Acute Water IntoxicationAcute Water IntoxicationDecember 17, 2003December 17, 2003Bruce R. Wall, MDBruce R. Wall, MD

Good old fashioned nephrology Good old fashioned nephrology

(with a large dose of (with a large dose of pulmonary) pulmonary) • Most nephrologists would chose to Most nephrologists would chose to evaluate and treat a SODIUM of 110 mEq/L evaluate and treat a SODIUM of 110 mEq/L rather than a BUN of 110mg%rather than a BUN of 110mg%

• ““Be careful what you ask for… you just Be careful what you ask for… you just might get it…” might get it…”

• Lt.Col. Theodore R. Wall, USMC, RetiredLt.Col. Theodore R. Wall, USMC, Retired• Patient admitted from ER with Patient admitted from ER with

hyponatremia and respiratory failure… no hyponatremia and respiratory failure… no problem…problem…

Today’s lecture:Today’s lecture:

• Chronic polydipsia – not this caseChronic polydipsia – not this case• Case presentationCase presentation• Laboratory reviewLaboratory review• Brief discussion of water intoxication Brief discussion of water intoxication • Pulmonary aspects @ Dr WeinmeisterPulmonary aspects @ Dr Weinmeister

Input minus output equals Input minus output equals accumulation accumulation• 75 kg male75 kg male• 60% water = approx 45 Liters TBW60% water = approx 45 Liters TBW

• Intracellular ExtracellularIntracellular Extracellular 30 L 15 L30 L 15 L 280mosm/kg 280mosm/kg 280mosm/kg 280mosm/kg

[K+] 140mEq/l [Na+] 140mEq/l[K+] 140mEq/l [Na+] 140mEq/l

How much water was How much water was ingested?ingested?

• Initial TB solute: 280 X 45 =12,600 mosmolInitial TB solute: 280 X 45 =12,600 mosmol• Initial ECF solute: 280 X 15 = 4,200 mosmolInitial ECF solute: 280 X 15 = 4,200 mosmol• Initial intracellular: 12600 – 4200 = 8,400 Initial intracellular: 12600 – 4200 = 8,400

mosmolmosmol

• NEW TBW : 45kg + 6 kg = 51 kgNEW TBW : 45kg + 6 kg = 51 kg• NEW TB OSM: 12,600 / 51kg = 251mosm/kgNEW TB OSM: 12,600 / 51kg = 251mosm/kg• NEW ECF volume: 4200 / 251 = 16.7kgNEW ECF volume: 4200 / 251 = 16.7kg• NEW intracellular volume: 8400 / 251 = 33.4kgNEW intracellular volume: 8400 / 251 = 33.4kg

How much water?How much water?• Assume an ingestion of 6 liters: Assume an ingestion of 6 liters:

serum osmolality of 251mosmol/kgserum osmolality of 251mosmol/kg

• Estimated nadir [Na+] = osmolality / 2 = Estimated nadir [Na+] = osmolality / 2 = 125.5mEq 125.5mEq

• Effective Posm is approximately 2 X Effective Posm is approximately 2 X [Na+][Na+]

Case PresentationCase Presentation• 21 year old AAM student at SMU21 year old AAM student at SMU• CC: can not be obtained (intubation)CC: can not be obtained (intubation)• History obtained from family membersHistory obtained from family members• Patient was asked to drink 3 - 4 gallons of Patient was asked to drink 3 - 4 gallons of

water (with hot sauce), as part of a water (with hot sauce), as part of a fraternity hazing on Friday eveningfraternity hazing on Friday evening

• Post ingestion, patient was confused, and Post ingestion, patient was confused, and became ‘less responsive’became ‘less responsive’

• At 4AM, patient developed a seizure, yet At 4AM, patient developed a seizure, yet was not transported to Presby ER until 7AM was not transported to Presby ER until 7AM

Hospital day:oneHospital day:one• Profound shock/hypotension – poor response Profound shock/hypotension – poor response

to high dose pressor medicationsto high dose pressor medications• Immediate respiratory failure with severe Immediate respiratory failure with severe

agitation and hypoxemia; endotracheal agitation and hypoxemia; endotracheal intubation confirmed “drowning”intubation confirmed “drowning”

• Transfer to ICU maximal support: 100% Transfer to ICU maximal support: 100% oxygen, maximum PEEP, IV norepinephrineoxygen, maximum PEEP, IV norepinephrine

• Initial SODIUM = 126mEq/L (IV @KO NS)Initial SODIUM = 126mEq/L (IV @KO NS)

Case presentation: Case presentation: continuedcontinued• Past medical history: nonePast medical history: none• Social history: 2 year football player for Social history: 2 year football player for

Austin College. No drug or alcohol Austin College. No drug or alcohol history Mother arrived from Houston; history Mother arrived from Houston; Father arrived from US Virgin Islands Father arrived from US Virgin Islands (lives in Wash D.C.)(lives in Wash D.C.)

