![]() The effect of each basic cause of hypernatremia on fluid compartment volumes is illustrated in. The mechanisms of fluid loss and sodium gain are outlined in. Hypertonic sodium gain is either iatrogenic or due to excessive NaCl ingestion. The underlying mechanism of fluid loss will determine whether it is pure water or hypotonic fluid. Excessive fluid loss may occur through the renal, gastrointestinal, integumentary, or respiratory system. Hypernatremia is the result of hypotonic fluid loss, pure water loss, or hypertonic sodium gain that is sufficient enough to overwhelm the hypothalamic osmoregulatory system. Any pathological process which limits water intake or increases water output may elevate the P Na. Together, these lead to the retention of water and lowering of the P Na. Thirst increases water intake by stimulating water ingestion and AVP decreases water output by increasing water reabsorption in the renal collecting tubule. In response to a rising P Na, osmoreceptor neurons in the hypothalamus signal the brain areas of thirst and arginine vasopressin (AVP) secretion. For the P Na to remain within the normal range of 135–145 mM, water intake and output must be equal. The P Na is regulated through changes in water balance. How would you approach this patient's hypernatremia? The P Na is 155 mM and the potassium concentration is 4.1 mM. A chest X-ray, electrocardiogram, and complete blood count are within normal limits. On physical examination, he is obtunded, the abdomen is soft and nontender, the skin turgor is diminished, the mucus membranes are dry, and the neck veins are flat. He is afebrile with a heart rate of 86/min, blood pressure of 110/80 mmHg, respiratory rate of 16/min, and oxygen saturation of 98% on room air. His home medications include furosemide, metoprolol, lisinopril, and atorvastatin. He has a medical history of hypertension, hyperlipidemia, congestive heart failure, and dementia. The objective of this article is to present a systematic clinical approach to the diagnosis and management of patients with hypernatremia.Īn 81-year-old man presents with a 4-day history of severe nausea, vomiting, and decreased fluid intake. ![]() The clinical approach to hypernatremia is often challenging for clinicians, as symptoms are nonspecific and improper management can lead to devastating complications. It is present in approximately 1% of hospitalized patients and is associated with a mortality rate as high as 42%. Hypernatremia is a disorder of water balance in which the plasma sodium concentration (P Na) exceeds 145 mM. How to cite this URL: Noto JG, Bollu R, Sturzoiu T, Nanda S. How to cite this article: Noto JG, Bollu R, Sturzoiu T, Nanda S. Keywords: Clinical approach, diagnosis, hypernatremia, sodium, systems based The following core competencies are addressed in this article: Patient care, Medical knowledge. As such, the purpose of this manuscript is to provide the reader with a systematic clinical approach to the diagnosis and management of patients with hypernatremia. The clinical approach to hypernatremia is often challenging for clinicians, as the underlying pathophysiology is complex and serious complications can result from its improper management. The relationship between the intracellular fluid compartment, interstitial fluid, and plasma can be seen in this figure.Hypernatremia is a commonly encountered disorder in hospitalized patients in which the plasma sodium concentration exceeds 145 mM. Note that this figure only demonstrates the relative sizes of body fluid compartments and does not provide any information regarding how these compartments are related to one another. In adult women, the total fluid volume is approximately 55% of the total body weight. ![]() In adult men, the total fluid volume is approximately 60% of the total body weight. All percentages shown in this figure refer to the percentage of the total body fluid volume in an adult human being. Transcellular fluid is found in small amounts in specialized compartments (e.g., cerebrospinal fluid, intraocular fluids, inner ear fluids, pericardial fluid, peritoneal fluid, synovial fluids, etc.). Interstitial fluid is the fluid that directly bathes the cells and tissues in the body. This compartment can be further subdivided into the interstitial fluid (~25% of total body fluid volume), plasma (~7% of total body fluid volume), and transcellular fluid (~1% of total body fluid volume). The extracellular fluid compartment makes up approximately 33% of the total volume of body fluids. This compartment holds approximately 67% of the total volume of body fluids. The intracellular fluid compartment contains the fluid that is present in the cytoplasm of all cells of the body. As shown in other figures for men and women, body fluids are located in two main compartments: intracellular fluid (ICF) compartment and extracellular fluid (ECF) compartment.
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