Uso de ibuprofeno en el tratamiento de pacientes pediátricos con poliuria y disnatremia. Reporte de una serie de casos / Ibuprofen use for the treatment of pediatric patients with polyuria and dysnatremia. A case series report

Los niños con lesiones selares y/o supraselares pueden presentar diabetes insípida central con posterior secreción inadecuada de hormona antidiurética. Nosotros observamos, en algunos casos, aumento de la incidencia de poliuria, natriuresis e hiponatremia, tríada diagnóstica del síndrome cerebral perdedor de sal. Aquí comunicamos la evolución de 7 pacientes con antecedentes de daño agudo del sistema nervioso central y diabetes insípida central seguida por síndrome cerebral perdedor de sal. Como tratamiento aportamos secuencialmente fluidos salinos parenterales, cloruro de sodio oral, desmopresina, mineralocorticoides e incluso tiazidas. Ante la persistencia de poliuria con hiponatremia, agregamos ibuprofeno. Como resultado de este esquema terapéutico secuencial, este grupo redujo significativamente los valores de diuresis diaria de 10 ml/kg/h a 2 ml/kg/h en un tiempo promedio de 5 días, normalizando también las natremias (de 161 mEq/L a 143 mEq/L) en un tiempo promedio de 9 días. En ningún caso observamos efectos adversos asociados al tratamiento.

Children with sellar and/or suprasellar lesions may develop central diabetes insipidus with subsequent inappropriate antidiuretic hormone secretion. An increased incidence of polyuria, natriuresis, and hyponatremia has been reported in some cases, which make up the diagnostic triad of cerebral salt wasting syndrome. Here we report the clinical course of 7 patients with a history of acute central nervous system injury and central diabetes insipidus followed by cerebral salt wasting syndrome. Treatment included the sequential use of parenteral saline solution, oral sodium chloride, desmopressin, mineralocorticoids, and even thiazides. Due to persistent polyuria and hyponatremia, ibuprofen was added. As a result of this sequential therapeutic regimen, daily urine output reduced significantly from 10 mL/ kg/h to 2 mL/kg/h over an average period of 5 days, together with a normalization of natremia (from 161 mEq/L to 143 mEq/L) over an average period of 9 days. No treatment-related adverse effects were observed in any case.

Pituitary immune-related adverse events induced by programmed cell death protein 1 inhibitors in advanced lung cancer patients: A report of 3 cases / 北京大学学报(医学版)

