rohit jacob popularly known as med health rj teaching is his passion he has hosted amazing talks on netflix he's here with us today to talk about hyponatremia what are the deciding factors and excellent ways to manage it welcome dr jacob thank you i think that's it over to you dr jacob yeah uh thank you so much so uh welcome to my next on netflix which is a practical approach to hype uh so yes uh so we are going to start with a topic for today that is approach to hyponatremia so in a day to day practice i think the one of the most common scenarios which we encounter is a 60 year old or a 65 year old male or female coming to the casualty with maybe giddiness maybe vomiting will be nausea and the only thing when we check out laboratory report is a sodium of 127 or 125 now some cases we are so unsure whether we need to treat the sodium whether not to treat the sodium in my entire um pg practice where i was training for empty medicine my teachers always used to tell me only one thing that we are supposed to treat the patient and not the lab reports so when we have that kind of a scenario in our mind do we need to treat or not is the biggest question that lies with us okay so to start with let us know what or how do we approach a case of hyponatremia first and foremost it's important to understand that the recommended intake for sodium level is about 1 to 1.5 gram per day so whenever we advise uh an elderly like 60 or 65 year old we say that add little bit salt to your diet and then we tell them that um you know we tell them that add a pinch of salt but we forget to realize that by adding a pinch of salt the bp also rises so a hypertensive patient always has this question in mind whether to add sodium whether to restrict sodium so until we ourselves are clear we don't know what to tell the patients so that is one thing which we need to remember coming to the basic physiology behind the control of sodium in our body it's important to know that sodium absorption takes place from the intestine via two mechanisms one is when it is freely permeable across the interstitial cell and second is through the import with glucose and amino acids but the excretion of sodium is basically dependent on the reabsorption at major regions of the nephron to start with the first is the proximal convoluted tubule where 65 percent of sodium reabsorption takes place from the loop of henle about 30 percent takes place via the apical sodium potassium two chloride transporter while the distilled convoluted tubule five percent of sodium re-absorption takes place by thiazide sensitive sodium chloride co transporter cortical and medullary collecting dull duct also epithelial sodium channel takes is present which is responsible for sodium reabsorption so whatever drugs we give whether to increase the sodium excretion or whether to increase the sodium reabsorption acts on these four major places and depending on that we decide whether we want to control the level of sodium by decreasing it or by increasing it hyponatremia is defined as a serum sodium level which is below 135 milli equivalents per liter which is usually caused by a failure to excrete water normally now the categorization of mild moderate silvia is about 130 to 135 120 to 130 and less than 120 as severe hyponatrium now as we go through this chart it's important that when we do a daily practice this chart should always be within our mind so to start with let's go from the top hyponatremia where serum sodium level is if it is less than 135 the first thing which we need to check is whether the patient is symptomatic or the patient is asymptomatic usually if it is a mild hyponatremia then patients will have symptoms like nausea vomiting but if it goes to moderate or severe hyponatremia patient will have obtaination stroke stupa coma seizures and such kind of symptoms so if symptoms such as confusion ataxia seizures obtaination coma or respiratory depression is there then you can assume that there is a possibility of severe hyponatremia but if the patient is asymptomatic or mildly symptomatic then we need to go for a different approach always remember there are three main things that you need to do one is called as v second is o and third is u v is where you assess the volume status o is where you assess the osmolarity osmolality and u is for the urinary studies by three basic steps we can understand as to what category of hyponatremia it falls into and accordingly we can decide what treatment to go for so if the patient is asymptomatic or the patient is having mild symptoms the first thing you need to do is determine the serum osmolality level now as we know that 275 to 295 is nearly 285 is nearly the milli uh normal osmoland that we know so if it falls in the range of normal osmolarity then it is called as an isotonic hyponatremia if it is low it is called as hypotonic hyponatremia and if it is high it is called as hypertonic hyponatremia if the patient is isotonic that means instead of sodium there is some other solute which is responsible for maintaining the serum osmolality level that may be proteins or it may be lipids so the next step is you need to assess for hyperproteinamia or hyperlipidemia that goes that is what you further proceed with when you know that it is an isotonic hyponatremia if the