Recommandations 2014 pour la prise en charge de l’hyponatrémie | NEPHROBLOG

Recommandations 2014 pour la prise en charge de l’hyponatrémie | NEPHROBLOG

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Recommandations 2014 pour la prise en charge de l’hyponatrémie

L’hyponatrémie est fréquente, mais sa prise en charge n’avait jamais l’objet d’un consensus d’expert. Plusieurs sociétés savantes (ESIM, ESE, ERA-EDTA (ERBP)) se sont regroupées pour élaborer des directives quant au diagnostique et au traitement de l’hyponatrémie vraie. Ces directives sont parues dans l’European Journal of Endocrinology en mars 2014.[1]

Cette prise en charge se focalise plus sur le patient que sur une valeur de laboratoire.[2]

L’hyponatrémie est définie comme un sodium sérique (Na) inférieur à 135 mmol/l avec plusieurs degrés (légère, modérée, sévère)

Légère	Na entre 130 et 135 mmol/l
Modérée	Na entre 125 et 129 mmol/l
Sévère	Na inférieur à 125 mmol/l

Elle est soit aiguë (< 48h), soit chronique (> 48h) et le patient peut être soit modérément symptomatique (nausées sans vomissements, confusion, céphalées) ou sévèrement symptomatique (vomissements, détresse cardio-respiratoire, somnolence, convulsions, GCS (Glasgow Coma Scale < 8). Ces définitions permettent ensuite de s’y retrouver dans les algorithmes proposés (!)


L’hyponatrémie concerne jusqu’à 30% des patients hospitalisés.
Tout praticien hospitalier doit être en mesure d’en poser le diagnostic
précis, de la classer et de la traiter efficacement.

 Par principe, il s’agit de traiter initialement l’hyponatrémie sévère indépendamment de la pathologie de base en évitant une correction trop rapide et en se concentrant davantage sur le patient que sur la valeur de laboratoire elle-même.

Pour utiliser les 2 algorithmes suivants, outre les définitions
données plus hautes, il faut avoir examiné son patient et pouvoir
évaluer sa volémie (hypovolémique, euvolémique ou hypervloémique)


Pour caractériser l’hyponatrémie, il faut obtenir l’osmolalité et le sodium urinaire et se servir de l’algorithme suivant:

Algorithm for the diagnosis of hyponatremia

Tiré de la référence 1

Pour la prise en charge, on a besoin de connaître les symptômes de
son patient, ainsi que la rapidité d’installation de l’hyponatrémie:

Algorithm for the management of hypotonic hyponatraemia

Modifié de la référence 1

Voici le résumé des recommandations (en anglais)


I. Hyponatraemia with severe symptoms

1. First-hour management, regardless of whether hyponatraemia is acute or chronic
   
   1. We recommend prompt i.v. infusion of 150 ml 3% hypertonic over 20 min (1D)
   2. We suggest checking the serum sodium concentration after 20 min,
      while repeating an infusion of 150 ml 3% hypertonic saline for the next
      20 min (2D)
   3. We sugget repeating therapeutic recommendations a. and b. twice or
      until a target of 5 mmol/l increase in serum sodium concentration is
      achieved (2D)
   4. Manage patient with severely
      symptomatic hyponatraemia in an environment where close biochemical and
      clinical monitoring can be provided (not graded)
2. Follow-up management in
   case of improvement of symptoms after a 5 mmil/l increase in serum
   sodium concentration in the first hour, regardless of whether
   hyponatraemia is acute or chronic
   
   1. We recommend stopping the infusion of hypertonic saline (1D)
   2. We recommend keeping the i.v. line open by infusing the smallest
      feasible volume of 0.9% saline until cause-specific treatment is started
      (1D)
   3. We recommend starting a diagnostic-specific treatment if available, aiming at least to stabilise sodium concentration (1D)
   4. We recommend limiting the increase in serum sodium concentration to a
      total of 10 mmol/l during the first 24h and an additional 8 mmol/l
      during every 24h thereafter until the serum sodium concentration reaches
      130 mmol/l (1D)
   5. We suggest checking the serum sodium concentration after 6 and 12h
      and daily afterwards until the serum sodium concentration has stabilized
      under stable treatment (2D)
3. Follow-up management in case of no
   improvement of symptoms after a 5 mmil/l increase in serum sodium
   concentration in the first hour, regardless of whether hyponatraemia is
   acute or chronic
   