Pituitary immune-related adverse events induced by programmed cell death protein 1 inhibitors in advanced lung cancer patients: A report of 3 cases SUMMARY Programmed cell death protein 1 (PD-1) and its ligand 1 (PD-L1) have been widely used in lung cancer treatment, but their immune-related adverse events (irAEs) require intensive attention. Pituitary irAEs, including hypophysitis and hypopituitarism, are commonly induced by cytotoxic T lymphocyte antigen 4 inhibitors, but rarely by PD-1/PD-L1 inhibitors. Isolated adrenocorticotropic hormone(ACTH) deficiency (IAD) is a special subtype of pituitary irAEs, without any other pituitary hormone dysfunction, and with no enlargement of pituitary gland, either. Here, we described three patients with advanced lung cancer who developed IAD and other irAEs, after PD-1 inhibitor treatment. Case 1 was a 68-year-old male diagnosed with metastatic lung adenocarcinoma with high expression of PD-L1. He was treated with pembrolizumab monotherapy, and developed immune-related hepatitis, which was cured by high-dose methylprednisolone [0.5-1.0 mg/(kg·d)]. Eleven months later, the patient was diagnosed with primary gastric adenocarcinoma, and was treated with apatinib, in addition to pembrolizumab. After 17 doses of pembrolizumab, he developed severe nausea and asthenia, when methylprednisolone had been stopped for 10 months. His blood tests showed severe hyponatremia (121 mmol/L, reference 137-147 mmol/L, the same below), low levels of 8:00 a.m. cortisol (< 1 μg/dL, reference 5-25 μg/dL, the same below) and ACTH (2.2 ng/L, reference 7.2-63.3 ng/L, the same below), and normal thyroid function, sex hormone and prolactin. Meanwhile, both his lung cancer and gastric cancer remained under good control. Case 2 was a 66-year-old male with metastatic lung adenocarcinoma, who was treated with a new PD-1 inhibitor, HX008, combined with chemotherapy (clinical trial number: CTR20202387). After 5 months of treatment (7 doses in total), his cancer exhibited partial response, but his nausea and vomiting suddenly exacerbated, with mild dyspnea and weakness in his lower limbs. His blood tests showed mild hyponatremia (135 mmol/L), low levels of 8:00 a.m. cortisol (4.3 μg/dL) and ACTH (1.5 ng/L), and normal thyroid function. His thoracic computed tomography revealed moderate immune-related pneumonitis simultaneously. Case 3 was a 63-year-old male with locally advanced squamous cell carcinoma. He was treated with first-line sintilimab combined with chemotherapy, which resulted in partial response, with mild immune-related rash. His cancer progressed after 5 cycles of treatment, and sintilimab was discontinued. Six months later, he developed asymptomatic hypoadrenocorticism, with low level of cortisol (1.5 μg/dL) at 8:00 a.m. and unresponsive ACTH (8.0 ng/L). After being rechallenged with another PD-1 inhibitor, teslelizumab, combined with chemotherapy, he had pulmonary infection, persistent low-grade fever, moderate asthenia, and severe hyponatremia (116 mmol/L). Meanwhile, his blood levels of 8:00 a.m. cortisol and ACTH were 3.1 μg/dL and 7.2 ng/L, respectively, with normal thyroid function, sex hormone and prolactin. All of the three patients had no headache or visual disturbance. Their pituitary magnetic resonance image showed no pituitary enlargement or stalk thickening, and no dynamic changes. They were all on hormone replacement therapy (HRT) with prednisone (2.5-5.0 mg/d), and resumed the PD-1 inhibitor treatment when symptoms relieved. In particular, Case 2 started with high-dose prednisone [1 mg/(kg·d)] because of simultaneous immune-related pneumonitis, and then tapered it to the HRT dose. His cortisol and ACTH levels returned to and stayed normal. However, the other two patients' hypopituitarism did not recover. In summary, these cases demonstrated that the pituitary irAEs induced by PD-1 inhibitors could present as IAD, with a large time span of onset, non-specific clinical presentation, and different recovery patterns. Clinicians should monitor patients' pituitary hormone regularly, during and at least 6 months after PD-1 inhibitor treatment, especially in patients with good oncological response to the treatment.

Experiencia clínica con el uso ambulatorio de tolvaptan. Costes y efectividad en nueve casos / Clinical experience with Tolvaptan outpatient use. Cost and effectiveness in 9 cases

Resumen Introducción: La introducción de tolvaptan ha supuesto la principal novedad en el tratamiento de la hiponatremia en los últimos años. Objetivo: Describir la experiencia con tolvaptan en el Complejo Asistencial Universitario de León, España. Método: Estudio observacional retrospectivo de utilización ambulatoria de tolvaptan en un hospital de tercer nivel, de marzo de 2014 a agosto de 2017. Resultados: Fueron tratados con tolvaptan de forma ambulatoria nueve pacientes, 23.1 % alcanzó eunatremia en 24 horas. Posterior a la administración de tolvaptan se registró reducción en días de hospitalización (361 versus 70, p = 0.007), especialmente por hiponatremia (306 versus 49, p = 0.009). Conclusiones: El uso a largo plazo de tolvaptan parece ser seguro y se relaciona con descenso en los días de hospitalización.