patient is hypotonic that is low osmolarity then osmolality the next step is you check the volume status easy ways of checking volume status is as we know assessing the jvp level looking for hepatomegaly looking for pedal edema looking for the mucous membrane skin turgor then even blood urea nitrogen and uric acid levels let me tell you on a laboratory parameter uric acid is an important marker to assess and differentiate between you volumic and hypovolemic hyponatremia it is said that uric acid level will be low in case of hypertonic hyponatremia and hypovolemic hyponatremia however it is not a completely foolproof marker so clinically if you see vital signs such as jvp skin turbo mucous membrane peripheral edema helps us to assess the volume status of the patient once you assess the volume status the next check the next step is to categorize it as hypovolemic yo volumic or hyper volume if the patient is hypovolemic that means that there are there are high chances that the patient is dehydrated so the next step which you need to see is checking the urinary sodium levels if the urinary sodium levels are more than 20 ml equivalent per liter that means sodium is getting lost through the renal filtration that means renal loss is happening more so probably the cause could be because of diuretics or mineralocorticoid deficiency but if urinary sodium is less than 20 that means only the volume so yes so i was saying that if urinary sodium is less than 20 then the chances of extra renal losses are always more so that is how you categorize a hypovolemic hyponatremia and further categorize it on the basis of urinary sodium levels now that let's go to the next category where which forms the major task for us that is the eu volumic hyponatremia let me tell you when a patient comes to the an old age patient comes to the casualty you have to be very quick in assessing as to which category of hyponatremia the patient belongs to then only you will be able to assess the cause just finding out the sodium level and giving a normal cell line or starting three percent ns is not the right way of tackling hyponatremia you have to find the cause to correct the cause then you can prove that at next stage of life the hyponatremia will not happen so if the patient is u-voluminous the next step is checking for urinary sodium levels once urinary sodium level is found usually it will be more than 20 then you have to check for urinary osmolarity levels whether it is more than 100 or less than 100 now one of the most common causes of hyponatremia that we see is when urinary sodium is more than 100 which is called as the siadh syndrome of inappropriate antidiuretic hormone secretion now we know very well that s idh means an increase in adh level secretion which causes more of water retention and it causes more of solute loss that is why urinary osmolality remains high now whenever a patient comes with si idh there are few things you need to remember number one the patient should have euvolimic or euvolimic hyponatremia patients should have hypertonic hyponatremia patients should have urinary osmolarity osmolality more than 100 and the final and most important thing is that you need to rule out adrenal cortical deficiency and at the same time hypothyroidism once all these parameters are there and the hypothyroidism and adrenocortical insufficiency is ruled out then only it fits in to the criteria of sieth so the other causes apart from siadh include hypothyroidism adrenal insufficiency adrenal insufficiency stress and drug use now coming to the next category if urinary osmolarity is less than 100 then the possibility is more of primary polydipsia or low solute intake so primary polytypicia means as you know that patient continues to keep taking water water trying to quench his thirst so whenever more intake of water is there there is more water loss and but the solute loss does not happen to that great extent even though urinary sodium loss is there this is called as primary polydipsia then there is pure protomania and so on and so forth now coming to the next level next step that is the hyper volumic hyponatremia in such cases we know that the volume status of the patient is high that means patient will have pedal edema or patient will have signs of failure so there may be causes such as cardiac failure hepatic failure nephrotic syndrome and so on and so forth but you need to further categorize it on the basis of urinary sodium levels so if urinary sodium level is less than 20 it falls into heart failure cirrhosis nephrosis or hypoalbuminemia if urinary sodium is more than 20 then there is a chance of renal failure so this is how basically we assess hyponatremia as a whole now coming to the signs and symptoms of hyponatremia if the patient belongs to the category of acute hyponatremia patient has high chances of presenting with symptoms if sodium level is between 121 to 130 then symptoms like nausea hiccups malaise headache lethargy muscle cramps disorientation and restlessness may occur if sodium level is less than 120 obtaination respiratory arrest seizures coma and that may also occur there are a wide variety of patients where patient has persistently low level of sodium maybe between 125 to 130 and that falls into the category of chronic hyponatremia so