Urgent C/S profound hyponatremia

[24858]

Spinal vs general. Thoughts?

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[abolt18]

Spinal vs general. Thoughts?

What's profound? 124? Or 114? Or 104?

 

[Iso4ane]

And for how long? And do we know why? Hypo, Hyper, Euvolemic? Hypothetically speaking.

 

[OneFellSwoop]

Lets go with 115-120 range, what would be your preferred method of anesthesia and why?

What makes it urgent? Could it wait for 12-24h while IM stabilizes? If needs to go, then, hope for 1: good surgeon, 2: her first c section, 3: adequate hgb and then:
A: If Mental status is Normal, SAB, gentle IVF with LR and monitor mental status. Neo gtt and rely on pressor rather than fluids to maintain BP. SAB is Tried and true method for c section and not aware of any reason other than AMS to avoid this method. (Similar to TURP as SAB is preferred so you can monitor mental status during procedure)
B: if AMS and won’t cooperate then GETA/RSI etc, again rely on pressor more than fluids for BP
C: explain increased risk of issues related to low Na to family and patient (if able).

 

[chocomorsel]

Lets go with 115-120 range, what would be your preferred method of anesthesia and why?

That’s profound. I need her asleep and I need to be pushing some Sodium Bicarb first if less than <110. I mean she could be getting to seizure zone from Cerebral Edema. What’s her GCS neuro exam? Is this because of Preeclampsia and water retention?
What is the cause? If she seizes I want her asleep and on Propofol hyperventilating her.

 

[deleted162650]

Can you give me one good reason why not to do this under spinal like any other section?

 

[deleted162650]

I was curious whether a spinal would be contraindicated in profound hyponatremia due to possible cerebral edema.

Please explain the mechanistic underpinnings of your concern.

 

[sevo00]

why would you used bicarb?

because it has a higher concentration of sodium than hypertonic saline

 

[OneFellSwoop]

honestly, this sounds subacute and incidental, if that’s truly the case then I don’t think I’d go trying to correct the Na while also doing a c section. Both will have dramatic effects on volume and solute status making correction in this moment extremely difficult and unpredictable. LR is what I use 99% of the time and is why I would continue to use it in this situation. The worse thing you can do in this situation is over correct.

 

[sevo00]

Interesting thank you. Would you then be concerned with myelinolysis?

sodium bicarb is like 8% sodium compared to hypertonic saline at 3%. But to answer your question it seems like this is acute hypo and not chronic so would be less concerned about myelinolysis

 

[Lidolover]

I would do CSE if time allows and the reason is that I would use smaller spinal dose given hyponatremia (this is my own non-evidence based theory given the mechanism of action. If pt is asymptomatic, I would not correct aggressively the sodium intraop as mentioned above. I would just slightly underresuscitate lol

 

[chocomorsel]

honestly, this sounds subacute and incidental, if that’s truly the case then I don’t think I’d go trying to correct the Na while also doing a c section. Both will have dramatic effects on volume and solute status making correction in this moment extremely difficult and unpredictable. LR is what I use 99% of the time and is why I would continue to use it in this situation. The worse thing you can do in this situation is over correct.

Depends on how severe, and how acute And the OP is being vague about that fact.
Severe <110 that is acute and symptomatic needs immediate treatment. And not with LR.
This sounds like water retentions from Preclqmpsia hence the Mag hint from the OP.

 

[MirrorTodd]

Basically same as Lido. If pt is asymptomatic, then you don't need to correct aggressively. Further if they are asymptomatic, then it's unlikely to be an acute process given how big of a drop it is to get to sub 120 levels

 

[IMGASMD]

Prop sux tube. We can do any case with that, no?

I want to know “any” neuro exam, mental status. Does the patient pass your eyeball exam? Certainly don’t want patient be seizing in the middle of the c-section.

 

[abolt18]

Spinal vs general. Thoughts?

