Individuals with hypernatremia in the initial stages suffer from lethargy, onset of edema, excitability, weakness and irritability. As the condition progresses to more advanced stages, there is onset of seizures and the patient can even enter the comatose stage. Severe symptoms are primarily experienced due to increase in level of serum sodium above 157 mEq/L. When the levels rise beyond 180 mEq/L in adults, then it can be a significant cause of mortality [6].

• Fever

  In all cases, symptoms of cerebral damage such as seizures, fever and somnolence developed within hours after salt ingestion. All individuals were admitted to hospital before their deaths. [ncbi.nlm.nih.gov]

  A fever and diabetes mellitus are from the most common causes of hypernatremia [5]. Fever in our case would be of central origin related to hypernatremia, like cerebral hemorrhage and hemiplegia as described in the literature [6]. [oatext.com]

  F - Fever & Flushed Skin Patients with prolonged fever can be more prone to developing hypernatremia, as it can cause excessive sweating and fluid loss. [allnurses.com]

• Swelling

  When sodium levels in the blood are too low, extra water goes into body cells causing them to swell. [livescience.com]

  The body may adapt to higher sodium concentrations, and a rapid lowering of sodium concentration may result in cellular swelling. This can cause serious cerebral edema. It is criticial to therefore proceed carefully. [sharinginhealth.ca]

  When this happens, your body's water levels rise, and your cells begin to swell. This swelling can cause many health problems, from mild to life-threatening. Hyponatremia treatment is aimed at resolving the underlying condition. [mayoclinic.org]

  During hypernatremia correction, downward shift of the ECF tonicity (by hypotonic fluid administration) causes water influx into the cell, creating a cell-swelling force, which activates regulatory volume decrease. [cjasn.asnjournals.org]

  This helps make sure that they don’t swell excessively or contract too much. It is also important for keeping your blood pressure in the right range. [verywellhealth.com]

• Fatigue

  Symptoms of hypernatremia include: Extreme thirst Fatigue Confusion Low blood pressure Diet changes Limit all foods that are high in sodium, including: Canned soups Canned beans Frozen dinners Commercially prepared tomato sauce and spaghetti sauce Pizza [fairview.org]

  If a person has unexplained fatigue, irritability, or other mood changes, they should speak with a doctor, as these may be symptoms of hypernatremia or other health conditions. [medicalnewstoday.com]

  Symptoms of Hypernatremia Thirst and extreme fatigue are the major symptoms of hypernatremia. Other symptoms manifest neurologically and include confusion, seizures, muscle twitching or spasms, and even coma. [safeopedia.com]

  Other symptoms are lethargy, which is extreme fatigue and lack of energy, and possibly confusion. Advanced cases may also cause muscle twitching or spasms. That’s because sodium is important for how muscles and nerves work. [healthline.com]

• Tachypnea

  […] mmol/L Ringer's lactate solution: 130 mmol/L 0.9% sodium chloride in water (0.9NS): 154 mmol/L An example of the use of the above calculations is as follows: An obtunded 80-year-old man is brought to the emergency room with dry mucous membranes, fever, tachypnea [emedicine.medscape.com]

  Vomiting Skin losses Burns Excessive sweating Renal losses Intrinsic renal disease Loop diuretics Osmotic diuresis (glucose, urea, mannitol ) Euvolemic hypernatremia Decreased TBW with near-normal total body Na Extrarenal losses from the respiratory tract Tachypnea [web.archive.org]

  Skin losses Burns Excessive sweating Renal losses Intrinsic renal disease Loop diuretics Osmotic diuresis (glucose, urea, mannitol ) Euvolemic hypernatremia Decreased TBW with near-normal total body sodium Extrarenal losses from the respiratory tract Tachypnea [merckmanuals.com]

  Hyperaldosteronism – infrequent Cushing syndrome – infrequent If the body weight is decreased, there is a lower amount of free water with a relative increase in total body salt Urine sodium is low and urine osmolality is high Diarrhea Insensible water loss – fever, tachypnea [pediatriceducation.org]

• Cough

  Teach patient about foods high in sodium and about sodium-retaining drugs (cough medicines, cortisone, and laxatives, with sodium). More questions related this topic: Hypernatremia – Endocrine and Metabolic Disorders. [nursingexercise.com]