Abstract Introduction: Tolvaptan introduction has constituted the main therapeutic novelty in the management of hyponatremia in recent years. Objective: To describe the experience with this drug at Complejo Asistencial Universitario de León, Spain. Method: Retrospective, observational study of tolvaptan outpatient use in a tertiary care hospital from March 2014 to August 2017. Results: A total of 9 patients were treated with tolvaptan in the outpatient setting. Eunatremia was reached in 24 h by 23.1%. After tolvaptan administration, a reduction in days of hospitalization was recorded (361 vs. 70; p = 0.007), especially in those days of hospitalization that were attributable to hyponatremia (306 vs. 49; p = 0.009). Conclusions: Long-term use of tolvaptan appears to be safe and is associated with a decrease in days of hospitalization.

Utility and Safety of Tolvaptan in Cirrhotic Patients with Hyponatremia: a Prospective Cohort Study

Abstract: Introduction and aim. Hyponatremia is common in patients with decompensated cirrhosis and is associated with increased mortality. Tolvaptan, a vasopressor V2 receptor antagonist, can increase free wáter excretion, but its efficacy and safety in cirrhotic patients remain unclear. Material and methods. We studied the usage and safety of tolvaptan in cirrhotic patients in a real-life, non-randomized, multicenter prospective cohort study. Forty-nine cirrhotic patients with hyponatremia were treated with tolvaptan 15 mg daily, and 48 patients not treated with tolvaptan in the same period served as controls. Improvement in serum sodium level was defined as an increase in serum sodium from < 125 to ≥ 125 mmol/L or from 125-134 to ≥ 135 mmol/L on day 7. Results. Twenty-three (47%) patients in the tolvaptan group and 17 (35%) in the control group had normal serum sodium on day 7 (p = 0.25). Serum sodium improved in 30 (61%) patients in the tolvaptan group and 17 (35%) patients in the control group (p = 0.011). Adverse events occurred in 46-47% of patients in both groups, and tolvaptan was not associated with worsened liver function. No patient with normal serum sodium on day 7 died within 30 days of treatment, whereas 16% of those with persistent hyponatremia died (p = 0.0019). Conclusion. In conclusion, short-term tolvaptan treatment is safe and can improve serum sodium level in cirrhotic patients with hyponatremia. Normalization of serum sodium level is associated with better survival.

SIADH secundario a adenocarcinoma seroso de ovario tratado con tolvaptán / SIADH secondary to serous ovarian adenocarcinoma treated with tolvaptan

La hiponatremia es la alteración electrolítica más frecuente en el medio hospitalario, y en un 30% de los casos se debe a un síndrome de secreción inapropiada de vasopresina (SIADH). El SIADH está descrito como cuadro paraneoplásico endocrinológico en múltiples tumores, entre los que excepcionalmente se encuentra el de ovario y las neoplasias ginecológicas en general. Presentamos un caso de SIADH paraneoplásico por un citoadenocarcinoma seroso de ovario de alto grado, estadio IV. Se trata del primer caso de SIADH crónico por cáncer de ovario tratado con Tolvaptán. En el presente caso el objetivo de eunatremia se alcanzó con una dosis baja de acuarético, lo que apoya la elevada sensibilidad, ya previamente documentada, de los SIADH tumorales al tratamiento con Tolvaptán.

Hyponatremia is the most common electrolyte disturbance in hospitals, and 30% of cases are due to syndrome of inappropriate secretion of antidiuretic hormone (SIADH). SIADH is described as an endocrine paraneoplastic syndrome in multiple tumors including, ovary and gynecological malignancies in general, although these are exceptional. We report a case of paraneoplastic SIADH for high-grade serous ovarian cystoadenocarcinoma stage IV. This is the first case of chronic SIADH for ovarian cancer treated with Tolvaptan. In this case the target of eunatremia was reached with a low dose of aquaretic, which supports the high sensitivity, as previously documented, of paraneoplasic SIADH to Tolvaptan.

