title: Treatment of Hyponatremia in Patients with Acute Neurological Injury.
abstract: BACKGROUND
  Little data exist regarding the practice of sodium management in acute neurologically injured patients. This study describes the practice variations, thresholds for treatment, and effectiveness of treatment in this population.
  
  
  METHODS
  This retrospective, multicenter, observational study identified 400 ICU patients, from 17 centers, admitted for ≥48 h with subarachnoid hemorrhage (SAH), traumatic brain injury (TBI), intraparenchymal hemorrhage, or intracranial tumors between January 1, 2011 and July 31, 2012. Data collection included demographics, APACHE II, Glascow Coma Score (GCS), serum sodium (Na+), fluid rate and tonicity, use of sodium-altering therapies, intensive care unit (ICU) and hospital length of stay, and modified Rankin score upon discharge. Data were collected for the first 21 days of ICU admission or ICU discharge, whichever came first. Sodium trigger for treatment defined as the Na+ value prior to treatment with response defined as an increase of ≥4 mEq/L at 24 h.
  
  
  RESULTS
  Sodium-altering therapy was initiated in 34 % (137/400) of patients with 23 % (32/137) having Na+>135 mEq/L at time of treatment initiation. The most common indications for treatment were declining serum Na+(68/116, 59 %) and cerebral edema with mental status changes (21/116, 18 %). Median Na+treatment trigger was 133 mEq/L (IQR 129-139) with no difference between diagnoses. Incidence and treatment of hyponatremia was more common in SAH and TBI [SAH (49/106, 46 %), TBI (39/97, 40 %), ICH (27/102, 26 %), tumor (22/95, 23 %); p = 0.001]. The most common initial treatment was hypertonic saline (85/137, 62 %), followed by oral sodium chloride tablets (42/137, 31 %) and fluid restriction (15/137, 11 %). Among treated patients, 60 % had a response at 24 h. Treated patients had lower admission GCS (12 vs. 14, p = 0.02) and higher APACHE II scores (12 vs. 10, p = 0.001). There was no statistically significant difference in outcome when comparing treated and untreated patients.
  
  
  CONCLUSIONS
  Sodium-altering therapy is commonly employed among neurologically injured patients. Hypertonic saline infusions were used first line in more than half of treated patients with the majority having a positive response at 24 h. Further studies are needed to evaluate the impact of various treatments on patient outcomes.
authors.affiliation: Barnes Jewish Hospital, Washington University St. Louis, St. Louis, MO, USA.
authors.forename: Theresa
authors.initials: T
authors.lastname: Human
authors.affiliation: University of Kentucky, Lexington, KY, USA.
authors.forename: Aaron M
authors.initials: AM
authors.lastname: Cook
authors.affiliation: Saint Louis University Hospital, St. Louis, MO, USA.
authors.forename: Brian
authors.initials: B
authors.lastname: Anger
authors.affiliation: University of Virginia Health System, Charlottesville, VA, USA.
authors.forename: Kathleen
authors.initials: K
authors.lastname: Bledsoe
authors.affiliation: Yale-New Haven Hospital, New Haven, CT, USA.
authors.forename: Amber
authors.initials: A
authors.lastname: Castle
authors.affiliation: Memorial University Center, Savannah, GA, USA.
authors.forename: David
authors.initials: D
authors.lastname: Deen
authors.affiliation: Johns Hopkins Hospital, Baltimore, MD, USA.
authors.forename: Haley
authors.initials: H
authors.lastname: Gibbs
authors.affiliation: New York Presbyterian Hospital, New York, NY, USA.
authors.forename: Christine
authors.initials: C
authors.lastname: Lesch
authors.affiliation: Hartford Hospital, Hartford, CT, USA.
authors.forename: Norah
authors.initials: N
authors.lastname: Liang
authors.affiliation: Spectrum Health, Grand Rapids, MI, USA.
authors.forename: Karen
authors.initials: K
authors.lastname: McAllen
authors.affiliation: Jackson Memorial Hospital, Miami, FL, USA.
authors.forename: Christopher
authors.initials: C
authors.lastname: Morrison
authors.affiliation: Detroit Receiving Hospital, Detroit, MI, USA.
authors.forename: Dennis
authors.initials: D
authors.lastname: Parker
authors.affiliation: University of Tennessee, Knoxville, TN, USA.
authors.forename: A Shaun
authors.initials: AS
authors.lastname: Rowe
authors.affiliation: University of North Carolina, Chapel Hill, NC, USA.
authors.forename: Denise
authors.initials: D
authors.lastname: Rhoney
authors.affiliation: University of Cincinnati-University Hospital, Cincinnati, OH, USA.
authors.forename: Kiranpal
authors.initials: K
authors.lastname: Sangha
authors.affiliation: University of Chicago Medical Center, Chicago, IL, USA.
authors.forename: Elena
authors.initials: E
authors.lastname: Santayana
authors.affiliation: Via Cristi, Wichita, KS, USA.
authors.forename: Scott
authors.initials: S
authors.lastname: Taylor
authors.affiliation: University of Illinois-Chicago, Chicago, IL, USA.
authors.forename: Eljim
authors.initials: E
authors.lastname: Tesoro
authors.affiliation: Virginia Commonwealth of Virginia, Medical College of Virginia, Richmond, VA, USA. gbrophy@vcu.edu.
authors.forename: Gretchen
authors.initials: G
authors.lastname: Brophy
mesh_terms: D000328:Adult; D000368:Aged; D000070642:Brain Injuries, Traumatic / Q000097:blood / Q000150:complications / Q000628:therapy*; D001932:Brain Neoplasms / Q000097:blood / Q000150:complications / Q000628:therapy*; D003422:Critical Care / Q000379:methods*; D005260:Female; D006801:Humans; D007010:Hyponatremia / Q000097:blood / Q000209:etiology / Q000628:therapy*; D007362:Intensive Care Units; D020300:Intracranial Hemorrhages / Q000097:blood / Q000150:complications / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D012189:Retrospective Studies; D012462:Saline Solution, Hypertonic / Q000627:therapeutic use*; D012965:Sodium Chloride / Q000008:administration & dosage
chemical_list: D012462:Saline Solution, Hypertonic; D012965:Sodium Chloride
keywords: Hyponatremia; Intensive care unit; Intracerebral hemorrhage; Intracranial tumor; Neurocritical care; Subarachnoid hemorrhage; Traumatic brain injury