I'm thinking spinal if normal mental status. LR for fluids. With a sodium content of 130mEq in the LR, I'm not worried that I'm going to correct too quickly with the usual 1-2L LR given during a C/S.

Obviously this patient is most likely fluid overloaded in the setting of this hyponatremia so I appreciate the above comments about avoiding excessive fluids in this setting and leaning on phenylephrine or NE in this setting.

If there was any chance of delaying a few days in attempt to correct Na, I'd prefer that for the sake of the patient.

 

[vector2]

Pregnant women don’t show up to L&D with a Na of 115 because simply because they’ve been taking some lasix for their puffy ankles. If it’s not emergent, do some work up, get MFM on board, and punt for a few days until the etiology and tx plan is clear.

 

[Beeftenderloin]

Assuming this has to go now and patient has normal GCS would proceed with spinal. Would use LR as fluid of choice since it’s Na of 130meq (relative to normal saline’s Na of 154meq) is less likely to dangerously overcorrect and cause osmotic demyelination. Would lean more on pressors than fluid as other have stated for same reasons. If patient seizes or has acute change in mental status that isn’t responsive to neo/ephedrine I’ll slowly push an amp of sodium bicarb (one 50cc amp of bicarb is roughly equivalent to 100cc of 3% saline). Along with ABCs etc (will that fly on oral boards?).

If this isn’t urgent admit to L&D (MFM if you’ve got it), have medicine see them and fix their Na. Then same plan sans hyponatemic seizure.

 

[woopedazz]

I suspect their Cl was also low?

Moderate-severe subacute hyponat in the final week(s) of pregnancy is relatively common. Oxytocin/ADH combined with massive fluid intake. They're almost always oedematous and require fluid restriction and it sorts them right out.

 

[abolt18]

Assuming this has to go now and patient has normal GCS would proceed with spinal. Would use LR as fluid of choice since it’s Na of 130 (relative to normal saline’s Na of 145) is less likely to dangerously overcorrect and cause osmotic demyelination. Would lean more on pressors than fluid as other have stated for same reasons. If patient seizes or has acute change in mental status that isn’t responsive to neo/ephedrine I’ll slowly push an amp of sodium bicarb (one 50cc amp of bicarb is roughly equivalent to 100cc of 3% saline). Along with ABCs etc (will that fly on oral boards?).

If this isn’t urgent admit to L&D (MFM if you’ve got it), have medicine see them and fix their Na. Then same plan sans hyponatemic seizure.

NS is 154mEq of both Na+ and Cl-.

 

[Beeftenderloin]

NS is 154mEq of both Na+ and Cl-.

Yes it is. Nice catch.

 

[coffeebythelake]

Interesting thank you. Would you then be concerned with myelinolysis?

Yes that is a concern and your aggressiveness in correcting sodium would have to be balanced with the acute, subacute or chronic nature of the hypoNa and if the patient had any ssxsymptoms of cerebral edema

 

[Hork Bajir]

for those worried about overly rapid correction, the plan is easy: place an art line, send an ABG q30 min, and if the sodium is rising faster than your liking give a 250-500cc bolus of d5 or 1/2NS. Wash rinse repeat

 

[chocomorsel]

So what the hell happened after all?

 

[abolt18]

My concern would by herniation in the setting of elevated ICP

My thinking was, you're using a tiny needle and not really removing fluid. This risk seemed small to negligible in my mind but I may be way off base.

 

[Ronin786]

Some of the suggestions in this thread would send a nephrologist early to their grave.

Without knowing if she's symptomatic or evidence that this is acute vs chronic, your management is going to be limited. If we pretend you get a 2AM page with a profoundly hyponatremic patient with fetal decel, do your best to figure out if she's symptomatic and do the least you possibly can to make things worse (I.e a spinal or even CSE to keep your hemodynamics as smooth as possible). Keep your fluids as minimal as possible. Send to ICU post-op.

