How low a Na+ for Elective Surgery?

[BLADEMDA]

Electrolyte Disorder Linked to Surgical Complications

Hyponatremic patients with low sodium levels are at an increased risk of complications and death within a month of surgery, according to a study published online in the Archives of Internal Medicine.
Of the nearly 1 million adult patients who underwent major surgery between 2005 and 2010, reviewed by researchers at Brigham and Women's Hospital in Boston, almost 8% presented for surgery with hyponatremia, an electrolyte disorder marked by low serum sodium levels. Patients with the condition were more likely to suffer major coronary complications, surgical site infections, pneumonia and prolonged hospital stays, and were also 44% more likely to die at 30 days post-op, according to the study.
The study's authors concede further research is needed to determine whether correcting pre-operative hyponatremia will mitigate associated risks, especially because of "legitimate concern" about interventions that significantly and rapidly alter sodium levels over a short time.
In an accompanying commentary, Joseph Vassalotti, MD, associate clinical professor of medicine and nephrology, and Erin DuPree, MD, assistant professor of obstetrics, gynecology and reproductive science at Mount Sinai Medical Center in New York City, note nearly 80% of patients involved in the study underwent pre-op serum sodium testing and wonder if the screening should be routine prior to all surgeries.
"The pre-op evaluation should strive to determine whether the patient is in optimal health and whether the individual's condition could be improved before surgery," they say. "Previous hyponatremia and conditions commonly associated with hyponatremia are reasonable indications to perform serum sodium assessment."

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[BLADEMDA]

Results A total of 75 423 patients with preoperative hyponatremia (sodium level <135 mEq/L [to convert to millimoles per liter, multiply by 1.0]) were compared with 888 840 patients with normal baseline sodium levels (135-144 mEq/L). Preoperative hyponatremia was associated with a higher risk of 30-day mortality (5.2% vs 1.3%; adjusted odds ratio [aOR], 1.44; 95% CI, 1.38-1.50), and this finding was consistent in all the subgroups. This association was particularly marked in patients undergoing nonemergency surgery (aOR, 1.59; 95% CI, 1.50-1.69; P < .001 for interaction) and American Society of Anesthesiologists class 1 and 2 patients (aOR, 1.93; 95% CI, 1.57-2.36; P < .001 for interaction). Furthermore, hyponatremia was associated with a greater risk of perioperative major coronary events (1.8% vs 0.7%; aOR, 1.21; 95% CI, 1.14-1.29), wound infections (7.4% vs 4.6%; 1.24; 1.20-1.28), and pneumonia (3.7% vs 1.5%; 1.17; 1.12-1.22) and prolonged median lengths of stay by approximately 1 day.
Conclusion Preoperative hyponatremia is a prognostic marker for perioperative 30-day morbidity and mortality

 

[sevoflurane]

Well let me tell you about my case this morning.

VIP request case. Likely euvolemic hyponatremia. Preoperative was 130, but not too long ago it was 118. Completely asymptomatic. Endocrinology w/o a firm diagnosis. Likely SIADH from narcotics and/or a tapering dose of steroids (subclinical hypoadrenalism).

Presents for enlarging inguinal hernia to the outpatient side.

These are the kind of studies I don't know what to do with. Cancell the case in asymptomatic patient for an inguinal hernia? Seems like overkill.

The neuropediatric population are quite often hyponatremic... and show up for their cases that way (most of the time asymptomatic)

 

[sevoflurane]

My approach to these cases are:
1) History
2) Chronic or not Chronic
3) Symptomatic or not symptomatic
4) What is the serum osmolarity. Urine NA and osmolarity.
5) Euvolemic, Hypervolemic, Hypovolemic?

I don't always get #4 on the day of surgery, but it helps if it's been worked up or the work up has started.

 

[sevoflurane]

One thing to remember is that General Anesthesia, surgery and narcotics can all cause hyponatremia.

http://www.ncbi.nlm.nih.gov/pubmed/9579259

 

[BLADEMDA]

Well let me tell you about my case this morning.

VIP request case. Likely euvolemic hyponatremia. Preoperative was 130, but not too long ago it was 118. Completely asymptomatic. Endocrinology w/o a firm diagnosis. Likely SIADH from narcotics and/or a tapering dose of steroids (subclinical hypoadrenalism).