• Medications: IV pressors, antibioticsMedications: IV pressors, antibiotics• ROS: not availableROS: not available

Physical exam:Physical exam:• BP 100/60 on very high dose IV pressors; pulse BP 100/60 on very high dose IV pressors; pulse

110 sinus tachycardia; R per vent; high pressures110 sinus tachycardia; R per vent; high pressures• Very muscular patient, intubated PO, who Very muscular patient, intubated PO, who

eventually developed subQ crepitation from eventually developed subQ crepitation from barotraumabarotrauma

• HEENT: mild swelling; anicteric NECK: WNLHEENT: mild swelling; anicteric NECK: WNL• LUNGS: bilateral breath sounds; increased rate LUNGS: bilateral breath sounds; increased rate • COR: no murmur, increased HRCOR: no murmur, increased HR• ABD: benign, although later the CT was ABD: benign, although later the CT was

abnormal…abnormal…• Ext: no cyanosis; warm; slowly progressive Ext: no cyanosis; warm; slowly progressive

edemaedema• Neuro: unresponsive pupils; ? signs of Neuro: unresponsive pupils; ? signs of

herniation herniation prompted use of IV mannitolprompted use of IV mannitol

Admit labsAdmit labs• WBC 17K 76%neutrophils, 6%lymphs WBC 17K 76%neutrophils, 6%lymphs

Hgb/Hct 13.2g%/38% Plts 380K Hgb/Hct 13.2g%/38% Plts 380K• Urinalysis: 2+ blood, few RBC’s, 360mOs/kgUrinalysis: 2+ blood, few RBC’s, 360mOs/kg• Initial Serum Osm: 272, falling to 263 in Initial Serum Osm: 272, falling to 263 in

8hrs8hrs• Toxicology screen negative for tylenol, PCP, Toxicology screen negative for tylenol, PCP,

ethylene glycol, MDMA, salicylate, ethanol, ethylene glycol, MDMA, salicylate, ethanol, cocaine, barbiturates, and narcoticscocaine, barbiturates, and narcotics

• CXR: ? RUL pneumoniaCXR: ? RUL pneumonia• CT Head: cerebral edema, especially in CT Head: cerebral edema, especially in

retrospect retrospect

Additional admit labs:Additional admit labs:• Calcium 8.6mg/dl Phos 4.2g/dlCalcium 8.6mg/dl Phos 4.2g/dl• Total protein 7.6g/dl Albumin 4.8g/dlTotal protein 7.6g/dl Albumin 4.8g/dl• Alk phos 63 LFT’s mildly elevatedAlk phos 63 LFT’s mildly elevated• INITIAL CPK 2100INITIAL CPK 2100• INITIAL BUN 10mg% CREAT 1.0mg%INITIAL BUN 10mg% CREAT 1.0mg%• ANION GAP 21ANION GAP 21• Therefore, working diagnosis of (+) AG Therefore, working diagnosis of (+) AG

lactic acidosis from seizure, 3 hours PTA lactic acidosis from seizure, 3 hours PTA

Electrolytes day one, as serum Electrolytes day one, as serum osmolality fell from 272 to osmolality fell from 272 to 263…263…08000800 11301130 13201320 18001800 23002300

Na+Na+ 126126 117117 120120 116116 117117K+K+ 4.64.6 3.83.8 3.63.6 4.04.0 3.83.8Cl-Cl- 8989 8888 9090CO2CO2 1616 1919 2222AGAG 2121 1010 99 55CreatCreat 1.01.0 1.11.1 1.11.1 1.21.2U osmU osm 360360 473473PO4PO4 4.04.0 4.44.4CPKCPK 21002100 34003400 40004000

Electrolytes: day 2Electrolytes: day 203000300 10451045 13001300 16001600 20002000