Hyponatremia

CONTENTS Rapid Reference 🚀 Diagnosis & symptoms Causes Evaluation Lab panel Isotonic fluid challenge Risk stratification Initial treatment (e.g., in ED) Initial hyponatremia package Target rate of increase Subsequent therapeutic strategy Rapidly reversible cause: DDAVP clamp DDAVP clamp-bolus...

emcrit.org

 

[nimbus]

Maybe more of a theoretical concern. Hyponatremia=/=increased ICP. They may occur together but there’s no correlation or causal relationship.

The relationship between serum sodium and intracranial pressure when using hypertonic saline to target mild hypernatremia in patients with head trauma

Limited data suggest mild hypernatremia may be related to lower intracranial pressure (ICP) in patients with traumatic brain injury (TBI). The practice at the study center has been to use hypertonic saline (HTS) to generate a targeted serum sodium of ...

www.ncbi.nlm.nih.gov

https://annalsofintensivecare.springeropen.com/track/pdf/10.1186/s13613-019-0574-z.pdf

 

[nimbus]

Gotcha, figured with the cerebral swelling there would be an auto correlation with increased icp, thanks for the correction

This paper explains why ICP doesn’t rise as expected in hypo-osmolar states.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5762960/pdf/main.pdf

 

[deleted162650]

Cerebral edema occurs in the setting of a rapid decrease in serum osmolarity. If the change is subacute, (over >48H), the brain is able compensate, and does not swell. The rate of change is what matters, not the absolute Na level.

If the patient is talking to you, they don’t have clinically significant cerebral edema that is at risk of herniation from an SAB anyways.

Also remember that an SAB with a 25g pencil point needle is not the same as a diagnostic LP with a larger bore cutter and removal of a decent volume of CSF.

 

[coffeebythelake]

It appears I am the only one concerned with a spinal in patients with profound hyponatremia. Honestly I can say I have encountered many instances of having to consider spinal anesthesia in profoundly hyponatremic patients.

If the patient is profoundly hyponatremic because she decided to drink 5 gallons of water in a water guzzling contest (Woman dies after being in water-drinking contest) then yes she might have cerebral edema and increased ICP, and pertinent ssx that reflect that.

 

[Southpaw]

As you posted your reasoning in another thread, I’ll address it here.

A Na of 115-120 is profound and beyond the typical hyponatremia of pregnancy related to increased levels of ADH and plasma volume. A Na that low deserves workup and if you’re in any sort of decent facility everyone would recognize that and appreciate it.

This could be severe preeclampsia or simply severe dilutional, or both. Either way, and since you don’t have prior labs, you determine your direction by the patients clinical status and the time available. Are they stable? Are they completely obtunded? Almost assuredly they’re stable, because this is almost always chronic and the body has had time to adjust (so no cerebral edema....). And since I don’t recall you saying, I’ll assume this patient has a normal GCS, so I’m proceeding with a spinal.

There’s no evidence you’ve presented showing a spinals effect on Na levels. You seem to be concerned about edema and herniation, though if you’re an anesthesiologist you’ve probably never seen the latter (from hypoNa....) and it’s debatable if you’ve seen the former (from hypoNa....) as it’s almost always chronic or at least subacute (not over 24hrs...) and the body has had time to adjust.

In my mind, a CS always starts at spinal anesthesia until proven otherwise. It is the default anesthetic for a CS. You have yet to address why this course needs deviation. It’s still a spinal.

I’m putting a 25g needle in the space of a presumed normal appearing parturient. I’m not concerned about herniation as I don’t see clinical evidence of increased ICP and I’m not taking CSF volume off.

You also didn’t address why the CS was urgent. Do you even have time for a spinal? What has the OB said? Is this a terminal decel? Or is it 5p at the end of a busy clinic day for the OB and they want to get it done and go home and you have a pretty decent appearing strip? Is this an abruption? Concern of uterine rupture? PreE? What’s the rest of the picture?