Presents for enlarging inguinal hernia to the outpatient side.

These are the kind of studies I don't know what to do with. Cancell the case in asymptomatic patient for an inguinal hernia? Seems like overkill.

The neuropediatric population are quite often hyponatremic... and show up for their cases that way (most of the time asymptomatic)

I'm willing to bet that the study listed above was Low Na+ and General Anesthesia. So, for your VIP how about a nice TAP block and some sedation? Or, just a MAC with local?

I've performed GA with Na+ below 130 many times. But, this study is now published and available for the trial lawyers to review. Proceed with caution.

 

[cincincyreds]

To play devil's advocate. Rather than saying hyponatremia along with surgery increase the risk of morbidity and mortality.

You could also say patients with hyponatremia are sick and being sick increases the risk of morbidity and mortality associated with surgery.


I think getting a good history especially looking at seizures and asking about daily activities is a good start in determing whether to do an elective case with a Na of 129.

 

[sevoflurane]

I'm willing to bet that the study listed above was Low Na+ and General Anesthesia. So, for your VIP how about a nice TAP block and some sedation? Or, just a MAC with local?

I've performed GA with Na+ below 130 many times. But, this study is now published and available for the trial lawyers to review. Proceed with caution.

I don't think my surgeon would like that.

Versed, Magnesium, Decadron preop. 10 mg Roc, Ketafol bolus followed by a low dose infusion (had a h/o PONV), slip in LMA, Des @ low flows @ around .4 MAC on PS 10. Tap Block @ the end of case. No narcs.

Woke up happy as a clam. Always good when it's a high up administration type patient.

So what do we do with the chronic hyponatremic patient? Say you get a patient with a h/o TBI that has a NA+ of 128 for the last 3 years?

 

[sevoflurane]

To play devil's advocate. Rather than saying hyponatremia along with surgery increase the risk of morbidity and mortality.

You could also say patients with hyponatremia are sick and being sick increases the risk of morbidity and mortality associated with surgery.


I think getting a good history especially looking at seizures and asking about daily activities is a good start in determing whether to do an elective case with a Na of 129.

Agree. The study describes a link not a cause to increased morbidity and mortality.

 

[Consigliere]

My question is BASS.....how low can you go?

 

[Bertelman]

I like my beats fast and my bass down low.

 

[cchoukal]

I suspect that, like many things, the Na isn't the driver of perioperative mortality, but rather a marker of some other severe disease (liver failure, CHF, and neurologic injury come to mind) that is the actual perpetrator. I wasn't able to download the PDF, but did the authors hazard any guesses as to why hyponatremia might plausibly increase mortality and complications? Was there any effort to tease out which hyponatremic patients were most at risk (as someone pointed out, the chronic TBI patient or the opiate-induced SIAD patient with Na of 128 are probably not at elevated risk, whereas the liver patient with Na of 128 probably IS)?

 

[Planktonmd]

I'm willing to bet that the study listed above was Low Na+ and General Anesthesia. So, for your VIP how about a nice TAP block and some sedation? Or, just a MAC with local?

I've performed GA with Na+ below 130 many times. But, this study is now published and available for the trial lawyers to review. Proceed with caution.

What makes you think that regional anesthesia or MAC with local is better than GA in this situation?
The crappy studies you provided are all saying that SURGERY with hyponatremia is bad for you... they don't specify the type of anesthesia!

 

[Noyac]

I would add #6 to Sevo's list:
Type of surgery.

I also think a well executed GA is as safe as local/MAC or regional in many situations.

 

[BLADEMDA]

What makes you think that regional anesthesia or MAC with local is better than GA in this situation?
The crappy studies you provided are all saying that SURGERY with hyponatremia is bad for you... they don't specify the type of anesthesia!

Crappy Study? I'd rather have you see it here first so we can discuss it then for your local malpractice attorney to point it out to you. Here is the link:
http://www.ncbi.nlm.nih.gov/pubmed/22965221

If you have an issue with the study take it up with the authors. As Physicians we need to be aware of all the "crappy" studies which others publish about our specialty especially when related to outcome.