nausea gait disturbance forgetfulness muscle cramps confusion lethargy fatigue all these are mild or moderate symptoms of chronic hyponatricum now coming to the investigations in hyponatremia if a patient presents with hyponatremia the major things that you need to do include first assessing the basic serum sodium level then serum osmolarity level urinary osmolarity level urinary specific gravity and then urinary sodium concentration additional labs depend on which category the patient falls into whether hypotonic isotonic or hypertonic for you volume a hypovolemic hyperbola depending on that you decide whether to check for tsh cortisol albumin triglycerides glucose urea creatine uric acid and acid-base balance now moving on to the treatment protocol of hyponatremia whenever a patient comes with approach to hyponatremia as i said earlier you have to go for three basic steps one assess the volume status second go for the osmolarity third go for urinary sodium excretion and this is how you check for the vou status depending on that you can categorize it further now if a patient is presenting with acute hyponatremia the patient is generally symptomatic so the risk of brain herniation is always high hence rapid correction is very necessary in hyponatremia acute hyponatremia if chronic patient is asymptomatic or has mild symptoms if mild symptoms you can go for hypotonics hypertonic saline which is infused at the rate of 0.5 to 2 ml per kg per hour and reassess the serum and urinary electrolytes every 4 to 6 hours if there is severe hyponatremia you go for 100 ml of 3 hypertonic saline infused iv over 1 hour but it's important to remember that you should not rapidly correct the sodium level because it may lead to a condition which is called as central pontine myelinolysis now this is just a basic structure of how we treat different categories of hyponatremia as the phrase goes hypovolemic hyponatremia so isotonic saline must be given to replace the intravascular volume second is hyper volumic hyponatremia in such a case you know the volume status is already excess so the next step is decrease the volume status that is by giving diuretics or salt and fluid restriction plus loop diuretics another step is using a v2 receptor antagonist like coney weapon or tolvactin always remember tall vaptin or veto receptor antagonist and hyper volumic hyponatremia it is not recommended in hypovolemic hyponatremia because you need to prevent more of water retention next step is your volumic hyponatremia where it is treated by free water restriction less than one liter per day if the patient is symptomatic then you can give a hypertonic saline or normal selling with diuresis with a low diuretic now this is more of a mathematical or probably a theoretical point of view because it's very difficult to be in the casualty and at the same time calculate all these things then decide how much sodium however i will just browse food dieting the first step you need to do is calculate the total deficit where desired sodium serum minus actual serum sodium to the total body weight now total body weight is that as 0.6 of the body weight change zero protein impenetration is calculated by infusion minus actual serum sodium upon total body water plus one so that means if you're giving isotonic saline as a part of the treatment then it contains 514 mil equivalent per liter of sodium that is the infused sodium and so on and so forth for 0.545 percent rl or 3 ns but always remember that you should not increase sodium more than 10 milli equivalent per liter in 24 hours or more than 18 mil equivalent per liter in 48 hours this is the most important statement of approach that sodium level should not be increased very rapidly now let's go to a case where a 45 year old male of 70 kg body weight after appendix ectomy received three litters of five percent dextrose per day along with liberal oral intake on the third day patient became confused and developed convergence clinically he was stuporous and euvoluming on investigation serum sodium was found to be 106. potassium was found to be 4.1 serum osmolality of 230 milliosmol per kg urinary osmolality of 480 milliosmol per kg diagnosis and plan of action now as you can see here we know one thing for sure that's so level slow okay now next if you see that the patient is due voluming okay now along with that what you see is serum osmolality is 230 that means patient belongs to the category of your volumic hypotonic hyponatremia in such a case now we don't know whether the patient is adrenocorticoid has got adrenocortical deficiency problem with the patient is hypothyroid we don't know all these things but we know one thing that it is post-op so post-op is one of the major causes for something called as siedh so the chances of it being silvh is more so as you can see here once we know the cause is siedh the next step is diagnosing the is moving ahead to the treatment plan the first step is restrict the water intake second give a loop diuretic and third hypertonic saline now how much hypertonics are lying to give and at what rate and how much fluid to be restricted now we know that the sodium is about 106 and weight is 70 kg so the first step is where we check the change in serum sodium concentration now as i said earlier that point