Na+Na+ 116116 128128 130130 132132 134134K+K+ 4.64.6 4.44.4CO2CO2 2626 2525AGAG 66 88CreatCreat 1.11.1 1.31.3 1.21.2PO4PO4 1.71.7 2.52.5CPKCPK 62006200 10,50010,500U osmU osm 803803 122122 600600theraptherapyy

DDAVDDAVPP

Hospital courseHospital course• Hemodynamics and oxygenation were Hemodynamics and oxygenation were

tenuous on day one…tenuous on day one…• Patient was considered for extra-coporeal Patient was considered for extra-coporeal

oxygenation therapy, resulting in a transfer oxygenation therapy, resulting in a transfer from 3 ICU to 4 ICUfrom 3 ICU to 4 ICU

• Post transfer, his BP and PO2 IMPROVEDPost transfer, his BP and PO2 IMPROVED• Abnormal CXR: bilateral infiltrates, air under Abnormal CXR: bilateral infiltrates, air under

R hemidiaphragmR hemidiaphragm• CT scan: larger amt of air surrounds tail of CT scan: larger amt of air surrounds tail of

pancreas, (L) kidney, anterior aspect of psoas pancreas, (L) kidney, anterior aspect of psoas muscle, tracking down from mediastinummuscle, tracking down from mediastinum

Hospital course: continuedHospital course: continued

• Electrolytes were normal, by hospital day Electrolytes were normal, by hospital day 33

• EEG always showed electrical activity EEG always showed electrical activity (patient had been severely hypoxemic, (patient had been severely hypoxemic, but never required ACLS)but never required ACLS)

• CNS began to improve by hospital day 4CNS began to improve by hospital day 4• Ventilator support was weaned by day 7Ventilator support was weaned by day 7• Transfer to floor day 8Transfer to floor day 8• Discharged home day 10Discharged home day 10

CNS damage associated with CNS damage associated with acute acute hyponatremia hyponatremia

• CPM: rare neurologic disorder reported in CPM: rare neurologic disorder reported in malnourished/alcoholic patientsmalnourished/alcoholic patients

• MORE COMMON – brain edema, with uncal and MORE COMMON – brain edema, with uncal and tonsillar herniation with diffuse cerebral tonsillar herniation with diffuse cerebral demyelination secondary to increased demyelination secondary to increased intracranial pressure, with necrosis, and intracranial pressure, with necrosis, and hypoxic brain damagehypoxic brain damage

• Compression of medullary respiratory center Compression of medullary respiratory center because of brain swelling, above 5 to 8% of because of brain swelling, above 5 to 8% of baseline volume can lead to herniation -- fixed baseline volume can lead to herniation -- fixed pupils, hypoventilation, cardio instability, pupils, hypoventilation, cardio instability, impaired temperature control, pituitary and impaired temperature control, pituitary and hypothalamic infarction also possiblehypothalamic infarction also possible

Water intoxication in cattleWater intoxication in cattle

• J AFR VET ASSOC 1999 DEC; 70(4)J AFR VET ASSOC 1999 DEC; 70(4)• Water intoxication is common in cattle, Water intoxication is common in cattle,

and also has been described in other and also has been described in other domestic animals. Comprehensive domestic animals. Comprehensive description is lacking…description is lacking…

Fatal water intoxication: Journal Fatal water intoxication: Journal of Clinical Pathology Oct 2003 p of Clinical Pathology Oct 2003 p 803803DJ Farrell et alDJ Farrell et al• 64 yo woman with known MV disease64 yo woman with known MV disease• Compulsively drinking water, one evening, in Compulsively drinking water, one evening, in

range of 30 to 40 glassesrange of 30 to 40 glasses• Hours later was described as “hysterical”Hours later was described as “hysterical”• Fell asleep, and found dead next morningFell asleep, and found dead next morning• Postmortem: no tumor, bilateral pleural Postmortem: no tumor, bilateral pleural

effusions, LVH with large heart; increased effusions, LVH with large heart; increased cortisols cortisols

• Na+ = 92meq/L (vitreous fluid, usually stable)Na+ = 92meq/L (vitreous fluid, usually stable)• Acute delirium, seizures, coma, and death Acute delirium, seizures, coma, and death

