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Acute Water Intoxication December 17, 2003 Bruce R. Wall, MD Good old fashioned nephrology (with a large dose of pulmonary) • Most nephrologists would chose to evaluate and treat a SODIUM of 110 mEq/L rather than a BUN of 110mg% • “Be careful what you ask for… you just might get it…” • Lt.Col. Theodore R. Wall, USMC, Retired • Patient admitted from ER with hyponatremia and respiratory failure… no problem… Today’s lecture: • Chronic polydipsia – not this case • Case presentation • Laboratory review • Brief discussion of water intoxication • Pulmonary aspects @ Dr Weinmeister Input minus output equals accumulation • 75 kg male • 60% water = approx 45 Liters TBW • Intracellular 30 L 280mosm/kg [K+] 140mEq/l Extracellular 15 L 280mosm/kg [Na+] 140mEq/l How much water was ingested? • Initial TB solute: 280 X 45 =12,600 mosmol • Initial ECF solute: 280 X 15 = 4,200 mosmol • Initial intracellular: 12600 – 4200 = 8,400 mosmol • • • • NEW NEW NEW NEW TBW : 45kg + 6 kg = 51 kg TB OSM: 12,600 / 51kg = 251mosm/kg ECF volume: 4200 / 251 = 16.7kg intracellular volume: 8400 / 251 = 33.4kg How much water? • Assume an ingestion of 6 liters: serum osmolality of 251mosmol/kg • Estimated nadir [Na+] = osmolality / 2 = 125.5mEq • Effective Posm is approximately 2 X [Na+] Case Presentation • • • • • • 21 year old AAM student at SMU CC: can not be obtained (intubation) History obtained from family members Patient was asked to drink 3 - 4 gallons of water (with hot sauce), as part of a fraternity hazing on Friday evening Post ingestion, patient was confused, and became ‘less responsive’ At 4AM, patient developed a seizure, yet was not transported to Presby ER until 7AM Hospital day:one • Profound shock/hypotension – poor response to high dose pressor medications • Immediate respiratory failure with severe agitation and hypoxemia; endotracheal intubation confirmed “drowning” • Transfer to ICU maximal support: 100% oxygen, maximum PEEP, IV norepinephrine • Initial SODIUM = 126mEq/L (IV @KO NS) Case presentation: continued • Past medical history: none • Social history: 2 year football player for Austin College. No drug or alcohol history Mother arrived from Houston; Father arrived from US Virgin Islands (lives in Wash D.C.) • Medications: IV pressors, antibiotics • ROS: not available Physical exam: • BP 100/60 on very high dose IV pressors; pulse • • • • • • • 110 sinus tachycardia; R per vent; high pressures Very muscular patient, intubated PO, who eventually developed subQ crepitation from barotrauma HEENT: mild swelling; anicteric NECK: WNL LUNGS: bilateral breath sounds; increased rate COR: no murmur, increased HR ABD: benign, although later the CT was abnormal… Ext: no cyanosis; warm; slowly progressive edema Neuro: unresponsive pupils; ? signs of herniation prompted use of IV mannitol Admit labs • WBC 17K 76%neutrophils, 6%lymphs Hgb/Hct 13.2g%/38% Plts 380K • Urinalysis: 2+ blood, few RBC’s, 360mOs/kg • Initial Serum Osm: 272, falling to 263 in 8hrs • Toxicology screen negative for tylenol, PCP, ethylene glycol, MDMA, salicylate, ethanol, cocaine, barbiturates, and narcotics • CXR: ? RUL pneumonia • CT Head: cerebral edema, especially in retrospect Additional admit labs: • Calcium 8.6mg/dl Phos 4.2g/dl • Total protein 7.6g/dl Albumin 4.8g/dl • Alk phos 63 LFT’s mildly elevated • INITIAL CPK 2100 • INITIAL BUN 10mg% CREAT 1.0mg% • ANION GAP 21 • Therefore, working diagnosis of (+) AG lactic acidosis from seizure, 3 hours PTA Electrolytes day one, as serum osmolality fell from 272 to 263… Na+ K+ ClCO2 AG Creat U osm PO4 CPK 0800 126 4.6 89 16 21 1.0 360 4.0 2100 1130 117 3.8 88 19 10 1.1 1320 120 3.6 1800 116 4.0 90 22 9 1.1 5 1.2 473 4.4 3400 2300 117 3.8 4000 Electrolytes: day 2 0300 1045 1300 1600 2000 Na+ 116 128 130 132 134 K+ 4.6 4.4 CO2 26 25 AG 6 8 Creat 1.1 1.3 PO4 1.7 2.5 CPK 6200 U osm 803 therapy 1.2 10,500 122 600 DDAVP Hospital course • Hemodynamics and oxygenation were tenuous on • • • • day one… Patient was considered for