   1. We recommend continuing an i.v. infusion of 3% hypertonic saline or
      equivalent for an additional 1 mmol/l per h increase in serum sodium
      concentration (1D)
   2. We recommend stopping the infusion of 3% hypertonic saline or
      equivalent when the symptoms improve, the serum sodium concentration
      reaches 130 mmol/l, whichever occurs first (1D)
   3. We recommend additional diagnostic exploration for other causes of the symptoms than hyponatraemia (1D)
   4. We suggest checking the serum sodium concentration every 4h as long
      as an i.v. infusion of 3% hypertonic saline or equivalent is continued
      (2D)

II. Hyponatraemia with moderately severe symptoms

1. We recommend starting prompt diagnostic assessment (1D)
2. Stop, if possible, medications and other factors that can contribute to or provoke hyponatraemia (not graded)
3. We recommend cause-specific treatment (1D)
4. We suggest immediate treatment with a single i.v. infusion of 150 ml 3% hypertonic saline or equivalent over 20 min (2D)
5. We suggest aiming for a 5 mmol/l per 24-h increase in serum sodium concentration (2D)
6. We suggest limiting the increase in serum sodium concentration to 10
   mmol/l in the first 24h and 8 mmol/l during every 24h thereafter, until
   a serum sodium concentration of 130 mmol/l is reached (2D)
7. We suggest checking the serum sodium concentration after 1, 6 and 12h (2D)
8. We suggest additional diagnostic
   exploration for other causes of the symptoms if the symptoms do not
   improve with an increase in sodium serum concentration (2D)

III. Acute hyponatraemia without severe or moderately severe symptoms

1. Make sure that the serum sodium
   concentration has been measured using the same technique used for the
   previous measurement and that no administrative errors in sample
   handling have occurred (not graded)
2. If possible, stop fluids, medications and other factors that can contribute to or provoke hyponatraemia (not graded)
3. We recommend starting prompt diagnostic assessment (1D)
4. We recommend cause-specific treatment (2D)
5. If the acute decrease in serum sodium concentration exceeds 10
   mmol/l, we suggest a single i.v. infusion of 150 ml 3% hypertonic saline
   or equivalent over 20 min (2D)
6. We suggest checking the serum sodium concentration after 4h, using the same technique used for the previous measurement (2D)

IV. Chronic hyponatraemia without severe or moderately severe symptoms

1. General management
   
   1. Stop non-essential fluids, medications and other factors that can contribute to or provoke hyponatraemia (not graded)
   2. We recommend cause-specific treatment (1D)
   3. In mild hyponatraemia, we suggest against treatment with the sole aim of increasing the serum sodium concentration (2C)
   4. In moderate or profound hyponatraemia, we recommend avoiding an
      increase in serum sodium concentration of > 10 mmol/l during the
      first 24h and > 8 mmol/l during every 24h thereafter (1D)
   5. In moderat or profound hyponatraemia, we suggest checking the serum
      sodium concentration every 6h until the serum sodium concentration has
      stabilized under stable treatment (2D)
   6. In case of unresolved hyponatraemia, reconsider the diagnostic algorithm and ask for expert advice (not graded)
2. Patients with expanded extracellular fluid
   
   1. We recommend against a treatment with the sole aim of increasing the
      serum sodium concentration in mild or moderate hyponatraemia (1C)
   2. We suggest fluid restriction to prevent further fluid overload (2D)
   3. We recommend against demeclocycline (1D)
3. Patients with SIAD
   
   1. In  moderate or profound hyponatraemia, we suggest restricting fluid intake at first-line treatment (2D)
   2. In moderate or profound hyponatraemia, we suggest the following can
      be considered equal second-line treatment: increasing solute intake with
      0.25-0.5 g/kg per day of urea or a combination of low-dose loop
      diuretics and an oral sodium chloride (2D)
   3. In moderate or profound hyponatraemia, we recommend against lithium or demeclocycline (1D)
   4. In moderate hyponatraemia, we do not recommend vasopressin receptor antagonists (1C)
   5. In profound hyponatraemia, we recommend against vasopressin receptor antagonists (1C)
4. Patients with reduced circulating volume
   
   1. We recommend restoring extracellular volume with i.v. infusion of
      0.9% saline or a balanced crystalloid solution at 0.5-1 ml/kg per h (1B)
   2. Manage patients with haemodynamic instability in an environment
      where close biochemical and clinical monitoring can be provided (not
      graded)
   3. In case of haemodynamic instability, the need for rapid fluid
      resuscitation overrides the risk of an overly rapid increase in serum
      sodium concentration (not graded)

Source

1.Clinical practice guideline on diagnosis and treatment of hyponatraemia Eur J Endocrinol 2014

http://nephroblog.org/2014/04/21/8302/