  Certain drugs such as anabolic steroids, antibiotics, corticosteroids, laxatives, cough medicines, and oral contraceptives may cause increased levels of sodium. [labtestsonline.org]

  Case Presentations An 88-year-old woman with history of moderate dementia presents via ground ambulance for irritability and increased weakness after having 2 weeks of cough and vomiting at her extended care facility. [ebmedicine.net]

• Polydipsia

  Typical DI symptoms such as polydipsia, polyuria, and marked thirst are concealed in these cases, because the hypothalamic "thirst center" cannot send thirst stimuli to the cerebral cortex. [ncbi.nlm.nih.gov]

  But, the amount of polyuria and polydipsia can be life-altering and prohibit sleep. [thecurbsiders.com]

  Both conditions result in the kidneys being unable to concentrate urine, leading to polyuria, nocturia, and polydipsia. [lecturio.com]

• Nausea

  You have nausea, and you are vomiting. You have muscle weakness or twitching. You have a headache, confusion, irritability, or any other changes in behavior. You are extremely drowsy. You have questions or concerns about your condition or care. [drugs.com]

  A 27 years old primigravid lady presented with nausea and recurrent vomiting at 35 weeks gestation. She was diagnosed with hyperemesis gravidarum at 5 weeks gestation. TPN was commenced but she continued vomiting. [endocrine-abstracts.org]

  Signs and symptoms of Hypernatremia include Loss of energy, Nausea, vomiting, confusion, irritability, restlessness, Muscle Cramps, Seizures etc. [omicsonline.org]

  Medicine may also be given to ease nausea. Prevention The risk of this problem may be lowered by drinking plenty of fluids. [winchesterhospital.org]

  The signs and symptoms include; altered mental status, lethargy, irritability, restlessness, seizures, muscle twitching, hyerreflexia, spasticity, fever, nausea, labored respiration, and intense thirst. [clinlabnavigator.com]

• Skin Turgor Decreased

  The diagnosis of hypovolemic hyponatremia is more likely in the patient with diminished skin turgor, decreased capillary refill, dry mucous membranes, and orthostasis. [ebmedicine.net]

• Renal Injury

  A patient must be hypovolemic, and salt wasting due to renal injury must be excluded. UNa is > 20 mmol/L and FENa is > 1%. [cancertherapyadvisor.com]

  Seizures [ 6, 11 ], acute renal injury [ 12 ], cerebral thrombosis, and hemorrhage [ 4 ] are among the most significant and potentially deleterious complications. [karger.com]

• Seizure

  Generalized tonic-clonic seizures, particularly those that result in lactic acidosis, may transiently elevate serum sodium. [epilepsy.com]

  A 19-year-old man presented to the Emergency Department in a comatose state with seizure-like activity 2 hours after ingesting a quart of soy sauce. [ncbi.nlm.nih.gov]

  Patient can present with lethargy, apathy, vomiting, headcahe, seizures and coma. Serum Na of 125meq/L is considered the seizure threshold, below which seizures or other central nervous manifestations will result. [cancertherapyadvisor.com]

  This had 18 infants who had no seizures and an average sodium lowering rate of 0.3 mmol/L/hr, and found that with oral rehydration achieving a mean sodium decrease of 0.32 mmol/L/h, no seizures were observed. [nephjc.com]

• Confusion

  Mainly, people are thirsty, and if hypernatremia worsens, they may become confused or have muscle twitches and seizures. Blood tests are done to measure the sodium level. [merckmanuals.com]

  Keep patient safe because they will be confused and agitated. Doctor may order to give isotonic or hypotonic solutions such as 0.45% NS (which is hypotonic and most commonly used). [registerednursern.com]

  Manifestations include confusion, neuromuscular excitability, hyperreflexia, seizures, and coma. [web.archive.org]

• Irritability

  High-pitched cry, muscle weakness, or unusual irritability or drowsiness in infants Headache, confusion, or irritability Drowsiness Seizures Muscle weakness or twitching Breathing faster than normal Nausea and vomiting Intense thirst Dry eyes or mouth [drugs.com]

  In addition to excessive weight loss (≥ 10%), the following clinical findings were observed: poor feeding, poor hydration state, jaundice, excessive body temperature, irritability or lethargy, decreased urine output, and epileptic seizures. [ncbi.nlm.nih.gov]