For me, I ignore the hypoNa in an urgent scenario because the patient appears normal. If this is truly urgent (after discussion w OB...) and there’s no time for a workup this is a spinal unless there’s no time for one, in which case it’s GA. In other words, it’s like just about every other OB scenario.

If theres time for a workup, then in a Na that low I would hope the OB would’ve started it after discussion with you.

 

[Southpaw]

This is a spinal unless there’s no time for one? How in the world would you know that this is not acute on chronic hyponatremia? You’re right I’ve never seen brain herniation, coma, from profound hyponatremia.
if this is urgent and the patient has hyponatremia of unknown duration (at a minimum since her first set of pregnancy labs) then I wouldn’t be comfortable performing a spinal anesthetic on a patient on unknown brain swelling. I just wouldn’t. I haven’t run across this scenario since I’ve been an attending, and doubt I ran across this as a resident. You make it seem like you’ve seen this scenario daily and I should be confident that doing an intrathecal anesthetic is not a big deal.

Then do GA. Quit wringing your hands and clutching your pearls over it. As you presented the case is urgent. So get on with it. No one in that room is suffering (except maybe the patient's birth plan.....) if you do GA and know what you're doing.

I don't make it seem like this is a scenario we run into daily. We don't. There are lots of scenarios we don't see daily, monthly, or even yearly but that doesn't in itself make them complex and it doesn't force one to go down some super complex decision making pathway. I am presenting you with a normal, well reasoned way of thinking through this not terribly complex scenario from the viewpoint of an anesthesiologist.

I've told you why I'd do a spinal. I'd defend my answer on the oral exam if presented with that scenario. However, you can just as easily defend GA or doing the case with an epidural or a CSE. That's part of the beauty of anesthesia.

You've not convinced me away from my default anesthetic for CS. You've given no details on the clinical exam for this patient and you've also given no details on why this case is urgent. Those are extremely important details that are helpful in the development of a plan for this patient. My guess is that you've avoided further details by design. Regardless, I've given you my reasoning and my plan based on very limited information.

 

[Southpaw]

“The most striking and severe symptoms of HNE are related to the compression of the brain parenchyma against the rigid skull. In severe cases, brain herniation and death often occurs preceded by seizures and coma. As discussed earlier, these symptoms often occur during acute and profound hyponatremia because the brain has no or little time to adjust to hypo- osmolality. “

“Parturients with intracranial lesions are often assumed to have increased intracranial pressure (ICP), and the risk of herniation is frequently cited as a contraindication to neuraxial anesthesia.11–18 To care for these parturients and ascertain which of them can safely undergo spinal or epidural analgesia or anesthesia;19–21 we must understand the factors that contribute to clinically significant brain tissue shifts (i.e., brain herniation), such as increased ICP, brain edema, or hydrocephalus. Anesthesiologists can then most effectively weigh the relative risks and benefits of neuraxial anesthesia for these patients and engage in productive multidisciplinary peripartum planning.”

“
Because epidural placement always entails the risk of a dural puncture even in the experienced hands,71 it is never a completely safe alternative if a spinal anesthetic is contraindicated. This is especially true because when inadvertent dural puncture does occur during epidural placement, it is with a much larger gauge needle. Conversely, even a small-gauge spinal needle causes a dural tear and potential CSF leak, so spinal anesthesia is not without risk when seeking to avoid significant loss of CSF.”

“In summary, there are no published randomized controlled trials comparing the safety of neuraxial versus general anesthesia in patients with intracranial lesions, nor are there likely to be any. As with all published case reports, there is an inherent bias in the cases that are chosen for reporting. Therefore, for each parturient with an intracranial lesion, there needs to be a collaborative team discussion, which includes anesthesia, obstetric, neurologic, and neonatology experts, and a rational exploration of the likelihood of increased ICP and the potential for related negative effects. To make recommendations on the proper anesthetic choice for any individual case, it is necessary to evaluate the relative contribution of each of the identified risks, in both severity and likelihood, and weigh them against the potential benefits.”

