Board Review: Down the watering hole
65 year old 70 kg female with past medical history significant for CKD stage II, HTN, and DM who presents from a Nursing Home after having a seizure. Patient is lethargic and continues to repeat herself. Patient has had nausea and vomiting with diarrhea for the last 3 days. Patient was last seen normal 2 days prior. Patient with the following vitals: T- 97.6; HR- 109; RR- 16; BP- 156/70; SpO2- 100% on RA. Accucheck is 85. EKG is non ischemic. CT scan of her head does not show any intracranial abnormality except for volume loss. Urinalysis shows no leukocyte esterase and is nitrite negative. CXR shows no focal infiltrate. Patient is found to have a sodium of 112. What is the appropriate choice of fluid resuscitation for this patient?
- 3 % NS at a rate of 45 cc/hr
- Lactated Ringer at 250 cc/hr
- 0.9 % NS at 45 cc/hr
- D51/2 NS at 90 cc/hr
Answer: A. Patient has hypovolemic hyponatremia. Patient has had nausea/vomiting/diarrhea which suggests volume losses. Seizure likely happened due to patient being hyponatremic which indicates correction of the sodium with 3% hypertonic saline. It is important to not correct the sodium too quickly to avoid complication of central pontine myelinolysis.
Braun, M., et al. "Diagnosis and Management of Sodium Disorders: Hyponatremia and Hypernatremia." Am Fam Physician. 2015 Mar 1;91(5):299-307. <https://www.aafp.org/afp/2015/0301/p299.html>. May 14, 2020.