The patient had SIADH. It was multi-factorial (Drugs, Colonic Irrigation, & Encephalitis).
first of all the clinically assess the volume satus, second, according to the sodium correction formula it should be apparent as to how many mEq/L/h might have been administered...for example a limit of 6th hr of IV therapy with a goal of 8-10mEq/L/h, you have to reassess clinically and determine blood pressure, urine output and if previously symptomatic the relief of symptoms...afterwards, the literature advise close review
important consideration is to assess those who are on follow up therapy with V2 blockers, urea or loop di-uretics...I'd leave that to a nephrologist :-D
You haven't said:
a) what the patient's usual Na concentration ( [Na] ) was
b) how old or frail the patient was
c) what the patient's symptoms were
Some people (by definition, given that a lab's 'normal' range is defined as 95% of the total distribution for the local population) alays have a lowish serum Na.
Older frail people are much more vulnerable to developing hyponatraemia from a variery of causes: drugs, infection, administration of hypotonic fluids, general illness, acute medical problems. The purists would say that SIADH cannot be diagnosed if drugs (esp diuretics) are a factor.
In practice, once the precipitating factors (irrigation, diuretics, infection) have resolved, one would expect the serum Na to return to normal for that patient. Knowing the prior [Na] allows one to see when that has happened.
My approach is that if there are no symptoms from low [Na] (esp, but not only, if the [Na] was low before the acute presentation), then I wouldn't worry too much about checking the [Na]. If symptoms do develop one can always re-check the level.
In general: treat the patient, not the number!
Thank you Dr Byatt,
His Na on discharge from the hospital (35 days ago) was 138mEq/L. 31 days ago it was 139mEq/L. 25 days ago it is 133mEq/L. 4 days ago it was 136.
Before hospital admission, the patient was oriented but has been extremely sleepy and drowsy (sleeps almost 23 hrs a day). He was also dizzy and walks unsteadily. No certain gait, just needs someone to fully support him while walking. Neurological examination shows no significant findings. He reached a state of stupor immediately prior to hospital admission.
His SIADH was attributed to drugs (Thiazide Diuretics, Alprazolam, Escitalopram), Hypothyroidism (his thyroid meds were stopped for 3 days during which SIADH developed, Infection (Suspected Sepsis from Gastroenteritis). Paraneoplastic syndrome was suspected because of elevated CA 19.9, and CEA. After thorough investigations, a .77cm sessile polyp was found in the sigmoid colon. It is to be removed and evaluated 3 months later.
The patient has had fleet enemas (colonic irrigation) six times in five days immediately before symptoms of hyponatremia first began to show.
He has HTN, DM, & Hypothyroidism. His blood pressure was controlled (130/90mmHg) but after hospital discharge his blood pressure ranges between (120-110/75-55).
His appetite is excellent, he didn't take Glimipiride(1mg) for the first 7 days after discharge. His fluid intake is normal (no fluid restriction).
Other: He has vetiligo, and has bouts oral HSV.
EXTRA INFO:
He was on Thiazide Diuretics until he had SIADH.
His Na when he had SIADH (20 days ago) was 103mEq/L.
He didn't have diarrhea when he had SIADH, nor does he have it now. But he had fleet enemas from tap water (colonic irrigation) five days in a row immediately before he developed SIADH because he was constipated and had abdominal pain.
If it is possible, patient's bed which can measure body weight could be used, total water balance including insensible perspiration is known. So as Dr.Quratulain said, sodium level is able to be normalized by simple water intake restriction. By the way, Autism spectrum syndrome patient drinks 2~3L daily rarely without exercise nor high body temperature and diarrhea. It is somewhat obcessibe and difficult to restrict water intake, but chronically continued and not so risky.
I am still don't know how old the patient is!
However, if he has no further symptoms - i.e. is managing as well as he did before he became ill, I would not worry too much. His Na has drifted down a little over the time since discharge - I suspect his is normally at the lower part of, or just below, the lab reference range. The absolute number is not so relevant if the patient is well.
If you wich to be cautious, you could check it in 4 weeks' time (or sooner if relevant symptoms - i.e. drowsiness, etc). It is helpful to find out what his usual Na level is when he is well. If indeed it is usually around 135mMol/L, this would suggest he does not have much 'osmotic control' reserve - and any of the precipitants you mention could provoke another symptomatic episode.
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