 

[2win]

128.
That's the limit.
2win

 

[aneftp]

Bumping old thread.

I'm on call tonight at my old hospital. Preop for my colleagues tomorrow.

Sodium is 123 for Rt CEA. Patient has classic TIA and was admitted last friday. 95% carotid blockage so needs surgery. It was 136 on admission.

Saw patient in room. She looked asymptomatic. Passed "the eye test".

They finally put her on fluid restriction today. Primary also took her off HCTZ.

Nephrology consulted. Likely won't see her till tomorrow.

I know the surgeon well so texted him likely postpone if no improvement.

Surgeon is very fast. Patient looks good with no other co morbidity.

But saw this 4 year old thread. Conservatives action would be to cancel surgery till sodium level is corrected.

 

[sigrhoillusion]

I don't think my surgeon would like that.

Versed, Magnesium, Decadron preop. 10 mg Roc, Ketafol bolus followed by a low dose infusion (had a h/o PONV), slip in LMA, Des @ low flows @ around .4 MAC on PS 10. Tap Block @ the end of case. No narcs.

Woke up happy as a clam. Always good when it's a high up administration type patient.

So what do we do with the chronic hyponatremic patient? Say you get a patient with a h/o TBI that has a NA+ of 128 for the last 3 years?

Just wondering when you say magnesium, decadron and versed "pre-op" what timeframe are you speaking? Pre-op Nurse order? As you're rolling back? Right before induction?

Not questioning, just wondering.

 

[BLADEMDA]

Bumping old thread.

I'm on call tonight at my old hospital. Preop for my colleagues tomorrow.

Sodium is 123 for Rt CEA. Patient has classic TIA and was admitted last friday. 95% carotid blockage so needs surgery. It was 136 on admission.

Saw patient in room. She looked asymptomatic. Passed "the eye test".

They finally put her on fluid restriction today. Primary also took her off HCTZ.

Nephrology consulted. Likely won't see her till tomorrow.

I know the surgeon well so texted him likely postpone if no improvement.

Surgeon is very fast. Patient looks good with no other co morbidity.

But saw this 4 year old thread. Conservatives action would be to cancel surgery till sodium level is corrected.

Sodium of 123 is too low unless the case is urgent. I agree that your case is a judgement call but getting the Na+ over 125 isn't that hard to do. Once the Sodium is over 130 I would proceed with the case. My comfort level for doing cases which are not "emergent" is a sodium of 125 (urgent case or sodium was corrected from a very low level to 125) but I prefer 130 or higher for any elective cases.

 

[BLADEMDA]

Preoperative hyponatremia predicts outcomes after cardiac surgery

http://www.journalofsurgicalresearch.com/article/S0022-4804(12)00539-2/abstract

 

[Planktonmd]

Bumping old thread.

I'm on call tonight at my old hospital. Preop for my colleagues tomorrow.

Sodium is 123 for Rt CEA. Patient has classic TIA and was admitted last friday. 95% carotid blockage so needs surgery. It was 136 on admission.

Saw patient in room. She looked asymptomatic. Passed "the eye test".

They finally put her on fluid restriction today. Primary also took her off HCTZ.

Nephrology consulted. Likely won't see her till tomorrow.

I know the surgeon well so texted him likely postpone if no improvement.

Surgeon is very fast. Patient looks good with no other co morbidity.

But saw this 4 year old thread. Conservatives action would be to cancel surgery till sodium level is corrected.

This is a dramatic drop from 136 to 123 in a couple of days, but this is an urgent surgery and she could have a stroke at any moment, so it can be argued both ways.
It is conceivable to see SIADH with ongoing brain hypoperfusion so that might be the etiology.

 

[Ezekiel2517]

Bumping old thread.

I'm on call tonight at my old hospital. Preop for my colleagues tomorrow.

Sodium is 123 for Rt CEA. Patient has classic TIA and was admitted last friday. 95% carotid blockage so needs surgery. It was 136 on admission.

Saw patient in room. She looked asymptomatic. Passed "the eye test".

They finally put her on fluid restriction today. Primary also took her off HCTZ.

Nephrology consulted. Likely won't see her till tomorrow.

I know the surgeon well so texted him likely postpone if no improvement.

Surgeon is very fast. Patient looks good with no other co morbidity.

