NDT Advance Access originally published online on December 9, 2007
Nephrology Dialysis Transplantation 2008 23(5):1562-1568; doi:10.1093/ndt/gfm831
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Hypernatraemia in critically ill patients: too little water and too much salt
1 Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands 2 Department of Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands
Correspondence and offprint requests to: Ewout J. Hoorn, Erasmus Medical Center, Dialysis Unit, Room Bd 391, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands. Tel: +31-10-4635335; Fax: +31-10-4633008; E-mail: ejhoorn{at}gmail.com
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Abstract |
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Background. Our objective was to study the risk factors and mechanisms of hypernatraemia in critically ill patients, a common and potentially serious problem.
Methods. In 2005, all patients admitted to the medical, surgical or neurological intensive care unit (ICU) of a university hospital were reviewed. A 1:2 matched case-control study was performed, defining cases as patients who developed a serum sodium 
150 mmol/l in the ICU.
Results. One hundred and thirty cases with ICU-acquired hypernatraemia (141 ± 3 to 156 ± 6 mmol/l) were compared to 260 controls. Sepsis (9% versus 2%), hypokalaemia (53% versus 34%), renal dysfunction (53% versus 13%), hypoalbuminaemia (91% versus 55%), the use of mannitol (10% versus 1%) and use of sodium bicarbonate (23% versus 0.4%) were more common in cases (P < 0.05 for all) and were independently associated with hypernatraemia. During the development of hypernatraemia, fluid balance was negative in 80 cases (–31 ± 2 ml/kg/day), but positive in 50 cases (72 ± 3 ml/kg/day). Cases with a positive fluid balance received more sodium plus potassium (148 ± 2 versus 133 ± 3 mmol/l, P < 0.001). On average, cases were polyuric (40 ± 5 ml/kg). Mortality was higher in cases (48% versus 10%, P < 0.001), for which hypernatraemia was an independent predictor (odds ratio 4.3, 95% confidence interval 2.5 to 7.2).
Conclusions. Hypernatraemia seems to develop in the ICU because various factors promote renal water loss, which is then corrected with too little water or overcorrected with relatively hypertonic fluids. Therapy should therefore rely on adding electrolyte-free water and/or creating a negative sodium balance. Adjustments in intravenous fluid regimens may prevent hypernatraemia.
Keywords: electrolyte disorders; intensive care; intravenous fluids; mortality; renal dysfunction
Received for publication: 15. 9.07
Accepted in revised form: 24.10.07