Electroencephalographic Changes during and after Water Intoxication*
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Abstract: A case of water intoxication with remarkable hyponatremia was investigated with a special reference to EEG changes during and after the episode. The patient recovered his EEG as his consciousness disturbance had improved through an intravenous infusion of high osmolality saline, correlating with the serum sodium level. Further, the clinical importance of recording EEG for water intoxication was stressed.Keywords:
Water intoxication
Pediatric seizures are a common presentation to the emergency department. It is important to separate non-febrile seizures from febrile seizures, as non-febrile seizures have a much broader differential diagnosis. For infants less than six months of age with a normal exam, hyponatremia is the leading cause of new onset non-febrile seizure. Most commonly, this is secondary to water intoxication from inappropriate feeding practices. This case report will review the initial workup of new onset non-febrile seizures in an infant and treatment recommendations for seizures secondary to hyponatremia.
Febrile seizure
Water intoxication
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High fever
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Hyponatremia is the most common electrolyte disorder that requires careful management. Water intoxication with hyponatremia is rare condition that originated from overhydration. Water intoxication, also known as dilutional hyponatremia, develops only because the intake of water exceeds the kidney's ability to eliminate water. Causes of this water intoxication include psychiatric disorder, forced water intake as a form of child abuse and iatrogenic infusion of excessive hypotonic fluid. We experienced and reported a case of symptomatic hyponatremia by forced water intake as a form of child abuse.
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Use of desmopressin (1-deamino-8-d-arginine vasopressin; DDAVP), a synthetic vasopressin receptor agonist, has expanded in recent years. Desmopressin leads to renal water retention, and iatrogenic hyponatremia may result if fluid intake is not appropriately restricted. It is common practice to stop a medication that is causing toxicity, and this advice is promulgated in Micromedex, which suggests withholding desmopressin if hyponatremia occurs. If intravenous saline solution is administered and desmopressin is withheld at the same time, rapid changes in serum sodium levels may result, which puts the patient at risk for demyelinating lesions. In the management of desmopressin-associated hyponatremia with neurologic symptoms, the drug should not be withheld despite the presence of hyponatremia. The medication should be continued while administering intravenous hypertonic saline solution. Desmopressin is also used to minimize water excretion during the correction of hyponatremia during water diuresis. When treating hyponatremia, clinicians should monitor closely to avoid free-water diuresis. To prevent ongoing water losses in urine and overly rapid "autocorrection" of serum sodium level, desmopressin can be given to reduce free-water losses. These treatment recommendations are the authors' perspective from previously published work and personal clinical experience.
Desmopressin
Hypertonic saline
Water intoxication
Tolvaptan
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Water intoxication usually happens in patients with a psychiatric problem, who are subject to compulsive water ingestion, and during clinical examinations, such as uroflowmetry, and is seldom observed in ordinary people. Here we report a patient with severe hyponatremia due to voluntary water drinking coexisting with no psychiatric problems. The case presented clinically significant hyponatremia 124 mmol/L without any signs of dehydration after voluntary ingestion of 4000 ml of water over 3 hours. She normally responded to ingestion of 1000 ml of water over 20 min after recovery from hyponatremia, and did not meet the diagnostic criteria of SIADH. She was not a compulsive drinker. The present case suggests that one should consider water intoxication as a cause of hyponatremia in a patient without signs of dehydration, even if he/she does not have a history of compulsive water ingestion.
Water intoxication
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Neonatal hyponatremia can be caused by increased sodium losses, inadequate sodium intake, increased maternal or neonatal water load or by water retention secondary to excess of ADH release. Cocaine use by pregnant women has not as yet been reported to correlate with hyponatremia in the newborn infant. We present a case of an infant whose mother used cocaine regularly during the last stages of pregnancy and who developed hyponatremia in the first week of life. A mechanism is proposed and discussed.
Cocaine use
Water intoxication
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Hypotonic hyponatremia secondary to acute water intoxication is most commonly associated with primary polydipsia in the setting of psychiatric illness. However, in certain circumstances, otherwise healthy individuals can be compelled to consume large enough volumes of water to overwhelm the kidney's dilutional capacity of urine and cause a potentially life-threatening rapid decline in serum sodium. We present such a case of a 20-year-old basic military trainee with acute symptomatic hypotonic hyponatremia after drinking five to six liters of water prior to urine drug testing. The clinical manifestations of this disorder are non-specific and can be seen with many different pathologic processes, presenting a diagnostic challenge to the emergency clinician. This challenge can be further complicated by unclear or unobtainable history depending on clinical presentation. The authors will discuss key diagnostic and treatment elements of this potentially life-threatening disease to encourage clinicians to utilize social history when evaluating cases of acute water intoxication and resultant symptomatic hypotonic hyponatremia.
Water intoxication
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Hyponatremia is the most frequent electrolyte disorder. Two forms of it, the "true"--and "pseudo"--hyponatremia are known. The normal osmoregulation is an accurate operation which ensures the steadiness of serum sodium level by regulating vasopressin (ADH) release and water intake. Hyponatremia usually indicates water excess in the body, however, it may be complicated by sodium loss as well. It has hypovolemic, hypervolemic and normovolemic forms; the syndrome of inappropriate antidiuretic hormone (SIADH) is associated mostly with the normovolemic states. Nowadays the pathomechanism, criteria, diagnosis and etiologic factors of SIADH (water intoxication) are fairly well known, but the number of drugs capable of inducing this syndrome is increasing day by day. According to the newest knowledge, SIADH may exist not only in the acute but chronic form as well, which should be born in mind when treating water intoxicated patients. The basic principle is that in cases with mild clinical disturbances aggressive treatment should be avoided. For mild hyponatremia water restriction is usually sufficient, but in serious cases hypertonic saline infusion should be administered. Its speed has to be determined and adjusted carefully according to the needs of the patient, and it can be combined with the administration of furosemide, when necessary. Vasopressin antagonists are under clinical investigation, their therapeutic value has not yet been determined. Water intoxication is not rare-if one keeps it in mind. The syndrome's simple treatment can be life saving for the patient and provides an easy problem solution for the physician.
Water intoxication
Electrolyte Disorder
Hypertonic saline
Vasopressin Antagonists
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In Brief Severe hyponatremia is associated with a mortality rate of more than 50%, primarily from cerebral edema and central nervous system dysfunction. Water intoxication is an unusual but potentially lethal cause of perioperative hyponatremia. We report a patient with severe postoperative hyponatremia resulting from excessive perioperative water consumption. Anesthesiologists should maintain an index of suspicion for hyponatremia from water intoxication in patients with neurologic symptoms during the perioperative period. Routine preoperative instructions regarding maximum perioperative water intake and inquiry into any concurrent alternative medical therapies may help to avoid this preventable complication. IMPLICATIONS: Water intoxication is an unusual but potentially lethal cause of perioperative hyponatremia. We report a patient with severe postoperative hyponatremia resulting from excess perioperative water consumption.
Water intoxication
Cerebral edema
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During a three-month period, 15 patients under two years of age presented with serum sodium concentrations less than 127 mEq/L. Seven (47%) of these patients presented with seizures. Hyponatremia accounted for a majority (58%) of the afebrile seizures in children under two years during this period. Of the eight patients without seizures, four later proved to have cystic fibrosis. Most of the patients with seizures appear to represent the syndrome of infant water intoxication. Hyponatremia may account for more seizures in early life than has been appreciated. Physicians and parents should avoid dietary practices which promote water intoxication. The etiology, diagnosis, and management of water intoxication and hyponatremic seizures are discussed.
Water intoxication
Etiology
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Water intoxication
Liter
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