The effect of NaCl 0.9% and NaCl 0.45% on sodium, chloride, and acid-base balance in a PICU population / Efeito do NaCl a 0,9% e do NaCl a 0,45% sobre o sódio, cloreto e equilíbrio ácido-base em uma população de UTIP

ABSTRACT OBJECTIVES: To study the effect of two intravenous maintenance fluids on plasma sodium (Na), and acid-base balance in pediatric intensive care patients during the first 24 h of hospitalization. METHODS: A prospective randomized controlled study was performed, which allocated 233 patients to groups: (A) NaCl 0.9% or (B) NaCl 0.45%. Patients were aged 1 day to 18 years, had normal electrolyte concentrations, and suffered an acute insult (medical/surgical). Main outcome measured: change in plasma sodium. Parametric tests: t-tests, ANOVA, X 2 statistical significance level was set at a = 0.05. RESULTS: Group A (n = 130): serum Na increased by 2.91 (±3.9) mmol/L at 24 h (p < 0.01); 2% patients had Na higher than 150 mmol/L. Mean urinary Na: 106.6 (±56.8) mmol/L. No change in pH at 0 and 24 h. Group B (n = 103): serum Na did not display statistically significant changes. Fifteen percent of the patients had Na < 135 mmol/L at 24 h. The two fluids had different effects on respiratory and post-operative situations. CONCLUSIONS: The use of saline 0.9% was associated with a lower incidence of electrolyte disturbances.

RESUMO OBJETIVO: Estudar o efeito de dois fluidos de manutenção intravenosos sobre o sódio (Na) plasmático e o equilíbrio ácido-base em pacientes de terapia intensiva pediátrica durante as primeiras 24 horas de internação. MÉTODOS: Foi feito um estudo controlado randomizado prospectivo. Alocamos aleatoriamente 233 pacientes para os grupos: (A) NaCl a 0,9% e (B) NaCl a 0,45%. Os pacientes com um dia a 18 anos apresentavam concentrações normais de eletrólitos e sofriam de insulto agudo (médico/cirúrgico). Principal resultado: variação no sódio plasmático. Testes paramétricos: teste t, Anova, qui-quadrado. O nível de relevância estatística foi estabelecido em a = 0,05. RESULTADOS: Grupo A (n = 130): o Na sérico aumentou 2,91 (± 3,9) mmol L-1 em 24 h (p < 0,01); 2% dos pacientes apresentaram Na acima de 150 mmol L-1. Concentração média de Na na urina: 106,6 (± 56,8) mmol L-1. Sem alteração no pH em 0 e 24 horas. Grupo B (n = 103): o Na sérico não apresentou alterações estatisticamente significativas; 15% dos pacientes apresentaram Na < 135 mmol L-1 em 24 h. Os dois fluidos tiveram efeitos diferentes sobre as situações respiratória e pós-operatória. CONCLUSÃO: O uso de solução fisiológica a 0,9% foi associado à menor incidência de distúrbios eletrolíticos.

Cerebral Salt Wasting Treated with Fludrocortisone in a 17-Year-Old Boy

Cerebral salt wasting is characterized by inappropriate natriuresis and volume contraction with associated cerebral pathology. It is distinct from the syndrome of inappropriate antidiuretic hormone secretion, which is characterized by inappropriate retention of free water. We report a patient with a porencephalic cyst who developed cerebral salt wasting. His initial treatment was supplementation of water and salt, which did not improve natriuresis or volume contraction. Fludrocortisone administration effectively managed the cerebral salt wasting.

A comparative study of the clinico-aetiological profile of hyponatremia at presentation with that developing in the hospital

