Urgent C/S profound hyponatremia

[Hoya11]

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.

Interesting how its so different place to place.

Our CS are no joke 2 hrs. And we have iStat machines able to give you chemistry/abg right in the OR in 2 minutes

They can also use the aline for days post op as they correct the NA and draw frequent labs

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[nimbus]

In head trauma patients, there is no correlation between hyponatremia and increased ICP. If anything there is a slight correlation between hypernatremia and increased ICP. In the hypothetical case, I would spinal away.

 

[GassYous]

Interesting how its so different place to place.

Our CS are no joke 2 hrs. And we have iStat machines able to give you chemistry/abg right in the OR in 2 minutes

They can also use the aline for days post op as they correct the NA and draw frequent labs

 

[coffeebythelake]

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.

If pt was hard stick getting an art line might be useful for frequent lab draws. Depending on severity of hypoNa (I think OP said 110-115) might not be a bad idea to sit the patient in ICU afterwards while correcting the sodium.

 

[IMGASMD]

“The kid is fine.”
“Put it down... there is fine.”

 

[abolt18]

This swirled downhill fast.

For what it's worth, I appreciated and enjoyed the hypothetical. Not something I had ever considered. And the articles shared by mea culpa were also interesting and worthwhile reads I felt.

People need to all just chiiilllllllll.

 

[woopedazz]

We had this last week, hence my reply earlier, before shenanigans.

We had an hour to make a decision and sodium was 120, not 110. Trending down over period of 2 weeks. Called neuro+endocrine who both pretty much laughed and queried why we were concerned re:neuraxial.

Did spinal, leant on pressor over fluid, brain did not cone. "Meh" all around

 

[deleted171991]

The number of board-certified idiots concerned that the brain will herniate from removing a couple cc's of CSF in an asymptomatic patient is scary.

 

[Southpaw]

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.

IMO the aline would be because this patient isn't going anywhere for at least a few days and she's gonna get poked (heh...) often checking that Na+. Not saying I'd do the aline, but there are far worse decisions I've seen. The bigger problem with the aline, IMO, is that most floors won't accept the patient with an aline and provided she's asymptomatic she certainly doesn't need an ICU bed.

 

[vector2]

IMO the aline would be because this patient isn't going anywhere for at least a few days and she's gonna get poked (heh...) often checking that Na+. Not saying I'd definitely do the aline, but there are far worse decisions I've seen. The bigger problem with the aline, IMO, is that most floors won't accept the patient with an aline and provided she's asymptomatic she certainly doesn't need an ICU bed.

Large-ish bore midline into basilic vein. Draw venous sample through that.

 

[coffeebythelake]

Large-ish bore midline into basilic vein. Draw venous sample through that.

A profoundly low sodium, need for frequent lab draws, and active correction sounds like it needs ICU level care. I wouldnt be so comfortable having a regular floor nurse with 6 patients doing that kind of care

 

[anbuitachi]

i would do spinal.

if emergency without time, i would do prop sux tube.

i saw someone wrote no to prop sux tube for GA. what is wrong with prop sux tube?

saw someone else wrote no to spinal because patient may seize and rather not deal with it. the c section is like 2 hrs long. getting baby out is like <20 minutes. i'll bolus some midaz if needed. but patient unlikely to seize on the table..

and someone else wrote bolus sodium bicarb instead of hypertonic saline... bc sodium bicarb has more sodium... well if you want a high sodium concentration.. theres 23.4% hypertonic saline


also, a Na of 110, how would that affect the baby? anyone?

 

[MirrorTodd]

i would do spinal.

if emergency without time, i would do prop sux tube.

i saw someone wrote no to prop sux tube for GA. what is wrong with prop sux tube?

saw someone else wrote no to spinal because patient may seize and rather not deal with it. the c section is like 2 hrs long. getting baby out is like <20 minutes. i'll bolus some midaz if needed. but patient unlikely to seize on the table..

and someone else wrote bolus sodium bicarb instead of hypertonic saline... bc sodium bicarb has more sodium... well if you want a high sodium concentration.. theres 23.4% hypertonic saline


also, a Na of 110, how would that affect the baby? anyone?

Baby will come out hyponatremic too. Hopefully nicu team is close by.

 

[deleted171991]

Baby will come out hyponatremic too. Hopefully nicu team is close by.

You sure?

 

[MirrorTodd]

You sure?

Well nothing is ever certain, but I would expect a baby to be hyponatremic if the mother was just before birth. Sodium still crosses the placenta right?

 

[coffeebythelake]

Well nothing is ever certain, but I would expect a baby to be hyponatremic if the mother was just before birth. Sodium still crosses the placenta right?

Assumption that ability to regulate sodium levels is also altered in the fetus / baby, which I dont know is true. Might depend on the underlying etiology of hyponatemia in mother

 

[MirrorTodd]

Assumption that ability to regulate sodium levels is also altered in the fetus / baby, which I dont know is true. Might depend on the underlying etiology of hyponatemia in mother

I was thinking the baby's kidneys don't know the difference, neither does the placenta and the mom's body isn't gonna care where the sodium comes from so if it experiences a low sodium level, the mom's body is gonna take that sodium from somewhere.

 

[deleted171991]

Well nothing is ever certain, but I would expect a baby to be hyponatremic if the mother was just before birth. Sodium still crosses the placenta right?

I would expect the baby to self-regulate her sodium-water homeostasis (i.e. functioning kidneys).

I was asking more out of curiosity.

 

[anbuitachi]

I would expect the baby to self-regulate her sodium-water homeostasis (i.e. functioning kidneys).

I was asking more out of curiosity.

was asking out of curiosity too. dont actually know if baby self regulates that well

 

[woopedazz]

The baby has the same sodium as the mother. Recall ficks law and placental transfer.

Going back to first principles, even if the baby could regulate its own electrolytes, where exactly is it going to excrete the excess sodium? And more pertinently, how would this slow correction not be immediately overcome by the continuous high volume placental exchange?

If i recall correctly, theres a number of case reports of hyponatraemic mothers birthing seizing babies.

 

[Guillemot]

Man this thread kind of sucked. Sometimes these case discussions are a lot better.

 

[MirrorTodd]

Man this thread kind of sucked. Sometimes these case discussions are a lot better.

Admittedly they tend to go better when it's a real case.

 

[deleted171991]

The baby has the same sodium as the mother. Recall ficks law and placental transfer.

Going back to first principles, even if the baby could regulate its own electrolytes, where exactly is it going to excrete the excess sodium? And more pertinently, how would this slow correction not be immediately overcome by the continuous high volume placental exchange?

If i recall correctly, theres a number of case reports of hyponatraemic mothers birthing seizing babies.

I would expect the baby to excrete the water excess into the amniotic fluid.

There are case reports of babies being born as hyponatremic as their mothers, so they don't seem able to self-regulate sodium independently. Per OpenAnesthesia, fetal levels of Na+ and Cl- are similar to the mother's, due to simple diffusion (unlike K+, for example, which is tightly regulated).

 

[coffeebythelake]

I would expect the baby to excrete the water excess into the amniotic fluid.

There are case reports of babies being born as hyponatremic as their mothers, so they don't seem able to self-regulate sodium independently. Per OpenAnesthesia, fetal levels of Na+ and Cl- are similar to the mother's, due to simple diffusion (unlike K+, for example, which is tightly regulated).

Now this thread js getting interesting / educational

 

[dhb]

If i recall correctly, theres a number of case reports of hyponatraemic mothers birthing seizing babies.

At least Apgar isn't 0

 

[deleted162650]

At least Apgar isn't 0

Couple points for tone and grimace?