What to do for frequent drop in sodium level?

Question

Hello doctor,

My father is out of a coma and on regular physiotherapy. However, we have a major concern now with frequent drops in his sodium level. Every five to six days his sodium level drops to 110-120. When that happens, his consciousness level goes down and stops body movement or response. He is given an injection of Sodium chloride 3% isotonic solution with Fludrocortisone one tablet per day. It takes about five to six days for his sodium level to improve to around 130. When he starts responding, he opens his eyes and moves body parts. We have seen this three to four times in the last one and a half months. Eight days back, his sodium level went down to 109 and currently, it is 121, but he has not shown much body movement yet. Normally, he recovers within five to six days. Please suggest what has to be done for faster recovery. What has to be done to prevent this from happening again and again? I have listed the medicines he is taking currently. Initially, Tolvaptan is given for 10 days (currently stopped). Fludrocortisone 10 g extra salt per day with liquid food, tablet Ofloxacin 200 mg, capsule or tablet Phenytoin sodium 100 mg, tablet vitamin B complex, tablet Losartan potassium 50 mg, tablet Metoprolol 50 mg and tablet Pantoprazole 40 mg.

Answer 1

Hi,

Welcome to icliniq.com.

I am sorry to note that he is having problems with sodium levels. I suggest the following.

Disturbances in sodium level indicate that there has been damage to the brain structures (hypothalamus) that control the levels of sodium in the blood.
One should identify the correct condition, whether there is a syndrome of inappropriate antidiuretic hormone (SIADH) or cerebral salt wasting syndrome - CSWS (tumors in brain cause low blood sodium). It is likely to be the latter.
The diagnosis can be made with blood and urine tests. It can be done by the treating neurosurgeon or the intensivist or an internal medicine doctor.
The treatment of SIADH is different from that of CSW. Hence, we need to make the correct diagnosis.
To prevent the sodium levels from going down, one should correctly identify whether the patient has SIADH or CSW. As I said, the treatment is different for these two conditions. I hope I have been able to help you.

Answer 2

Hello,

Welcome back to icliniq.com.

One has to monitor intake and output every hour and look at serum sodium levels every sixth to eighth hour, monitor serum and urine specific gravity. I do not think the medicines are causing hyponatremia. However, there is no need to continue Phenytoin. It can be tapered and stopped. Yes, it is due to the damage from the accident. With appropriate therapy, SIADH can be effectively treated. However, cerebral salt wasting is difficult to treat. Each patient responds differently to therapy.