But saw this 4 year old thread. Conservatives action would be to cancel surgery till sodium level is corrected.

Why do you need a renal consult to manage this? There are simple algorithms to work up hyponatremia. This is basic medicine. Correct the sodium and check the Na with the morning labs

 

[sigrhoillusion]

Why do you need a renal consult to manage this? There are simple algorithms to work up hyponatremia. This is basic medicine. Correct the sodium and check the Na with the morning labs

I'm assuming consult is for follow up care. Granted that's assuming the sodium is due to renal causes and not neurological, cardiac, cancer or the other things that change sodium levels...

 

[deleted682700]

Why do you need a renal consult to manage this? There are simple algorithms to work up hyponatremia. This is basic medicine. Correct the sodium and check the Na with the morning labs

My friends mom also an anesthesiologist died form central pontine myelinolysis, because of rapid correction by interns. Why would i want to tread beyond my scope of practice?

 

[deleted682700]

Thanks blade for this Moca minute.

 

[aneftp]

Why do you need a renal consult to manage this? There are simple algorithms to work up hyponatremia. This is basic medicine. Correct the sodium and check the Na with the morning labs

I didn't order renal consult. Primary did.

Not gonna to over ride the primary consult

It's like if primary doc consult order cards eval. Once it's on the chart. U really want to just say F it. And proceed. I wouldn't once it's in the chart. Setting up yourself for legal issues if you proceed

Anyways. Checked with my colleagues this morning Sodium was 126 today. They went ahead since it was stable and not going down. Surgeon is quick and done already.

 

[BLADEMDA]

Here is my approach:

Elective- Sodium 130 or greater
Urgent- Sodium 125 or greater
Emergent- Proceed with the case

Obviously, if the surgeon is breathing down your neck to do the urgent case and the sodium is 124 I would insist on a Renal Consult or documentation on the chart why the case can't wait 24 hours.

I've seen a Sodium as low as 107 which was corrected to 123 before I did the elective case; this took 48 hours to accomplish.

 

[BLADEMDA]

Hyponatremia is an important and common electrolyte abnormality that can be seen in isolation or, as most often is the case, as a complication of other medical illnesses (eg, heart failure, liver failure, renal failure, pneumonia). The normal serum sodium level is 135-145 mEq/L. Hyponatremia is defined as a serum sodium level of less than 135 mEq/L. Joint European guidelines classify hyponatremia in adults according to serum sodium concentration, as follows[1, 2] :

• Mild: 130-134 mmol/L
• Moderate: 125-129 mmol/L
• Profound: <125 mmol/L

Severe hyponatremia (<125 mEq/L) has a high mortality rate. In patients whose serum sodium level falls below 105 mEq/L, and especially in alcoholics, the mortality is over 50%.[5]


To avoid osmotic demyelination syndrome (ODS) in patients with chronic hyponatremia (known duration >48 hours), the recommendations include the following[29] :

• Minimum correction of serum sodium by 4-8 mmol/L per day, with a lower goal of 4-6 mmol/L per day if the risk of ODS is high
• For patients at high risk of ODS: maximum correction of 8 mmol/L in any 24-hour period
• For patients at normal risk of ODS: maximum correction of 10-12 mmol/L in any 24-hour period; 18 mmol/L in any 48-hour period

http://emedicine.medscape.com/article/242166-treatment

 

[deleted171991]

My friends mom also an anesthesiologist died form central pontine myelinolysis, because of rapid correction by interns. Why would i want to tread beyond my scope of practice?

You don't get CPM from increasing sodium from 123 to 130 overnight. It shouldn't be fixed by renal, but by whoever is primary.

 

[sigrhoillusion]

Here is my approach:

Elective- Sodium 130 or greater
Urgent- Sodium 125 or greater
Emergent- Proceed with the case

Obviously, if the surgeon is breathing down your neck to do the urgent case and the sodium is 124 I would insist on a Renal Consult or documentation on the chart why the case can't wait 24 hours.

I've seen a Sodium as low as 107 which was corrected to 123 before I did the elective case; this took 48 hours to accomplish.

