Manejo de la hiponatremia en pacientes con nutrición artificial

– Autores:

Emilia Gómez Hoyos
Hospital Clínico Universitario de Valladolid.

Cristina Serrano Valles
Hospital Clínico Universitario de Valladolid.

Daniel Antonio de Luis Román
Hospital Clínico Universitario de Valladolid.

Resumen
350 mOsmol/kg. En los pacientes con SIADH, si a pesar de las medidas previas persiste la hiponatremia, se debe valorar el uso de Tolvaptan; en NE por sonda nasogástrica y en NP por vía oral (deglución y 2ª porción de duodeno conservadas), administrándolo según el protocolo adaptado del algoritmo multidisciplinar y la perfusión conjunta de suero glucosado

Palabras Clave
hiponatremia, nutrición artificial, nutrición enteral, nutrición parenteral, SIADH

Abstract
Hyponatremia is the most frequent electrolyte disturbance in hospitalized patients. The rate of hyponatremia is even higher in patients receiving parenteral nutrition (PN) or enteral feeding (EF) than that described in the general adult hospitalized population. Hyponatremia is associated with increased morbimortality. In fact, hyponatremic patients on PN have been found to present a higher mortality rate than eunatremic patients receiving PN. The treatment of severe hyponatremia with hypertonic saline decreased the mortality rate. On other hand the improvement of non severe hyponatremia was associated with a reduction in the mortality rate of hospitalized patients. The correction of hyponatremia is only achieved with the treatment adjusted to the clinical volemia (hypo-, eu- and hyper-volemia) and the etiology of hyponatremia (congestive heart failure, syndrome of inappropriate secretion of ADH-SIADH-, adrenal insufficiency (AI) 1ª and 2ª, diuretics …) denominated appropriate treatment. This treatment in the case of hypovolemic hyponatremia is based on the restitution of volemia with isotonic saline in addition to removing the diuretic, administering hydrocortisone if it has AI 1 and fludrocortisone in some cases of isolated hypoaldosteronism. In patients with hypervolemic hyponatremia, together with furosemide, the sodium contribution will be implemented at a minimum of 136 mEq/day to guarantee its therapeutic action. In turn, we will try to reduce the total fluids provided by administering a hypercaloric enteral formula and concentrating the PN formula if possible. Other therapies that should be considered in patients with hyponatremia secondary to congestive heart failure and cirrhosis with ascites are the blockade of the renin-angiotensin system and in ascites the administration of albumin/paracentesis. Finally, in euvolemic hyponatremia, adequate treatment is based on the reduction of total fluid intake as well as hypervolemic hyponatremia, accompanied by an increase in sodium intake to compensate for renal losses. In turn, in the elevation of ADH due to pain and nausea, antiemetics and analgesia should be administered. As well as, hydrocortisone in patients with AI 2ª and furosemide in patients with SIADH and urinary osmolality> 350 mOsmol /kg. In patients with SIADH, if despite the previous measures persists hyponatremia, the use of Tolvaptan should be assessed; in EF by nasogastric tube and oral PN (swallowing and 2nd portion of the duodenum conserved), administering it according to the adapted protocol of the multidisciplinary algorithm and the joint intravenous perfusion of glucose-solution

Key words
hyponatremia, artificial nutrition, enteral feeding, parenteral nutrition, SIADH