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].

• Splenomegaly

  There is no hepatomegaly or splenomegaly, or jaundice. The electrocardiogram is normal, no disturbance of repolarization or conduction. [oatext.com]

• 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]

• Falling

  They are also a major cause of hospital admissions and delirium and are associated with frailty, falls, and hip fractures. Both hypernatremia and hyponatremia are potentially preventable. [ncbi.nlm.nih.gov]

  TITRATION  Rapid fall >0.5meq/hr  Increase sodium concentration from ½ NS to ¾ NS.  Optimum fall 0.5 meq/hr- continue same fluid at same rate  Slow fall 26. [slideshare.net]

  Cerebral edema is seen heterogenous group of neurological disease states that mainly fall under the categories of metabolic, infectious, neoplasia, cerebrovascular, and traumatic brain injury disease states. [clinicaltrials.gov]

• Pain

  Scrotal Pain (Acute) This pathway provides guidance for the imaging investigation of male patients with acute scrotal pain. Bronchiectasis This pathway provides guidance on imaging patients with suspected bonchiectasis. [evidence.nhs.uk]

  In emergency room patient was nonverbal and was responsive only to painful stimuli but with stable vital signs (BP103/69, HR88, RR18, and T98.2F). [hindawi.com]

  Shortness of breath, chest pain or discomfort; should be evaluated immediately. If you feel suddenly confused. [chemocare.com]

  Other afferent stimuli, such as a decrease in effective arterial blood volume, pain, nausea, anxiety, and numerous drugs, can also cause a release of AVP. [emedicine.medscape.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]

• Fishing

  However, some types of fish contain high levels of mercury, which is dangerous to a developing fetus. Pregnant women must take care when choosing the types of fish they eat during pregnancy to reduce this risk. [web.archive.org]

  And what’s this about fish the look like aliens. September’s Words in the News explain all. Read more [collinsdictionary.com]

  McAloon Dyke M, Davis KM, Clark BA, Fish LC, Elahi D, Minaker KL. Effects of hypertonicity on water intake in the elderly: an age-related failure. Geriatr Nephrol Urol. 1997;7(1):11–16. 20. O’Neill PA, McLean KA. Water homeostasis and ageing. [dovepress.com]

• 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]

• Heart Failure

  Yet, beyond the heart, heart failure with preserved ejection fraction is typified by much stiffer arteries and a lower venous capacitance compared to heart failure patients with reduced ejection fraction. [pulmccm.org]

  Recently, CRRT was also introduced as a useful tool for treating severe congestive heart failure (CHF). By using CRRT, we successfully treated hypernatremia in a patient with severe CHF, without observing any fluid overload. [ncbi.nlm.nih.gov]

  Kociol R (2013) Circulation: Heart Failure Editors’ Picks, Circulation: Heart Failure, 6:5, (e64-e70), Online publication date: 1-Sep-2013. [ahajournals.org]

• Tachycardia

  The following day she became polyuric and dehydrated with tachycardia and low blood pressure. [ncbi.nlm.nih.gov]

  Four other signs (tachycardia, abnormal subclavicular skin turgor, dry oral mucosa, and recent change of consciousness) had a specificity of greater than 79%. [dx.doi.org]

  Blood pressure was 90/60 mmHg, tachycardia at 133/ min. Cardiac auscultation is normal. Vascular axes were weakly perceptible. Oxygen saturation was 95%. [oatext.com]

  Orthostatic hypotension and tachycardia are usually present in hypovolemic hypernatremia. [physio-pedia.com]

• Muscle Weakness

  Your baby has a high-pitched cry, muscle weakness, or unusual irritability or drowsiness. You have dry eyes or mouth. You have nausea, and you are vomiting. You have muscle weakness or twitching. [drugs.com]

  weakness, cramps, or twitching Irritability Weight loss Urinating (peeing) less than usual Confusion Dry Mouth Dry mouth is a symptom of hypernatremia. [winchesterhospital.org]

  Muscle weakness. Poor appetite that does not improve. Shortness of breath, chest pain or discomfort; should be evaluated immediately. If you feel suddenly confused. [chemocare.com]

  Muscle weakness, confusion, and coma are sometimes manifestations of coexisting disorders rather than of the hypernatremia itself ( Table 2 ). [ncbi.nlm.nih.gov]

• Osteoporosis

  Schilling, Increased levels of sodium chloride directly increase osteoclastic differentiation and resorption in mice and men, Osteoporosis International, 10.1007/s00198-017-4163-4, 28, 11, (3215-3228), (2017). Paul L. [dx.doi.org]

  A high level of salt intake increases the amount of calcium excreted in the urine, which may also contribute to osteoporosis and increased risk of fracture. [web.archive.org]

• 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]

• 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. [msdmanuals.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]

• 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]

• Agitation

  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]

  In view of increasing agitation, fentanyl and midazolam infusions were started. [sjkdt.org]

  Hypernatremia causes ICU patients to be delirious, thirsty, agitated, and miserable. It requires prompt, precise, and definitive management. This is a core competency for anyone managing critically ill patients. [emcrit.org]

  This often manifests as agitation, restlessness, short attention span, and confusion. Initially, the increased sodium excessively stimulates cells but as fluid volume shifts to the ECF, the cells dehydrate and are unable to respond to any stimuli. [picmonic.com]

  Infants and Children present with irritability and agitation, which can progress to lethargy, somnolence, and coma. Other symptoms include increased thirst response in alert patients and high-pitched cry in infants. [physio-pedia.com]

• Tremor

  September 12, 2006; 67 (5) NeuroImages First published September 11, 2006, DOI: https://doi.org/10.1212/01.wnl.0000221726.41727.06 A 73-year-old man presented with vomiting, tremor, and consciousness disturbance 12 hours after ingesting soy sauce in an [n.neurology.org]

  In cases where [Na+]>180, neurological defects can appear, including ataxia, tremor, coma, and seizures. Investigations Taking a thorough clinical history is the most important tool in evaluating the cause of hypernatraemia. [teachmesurgery.com]

  Assess the patient for muscle twitching, hyperreflexia, tremors, seizures, and rigid paralysis. Check the patient’s ability to obtain adequate fluid intake as lethargic state contributes to the poor fluid intake. [nursingexercise.com]

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.

• Leukocytosis

  They were a biological inflammatory syndrome with leukocytosis 16,000/mm 3 and CRP 30 mg/l; the rest of the blood count notes hemoglobin to 15 g/dl and a hematocrit to 45%. [oatext.com]

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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