  ADH) Diarrhea Diuretic medication Excessive salt intake Excessive vomiting Heavy respiration (e.g., exercise, exertion) Severe burn Sweating Hypernatremia is associated with the same symptoms as hyponatremia, and also causes the following: Delerium Irritability [healthcommunities.com]

  […] symptoms determined by both speed and magnitude of Na+ change Acute symptoms usually seen once Na+ > 158 mEq/L Rise in serum Na+ and serum Osm cause water movement out of brain Thirst, confusion, decreased mental status, ataxia, seizure, coma, weakness, irritability [fprmed.com]

  Idiopathic Renal losses Glucosuria Mannitol Urea therapy Loop diuretics Post obstructive diuresis Hyperaldosteronism Generally, adverse effects of hypernatremia develop at sodium concentrations in excess of 155-160 mmol/L Increased temperature Restlessness Irritability [derangedphysiology.com]

• Altered Mental Status

  Hypernatremia due to water loss occurs only in patients who can’t access water such as infants, elderly, patients with altered mental status and hypodipsia ( 5 ).This is called dehydration and differs from hypovolemia where both salt and water are lost [unboundmedicine.com]

  mental status, and coma. [emdocs.net]

  An increase in the serum sodium concentration is most often due to a free water deficit caused by excessive fluid loss (e.g., diarrhea/vomiting, sweating, increased diuresis) or insufficient water intake (e.g., altered mental status, impaired thirst mechanism [amboss.com]

  The signs and symptoms include; altered mental status, lethargy, irritability, restlessness, seizures, muscle twitching, hyerreflexia, spasticity, fever, nausea, labored respiration, and intense thirst. [clinlabnavigator.com]

  Patient did not develop any neurological sequela and reached base line mental status before discharge. 2. [hindawi.com]

• Cognitive Impairment

  Infants and adults with cognitive impairment are most commonly affected because of their inability to express thirst and limited access to water. [us.bestpractice.bmj.com]

  The patient had been previously healthy but in the past year had experienced progressive fatigue and neurologic disturbances including somnolence, constructional apraxia, cognitive impairment, narcolepsy, cataplexy, and rapid eye movement sleep behavior [mayoclinicproceedings.org]

  Table 5 Studies reporting out-of-hospital acquired hypernatremia Full size table In our study, hypernatremic patients were old (mean age 79.7 years-old), lived in medical institutions or at home with medical care (55%), and had cognitive impairment (28% [bmcnephrol.biomedcentral.com]

  Impairment in Patients Treated with Peritoneal Dialysis, Clinical Journal of the American Society of Nephrology, 10.2215/CJN.02240215, 10:10, (1806-1813), Online publication date: 7-Oct-2015. [ahajournals.org]

An elevated serum sodium level of greater than 145 mEq/L confirms the diagnosis of hypernatremia. Laboratory studies are indicated in such cases, which include determining levels of urea, creatinine, glucose, serum and urine electrolytes. In addition, 24 hour urine volume along with urine and plasma osmolality also needs to be determined.

Imaging studies such as MRI and CT scan of the brain are indicated if the patient has suffered head injuries or trauma or shows signs of central diabetes insipidus. Histologic findings are of no significance unless vital signs indicate presence of central diabetes insipidus.

Treatment of hypernatremia is based on 4 goals, including recognizing the symptoms, determining the underlying disease, correcting the disturbances in volume and correction of hypertonicity [7].

The sodium levels are gradually brought to normal because rapid correction of volume can get very dangerous. This is so because, the brain very readily adapts to the increased sodium concentration. As a result of this, when the sodium levels are rapidly brought to normal, then water can enter the brain cells causing them to swell and giving rise to conditions like cerebral edema and seizures which can turn life threatening and cause permanent damage to brain [8].

Chronic cases of hypernatremia with mild or no symptoms are corrected at rate of 0.5 mEq/L/h and a total of 8-10mEq/L should be given in 24 hour period. Diurertic therapy is indicated in patients suffering from nephrogenic diabetes insipidus. Several drugs such as clofibrate, chlorpropamide and carbamazepine are given to patients with central diabetes insipidus to increase the hormone arginine vasopressin [9].