nine percent normal saline contains 512 milli equivalent per liter so you calculate it as 112 my natural seed of sodium silence is upon total bonding this total body water 1.6 into 70 plus 1 it comes to 9.44 milli equivalent per liter so from this 9.44 milli equivalent per liter to raise the nine point four four milli equivalent of sodium 1000 ml of three percent nacl is required that is a meaning of nine point four four milli equivalent per liter now we have to consider that the average rate of correction is eight milli equivalent per liter in 24 hours hence to raise eight milli equivalent of sodium the required three percent nacl would be eight thousand upon nine point four four that is 847 ml so the rate of correction if you see divided by 24 hours will be 35 ml per hour so that is how you will set the infusion pump to increase the sodium levels but remember one thing that all this is theoretical we usually do not whenever we set an infusion pump to give hypertonic saline 35 ml per hour we never keep because we consider it as a very high or a rapid rate so that is why we try to keep it between 15 to 20 ml per hour however theoretically if you see 35 ml per hour is recommended in this case now another important point is fluid restriction whenever you're treating hyponatremia it is important to maintain a particular level of a fluid balance okay now when you maintain a fluid balance it's important to know how much fluid to restrict how much fluid to give and that forms a major determinant of matching the sodium levels so one way to do it is calculating the urinary electrolytes to the plasma electrolytes ratio so urinary sodium plus urinary potassium upon serum sodium level if the ratio is more than 1 then fluid restricted to less than 500 ml per day if ratio is equal to 1 fluid restricted to 500 to 700 ml per day if ratio is less than 1 then fluid restricted up to 1 liter per day again this is again a mathematical level where you can restrict the fluid level up to a particular judgment now coming to this flowchart now this flowchart is basically taken from up to date where they have given a guidelines of how to manage a case of hyponatremia now we know acute hyponatremia means if the patient is having low sodium levels of less than up to a duration of less than 48 hours chronic hyponatremia if hyponatremia has been persistent for 48 hours or more if the duration is unknown now if the patient is belonging to the acute category you need to check whether the patient is having symptoms or not now if the patient is not having any symptoms then you need to check whether the body is automatically auto correcting it because of a water diuresis if it is like that then you can directly just monitor serum sodium level and if the serum sodium level is low or falling below category then only you need to give a 50 ml bonus of three percent hypertonic selling now if it is not auto correcting then again you will give a 50 ml bolus of three per sensor line to prevent a further decline in serum sodium but again you will monitor serum sodium hourly to determine the need for repeat polis this is the general measure now if the patient is having mild to moderate symptoms of hyper hyponatremia then you will give 100 ml bolus of three percent saline and repeat twice or more as needed if symptoms persist again you will monitor serum sodium hourly until the serum sodium has increased by 4 to 6 ml equivalent per liter after which the frequency can be reduced when you get a case of recurrent hyponatremia you can repeat the entire correction again now if we go to the case of chronic hyponatremia first you will see whether patient is having severe symptoms of hyponatremia if it is like that then again you will follow the protocol of giving hypertonic saline and increasing it by four to six mil equivalent per liter now if the patient is not having particular symptoms then you have to look for the cause behind it for chronic hyponatremia that includes the intracranial pathology such as recent traumatic brain injury intracranial surgery or hemorrhage or space occupying lesion and so on and so forth if any of these are there then again you will manage as inpatient and go for giving hypertonic saline or else you will check for the serum sodium level if it is less than 120 again manages inpatient and if the patient is having serum sodium of more than 120 and patient is having no symptoms then just keep monitoring but if patient is having symptoms then again go towards correcting it and monitoring it periodically now remember one thing that apart from giving hypertonic saline it is important that you correct the volume status also so as you see here if the patient is having hyponatremia due to water intoxication then diuretics are also necessary but if the patient is having hypovolemia then you will go for giving isotonic select so apart from that the next step which you need to know or a rough summary of all of this is that let's say a patient is having hyponatremia now first time you give a correction let's say if the patient sodium level was 110 you gave a correction then you next we saw the patient sodium level has gone to one or two then further you gave a correction then again it has gone to 94. you can see repeatedly recurrent hyponatremia is happening in