extra-coporeal oxygenation therapy, resulting in a transfer from 3 ICU to 4 ICU Post transfer, his BP and PO2 IMPROVED Abnormal CXR: bilateral infiltrates, air under R hemidiaphragm CT scan: larger amt of air surrounds tail of pancreas, (L) kidney, anterior aspect of psoas muscle, tracking down from mediastinum Hospital course: continued • Electrolytes were normal, by hospital day 3 • EEG always showed electrical activity (patient had been severely hypoxemic, but never required ACLS) • CNS began to improve by hospital day 4 • Ventilator support was weaned by day 7 • Transfer to floor day 8 • Discharged home day 10 CNS damage associated with acute hyponatremia • CPM: rare neurologic disorder reported in • • malnourished/alcoholic patients MORE COMMON – brain edema, with uncal and tonsillar herniation with diffuse cerebral demyelination secondary to increased intracranial pressure, with necrosis, and hypoxic brain damage Compression of medullary respiratory center because of brain swelling, above 5 to 8% of baseline volume can lead to herniation -- fixed pupils, hypoventilation, cardio instability, impaired temperature control, pituitary and hypothalamic infarction also possible Water intoxication in cattle • J AFR VET ASSOC 1999 DEC; 70(4) • Water intoxication is common in cattle, and also has been described in other domestic animals. Comprehensive description is lacking… Fatal water intoxication: Journal of Clinical Pathology Oct 2003 p 803 DJ Farrell et al • 64 yo woman with known MV disease • Compulsively drinking water, one evening, in range • • • • • of 30 to 40 glasses Hours later was described as “hysterical” Fell asleep, and found dead next morning Postmortem: no tumor, bilateral pleural effusions, LVH with large heart; increased cortisols Na+ = 92meq/L (vitreous fluid, usually stable) Acute delirium, seizures, coma, and death Autopsy case of rare iatrogenic water ingestion; Chen et al, Tongji Med Univ, Forensic Sci International: Nov 95 • 21 yo female suicide attempt (powder scraped from 18 matches) • 1700 hrs: 3L of water 1730 hrs: 800ml • 1800 hrs: 4L of water, via NG tube • Headache, dyspnea, cyanosis, then coma • Autopsy: cerebellar herniation, Na+ 112, pulmonary edema, trachea and bronchial tubes full of fluid… Literature review: Forensic Science International (1995): continued • 534 papers over 17 years – only 16 fatalities • 15 cases diagnosed during hospitalization for various types of psychosis • Water intoxication is unusual in normal people, and death is even rarer • Case report of death within 2.5 hrs is rare Fatal child abuse by forced water intoxication • Pediatrics 1999 JUN;103 Alan Arief,MD • 3 children punished by forced intoxication • > 6 liters • Seizures, emesis, coma, hypoxemia, average sodium 112mEq/L • Autopsy confirmed cerebral edema • Tried and convicted Death by hyponatremia as result of water intoxication in a Army trainee • MIL MED 1999 MAR;164 • Excessive water intake by athletes during endurance races, to prevent heat injury has been the recommendation • Describe a case of programmed drinking > 8 liters during initial training • One death, cerebral edema with seizure Death by Water intoxication MIL MED 2002 May; 167 • 3 deaths in recruits, usual water load of 6 to 10 liters in 2 to 3 hrs • “safe limit” probably 1 liter per hour Chronic Polydipsia and hyponatremia • Psychiatric patients, especially schizophrenia, often • • • • have problems with water balance 6% to 8% have a history compatible with compulsive water drinking; ½ of these pts had intermittent symptoms of hyponatremia Normal patients can excrete 10 to 15 liters/d by decreasing Uosm from 40 to 100 mosm/kg Episodes of transient ADH release with acute psychotic episodes Carbamazepine and fluoxetine are associated with SIADH Chronic polydipsia • This is an uncommon clinical scenario, but does • not apply to our current case (which is rare) “Rx” hypontremia with acute encephalopathy rate of correction – 0.5 to 1 meq/l per hr (until a sodium of 120meq/l) Never actively correct > 130meq/l