The lowest sodium you've ever seen

[DrQuinn]

As the title reads, what is the lowest sodium you guys have ever seen? I am toying with the idea of writing up a case report of an internal medicine attending who presented to the ED with AMS and resp distress... he had told his wife he felt like he had "pneumonia" and taken Levaquin 750 for a week... well he's on BiPAP for like 3 hours then needs RSI. Anywho, his labs come back with a Na of 106 and a chloride of 66. That's the absolute lowest I've ever seen... and am just testing the waters to see how this ranks amongst my colleagues (beat all of ya's in the "hall of fame thread").

BTW, that was 4 weeks ago and the guy is still in the MICU.

Q, DO

---

Members don't see this ad.

 

[12R34Y]

Years ago at the University of iowa we saw a guy who drank several liters of water (unknown exactly) .........psychogenic polydypsia........his sodium was around 100 i believe. he was unconcious and seizing and quite ill, but its been probably 10 years and i don't remember anything other than is sodium being very very low. I don't think it was below 100 though.

later

 

[docB]

I just saw a lady the other day with 106. She was altered (of course) and the husband couldn't give a good history. I don't know what happened to her. She also had a slichtly elevated troponin.

 

[ERMudPhud]

I've seen double digits a few times. Usually when someone draws of a line running 1/2NS without wasting some blood first.

 

[A little elf]

were these pts glucose levels within norm range? Damn, those are low sodiums if there is absolutely no pseudohyponatremia involved

elf

 

[docB]

were these pts glucose levels within norm range? Damn, those are low sodiums if there is absolutely no pseudohyponatremia involved

elf

As I recall my patient's glu was ~250 or so.

 

[margaritaboy]

As you mentioned, you've trumped my lowest sodium ever of 107. Congrats.

I'd certainly read your case report. Anyone with that kind of lab value is definantly worth reading about.

 

[southerndoc]

98 in my own step-grandmother. Surprisingly she wasn't seizing. She was comatose though.

 

[RuralMedicine]

I think the key with sodium is the rate of rise or fall to some extent more than the actual number. I inherited a patient from an outside hospital who initially presented with gastroenteritis and a sodium of 104 she was actually fine then (nursing notes document the uno game she and her 5 year old daughter were playing) about 12 hours later she was seizing (Repeat sodium 154) and transferred to the ICU at our local hospital. Someone had decided to give 3% NaCl without really looking at the correction. Central Pontine Myelinosis and subsequent PVS. Her family after much deliberation finally opted to withdraw support and she died a little less than 24 hours after that. I think we as physicians tend to be rather cavalier about Na correction (and other things as well but this is the topic) but we really can burn our patients when we get sloppy.

I think the lowest sodium I've seen is 95 and that was an infant who had been given bottles of water when the family ran out of formula. Sadly it's not an uncommon occurrence in our area.

Quinn, as far as publications I presume the angle you're taking is the pneumosepsis and SIADH (and possible adrenal insufficiency) leading to the hyponatremia and there seems to be literature on that association. Your vignette raises some other questions for me though: Did your patient drink alcohol (beer potomania was his sodium chronically on the lower side so the CNS effects were less?). Is there an underlying Lung CA that complicates things? Was he intubated for respiratory failure (and since you say he was on BiPAP for awhile I presume he was judged to be protecting his own airway and had a clear sensorium on presentation) which sounds reasonable or was it more of a mental status and airway protection issue. His long ICU course makes me of course presume this was Pneumosepsis and then he went the severe sepsis/ARDS route. Was adrenal insufficiency an issue? (Random cortisol? Cosyntropin Stim?) How intact is he now after his month course in the ICU?

 

[lloydchristmas]

I think the lowest sodium I've seen is 95 and that was an infant who had been given bottles of water when the family ran out of formula. Sadly it's not an uncommon occurrence in our area.

Ughh... that brought tears to my eyes. What a horrible, easily preventable thing.

 

[DrQuinn]

Quinn, as far as publications I presume the angle you're taking is the pneumosepsis and SIADH (and possible adrenal insufficiency) leading to the hyponatremia and there seems to be literature on that association. Your vignette raises some other questions for me though: Did your patient drink alcohol (beer potomania was his sodium chronically on the lower side so the CNS effects were less?). Is there an underlying Lung CA that complicates things? Was he intubated for respiratory failure (and since you say he was on BiPAP for awhile I presume he was judged to be protecting his own airway and had a clear sensorium on presentation) which sounds reasonable or was it more of a mental status and airway protection issue. His long ICU course makes me of course presume this was Pneumosepsis and then he went the severe sepsis/ARDS route. Was adrenal insufficiency an issue? (Random cortisol? Cosyntropin Stim?) How intact is he now after his month course in the ICU?

Actually, it was NOT SIADH, which is why it is so intriguing, even to my MICU attending and to all the other IM guys at my hospital. His urine Na+ was low, his urine osmo was low too.

It took me like 6 days to correct his sodium.

Cortisol levels were normal.

He was off the vent for a while but had some AMS, neuro didnt' evaluate him while he was unintubated (family demanded a family friend neurologist (since the guy is an IM attending) and the family neurologist didnt' round on him everyday). That's why you don't mix friendsihp and medical care.

He's still in the unit and i am checking on him periodically.

I actually should just grab the attending and pick his brain... (this is the same attending who said no NS for initial fluid resus in DKA, no Levaquin, and PF ratios on all patients).

I do check PF ratios on all vented patients now but I never did it before him, its actually pretty useful.

Q, DO