such a case what you must do is you can think of supplementing it with lithium or dimethylcycline however this has not been routinely practiced nowadays because lithium and the microcycline have held lot of side effects so the only possible way of continuously correct of treating hyponatremia is by continuously correcting it so this is the usually practiced and the most important way of correcting hyponatremia in a critical care setting so this was the basis of approach to hyponatremia so one thing i want to conclude is that whenever your case of hyponatrem get a case of hyponatremia it's important that you find the cause behind it or at least have a rough estimate as to which category of hyponatremia falls into and treat it accordingly so that's all about approach to hyponatremia thank you thank you dr jacob i'll just go through your questions so dr akula is asking kindly explain how adrenal insufficiency cause increased urinary osmolarity urine osmolarity right okay so first and foremost we also know that adrenal gland is responsible for secreting lot of level of mineralocorticoids so when you secret when there is a lot of mineralocorticoid secretion it is responsible for maintaining the fluid and electrolyte balance so whenever um adrenocortical insufficiency occurs there is decrease in level of mineral or corticoids which is responsible for causing the increase in sodium loss and not retaining the sodium levels so that is one major cause of hyponatremia so apart from adrenal insufficiency even hypothyroidism is said to play a major role behind causing hyponatremia right uh we have another question from dr surapu can you explain how can we go about hyponatremia in op bases only with serum sodium levels right so uh let me tell you one thing that if a patient is having hyponatremia and you're seeing on op bases it depends on what kind of symptoms they have right now if suppose patient is having mild symptoms like nausea vomiting and so on and so forth and if you know that sodium level belongs to a range between 125 to 135 then you can go towards giving them salt capsule now let me tell you in majority of the pharmacies know this salt capsule is not available so what you're supposed to do is that you need to take a b cause you because you'll is a vitamin supplement b complex open it remove the content add some salt in it and that is how you give big costumes uh that's how you give salt capsule so salt capsule you recommend to giving two caps per day but let me tell you one thing treating a patient of hyponatremia with just salt is not a very good way right on op bases this is not a recommended treatment by the guidelines but this is what is usually followed only to maintain further decline in sodium level so that if a patient comes with chronic hyponatremia the patient does not have symptoms and the sodium level is maintained at that particular level so this is one op basis of treating chronic hyponatremia understood so we have a question from dr sriram um how long can dolphton be used in chronic hyponatremia if mild symptoms are present okay now let me tell you this is a very good question if a patient is uh having hyponatremia and you want to prescribe chronic or tolerable you start it with a dose of 7.5 milligram once a day that is you get a 15 milligram tablet you give it half a day half tablet once a day now usually what is said is that this vaptins have high chances of increasing sodium levels at a very rapid rate so once you give a toll weapon it is important that you monitor the sodium level for the next two weeks not daily but at least once or twice a week then later on you can maintain the toll weapon for a month or two now again it depends upon what cause of hyponatremia it is let's say the cause is siedh or it is a case of hyper volumic or euvolemic hyponatremia then you can continue to give tolerance for a long period of time maybe three to six months also but if a patient is having hyponatremia and you're not sure about the cause and you are giving tolerability then it is important that you monitor the sodium levels at least monthly so that you can maintain a tract and the patient does not go in hyper naturamia or central content myelodysses uh i hope dr sriram uh this answers your question how much period uh will we treat patients with dolphton yeah that's what that's what i said so uh you can actually start treating with tall vaptin and then you can keep periodically monitoring with sodium level and then if the cause is persistent let me tell you sadh has got a major cause of malignancy now the malignancy is going to remain lifelong or the patient has already been treated and sids will process for a long period of time in such a case you will continue with tolvapen and keep monitoring sodium levels at least monthly we have question from dr abhinash so what about relative hyponatremia in diabetic ketoacidosis right so let me tell you one thing hyponatremia is um okay see we know i told you that whenever we start treating or when we go for an approach to hyponatremia it's important to find the cause the answer lies in your question only you know that hyponatremia has a cause of diabetic ketosis you know that diabetic ketosis acidosis is the case of hypovolemic hyponatremia so just correct the volume sodium will