👴 w Cirrhosis ➡️🏥 with spontaneous bacterial peritonitis and septic shock
After fluid resuscitation, vasopressors and antibiotics shock resolved
However now with oliguria and ⬆️ Na (165 meq/L). Cr 1.0 mg/dl, BUN 30 mg/dl
1/10
After fluid resuscitation, vasopressors and antibiotics shock resolved
However now with oliguria and ⬆️ Na (165 meq/L). Cr 1.0 mg/dl, BUN 30 mg/dl
1/10
BP is 155/63 (MAP 94), HR 77, O2 is 94 on O2 8 L/min.
🧠 Encephalopahy on tx w lactulose, edema +++, CRT 1 second, mild ascites.
#POCUS LV/RV OK, LVOT VTI 40 (CO 9.8 L/min), B-Lines, VExUS = 2 (Plethoric IVC + Biphasic Intra-renal Doppler) ➡️ High Output Heart Failure
2/10
🧠 Encephalopahy on tx w lactulose, edema +++, CRT 1 second, mild ascites.
#POCUS LV/RV OK, LVOT VTI 40 (CO 9.8 L/min), B-Lines, VExUS = 2 (Plethoric IVC + Biphasic Intra-renal Doppler) ➡️ High Output Heart Failure
2/10
1⃣¿Why is the pt Oliguric?
Is this hemodynamic AKI?
🔷Hypovolemic unlikely given congestion and ⬆️ CO
🔷Distributive? Although pt has Cirrhosis, MABP is 94 without vasopressors, also unlikely
🔷Congestive? Possible given VExUS 2
3/10
Is this hemodynamic AKI?
🔷Hypovolemic unlikely given congestion and ⬆️ CO
🔷Distributive? Although pt has Cirrhosis, MABP is 94 without vasopressors, also unlikely
🔷Congestive? Possible given VExUS 2
3/10
Urine SG was 1.037 ➡️ So ADH is VERY high (this is Appropriate ADH secretion of course)
This is Hypervolemic Hypernatremia
This developed because:
⬆️ Total body sodium
🔷 Agressive Crystalloid Resuscitation
⬇️ Total body water (relative)
🔷 Lactulose
🔷 Furosemide
4/10
This is Hypervolemic Hypernatremia
This developed because:
⬆️ Total body sodium
🔷 Agressive Crystalloid Resuscitation
⬇️ Total body water (relative)
🔷 Lactulose
🔷 Furosemide
4/10
How to treat? 🤔
The easiest way to treat HyperNa+ is just to give free water💧. But the free water deficit is 10 L !
Given severe volume overload, we were not keen on giving 10 L of water
A more difficult-to-achieve strategy is to remove sodium 🧂!
5/10
The easiest way to treat HyperNa+ is just to give free water💧. But the free water deficit is 10 L !
Given severe volume overload, we were not keen on giving 10 L of water
A more difficult-to-achieve strategy is to remove sodium 🧂!
5/10
Can this be achieved with Furosemide?
No way! We ordered urine lytes while on Furosemide
Urine Na is only 38 mEq/L!
This Urine WILL result in further Free Water LOSS! 😱
Free water clearance is Uvol x ( 1 - [101/ 165]) = Uvol x 0.4 ➡️ 40% of Urine is free water!
6/10
No way! We ordered urine lytes while on Furosemide
Urine Na is only 38 mEq/L!
This Urine WILL result in further Free Water LOSS! 😱
Free water clearance is Uvol x ( 1 - [101/ 165]) = Uvol x 0.4 ➡️ 40% of Urine is free water!
6/10
🔑 We need a strategy to minimize free water loss!
This can only be achieved by increasing UNa. Aiming for a value near plasma sodium!
Ultrafiltration will make this easy (no brainer).
However, can this be achieved with diuretics?
7/10
This can only be achieved by increasing UNa. Aiming for a value near plasma sodium!
Ultrafiltration will make this easy (no brainer).
However, can this be achieved with diuretics?
7/10
Trials show that both acetazolamide and thiazides marginally increase UNa on top of furosemide, but not enough...
What about combination diuretics? Blocking every site of Na reabsorption in order to maximally increase UNa makes sense! (of course no iSGLT2 which lowers UNa)
8/10
What about combination diuretics? Blocking every site of Na reabsorption in order to maximally increase UNa makes sense! (of course no iSGLT2 which lowers UNa)
8/10
We aimed for as high UNa as possible by giving furo + acetazolamide + thiazides + spironolactone!
This worked🤯! We achieved a UNa of 146 mEq/L!
Uvol was ≈ 6 L/24 hrs. This allowed us to give 3 L/day of free water AND achieve a negative fluid balance! #DiuresisJedi
9/10
This worked🤯! We achieved a UNa of 146 mEq/L!
Uvol was ≈ 6 L/24 hrs. This allowed us to give 3 L/day of free water AND achieve a negative fluid balance! #DiuresisJedi
9/10
After a couple of days, Na returned to normal and patient fully decongested! 😎
🔷 Hypervolemic Hypernatremia needs 1⃣Negative Sodium balance and 2⃣ Positive water balance
🔷 The higher the UNa, the less free water will be lost in Urine!
🔷Combination diuretics rule!
/END
🔷 Hypervolemic Hypernatremia needs 1⃣Negative Sodium balance and 2⃣ Positive water balance
🔷 The higher the UNa, the less free water will be lost in Urine!
🔷Combination diuretics rule!
/END
BONUS: Read more on using combination diuretics to avoid hypernatremia in this elegant post by @PulmCrit !
emcrit.org).
emcrit.org).
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