Turkiye Klinikleri Journal of Internal Medicine

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Güncel Kılavuzlar Eşliğinde Hiponatremik Hastaya Yaklaşım: Geleneksel Derleme
Approach to the Hyponatremic Patient with Current Guidelines: Traditional Review
Ethem Turgay CERİTa, İlhan YETKİNb
aMemorial Ankara Hastanesi, Endokrinoloji ve Metabolizma Hastalıkları Kliniği, Ankara, TÜRKİYE
bGazi Üniversitesi Tıp Fakültesi, İç Hastalıkları ABD, Ankara, TÜRKİYE
Turkiye Klinikleri J Intern Med. 2021;6(2):86-95
doi: 10.5336/intermed.2020-80796
Article Language: TR
Full Text
ÖZET
 Hiponatremi, klinik pratikte en sık görülen sıvı elektrolit bozukluğudur. Hastanede yatış süresini artırmakta ve hastalıkların seyri sırasında mortalite için bağımsız bir risk faktörü olarak kabul edilmektedir. Serum sodyum konsantrasyonunun 135 mEq/L'nin altında olması, hiponatremi olarak tanımlanır. Hiponatremiler, serum ozmolalitesine göre 3'e ayrılır. Gerçek hiponatremi, serum ozmolalitesinin 275 mOsm/kg H2O'dan düşük olduğu hipotonik hiponatremilerdir. Normal serum ozmolaliteli ya da 295 mOsm/kg H2O'dan yüksek serum ozmolaliteli hiponatremiler de olabilir ve bunlar gerçek olmayan yani nonhipotonik hiponatremilerdir. Nonhipotonik hiponatremiler, beyin ödemine yol açmazken, hipotonik hiponatremiler beyin ödemine yol açabilirler. Hipotonik hiponatremide klinik bulgulara neden olan asıl faktör, serum ozmolalitesindeki azalma ve buna bağlı gelişen beyin ödemidir. Beyin ödemi ve hayatı tehdit eden klinik bulguların gelişmesini belirleyen temel faktörler, hiponatreminin gelişme süresi ve derinliğidir. Beynin hipotonik ortama uyum sağlaması için gereken minimum süre 48 saattir. Kırk sekiz saatten kısa sürede gelişen hiponatremiler akut, 48 saatten uzun sürede gelişenler ise kronik hiponatremi olarak tanımlanmaktadır. Baş ağrısı ve bulantı, beyin ödeminin uyarıcı işaretleridir. Klinik tablo ilerledikçe kusma, nöbet ve sonunda beyin sapı herniasyonu ve solunum durması gelişecektir. Kronik hiponatremilerde ise beyin hücreleri adaptasyon için yeterli zamana sahiptir ve beyin ödemi riski azalır. Baş ağrısı, bulantı ve konfüzyon orta-ciddi semptomlar olarak değerlendirilirken; kusma, somnolans, nöbet, kardiyopulmoner sıkıntı ve koma ciddi semptomlar olarak değerlendirilmelidir. Ciddi semptomların mortalitesi yüksektir ve daha agresif tedavi gerektirmektedir. Bu derlemede, hiponatremi gelişiminde rol oynayan etiyolojik faktörler, tanı ve tedavi yaklaşımları güncel kılavuzlar ışığında özetlenecektir.

Anahtar Kelimeler: Sodyum; hiponatremi; beyin ödemi; ozmotik demiyelinizasyon sendromu
ABSTRACT
 Hyponatremia is the most common fluid electrolyte disorder in clinical practice. It prolongs hospital stay and it is considered as an independent risk factor for mortality. A serum sodium concentration below 135 mEq/L is defined as hyponatremia. There is an excess of water compared to sodium and can be dilutional or depletional. Hyponatremia can be divided into 3 groups according to serum osmolality. True hyponatremia is hypotonic hyponatremia in which serum osmolality is below 275 mOsm/kg H2O. Hyponatremias with normal serum osmolality or serum osmolality higher than 295 mOsm/kg H2O are called as non-hypotonic hyponatremias. Non-hypotonic hyponatremias do not cause brain edema, whereas hypotonic hyponatraemia can cause. The depth of hyponatremia and time to occurrence of hyponatremia are the factors that determine brain edema and life threatening clinical findings. Hyponatremia that develops in less than 48 hours is defined as acute and more than 48 hours is defined as chronic. Headache and nauseas are the warning signs of brain edema. As this clinical condition progresses, vomiting, convulsions, brainstem herniation and respiratory arrest will develop. In chronic hyponatremia, the brain cells gain enough time for adaptation and reduces the risk of brain edema. Headache, nausea and confusion are moderate to severe symptoms and vomiting, somnolence, cardiopulmonary distress should be considered as severe symptoms. Serious symptoms have higher mortality and require more aggressive treatment. In this review, etiological factors, diagnosis and treatment approaches of hyponatremia will be summarized in the light of current guidelines.

Keywords: Sodium; hyponatremia; brain edema; osmotic demyelination syndrome
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