get corrected that's the answer so so we have question uh from dr karthik uh your thoughts on central pontine myelinosis right okay central pontine myelinolysis is a condition where patient when is given a rapid correction of sodium level of let's say above 12 mil equivalent per liter over a period of 24 hours what happens is that patient starts developing flaccid paralysis dysphagia dysarthria which are the most common kind of symptoms which presents with central pontine myelinolysis now let me tell you once patient that develops this kind of symptoms if the patient is at an initial stage of cpm then you can reverse it okay but if the patient develops cpm for a long period of time then probably it may not be reversible so that is just a rough idea of central quantile myelinolysis where the nerve sheaths the myelin sheath behind the north uh coverings those get damaged and those are responsible for causing these kind of symptoms right so we have question from dr uh hypertonic saline um should be given by a central line only okay it is recommended that hypertronics align should be given by a central line only because when you give by a peripheral line it is patient may develop numbness or irritability through one particular arm so it is always recommended that you give it via central line now again in central line also there are two one uh two or three where you insert the central line via the jugular vein via the subclavian vein or the femoral vein now it is always recommended not to give wire the jugular vein because directly it is connected to the heart right so femoral is recommended but however even via jugular vein the through the central line hypertonic saline can be given and there's no problem in that we have a question from dr josephine how long do we wait before checking urine spot sodium if patient has history of vomiting and hyponatremia okay now let me tell you when a patient comes with hyponatremia the best result or the most accurate result you get when the patient comes with it because the moment you give a three percent hypertonic saline that moment itself the urinary osmolarity serum osmolality urinary sodium everything changes okay so you don't want to hamper with your diagnosis so the best way is when the patient comes immediately send all these samples and then start the correction if you start the correction then send the samples then probably it may not be a reliable result okay i can see one question uh yeah ruby says 19 and hyponatremia so let me tell you one thing that ovid 19 is very very very commonly associated with hyponatremia on a critical care setting so it is important that in a patient of covet 19 with hyponatremia please please do not restrict the fluids because in a patient of covet 19 there are high chances of malnutrition there are high chances of hyperventilation which causes the body to use up more fluid or more water so that is why it's important that you do not restrict the fluid continue giving isotonic saline and that will replace the sodium levels so just make sure you don't give diuretics in treating a covalent 19 with hyponatremia until unless uh cardiac failure or nephrotic syndrome or something like that is associated with it if it is plain covet 19 hyponatremia just replace the volume status it will correct the sodium levels i hope dr ruby this answers your question uh we have a question uh from dr mandeep can we use three percent in severe chronic hyponatremia when patient has only mild symptoms uh okay so that is more of a clinical judgment level of question because it varies from person to person but if a patient is having chronic hyponatremia and the patient is having mild symptoms i would suggest that you repeat the serum sodium levels maybe after a week or so so that you can understand whether it is further on a decreasing trend okay if that is the case then you give a three percent hypertonic saline now let me tell you one of the most common situations that i see in my daily practice is a patient comes with hyponatremia maybe an old age category and first and foremost is that you check the drug history because majority of the patient would be on a thiazide diuretic and that is responsible for causing the hyponatremia so just replace the triside diuretic let's say with calcium channel blocker with maybe ace or erb so when you combine those both uh what will happen is that the sodium level will automatically get corrected but there are situations where i've seen that trisideric diuretics are given simultaneously salt capsule is given then admitted for three percent is aligned but the cause is not corrected so the sodium level persistently remains low so it's important that you find the cause and treat it right dr ashok is asking your thoughts on post operational hyponatremia right so we know that post operative there are a lot of changes in the fluid status of the patient so when that kind of a situation comes in hyponatremia is a common scenario in post-operative cases but always it is recommended that you don't wait for sodium level for the body to restore the sodium level on its own don't do that because that is putting the patient at a risk so better way is to continuously monitor it and when you monitor it if you find a fast decline in serum sodium level go for replacing