Background & objectives: Hyponatremia is a common problem encountered in patients presenting with nonspecific symptoms. We undertook this study to investigate the clinical profile of patients with hyponatremia, the precipitating factors, the response to therapy and to compare, using these parameters, hyponatremia at presentation to that developing in the hospital. Methods: Seventy consecutive patients with serum sodium less than or equal to 125 mmol/l at presentation or at any time during hospital admission were identified and studied using a proforma. The severity of hyponatremia, therapy given and time taken for recovery were analysed. Results: The mean age of patients was 48.1 ± 16.1 yr. The mean serum sodium was 117.8 ± 6.4 mmol/l. Confusion, headache and malaise were the most common symptoms, two patients had seizures, and 20.0 per cent patients showed no clinical manifestations. Nausea was significantly (P<0.05) more common in patients presenting with hyponatremia. 22 patients (31.4%) developed hyponatremia during their stay in the hospital. 3 patients (4.3%) presented with hyponatremia which got worse during the admission period. Most had multiple precipitating factors, decreased intake being the most common (82.9%), followed by increased losses (65.7%) and miscellaneous factors (70.0%). Drugs, fluid overload and inappropriate Ryle's tube feeds more commonly precipitated hyponatremia in in-hospital patients. Time taken for recovery showed negative correlation with the serum sodium. Patients with in-hospital hyponatremia took significantly longer time to recover (P<0.05). Interpretation & conclusions: Decreased intake was found to be the commonest cause of hyponatremia, thus, ensuring adequate oral intake, especially in patients on liquid diet and in manual labourers, and correction of hyponatremia as soon as an abnormality is detected is important.

Manejo de ascitis refractaria e hiponatremia dilucional en pacientes con cirrosis / Management of refractory ascites and dilutional hyponatremia in cirrhotic patient

Ascites and dilutional hyponatremia are frequent conditions in cirrhotic patients and its occurrence has a worse prognosis. Thus, patients with ascites should generally be considered for referral for liver transplantation. The present article explores issues related with ascites classification and the treatment corresponding to each of the 3 degrees of ascites. Regarding refractory ascites, recommendations are included on the use of diuretics, large volume paracentesis with the administration of intravenous albumin and use of transjugular intrahepatic portosystemic shunt (TIPS). Finally, physiopathological aspects involved in the development of dilutional hyponatremia and vaptans treatment, are presented, which are aquaretics that selectively blockade vasopressin V2 receptors in the principal cells of the collecting ducts, being one of the most innovative pharmacological interventions for the management of hyponatremia in cirrhotic patients, in the recent years.

La ascitis e hiponatremia dilucional son complicaciones frecuentes en pacientes con cirrosis avanzada y su aparición implica un peor pronóstico. Por ello, los pacientes con ascitis deberían ser referidos para trasplante hepático. El presente artículo explora los aspectos relacionados con la clasificación de la ascitis y el tratamiento correspondiente a cada uno de los 3 grados de ascitis. En relación al manejo de la ascitis refractaria, se incluyen recomendaciones respecto a la eficacia del uso de diuréticos, paracentesis evacuadora radical con reposición de albúmina intravenosa y uso de cortocircuito porto-sistémico intrahepático (TIPS). Finalmente, se abordan los aspectos fisiopatológicos involucrados en el desarrollo de hiponatremia dilucional y el tratamiento con vaptanes, que son acuaréticos que bloquean selectivamente los receptores V2 de vasopresina en las células principales del túbulo colector, constituyendo una de las intervenciones farmacológicas más innovadoras en el manejo de la hiponatremia en cirrosis en los últimos años.

Hiponatremia grave como manifestación inicial de síndrome de Sheehan de diagnóstico tardío: caso clínico / Hyponatremia secondary to panhypopituirarism: report of one case

Hyponatremia is common among older people and its possible causes are not thoroughly investigated in this age group. We report a 69 years old female with a history of hypothyroidism in treatment that consulted for malaise, anorexia and a severe hyponatremia that required hospital admission. A new interrogation, revealed that the patient suffered an uterine hemorrhage in 1977, remaining with agalactia. She also referred asthenia since 1990. Her serum cortisol was below normal limits and a sella turcica magnetic resonance imaging revealed a pituitary atrophy. The patient was treated with cortisol and discharged in good conditions.

