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Hypernatremia in Hospitalized Patients

Paul M. Palevsky, MD; Ravinder Bhagrath, MD; and Arthur Greenberg, MD
[+] Article and Author Information

From the University of Pittsburgh School of Medicine and Medical Service, and the Veterans Affairs Medical Center, Pittsburgh, Pennsylvania. Requests for Reprints: Paul M. Palevsky, MD, Renal-Electrolyte Division, University of Pittsburgh School of Medicine, A919 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15261. Current Author Addresses: Drs. Palevsky and Greenberg: Renal-Electrolyte Division, University of Pittsburgh School of Medicine, A919 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15261.


Copyright ©2004 by the American College of Physicians


Ann Intern Med. 1996;124(2):197-203. doi:10.7326/0003-4819-124-2-199601150-00002
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Objective: To determine the incidence, clinical characteristics, and outcome for general medical-surgical hospital patients with hypernatremia.

Design: A prospective cohort study.

Setting: A 942-bed urban university hospital.

Patients: All patients who developed a serum sodium concentration of 150 mmol/L or greater during a 3-month observation period.

Measurements: Daily fluid balance, mental status, and serum and urine electrolytes and osmolality.

Results: 103 patients were identified. Eighteen patients were hypernatremic on hospital admission, and 85 developed hypernatremia during hospitalization. Patients who developed hypernatremia during hospitalization were younger than patients who developed hypernatremia before hospital admission (mean age ±SD, 58.9 ± 19.2 years compared with 76.6 ± 16.6 years; P < 0.01) but did not differ in age from the patients of the general hospitalized population. Eighty-nine percent of patients who developed hypernatremia during hospitalization had urine concentrating defects, primarily as the result of the use of diuretics or of solute diuresis, whereas only 50% of patients who were hypernatremic on admission could be shown to have concentrating defects (P < 0.01). Fifty-five percent of all hypernatremic patients had increased insensible water losses, and 35% had increased enteral water losses. Eighty-six percent of patients with hospital-acquired hypernatremia lacked free access to water, 74% had enteral water intake of less than 1 L/d, and 94% received less than 1 L of intravenous electrolyte-free water per day during the development of hypernatremia. No supplemental electrolyte-free water was prescribed during the first 24 hours of hypernatremia in 49% of patients. The duration of hypernatremia was shorter in patients who were hypernatremic on admission (median duration, 3 days) than in patients with hospital-acquired hypernatremia (median duration, 5 days; P < 0.05). Mortality was 41% for all patients, but hypernatremia was judged to have contributed to mortality in only 16% of patients.

Conclusions: Although the development of hypernatremia before hospital admission occurs primarily in geriatric patients, hospital-acquired hypernatremia was more common in our cohort and had an age distribution similar to that of the general hospitalized population. Hospital-acquired hypernatremia was primarily iatrogenic, resulting from inadequate and inappropriate prescription of fluids to patients with predictably increased water losses and impaired thirst or restricted free water intake or both. Treatment of hypernatremia is often inadequate or delayed. Efforts to manage hypernatremia better and altogether avoid hospital-acquired hypernatremia should focus on both physician education and the development of hospital systems to prevent errors in fluid prescription.

Figures

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Figure 1.
Age distribution of patients with hypernatremia.P

Ages of 18 patients who were hypernatremic at the time of hospitalization and 85 patients who developed hypernatremia during hospitalization. Individual patient ages (crosses) and group mean age ±SD (filled diamond and bar) are shown; < 0.01.

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Figure 2.
Urine volume during hypernatremia.P

Twenty-four-hour urine volume during hypernatremia in 11 patients who were hypernatremic on admission and in 82 patients with hospital-acquired hypernatremia. For patients who had multiple measurements of urine volume, the value reported is for the measurement for the first 24-hour period. Individual patient values (crosses) and group mean ±SD (filled diamond and bar) are shown; < 0.01.

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Figure 3.
Urine osmolality during hypernatremia.P

Urine osmolality during hypernatremia in 7 patients who were hypernatremic on admission and 41 patients with hospital-acquired hypernatremia. Individual patient values (crosses) and group mean ±SD (filled diamond and bar) are shown; < 0.05. For patients who had multiple measurements of urine osmolality during hypernatremia, the value reported is the first measurement. A urine osmolality of greater than 700 mmol/kg during hypertonicity was considered to indicate normal urinary concentration, and a urine osmolality of less than 300 mmol/kg during hypertonicity was considered diagnostic of diabetes insipidus.

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