You're not telling us anything we don't already know. All of your quotes are pretty basic stuff for the anesthesiologist, and it's stuff you should already know as an attending. I don't know why you're posting it. What specifically about this patient, other than Na 115-120, should put the laryngoscope in my hand?

 

[coffeebythelake]

I think it is also worth mentioning, (which everyone should know alreqdy) that ICP elevation in of itself is not a contraindication to neuraxial. Patients with pseudotumor cerebri get spinal taps for treatment. It depends if there is an actual gradient for herniation to occur (communicating vs noncommunicating)

 

[Southpaw]

I’m not trying to convince anyone of anything. I asked what anesthetic people would choose. I next asked if there would be a concern about performing a spinal anesthetic in an unclear picture of profound hyponatremia in a setting of possible cerebral edema. I didn’t give much detail, out of any design as you claim other than to have an intellectual discussion. You seem preoccupied with my knowledge base, skill, and deriding my thoughtful questions. Asking questions and raising concerns about how I would perform an anesthetic in a novel scenario in a complex patient, yes is hand wringing, I would rather hand wring now, when all that is at stake for me is having some rando on the internet belittle me, than hand wring and potentially encounter a disastrous situation in real life. This should be a forum to explore complex or non complex issues free from harassment and degradation of others clinical competence. You seem to have a massive chip on your shoulder and don’t like anyone asking questions. I understand you know it all, this is all very gauche for you, but perhaps us common folk can ask questions without you haranguing us and calling us stupid.

You were rude and condescending in the other thread. Further, you attempted to derail it. Further, don’t be shocked when people respond rudely and condescendingly when that is what you yourself put forth.

 

[vector2]

Then do GA. Quit wringing your hands and clutching your pearls over it. As you presented the case is urgent. So get on with it. No one in that room is suffering (except maybe the patient's birth plan.....) if you do GA and know what you're doing.

I don't make it seem like this is a scenario we run into daily. We don't. There are lots of scenarios we don't see daily, monthly, or even yearly but that doesn't in itself make them complex and it doesn't force one to go down some super complex decision making pathway. I am presenting you with a normal, well reasoned way of thinking through this not terribly complex scenario from the viewpoint of an anesthesiologist.

I've told you why I'd do a spinal. I'd defend my answer on the oral exam if presented with that scenario. However, you can just as easily defend GA or doing the case with an epidural or a CSE. That's part of the beauty of anesthesia.

You've not convinced me away from my default anesthetic for CS. You've given no details on the clinical exam for this patient and you've also given no details on why this case is urgent. Those are extremely important details that are helpful in the development of a plan for this patient. My guess is that you've avoided further details by design. Regardless, I've given you my reasoning and my plan based on very limited information.

He already said earlier in the thread it's a case that he made up. That's why there are no further details.

 

[pgg]

How about if nobody's rude to anybody? There's no need.

Case discussions tend to go better though if there are consistent details, or an upfront "hey this is all hypothetical" statement. This thread almost reads like an annoying "guess what I'm thinking" conversation with an attending.

 

[chocomorsel]

How about if nobody's rude to anybody? There's no need.

Case discussions tend to go better though if there are consistent details, or an upfront "hey this is all hypothetical" statement. This thread almost reads like an annoying "guess what I'm thinking" conversation with an attending.

I am gonna channel @FFP and call a snowflake a snowflake.
Because apparently you are being rude after admonishing rudeness.
Where did this person come from?
Haha

 

[Southpaw]

I am gonna channel @FFP and call a snowflake a snowflake.
Because apparently you are being rude after admonishing rudeness.
Where did this person come from?
Haha

They came from here:

• MeaCulpa​

• Oct 3, 2017

Hi vac1476! I would love to hear more about ur experience at lecom. I'm a junior in high school
And my dad is a do from
Une. Thanks!