Hyponatraemia: etiology, management and outcome

To determine the etiology of hyponatraemia, the treatment instituted and the outcome of treatment in a tertiary care hospital setting. Case series. The Aga Khan University Hospital, Karachi, between January and June 2004. Case records of 220 patients admitted to the medical service were identified through computerized hospital patients' data. All patients >/= 15 years with a sodium level on admission of 10 mmol/L/ 24 hours in 17% patients. The average duration of stay was 4 days. The mortality was 6.8%. Medicines accounted for 30% cases of hyponatraemia, of which diuretics, angiotensin converting enzyme inhibitor [ACEI] and angiotensin receptor blockers [ARBs] were top of the list. Other causes were gastrointestinal in 25%, chest infection in 11% patients, depletional hyponatraemia in 10% patients, SIADH [Syndrome of Inappropriate Antidiuretic Hormone] in 6% patients, congestive cardiac failure and malignancy in 5% each and chronic liver disease in 3.6% patients. Hyponatraemia was seen more commonly in the elderly, major causes being gastrointestinal losses and use of drugs. Serum sodium correction should be less than 10 mmol/L/24 hours. The treatment plan be directed to correction of the underlying cause. Diagnosis of SIADH should be sought with appropriate investigation

Solução salina hipertônica para prevenção de insuficiência renal em pacientes com insuficiência cardíaca descompensada e hiponatremia / Hypertonic saline solution for renal failure prevention in patients with decompensated heart failure

FUNDAMENTO: Hiponatremia e fenômenos congestivos indicam mau prognóstico na insuficiência cardíaca descompensada. A ocorrência de insuficiência renal está associada a aumento do risco de morte. OBJETIVO: Avaliar a segurança e a eficácia da solução hipertônica em pacientes com insuficiência cardíaca descompensada para prevenção de insuficiência renal. MÉTODOS: Participaram do estudo pacientes com insuficiência cardíaca descompensada, congestão e hiponatremia. Além do tratamento padrão, os pacientes receberam solução salina hipertônica, e foram submetidos a avaliação tanto clínica como laboratorial. RESULTADOS: Foram incluídos 9 pacientes. A média das idades dos pacientes foi de 55 + 14,2 anos, sendo 5 (55,5 por cento) do sexo masculino e 4 (44,5 por cento), do feminino. Todos apresentavam classe funcional III-IV da New York Heart Association (NYHA), e 5 (55,5 por cento) recebiam dobutamina. Todos apresentaram creatinina inicial acima de 1,4 mg/dl. A tonicidade média da solução foi de 4,39 por cento + 0,018 por cento (2,5 por cento a 7,5 por cento) e a duração do tratamento foi de 4,9 dias + 4,1 dias (1 dia a 15 dias). Não houve efeitos adversos graves; em nenhum caso houve piora clínica ou distúrbios neurológicos; hipocalemia ocorreu em 4 (44,5 por cento) casos. A comparação das variáveis pré- e pós-tratamento demonstrou queda da uréia (105 mg/dl + 74,8 mg/dl vs. 88 mg/dl + 79,4 mg/dl; p = 0,03) e aumento do volume urinário (1.183 ml/dia vs. 1.778 ml/dia; p = 0,03); houve tendência a redução da creatinina (2,0 mg/dl + 0,8 mg/dl vs. 1,7 mg/dl + 1,0 mg/dl; p = 0,08). Apesar da elevação do valor do sódio (131 mEq/l + 2,8 mEq/l vs. 134 mEq/l + 4,9 mEq/l) e da redução do peso (69,5 kg + 18,6 kg vs. 68,2 kg + 17,1 kg), não houve diferença estatisticamente significante. CONCLUSÃO: O uso de solução salina hipertônica em pacientes com insuficiência cardíaca descompensada pode ser método terapêutico seguro e potencialmente relacionado a melhora...