The prognosis of hypernatremia is good, unless an underlying neurological condition is causing the condition. The rate of mortality associated greatly depends on the severity of the condition; with a rate of 40 to 70% seen in elderly patients with severe hypernatremia [5].

Inadequate intake of water is the major cause of hypernatremia, which can occur due to the following factors [2]:

• Conditions of diarrhea
• Loss of water through the urinary tract, which occurs due to glycosuria or osmotic diuretics
• Water loss due to excessive sweating
• Diabetes, which favors excessive water excretion from kidneys; wherein there is either inadequate production of the hormone vasopressin or the kidneys do not adequately respond to the hormone
• Hypernatremia can also occur in those individuals who consume excessive amounts of sea water or products containing high concentration of sodium, such as soy sauce

It has been estimated that, in the US, the incidence of hypernatremia amongst the hospitalized population is 0.3 to 5.5%. Research has pointed towards the fact that, more than 60% cases of hypernatremia are acquired. Very low incidence of 0.12 to 1.4% of hypernatremia is recorded upon hospital admission. Critically ill patients are also at high risk of contracting the disorder due to factors such as sedation, coma or ventilation.

A high mortality rate of 30 to 48% has been recorded in patients admitted to intensive care unit. Such patients had serum sodium levels of more than 150 mmol/L [3].

Patients admitted to hospital due to severe sepsis, were found to develop hypernatremia within the first 5 days of hospital admission. The basic reason behind this was the 0.9% of saline that was given during the first 48 hours, which led to an increase in sodium concentration.

Hypernatremia primarily occurs due to water loss or sodium gain that essentially results from various factors. Researchers and clinicians have strongly put forth the fact that hypernatremia is a water problem and majorly occurs due to the phenomenon of decrease in total body water. In view of this, conditions favoring such a type of event cause an increase in the sodium concentration, leading to hypernatremia.

Under normal physiologic conditions, thirst and release of arginine vasopressin are triggered by increase in fluid osmolality of body beyond 280 to 290 mOsm/L. This osmotic threshold is similar for conditions of thirst as well as release of arginine vasopressin hormone. When there is an increase in the osmolality, water is drawn from the cells, which causes dehydration of the neurons in the brain, known as tonicity receptors. Upon stimulation, signals are sent to parts of brain to trigger thirst and the simultaneous release of the hormone arginine vasopressin. Such sequence of events causes increased consumption of water and increased urinary concentration, thereby correcting the hypernatremic state [4].

Maintenance of proper fluid balance forms the basis of preventing hypernatremia. Replenishing for lost fluids after heavy physical activity or exercise should be done. Infants and children should be fed water after short intervals. Elderly patients who are critically ill or are unable to fetch water for themselves should be taken care of and given water in between intervals [10].

Hypernatremia is primarily caused due to significant decrease in total body water. Due to this reason, hypernatremia often corresponds with dehydration. Such a type of condition commonly strikes the infants, individuals with altered mental status and the elderly population. The reason being, in these groups of population, the thirst mechanism is intact but they are not in a position to ask for water or help themselves [1].

Definition: Hypernatremia is a condition, characterized by increased serum sodium level above 145 mmol/L. The condition is a common occurrence in the infant and elderly population. It has also been noted that, majority of hospitalized patients are also susceptible to acquire hypernetremia.

Cause: It practically occurs due to reduction in total body water and does not occur due to sodium homeostasis. Factors that induce water loss include excessive sweating, diarrhea, excess of mineral corticoid due to disease such as Conn’s syndrome, salt poisoning and excess secretion of water by kidney in disease conditions such as diabetes insipidius.

Symptoms: Symptoms of hypernatremia include persistent lethargy, undue fatigue, weakness, edema and neuromuscular excitability. In severe condition, individuals can experience seizures or can even enter the comatose stage.

Diagnosis: Determining the serum sodium levels forms the preliminary base of diagnostic profile. In addition, various laboratory studies such as measuring the glucose levels, serum and urine electrolytes, urea, creatinine, 24 hour urine volume and levels of plasma hormone arginine vasopressin are also required.

Treatment: Treatment of hypernatremia is geared towards normalizing the serum sodium levels by increasing the total body water. This is done by administration of water either orally or through intravenous route. However, water alone cannot be given and therefore, it given through dextrose or saline solution.

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