Autopsy case of rare iatrogenic Autopsy case of rare iatrogenic water ingestion; Chen et al, water ingestion; Chen et al, Tongji Med Univ, Forensic Sci Tongji Med Univ, Forensic Sci International: Nov 95International: Nov 95• 21 yo female suicide attempt (powder 21 yo female suicide attempt (powder

scraped from 18 matches)scraped from 18 matches)• 1700 hrs: 3L of water 1730 hrs: 800ml1700 hrs: 3L of water 1730 hrs: 800ml• 1800 hrs: 4L of water, via NG tube1800 hrs: 4L of water, via NG tube• Headache, dyspnea, cyanosis, then comaHeadache, dyspnea, cyanosis, then coma• Autopsy: cerebellar herniation, Na+ 112, Autopsy: cerebellar herniation, Na+ 112,

pulmonary edema, trachea and bronchial pulmonary edema, trachea and bronchial tubes full of fluid…tubes full of fluid…

Literature review: Forensic Literature review: Forensic Science International (1995): Science International (1995): continuedcontinued

• 534 papers over 17 years – only 16 fatalities534 papers over 17 years – only 16 fatalities• 15 cases diagnosed during hospitalization 15 cases diagnosed during hospitalization

for various types of psychosisfor various types of psychosis• Water intoxication is unusual in normal Water intoxication is unusual in normal

people, and death is even rarerpeople, and death is even rarer• Case report of death within 2.5 hrs is rareCase report of death within 2.5 hrs is rare

Fatal child abuse by forced Fatal child abuse by forced water water intoxicationintoxication

• Pediatrics 1999 JUN;103 Alan Arief,MDPediatrics 1999 JUN;103 Alan Arief,MD• 3 children punished by forced intoxication3 children punished by forced intoxication• > 6 liters> 6 liters• Seizures, emesis, coma, hypoxemia, Seizures, emesis, coma, hypoxemia,

average sodium 112mEq/Laverage sodium 112mEq/L• Autopsy confirmed cerebral edemaAutopsy confirmed cerebral edema• Tried and convictedTried and convicted

Death by hyponatremia as Death by hyponatremia as result of result of water water intoxication in aintoxication in a Army trainee Army trainee• MIL MED 1999 MAR;164MIL MED 1999 MAR;164• Excessive water intake by athletes Excessive water intake by athletes

during endurance races, to prevent heat during endurance races, to prevent heat injury has been the recommendationinjury has been the recommendation

• Describe a case of programmed Describe a case of programmed drinking > 8 liters during initial trainingdrinking > 8 liters during initial training

• One death, cerebral edema with seizureOne death, cerebral edema with seizure

Death by Water Death by Water intoxicationintoxication MIL MED 2002 May; 167 MIL MED 2002 May; 167

• 3 deaths in recruits, usual water load 3 deaths in recruits, usual water load of 6 to 10 liters in 2 to 3 hrsof 6 to 10 liters in 2 to 3 hrs

• ““safe limit” probably 1 liter per hoursafe limit” probably 1 liter per hour

Chronic Polydipsia and Chronic Polydipsia and hyponatremiahyponatremia

• Psychiatric patients, especially schizophrenia, Psychiatric patients, especially schizophrenia, often have problems with water balanceoften have problems with water balance

• 6% to 8% have a history compatible with 6% to 8% have a history compatible with compulsive water drinking; ½ of these pts had compulsive water drinking; ½ of these pts had intermittent symptoms of hyponatremiaintermittent symptoms of hyponatremia

• Normal patients can excrete 10 to 15 liters/d Normal patients can excrete 10 to 15 liters/d by decreasing Uosm from 40 to 100 mosm/kgby decreasing Uosm from 40 to 100 mosm/kg

• Episodes of transient ADH release with acute Episodes of transient ADH release with acute psychotic episodespsychotic episodes

• Carbamazepine and fluoxetine are associated Carbamazepine and fluoxetine are associated with SIADH with SIADH

Chronic polydipsiaChronic polydipsia

• This is an uncommon clinical scenario, but This is an uncommon clinical scenario, but does not apply to our current case (which is does not apply to our current case (which is rare)rare)

• ““Rx” hypontremia with acute encephalopathyRx” hypontremia with acute encephalopathy rate of correction – 0.5 to 1 meq/l per hr rate of correction – 0.5 to 1 meq/l per hr

(until a sodium of 120meq/l) (until a sodium of 120meq/l) Never actively correct > 130meq/lNever actively correct > 130meq/l