BACKGROUND: Hyponatremia and congestive phenomena indicate a bad prognosis in decompensated heart failure. The occurrence of renal failure is associated to an increased death risk. OBJECTIVE: To evaluate the safety and efficacy of the hypertonic saline solution in patients with decompensated heart failure for renal failure prevention. METHODS: Patients with decompensated heart failure, congestion and hyponatremia participated in the study. In addition to the standard treatment, the patients received hypertonic saline solution and were submitted to clinical as well as laboratory assessment. RESULTS: Nine patients were enrolled in the study. Mean age was 55 + 14.2 years, being 5 male (55.5 percent) and 4 (44.5 percent) female patients. All of them presented functional class III-IV of the New York Heart Association (NYHA), and 5 (55.5 percent) received dobutamine. All of them presented initial creatinine > 1.4 mg/dl. The mean tonicity of the solution was 4.39 percent + 0.018 percent (2.5 percent to 7.5 percent) and the duration of treatment was 4.9 days + 4.1 days (1-15 days). There were no severe adverse effects; none of the patients presented clinical worsening or neurologic disorders; hypokalemia occurred in 4 cases (44.5 percent). The comparison of the variables before and after treatment showed a decrease in urea (105 mg/dl + 74.8 mg/dl vs. 88 mg/dl + 79.4 mg/dl; p = 0.03) and increase in the urinary volume (1,183 ml/day vs. 1,778 ml/day; p = 0.03); there was no tendency to creatinine decrease (2.0 mg/dl + 0.8 mg/dl vs. 1.7 mg/dl + 1.0 mg/dl; p = 0.08). Despite the elevation in sodium levels (131 mEq/l + 2.8 mEq/l vs. 134 mEq/l + 4.9 mEq/l) and weight decrease (69.5 kg + 18.6 kg vs. 68.2 kg + 17.1 kg), there was no statistically significant difference. CONCLUSION: The use of hypertonic saline solution in patients with decompensated heart failure can be a safe therapeutic method and potentially related to clinical improvement and renal...

Central myelinolysis in a patient with hyponatraemia

We present a case of a 50-year old man who developed mutism and a flaccid quadriparesis within 48 hours of presentation to hospital with severe hyponatraemia. A diagnosis of central pontine myelinolysis was made based on the clinical features and typical appearances on magnetic resonance imaging.

Revisión a partir de un caso clínico: encefalopatía perdedora de sal secundaria a asfixia por ahorcamiento / Review in relation to a clinical case: cerebral salt wasting secondary to asphyxia by hanging

Siendo la hiponatremia un trastorno frecuente en unidades de tratamiento intensivo en especial neuroquirúrgico, se deben tener en consideración las dos etiologías más frecuentes: SIADH y encepalopatía perdedora de sal. La importancia del diagnóstico diferencial radica en que la forma de aproximación diagnóstica y el tratamiento son diferentes, de tal modo que el manejo inadecuado puede intensificar la hiponatremia poniendo en riesgo vital al paciente. Aún así existen otras causas que pueden aumentar la natriuresis: infusiones prolongadas de soluciones salinas pueden provocar un balance negativo de Na y Cl, por internalización de canales Na/K ATP. Además non todos pacientes con EPS presentan niveles elevados de péptido natriurético cerebral. Por lo que aún está en discusión y no se tiene consenso absoluto respecto de su fisiopatología.

Correção dos desvios da concentração de sódio e potássio na infância / Treatment of the sodium and potassium disturbances in childhood

Este artigo tem por objetivo abordar os aspectos mais relevantes da correção das alterações da concentração de sódio e potássio na infância. Sao abordados inicialmente os distúrbios do sódio, hipernatremia e hiponatremia. A hipernatremia é considerada clinicamente relevante se a concentração de sódio exceder a 160 mEq/I e a hiponatremia rio caso de ser inferior a 120 mEq/1. Para a correção dos distúrbios do sódio devem ser levados em conta a volemia do paciente, o tempo de instalação do distúrbio e a intensidade do mesmo. É importante evitar as complicações decorrentes da correção inadequada dos desvios da concentração de sódio que são o edema cerebral, no caso da hipernatremia, e a mielinólise pontina central, em relação à hiponatremia. Os distúrbios do potássio são abordados na segunda parte do texto. Tanto na hiperpotassemia quanto na hipopotassemia é importante avaliar a distribuição do potássio entre os compartimentos intra e extracelular, a capacidade do rim em excretar esse ion e o conteúdo de potássio corporal total. As manifestações clínicas mais graves decorrentes dos desvios da concentração de potássio dizem respeito a seus efeitos sobre o miocárdio e outros tecidos excitáveis. A correção desses desvios deve priorizar a reversão dos efeitos eletrofisiológicos tanto da hiper quanto da hipopotassemia e, posteriorrnente, a normalização dos níveis séricos deste íon.

