Letter to the Editor
Unmeasurable severe hypernatremia: A different way of using the calculated serum osmolality formula
Hipernatremia incalculable severa: una manera diferente de utilizar la fórmula de osmolaridad sérica
Aravindhan Arumugarajah, Christopher Webster, Luis M. Ortega
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Allegheny General Hospital, Division of Nephrology and Hypertension, 320 East North Avenue, Pittsburgh, PA 15212, United States
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Ortega" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Aravindhan" "apellidos" => "Arumugarajah" ] 1 => array:2 [ "nombre" => "Christopher" "apellidos" => "Webster" ] 2 => array:4 [ "nombre" => "Luis M." "apellidos" => "Ortega" "email" => array:1 [ 0 => "lortega@ahn.org" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Allegheny General Hospital, Division of Nephrology and Hypertension, 320 East North Avenue, Pittsburgh, PA 15212, United States" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Hipernatremia incalculable severa: una manera diferente de utilizar la fórmula de osmolaridad sérica" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 966 "Ancho" => 2144 "Tamanyo" => 173692 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Serum osmolality calculator with algebraic modification.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Hypernatremia is a common electrolyte disorder with increased morbidity and mortality, especially in elderly and critically ill patients. It is most frequently associated with free water losses, but it can also be induced by the administration of hypertonic saline or sodium bicarbonate.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,2</span></a> The mortality rates for critically ill patients with hypernatremia are as high as 50%.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Symptoms from hypernatremia include lethargy, weakness, irritability, seizures, and are as severe as coma.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">A 59-year-old Caucasian female presented to the hospital with subarachnoid hemorrhage and severe intracranial hypertension (ICH). The patient required intubation for ventilator support, and started on vasopressors for hemodynamic support. She was also started on hypertonic (3%) saline as an adjunctive therapy for her ICH. On admission, her serum sodium was 141<span class="elsevierStyleHsp" style=""></span>mEq/l. Over the next 4 days, despite hypertonic saline having been discontinued, the patient developed severe hypernatremia that was undetectable by the standard assay (ion specific electrode). Her serum sodium was measured as >180<span class="elsevierStyleHsp" style=""></span>mEq/l. She also developed polyuria with a urine osmolality of 220<span class="elsevierStyleHsp" style=""></span>mOsm/l, raising the possibility of diabetes insipidus. D5W was started for this patient in combination with scheduled doses of DDAVP to decrease her serum sodium slowly. We had to use the equation (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) for serum osmolality to calculate the serum sodium, given the significantly elevated levels, to ensure proper correction. We recognized that the equation is an indirect marker for serum sodium determination, which incorporates blood urea nitrogen and serum glucose concentrations in its calculation. Her peak serum osmolality was 403<span class="elsevierStyleHsp" style=""></span>mOsm/kg, and it was later lowered to 381<span class="elsevierStyleHsp" style=""></span>mOsm/kg in a 24-h interval (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). It was not until 30<span class="elsevierStyleHsp" style=""></span>h into therapy that the serum sodium level became detectable at 173<span class="elsevierStyleHsp" style=""></span>mEq/l, with a concomitant serum osmolality of 366<span class="elsevierStyleHsp" style=""></span>mOsm/kg.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">In conclusion, using the equation for serum osmolality is an indirect method to calculate the serum sodium level,<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> which was especially useful in this patient with severe hypernatremia that was unmeasurable (>180<span class="elsevierStyleHsp" style=""></span>mEq/l) with our standard assay. The applicability of the above mentioned formula allowed us to decreased the patients undetectable serum sodium close to normal range, preventing over-correction and under-correction.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7,8</span></a> We estimate that the patient's serum sodium could have been as high as 194<span class="elsevierStyleHsp" style=""></span>mEq/l.