Looking at my first case tomorrow... PEG/PEJ (poss open) for some oral CA with inability to open mouth. Probably going to be an awake nasal FOI, but my bigger concern is last preop sodium was 127 three days ago. Likely from poor intake and hypovolemia, but the problem is that ten days ago it was 134, so this is somewhat acute drop. This is the thing that pisses me off about our PAT. These are the things that should be caught before DOS. Kind of patient that would benefit from being brought in the night before and tanked up. Right now my plan is to send a repeat BMP when they get his IV in the morning, and hope the sodium is somewhere around 127 still. Question is, what if it's 120-125... the guy needs PEG/PEJ and a port for chemo (maybe even a trach) but can this initial procedure wait a day if his sodium is still dropping...? probably! But of course these cases are always scheduled on a Friday, and at a busy level 1 trauma center the last thing the weekend anesthesiologists need are "elective" difficult airways...

I know some of my colleagues would just shrug at the sodium and press on. I'm at least willing to send a repeat, if it gets done right away in the morning, it shouldn't delay the case assuming it's normal or close to what it's at. Anyone doing anything different?

 

[deleted171991]

Repeat. Unless under 125 or symptomatic or signs of significant hypovolemia, shrug. Put 1-2L of NS in him, preinduction, if concerned about some hypovolemia. Watch the preload during laparoscopy.

Textbook, the patient should be admitted to the hospital for 24 hours and properly resuscitated preop. This is not emergent surgery. Do what you'd like somebody to do for your family member - this is already a sick sad human being who needs TLC. (I usually have an honest risks v benefits discussion with the patient and family, unless it's a clear call.)

 

[Ronin786]

Looking at my first case tomorrow... PEG/PEJ (poss open) for some oral CA with inability to open mouth. Probably going to be an awake nasal FOI, but my bigger concern is last preop sodium was 127 three days ago. Likely from poor intake and hypovolemia, but the problem is that ten days ago it was 134, so this is somewhat acute drop. This is the thing that pisses me off about our PAT. These are the things that should be caught before DOS. Kind of patient that would benefit from being brought in the night before and tanked up. Right now my plan is to send a repeat BMP when they get his IV in the morning, and hope the sodium is somewhere around 127 still. Question is, what if it's 120-125... the guy needs PEG/PEJ and a port for chemo (maybe even a trach) but can this initial procedure wait a day if his sodium is still dropping...? probably! But of course these cases are always scheduled on a Friday, and at a busy level 1 trauma center the last thing the weekend anesthesiologists need are "elective" difficult airways...

I know some of my colleagues would just shrug at the sodium and press on. I'm at least willing to send a repeat, if it gets done right away in the morning, it shouldn't delay the case assuming it's normal or close to what it's at. Anyone doing anything different?

Poor intake and hypovolemia cause hypernatremia unless you're in a severe nutritional state like kwashiorkor.

 

[sigrhoillusion]

Poor intake and hypovolemia cause hypernatremia unless you're in a severe nutritional state like kwashiorkor.

"Poor intake and hypovolemia cause hypernatremia unless you're in a severe nutritional state like kwashiorkor."

I know, but for some reason I feel like all these ENT cancer patients with decreased oral intake always seem to be hyponatremic. It is probably some sort of SIADH going on but I'll have to recheck what meds he's on which are also a likely source. Although, I don't remember seeing anything. Again, I'm more concerned about the sudden drop than the overall number. Seems like most of these patients come in in the 120s but they've been hovering there for months/years.

 

[sigrhoillusion]

Well... I'm a lying POS... Just looked at his medication list. He's on Losartan/HCTZ (not sure how long) but also was started on oxycodone at the start of the month, as well as Compazine and Zofran two weeks ago. All of which can cause hyponatremia... seems like a pretty good correlation with the drop.

Still planning on getting a repeat with IV placement to make sure it's not <125.

 

[BLADEMDA]

"Poor intake and hypovolemia cause hypernatremia unless you're in a severe nutritional state like kwashiorkor."

I know, but for some reason I feel like all these ENT cancer patients with decreased oral intake always seem to be hyponatremic. It is probably some sort of SIADH going on but I'll have to recheck what meds he's on which are also a likely source. Although, I don't remember seeing anything. Again, I'm more concerned about the sudden drop than the overall number. Seems like most of these patients come in in the 120s but they've been hovering there for months/years.