The aim of this paper is to establish some guidelines for the treatment of sodium and potassium disturbances in childhood. First, sodium disorders, such as hypernatremia and hyponatremia, are discussed. The hypernatremia is considered clinically relevant if the sodium concentration is above 160 mEq/1. Regarding hyponatremia, the inferior limit for sodium concentration is 120 mEq/1. The patient's extracellular fluid volume, the duration of the disturbance and the magnitude of the alteration in sodium levels must be taken into account in order to correct the hydroelectrolyte imbalance. It is important to avoid the complications due to an inadequate correction of sodium disarrangement such as brain edema in hypernatremia and central pontine myelinolysis in hyponatremia. The disorders of potassium metabolism are discussed in the second part of this article. For the appropriate treatment of hyperkalemia and also hypokalemia, it is important to evaluate the distribution of potassium between extra and intracellular fluid, its renal excretion and the total amount of this ion in the body. The most severe clinical features are due to the effect of potassium disorders on the cell membranes. The treatment of potassium disarrangement must emphasize the correction of electrophysiological effects of the hyperkalemia and also hypokalemia. The normalization of potassium levels should be obtained afterward.

Hemorragia subaracnoidea de causa aneurismática / Subarachnoid hemorrhage by aneurysmatic cause

La hemorragia subaracnoidea (HSA) por rotura aneurismática es responsable del 6 por ciento de los accidentes cerebrovasculares. Los aneurismas cerebrales se encuentran presentes en el 0.2 - 9.9 por ciento de la población y la tasa de sangrado es de 10 por 100.000 habitantes. La conferencia de consenso analizó los distintos esquemas de tratamiento y efectuó recomendaciones terapeúticas de acuerdo a los criterios de la medicina basada en la evidencia. Se determinaron los niveles de evidencia, de I a V. Los grados de recomendación fueron clasificados en: A, determinado por evidencias de nivel I, B por evidencia de nivel II, y C sugerido por evidencias de niveles III, IV y V. Las recomendaciones deben adaptarse a cada paciente. Sin embargo las de grado A constituyen estándares para el tratamiento. La gravedad de los pacientes al ingreso fue evaluada sobre la base de la escala de Hunt y Hess. Se analizaron sucesivamente: las medidas de tratamiento general, la prevención y tratamiento del vasoespasmo cerebral, el diagnóstico y tratamiento de la hiponatremia y la prevención de las convulsiones

Hiponatremia e hipokalemia graves, recientes, asociadas a hidroclorotiazida, enalaprila y citalopram: caso clínico / Severe and recent hyponatremia and hypokalemia associated to the use of hydrochlorothiazide, enalapril and cytalopram: clinical case

We report a 72 years old hypertensive female, treated with enalapril 10 mg/day and hydrochlorothiazide 25 mg/day during three years. She presented a depressive disorder and cytalopram was prescribed in a dose of 10 mg/day. Two weeks before admission, a serum electrolyte analysis disclosed normal results and the cytalopram dose was increased to 20 mg/day. The patient was admitted with a hyponatremic encephalopathy with a plasma sodium of 100 mEq/L and a plasma potassium of 2.0 mEq/L. cytalopram, enalapril and hydrochlorothiazide were discontinued, hypertonic NaCl and KCl were administered. The patient had a favorable evolution with a remarkable improvement of her symptoms