the or replacing the sodium level or replacing the volume status of the patient now post-operative cases majority of the cases are given let's say one liter two liter normal saline so that itself is re-correcting the sodium level but still if it doesn't do it then i would recommend giving hypertonic saline so i hope dr ashok this answers your question uh we have question from dr shubham how can a physiotherapist help a patient with hyponatremia okay now that is one question which i cannot help much but one thing i can tell you that if a patient is having hyponatremia it depends on the cause behind it okay so um if the patient is having symptoms like muscle cramps due to hyponatremia then more work comes in treating the cause rather than the rehabilitative techniques rehabilitative techniques depends upon the cause of hyponatremia let's say it's a long-standing malignancy if a patient is completely bedrest or something like that then a physiotherapist role comes into picture but otherwise per say if you see for hyponatremia then we cannot say that there is much of a role until we treat the cause we have a question from dr prashanth if the patient has high vp issue and low sodium level up to 120 at the same time which will be the same for a way to balance sodium right now let me tell you one thing whenever you have a patient with a you have a tricky scenario as to which to treat first let me tell you find out which of these is more life threatening a high bp is also life threatening a low sodium level is also life threatening but depends if the sodium level is let's say between 120 to 125 the patient is having high bp i would go for correcting the bb first and correcting the sodium level with let's say oral therapy like giving salt capsule or something like that but if the patient is having a sodium level of let's say 110 to 120 and still patient is having high bp i would give three percent hypertonic saline because correcting sodium level at this range is very important bp can be monitored and controlled with let's say an infusion pump or let's say giving npg let's say giving nitro proside let's say giving uh labitolol or any particular oral antihypertensive also but whenever it lands up to a life threatening situation treat the cause where life threatening is more uh possible in that particular course right right i can see one question uh mr kundal sarkar has said father has brainstormed 81 years on liverpool lacrosse my donor puzzle urimax pramipex potassium sodium levels keep declining what would be the cause he also has high blood pressure okay now if you see a lot of case reports you can see that pramipexole has a very high chance of causing hyponatremia so what what i would suggest is you modify the dose of primavex let's say he's taking a dose of let's say half tedious then you can reduce it to half bdd so something like that so if you modify the doses of drugs which have high propensity to cause hyponatremia probably sodium levels and production levels can be corrected second thing is that since he has already had a history of brain stroke there are high chances of small lacunar infarcts to be there or you know cerebral atrophy to be there in such cases hyponatremia will remain persistent it may fall into the chronic hyponatremia category so it is very difficult to maintain a proper normal level but make sure that he does not develop symptoms because of it and treat it accordingly so we have question from dr abhinash in renal failure why urinary sodium is gets increased uh is it due to low absorption or or it's because of renal failure and gfr like it's also low okay let me tell you one thing that renal failure yeah so renal failure let me tell you is not is a very broad so if the patient is in renal failure let me tell you there are various stages in it one is the oligo-uric phase one is the maintenance phase and one is the diuretic phase diuretic phase so renal failure per se will of course cause um you know uh lower gfr but let me tell you in the initial stages of renal failure there is a phase where there is uh diuresis so with this not only water is lost but urinary sodium is also lost so in that kind of aki what we call as the acute kidney injury in such cases there are possibilities where urinary sodium can be used right i think we've answered most of the questions so i think it was a very amazing session you've almost all answered all the questions thank you so much for taking out time and we are looking forward for your next session thank you so much

SPEAKERS

dr. Samadnya D

Dr. Samadnya D

Dentist, MBA in Hospital and Healthcare Management. “Be like a Stem Cell, differentiate yourself from others”

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dr. Rohit Jacob

Dr. Rohit Jacob

Consultant Physician & Intensivist at Craft Hospital & AR Medical Center, Kodungallur, Cochin | General Physician MIT Mission Hospital, Kodungallur, Cochin Senior Resident at Dept of Medicine, Al Azha...

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dr. Samadnya D

Dr. Samadnya D

Dentist, MBA in Hospital and Healthcare Manag...

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dr. Rohit Jacob

Dr. Rohit Jacob

Consultant Physician & Intensivist at Craft H...

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