Please explain to me why demanding a Na+ of 125 or greater for this elective case is unreasonable based upon the published data? Sure, the patient isn't long for this world and has less than 6 months to live but why exactly should you be forced to provide anesthesia with such a severe electrolyte abnormality? The vast majority of cases (like the one you described) can easily be treated over 48 hours to bring the NA+ over 125.

The vast majority of Anesthesiologists at my practice would cancel this elective GI case if the NA+ was less than 125. That said, I fully understand the pressure one faces from GI docs and surgeons to NEVER delay a case.

 

[BLADEMDA]

 

[deleted171991]

I don't know where it's from, but I would argue it's hugely exaggerated. One doesn't have a 10% risk of death with a sodium of 125, or 5+% at 130, if chronic and asymptomatic. A lot of elderly have chronic hyponatremia in the low 130s, and we don't see them dying periop.

 

[sigrhoillusion]

So as I stated my plan was to recheck the BMP as soon as the patient arrived, in hopes that it would get back and we'd be able to make a decision prior to the 7:30AM start. So I get in and check the board and notice the case had been bumped for an inpatient lap chole... and was now scheduled for around 10AM. So I start my 7AM case, and bump into the surgeon and she says "so I told the patient to come in a little later so we can figure out what's going on with his labs. My office called me yesterday and told me his sodium was low."

I just stood there mouth agape... a surgeon delayed their own case to figure out a medical problem... and I literally almost went into convulsions... the end of days is near...

So we had a nice decision about our plan that if the sodium was stable we'd proceed and if it was dropping we'd postpone the case until at least Monday because she, nor I, nor any of my colleagues didn't want to do the case later in the day or on the weekend due to the difficult airway (another shocker...)

So of course his sodium was 132, we "proceeded" and by proceeded I mean the case kept getting delayed until almost 3pm, which was after I had signed out my room and left the difficult airway to another person... but in the end the awake nasal FOI went fine and the patient did well.

But yea, in case anyone missed it... a surgeon preemptively "obstructed" an anesthesiologist...

 

[deleted697535]

and she says...QUOTE]
I think this is the key to it...
And tbh I don't really like surgeons who think. Esp those who think they're medics
I much prefer surgeons who cut and sew like an Asian tailor

 

[BLADEMDA]

Another interesting study:

 

[BLADEMDA]

Our findings differ from those of previous studies in the sense that in our study only severe hypernatraemia was independently associated with increased mortality after surgery. These results are in contrast with the findings of Leung and colleagues 16,17in the perioperative setting and studies in medical and critically ill patients. 9,11,20 In two separate studiess from a large American database, Leung and colleagues 16,17found that both hyponatraemia and hypernatraemia were independently associated with increased mortality and incidence of postoperative complications. In a large cohort of patients from the Austrian Center for Documentation and Quality Assurance in Intensive Care, Funk and colleagues 11 found that mild degrees of dysnatraemia (hyponatraemia and hypernatraemia) were associated with worse outcome. This was confirmed recently by Darmond and colleagues 9 in another large multicentre study in French ICUs. From a physiological point of view, dysnatraemia originates from disturbances in water balance; 10,21 this is normally under the control of antidiuretic hormone. 14,21

Preoperative abnormalities in serum sodium concentrations are associated with higher in-hospital mortality in patients undergoing major surgery | BJA: British Journal of Anaesthesia | Oxford Academic

 

[BLADEMDA]

Multiple logistic regression analysis showed an independent mortality risk rising with increasing severity of both hyponatremia and hypernatremia.

Incidence and prognosis of dysnatremias present on ICU admission

 

[BLADEMDA]

Key messages

• Dysnatremia is common at ICU admission. Mild to severe hypernatremia and hyponatremia were present in respectively 7.8% and 27.4% of the critically ill patients.
  
  
• Dysnatremia is independently associated with ICU mortality. In our study, mild hypernatremia (that is serum sodium concentration > 145 mmol/L) and moderate hyponatremia (that is serum sodium concentration < 130 mmol/L) are independently associated with poor outcome (respective sHR of 1.34 (95% CI 1.14 to 1.57) and 1.18 (95% CI 1.002 to 1.40)).
  