Either Mea has a kid posting with their username or they're the snowflakiest of the snowflakes, or both.

 

[chocomorsel]

They came from here:



Either Mea has a kid posting with their username or they're the snowflakiest of the snowflakes, or both.

Please don’t tell me we are entertaining a child.
Mods @Arch Guillotti, could you do something about this please? A child pretending to be someone they are not? Isn’t that some kind of TOS violation?

 

[dhb]

This paper explains why ICP doesn’t rise as expected in hypo-osmolar states.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5762960/pdf/main.pdf

Shout out to the author who i was in class with in med school!

 

[chocomorsel]

Well please feel free to leave. You seem to be annoying an awful lot of us. And are quite a Prima Donna snowflake.
Go ahead and block me too. In fact, block all of us.

 

[Southpaw]

Please don’t tell me we are entertaining a child.
Mods @Arch Guillotti, could you do something about this please? A child pretending to be someone they are not? Isn’t that some kind of TOS violation?

@MeaCulpa does appear to be an anesthesiologist per post history. But there’s a student who’s also posted under that name which is why I’ve posted as I have. They also post, recently, with a severely concrete and overly sensitive nature typical of a millennial. So I’m not sure what’s what. Regardless, I’m ignoring.

 

[chocomorsel]

I’m annoying people who waste time of everyone involved. I will be blocking you thanks for the suggestion. Don’t speak for everyone else. Plenty of people have been able to answer questions in an appropriate manner, you hysterical worm.

Well let's see, I am a hysterical worm, @pgg is rude and @Southpaw is petty, all of us getting vaccinated are a bunch of sheep and ......

YOU are "truly shocked at the rapidity in which my partners and it appears that the majority of posters here have adopted the belief that this vaccine is inherently safe with very little short or long term risk associated."

Well, maybe the one with the issues here is you. You got enough tin foil, Xanax and Prozac? Because it sounds like your snowflake butt is about to have a nervous breakdown.

 

[deleted697535]

What does no time for a spinal mean?
Why are we talking about sodium (aka the most controversial topic in IM). Theres about 74 different international guidelines on how to manage hypoNa therefore its all nonsense

 

[deleted697535]

It appears I am the only one concerned with a spinal in patients with profound hyponatremia. Honestly I can say I have encountered many instances of having to consider spinal anesthesia in profoundly hyponatremic patients.

you have done/considered many cases of spinal in profoundly hyponatremic patients?
Im 8 years in a very large academic centre and maybe seen/heard of < 20 patients come with sodiums under 120. What is in yere water?

 

[Arch Guillotti]

What does no time for a spinal mean?

When it's an emergency and the pt. has to be put to sleep.

 

[IMGASMD]

So prop sux tube don’t work in this hypothetical situation?

 

[Arch Guillotti]

So prop sux tube don’t work in this hypothetical situation?

Hypothetically no.

 

[Hoya11]

You're not telling us anything we don't already know. All of your quotes are pretty basic stuff for the anesthesiologist, and it's stuff you should already know as an attending. I don't know why you're posting it. What specifically about this patient, other than Na 115-120, should put the laryngoscope in my hand?

Agree.

I'm not making the strong connection between a sodium of 117 and profoundly increased ICP and brain swelling.

This is probably caused by baseline NA in the 125-130 range due to the HCTZ, combined with fluid overload/siadh.

Less is more. I would do a spinal. I like the aline idea for frequent lab draws. Nothing like talking to mom and asking her how she is feeling, awake, interactive - to reassure you everything is OK. Induction of GA and laryngoscopy can also raise ICP. At least with the spinal I can talk to her and make sure she is mentating , and you can always go to sleep later if there is a problem.

 

[Arch Guillotti]

No way I am starting an aline for this case. 30 minutes into the case, send some labs? Case would be over by the time they were back.