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Despite these limitations, we were able to indirectly monitor the patient's serum sodium level and adequately correct to goal.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">9,10</span></a> The patient survived her hospitalization and was discharged to a rehabilitation unit with improved serum sodium levels.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 966 "Ancho" => 2144 "Tamanyo" => 173692 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Serum osmolality calculator with algebraic modification.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">5/10/17 determinations made during 5<span class="elsevierStyleHsp" style=""></span>h intervals.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Date \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Serum osmolality \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">BUN \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Glucose \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Na<span class="elsevierStyleSup">+</span> (measured) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Na<span class="elsevierStyleSup">+</span> (calculated) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5/10/17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">394 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">196 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">>180 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">191 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5/10/17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">403 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">220 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">>180 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">194 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5/10/17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">395 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">126 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">>180 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">194 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5/10/17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">387 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">169 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">>180 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">188 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 12 | 3 | 15 |
| 2024 October | 42 | 38 | 80 |
| 2024 September | 68 | 43 | 111 |
| 2024 August | 128 | 59 | 187 |
| 2024 July | 120 | 28 | 148 |
| 2024 June | 77 | 39 | 116 |
| 2024 May | 98 | 39 | 137 |
| 2024 April | 104 | 37 | 141 |
| 2024 March | 143 | 37 | 180 |
| 2024 February | 189 | 40 | 229 |
| 2024 January | 182 | 30 | 212 |
| 2023 December | 263 | 23 | 286 |
| 2023 November | 260 | 28 | 288 |
| 2023 October | 365 | 33 | 398 |
| 2023 September | 418 | 39 | 457 |
| 2023 August | 400 | 28 | 428 |
| 2023 July | 423 | 38 | 461 |
| 2023 June | 298 | 29 | 327 |
| 2023 May | 278 | 31 | 309 |
| 2023 April | 208 | 22 | 230 |
| 2023 March | 157 | 24 | 181 |
| 2023 February | 168 | 25 | 193 |
| 2023 January | 180 | 29 | 209 |
| 2022 December | 211 | 30 | 241 |
| 2022 November | 233 | 30 | 263 |
| 2022 October | 209 | 49 | 258 |
| 2022 September | 139 | 39 | 178 |
| 2022 August | 123 | 68 | 191 |
| 2022 July | 139 | 48 | 187 |
| 2022 June | 144 | 45 | 189 |
| 2022 May | 209 | 38 | 247 |
| 2022 April | 179 | 60 | 239 |
| 2022 March | 200 | 49 | 249 |
| 2022 February | 209 | 57 | 266 |
| 2022 January | 261 | 95 | 356 |
| 2021 December | 222 | 33 | 255 |
| 2021 November | 179 | 38 | 217 |
| 2021 October | 203 | 43 | 246 |
| 2021 September | 234 | 36 | 270 |
| 2021 August | 230 | 42 | 272 |
| 2021 July | 173 | 38 | 211 |
| 2021 June | 177 | 43 | 220 |
| 2021 May | 158 | 44 | 202 |
| 2021 April | 268 | 69 | 337 |
| 2021 March | 206 | 44 | 250 |
| 2021 February | 203 | 41 | 244 |
| 2021 January | 92 | 24 | 116 |
| 2020 December | 121 | 19 | 140 |
| 2020 November | 156 | 13 | 169 |
| 2020 October | 129 | 16 | 145 |
| 2020 September | 164 | 15 | 179 |
| 2020 August | 139 | 12 | 151 |
| 2020 July | 197 | 25 | 222 |
| 2020 June | 140 | 15 | 155 |
| 2020 May | 164 | 20 | 184 |
| 2020 April | 130 | 19 | 149 |
| 2020 March | 87 | 13 | 100 |
| 2020 February | 67 | 16 | 83 |
| 2020 January | 132 | 18 | 150 |
| 2019 December | 113 | 38 | 151 |
| 2019 November | 133 | 20 | 153 |
| 2019 October | 229 | 20 | 249 |
| 2019 September | 226 | 32 | 258 |
| 2019 August | 95 | 21 | 116 |
| 2019 July | 42 | 29 | 71 |
| 2019 June | 59 | 18 | 77 |
| 2019 May | 42 | 24 | 66 |
| 2019 April | 64 | 45 | 109 |
| 2019 March | 45 | 17 | 62 |
| 2019 February | 59 | 21 | 80 |
| 2019 January | 70 | 32 | 102 |
| 2018 December | 76 | 49 | 125 |
| 2018 November | 36 | 12 | 48 |
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