  
• Although a causal role for dysnatremia in death is biologically plausible, we cannot determine from our data whether the association between dysnatremia and mortality reflected a direct effect of dysnatremia, a surrogate marker for underlying comorbidities or reason for ICU admission, or both.

Prognostic consequences of borderline dysnatremia: pay attention to minimal serum sodium change

 

[deleted171991]

Sodium disorders have a completely different meaning in the ICU, where they are mostly acute and associated with inappropriate fluid management.

 

[BLADEMDA]

Sodium disorders have a completely different meaning in the ICU, where they are mostly acute and associated with inappropriate fluid management.

FFP, I think I have established a link between Sodium disorders (severe) and increased morbidity/mortality. Even if you won't accept the data many other physicians and trial lawyers will.

I prefer to practice in a reasonable manner based on the evidence especially for elective cases. What you do with the data and how you choose to practice Anesthesiology is clearly up to you.

"In two separate studies from a large American database, Leung and colleagues found that both hyponatraemia and hypernatraemia were independently associated with increased mortality and incidence of postoperative complications. "

 

[BLADEMDA]

In this study of hospitalized patients undergoing major orthopedic procedures, we report that abnormal preadmission and perioperative SNa during hospitalization are: (1) present in approximately 10% of patients, (2) associated with greater hospital length of stay, and (3) associated with greater 30-day mortality.

Association of Serum Sodium With Morbidity and Mortality in Hospitalized Patients Undergoing Major Orthopedic Surgery

 

[nimbus]

Like hypotension, hyponatremia is another marker for sick patients who will have worse perioperative outcomes. Of course a population of patients with serum sodium of 140 will do better than a population with a sodium of 125. The more important question to ask is, “Does intervention to correct preop serum sodium improve outcomes?” That has not been answered.

 

[deleted171991]

FFP, I think I have established a link between Sodium disorders (severe) and increased morbidity/mortality. Even if you won't accept the data many other physicians and trial lawyers will.

I prefer to practice in a reasonable manner based on the evidence especially for elective cases. What you do with the data and how you choose to practice Anesthesiology is clearly up to you.

"In two separate studies from a large American database, Leung and colleagues found that both hyponatraemia and hypernatraemia were independently associated with increased mortality and incidence of postoperative complications. "

No need to take it personally.

 

[deleted171991]

So let me begin by pointing out that this kind of thread is one of my pleasures on SDN. I remember reading, just this week, about a study that showed that doctors who regularly consult others about their own patients tend to make fewer mistakes and have better outcomes.

Like hypotension, hyponatremia is another marker for sick patients who will have worse perioperative outcomes. Of course a population of patients with serum sodium of 140 will do better than a population with a sodium of 125. The more important question to ask is, “Does intervention to correct preop serum sodium improve outcomes?” That has not been answered.

This is an EXCELLENT point. It reminds me of hypocalcemia in sepsis (associated with worse outcomes), and how it's useless to correct it.

And in my eagerness to contradict Blade, I missed a very important proof that he himself had posted:

Key messages

• Dysnatremia is independently associated with ICU mortality. In our study, mild hypernatremia (that is serum sodium concentration > 145 mmol/L) and moderate hyponatremia (that is serum sodium concentration < 130 mmol/L) are independently associated with poor outcome (respective sHR of 1.34 (95% CI 1.14 to 1.57) and 1.18 (95% CI 1.002 to 1.40)).

CI ending at 1.002 means that the conclusion could be insignificant. Hence sodium concentration of less than 130 has not been proven to do crap (as expected by this arrogant intensivist).

But I still like you, @BLADEMDA, I promise.

 

[BLADEMDA]

Like hypotension, hyponatremia is another marker for sick patients who will have worse perioperative outcomes. Of course a population of patients with serum sodium of 140 will do better than a population with a sodium of 125. The more important question to ask is, “Does intervention to correct preop serum sodium improve outcomes?” That has not been answered.

Another question that needs to be asked is "should I proceed with this elective case knowing the Na+ is 125 based upon the available evidence?" For me, the answer is a clear "NO" and I'm going to cancel the case. For FFP and you, feel free to proceed knowing that any bad outcome may be linked to your decision.