Syndrome InAppropriate ADH
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Transcript of Syndrome InAppropriate ADH
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Titis Kurniawan
Fakultas Ilmu Keperawatan
Universitas Padjadjaran
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Outline
� Physiology of ADH
� Hyponatremia
� SIADH & Etiology� SIADH & Etiology
� Diagnostic test
� Sign & Symptom SIADH
� Patofisiology SIADH
� SIADH Management
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Anti Diuretic Hormone� Kelenjar pituitary posterior menghasilkan ADH & oxitosin
� Disekresi dari kelenjar pituitary posterior sbg respon terhadap:
� Peningkatan onkotik plasma
� Peregangan atrium kiri
� Olahraga� Olahraga
� Keadaan emosional tertentu
� Bekerja pd duktus kolektivus ginjal� M>> absorbsi air
� Kekurangan ADH (Diabetes insipidus) � absorbsi air di tubulus
ginjal << � hipernatremia, poliuria & BJ urine rendah
� Kelebihan sekresi ADH (SIADH) � absorbsi air di tubulus ginjal
>> � Dilutional Hyponatremia, oliguria, & BJ urine tinggi
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Hyponatremia� Sign & symptoms:
� Cells swelling
� Cerebral edema; Seizure, headache, confusion, unconsciousness/coma
� Restlessness
� Muscle weakness� Muscle weakness
� Muscle spasm/cram
� Nausea/vomiting
� Caused by SIADH and other causes
� Mortality rate in hyponatremic patients 50x higher than non
� Mortality rate in patients with Na serum < 120 � twice those
� Mortality in adult patients (5-50%) >> infant (8%)
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SIADH� Adalah: Kondisi dimana ADH disekresikan secara berlebihan dari kelenjarpituitari posterior� retensi air � intoksikasi air (hipoosmolality serum & hyponatremia)
� Kriteria Diagnostik:
1. Hypo-osmolality; plasma osmolality > 280 mosmol/kg, or plasma sodium concentration < 134 mmol/lconcentration < 134 mmol/l
2. Inappropriate urinary concentration (Uosm >100 mosmol/kg) forhyponatraemia
3. Elevated urinary sodium (> 40 mmol/l), with normal dietary salt and water intake
4. Patient is clinically euvolaemic
5. Exclusion of hypothyroidism, diuretics and glucocorticoid deficiency –particularly in patients with neurosurgical conditions
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Laboratory Test
� Electrolyte test; Na, K
� Serum & urine osmolality;
� Serum osmolality <<
� Urine osmolality >>, high serum Na (> 30 � Urine osmolality >>, high serum Na (> 30
mosm/L)
�BUN � urea <<
�Other laboratory test; blood glucose
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Etiology of SIADH� Malignancy; small cell lung cancer, nasopharyngeal cancer,
mesothelioma, GI tract malignancy, Lymphoma, sarcoma.
� CNS Disorder/Intracranial Diseases; tumor, meningitis,
encephalitis, abscess, subarachnoid hemorrhage, subdural
hemorrhage, traumatic brain injuryhemorrhage, traumatic brain injury
� Medication; desmopressin, selective serotonin reuptake inhibitors
(SSRI, carbamazepine, haloperidol, quinolones, vincristine, etc),
narcotic, general anesthesia, thiazide diuretic, hypoglycemic agent
� Pulmonary; pneumonia, TB, vasculitis, Positive pressure ventilation
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Malignancy
Drug
Pulmonary infection
Cerebral edema
GIT
Headhace, seizure, Coma,
unconsciousness, TTIK,
irritable, confusion
Nausea, Vomiting, Abdominal
cramp, anorexia, thirst
PatofisiologyWater intoxicacy
HyponatremiaWater retention
Cells edema
Hypoosmolarextra celular
Cardiovascular CVP>>, TD>>
Musculosceletal Weakness,
fatigue, muscle
crampUrinaria
Oliguria, BJ urine <<
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Manifestasi Klinis SIADH
� Plasma sodium (> 130 mmol/L) Asymptomatic
� Plasma Sodium (125 – 130 mmol/L); anorexia, nausea, vomiting, &
abdominal pain/cramp
� Plasma Sodium (115 – 125 mmol/L); >> TD, >> BB, headache,
agitation, confusioon, hallucination, incontinence, & other agitation, confusioon, hallucination, incontinence, & other
neurological symptoms
� Hyponatremia < 115 mmol/L; pulmonary edema, neurological
squele, seizure & coma due to >> Intracranial pressure
� Patient with intracranial problem (space-occupaying lesion &
neurosurgical treatment), the onset of symptom my occur at higher
level of sodium concentration
� In chronic hyponatremia� asymptomatic
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Serum Values of Electrolytes
Cations Concentration, mEq/L
Sodium 135 - 145
Potassium 3.5 - 4.5
Calcium 4.0 - 5.5Calcium 4.0 - 5.5
Magnesium 1.5 - 2.5
Anions
Chloride 95 - 105
CO2 24 - 30
Phosphate 2.5 - 4.5
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Medical Management
� Fluid restriction (7-10ml/KgBB/Day) depend on
hyponatremia severity � lower serum level � more
aggressive restriction
�Gradual correction of sodium serum level with IV Gradual correction of sodium serum level with IV
electrolyte, food, fluids.
�Medication; demecocycline/lithium (block ADH)
� Identified underlying causes of SIADH and provide
recommended therapy (surgery, radiation, antibiotic)
�Drugs suspected as SIADH etiology must be STOPED
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Nursing Management� Assessment:
� History; medication, malignancy, lung infection, etc� Hydration: skin turgor, I:O, daily weight, vital sign (TD, RR, HR, etc), CVP,
urine characteristic etc� Cells edema signs & symptoms; neurological status, GIT, etc
� Diagnosis:� Excess fluid volume� Excess fluid volume� Electrolyte imbalance� Disturbed thought process
� Intervention� Monitoring I/O (including educating family in recording I/O & BW)
� Monitoring neurological status; take seizure precautions
� Work with patients & family to run fluid restriction
� Encouraged high sodium fluids (tomato juice, milk)
� Sugar less gum for minimizing dry mouth during fluid restriction
� Therapy of underlying causes of SIADH
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Central Pontine Myelinosis� Neurological disease caused by severe damage of the myelin sheath of nerve cells in the brainstem
� Characterized by acute paralysis, dysphagia (difficulty swallowing), and dysarthria (difficulty speaking), and other neurological symptoms.neurological symptoms.
� Results from overcorrection of sodium
� Correction of > 25 mEq per 24-48 hrs
� Concurrent hypoxia
� Presence of liver disease
� Acute correction limit 25 mEq /day
� Chronic correction limit 10 mEq/day