Digestive and Metabolic Diseases

Biography

Biography: Devina Sharma

Abstract

Introduction

We introduced the hospital policy on the management of severe symptomatic hyponatraemia (SSH), with hypertonic saline (HS)of 1.8% and 5% saline in 2017. This is one of the few UK centres to offer this treatment, therefore the evidence is limited. The policy was based on European and American guidelines (1)(2). Objectives To study the adherence, and effectiveness, of this guideline in managing patients with SSH.

Methods

Patients were identified using the Biochemistry tracking system between 01/01/18 until 14/05/20. The terms - Hypona, sod, Hypertonic, 5%, 1.8% a were searched. The laboratory result system was used to identify hyponatraemic (<130 mmol/L) patients at the time they were logged onto the tracking system. Clinical notes were crossmatched for the use of 1.8% and 5% saline for those with sodium <130mmol/L. 12 patients were identified. The following data was collected using hospital records: age, gender, location, fluid status, presentation, symptoms after HS adminsitration, volume and type of fluids. Sodium was recorded; prior to and during presentation, after HS saline, at 24, 48 hours and at discharge or death. Cause of death (if applicable), complications of HS and lenght of admission after treatment were also noted. This was compared to the 2017 current hospital guideline. Standard 1: 11 patients had symptoms of hyponatraemia. They were confusion (6), somnolence (5), seizure (4), vomiting (3). Other sympotms included muscle twitching, fatigue and nausea. SSH was suspected in 2/11 patients, but it was not the primary diagnoses. One patient was asymptomatic- the only patient with chronic hyponatraemia. Standard 2a/b: All patients identified were treated with 1.8% saline. None with 5% saline. Standard 2c: 7/12 patients overcorrected (there should be a <5mmol/L increase following HS). In 4/7 there was inappropriate application of the guideline; HS was given despite improvement of symptoms or after the 5mmol/L target had been achieved. An average volume of 481ml (range 100-1250ml) HS was given over an average of 3h 53m. This increased sodium by mean of 6.4mmol/L (range 2-12) by the end of treatment with HS. Standard 2d: 9/11 patients had atleast partial or full improvement in the symptoms at the end of treatment with 1.8% saline. In 2/11 whose symptoms were secondary to other causes (paranoia/ hallucinations), did not have improvement of symptoms after HS. Standard 2e: 9/12 patients had HS administered as per the recommended guideline calculation for rate. 2 patients were hypervolaemic and were treated with a slower infusion to prevent overload. 1 patient was treated using 100mls 1.8% saline for no clear reason. Standard 2f: 2 patients were clinically hypervolaemic - NS was avoided due to risk of overload. 1 patient had a 9mmol increase after 24 hours, (<10mmol increase advised). Standard 3a/b: There was 7/12 who overcorrected at 24 hours, and 5/12 at 48 hours (should be <10mmol/L and <18mmol/L, respectively). The mean increase in serum sodium at 24 and 48 hours were 12.25mmol/L (range 7-21) and 17.25mmol/L (range 10-26) respectively. 11/12 patients eventually normalised (>130mmol/L) their serum sodium. 1 patient self discharged before this. The mean lenght of time to achieve this was 6.5 days In addition: 3 patients died. No deaths were attributed to treatment with 1.8% saline. Specifically, no patients developed central pontine myelinolysis

Conclusions

1. Our audit showed symptomatic improvement in moderate and SSH, following HS use. 2. Patients with symptoms due to other causes, did not show improvement in symptoms following HS. Before administrating HS, SSH should be the most likely diagnoses. 3. 5% Saline was not adminstered, it should be removed from the guidelines. 1.8% can safely be used in severe and moderate cases. 4. The guideline was inappropriately followed for cases where there was overcorrection following HS. It should be clearly stated that HS can be stopped once there is symptomatic improvement, even if this occurs prior to the 5mmol/L target. 5. The increase in serum sodium at 24 hours and 48 hours should be <10mmol and <18mmol from baseline. This includes administeration of HS followed by NS. 6. No adverse events were identified from treatment with HS or from overcorrection. References and Grant acknowledgments (2) Verbalis JG, Goldsmith SR, Greenberg A, Korzelius C, Schrier RW, Sterns RH, Thompson CJ. Diagnosis, evaluation, and treatment of hyponatremia: expert panel recommendations. American Journal of Medicine. 2013;126:S1–S42. doi: 10.1016/j.amjmed.2013.07.006 (1) Spasovski G, Vanholder R, Allolio B, Annane D, Ball S, Bichet D, Decaux G, Fenske W, Hoorn E, Ichai C, et al. Clinical practice guideline on diagnosis and treatment of hyponatraemia. European Journal of Endocrinology. 2014;170:G1–G47. doi: 10.1530/EJE-13-1020.