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VOLUME 17 , ISSUE 1 ( February, 2013 ) > List of Articles

RESEARCH ARTICLE

Risk factors for hospital-acquired hypernatremia among critically ill medical patients in a setting utilizing a preventive free water protocol: Do we need to do more?

Georgi Abraham, Sundar Varun, Emmanuel Bhaskar, Anandabhavan Sukumaramenon Arunkumar, Muthiah Kothandaramanujam Renuka

Keywords : Critical care, hospital, hypernatremia, mortality

Citation Information : Abraham G, Varun S, Bhaskar E, Arunkumar AS, Renuka MK. Risk factors for hospital-acquired hypernatremia among critically ill medical patients in a setting utilizing a preventive free water protocol: Do we need to do more?. Indian J Crit Care Med 2013; 17 (1):28-33.

DOI: 10.4103/0972-5229.112157

License: CC BY-ND 3.0

Published Online: 01-05-2014

Copyright Statement:  Copyright © 2013; The Author(s).


Abstract

Context: Hospital-acquired hypernatremia (HAH) is a frequent concern in critical care, which carries high mortality. Aims: To study the risk factors for HAH in settings that practice a preventive protocol. Settings and Design: Two tertiary-care hospitals. Prospective observational study design. Materials and Methods: Patients aged >18 years admitted for an acute medical illness with normal serum sodium and need for intensive care >48 h formed the study population. Details of the basic panel of investigations on admission, daily electrolytes and renal function test, sodium content of all intake, free water intake (oral, enteral and intravenous) and fluid balance every 24 h were recorded. Individuals with serum Na 140-142 meq/l received 500 ml of free water every 24 h, and those with 143-145 meq/l received 1000 ml free water every 24 h. Statistical Analysis Used: Risk factors associated with HAH was analysed by multiple logistic regression. Results: Among 670 study participants, 64 (9.5%) developed HAH. The median duration of hypernatremia was 3 days. A total 60 of 64 participants with HAH had features of renal concentrating defect during hypernatremia. Age >60 years ( P = 0.02), acute kidney injury (AKI) on admission ( P = 0.01), mechanical ventilation ( P = 0.01), need for ionotropes ( P = 0.03), worsening Sequential Organ Failure Assessment (SOFA) score after admission ( P < 0.001), enteral tube feeds ( P = 0.002), negative fluid balance ( P = 0.02) and mannitol use ( P < 0.001) were the risk factors for HAH. Mortality rate was 34.3% among hypernatremic patients. Conclusions: The study suggests that administration of free water to prevent HAH should be more meticulously complied with in patients who are elderly, present with AKI, suffer multi-organ dysfunction, require mechanical ventilation, receive enteral feeds and drugs like mannitol or ionotropes.


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  1. Hoorn EJ, Betjes MG, Weigel J, Zietse R. Hypernatraemia in critically ill patients: Too little water and too much salt. Nephrol Dial Transplant 2008;23:1562-8.
  2. Adrogué HJ, Madias NE. Hypernatremia. N Engl J Med 2000;342:1493-9.
  3. Tisdall M, Crocker M, Watkiss J, Smith M. Disturbances of sodium in critically ill adult neurologic patients: A clinical review. J Neurosurg Anesthesiol 2006;18:57-63.
  4. Palevsky PM, Bhagrath R, Greenberg A. Hypernatremia in hospitalized patients. Ann Intern Med 1996;124:197-203.
  5. Polderman KH, Schreuder WO, Strack van Schijndel RJ, Thijs LG. Hypernatremia in the intensive care unit: An indicator of quality of care? Crit Care Med 1999;27:1105-8.
  6. Milionis HJ, Liamis G, Elisaf MS. Hypernatremia in hospitalized patients: A sequel of inadvertent fluid administration. Arch Intern Med 2000;160:1541-2.
  7. Vincent JL, Moreno R, Takala J, Willatts S, De Mendonça A, Bruining H, et al. The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. Intensive Care Med 1996;22:707-10.
  8. Darmon M, Timsit JF, Francais A, Nguile-Makao M, Adrie C, Cohen Y, et al. Association between hypernatraemia acquired in the ICU and mortality: A cohort study. Nephrol Dial Transplant 2010;25:2510-5.
  9. Liamis G, Tsimihodimos V, Doumas M, Spyrou A, Bairaktari E, Elisaf M. Clinical and laboratory characteristics of hypernatraemia in an internal medicine clinic. Nephrol Dial Transplant 2008;23:136-43.
  10. Aiyagari V, Deibert E, Diringer MN. Hypernatremia in the neurologic intensive care unit: How high is too high? J Crit Care 2006;21:163-72.
  11. Funk GC, Lindner G, Druml W, Metnitz B, Schwarz C, Bauer P, et al. Incidence and prognosis of dysnatremias present on ICU admission. Intensive Care Med 2010;36:304-11.
  12. Lindner G, Funk GC, Schwarz C, Kneidinger N, Kaider A, Schneeweiss B, et al. Hypernatremia in the critically ill is an independent risk factor for mortality. Am J Kidney Dis 2007;50:952-7.
  13. Stelfox HT, Ahmed SB, Khandwala F, Zygun D, Shahpori R, Laupland K. The epidemiology of intensive care unit-acquired hyponatraemia and hypernatraemia in medical: Surgical intensive care units. Crit Care 2008;12:R162.
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