Journal of ISSN: 2373-6437JACCOA

Anesthesia & Critical Care: Open Access
Letter to Editor
Volume 6 Issue 3 - 2016
Critical Hypernatremia and Neurological Outcome in Craniopharyngioma Surgery, Probably Secondary to Salt Excess
Fernandez Ana Belen1*, Perera Gladys2 and Viera David3
1Staff of Anesthesiology, Ntra Sra de Candelaria University Hospital, Spain
2Critical Care Nursing, Spain
3Resident Anesthesiology 3th, Department of Anesthesia and Intensive Care Unit and Pain Therapy, Ntra Sra de Candelaria University Hospital, Spain
Received: October 23, 2016 | Published: December 06, 2016
*Corresponding author: Ana Belen Fernandez, Department of Anesthesiology, Ntra Sra de Candelaria University Hospital, Avenida tres de mayo num 9, Postal Code 38005 Santa Cruz de Tenerife (Canary Islands) Spain, Tel: 00 34 65561234; Email:
Citation: Belen FA, Gladys P, David V (2016) Critical Hypernatremia and Neurological Outcome in Craniopharyngioma Surgery, Probably Secondary to Salt Excess. J Anesth Crit Care Open Access 6(3): 00231. DOI: 10.15406/jaccoa.2016.06.00231

Letter to Editor

Abnormalities of salt and water balance are common in neurosurgical patients. They are most commonly seen after subarachnoid hemorrhage, traumatic brain injury, with intracranial tumors, and after pituitary surgery [1-3]. According to the literature reviewed we have not found any case of major hypernatremia 172 mEq / mL in immediate post-surgical brain tumor eu / hyperchloremic hypervolemia and acidosis, so it is interesting to relate it to neurological complications and medium-term forecast.

41-year-old woman was admitted to the hospital with a six month history of menstrual abnormalities, headache and progressive loss of vision. A CT scan showed to lobular suprasellar mass lesion, greatest diameter of 3.3 cm in pituitary stalk with compression of the optic chiasm and third ventricle. A left pterional craniotomy was performed and the tumour was classified as a Craniopharyngioma with a duration of 8 hours. Intravenous mannitol 1.5 gr/kg, methylprednisolone 125 mg and saline solution 0,9% was given, resulting in a urinary output of 1.5 mL/kg/H during surgery. Laboratory test and arterial blood gas value in the operating room (OR) were normal. The patient awakened in the OR and was taken to the Postsurgical Intensive Care Unit (PICU) with no apparent neurologic problems.

2 hours after, laboratory data and arterial blood gas values were Na 172 mEq / mL, CL 125 mmol/L, lactate levels 5.8 mM/L mEq, pH 7.23, HCO3 20 mEq, BE – 8.5 mmol/L, hyperchloremic acidosis, eu / hypervolemia and normal urinary tests.

Correction of hypernatremia starts but eight hours after, acute neurological deterioration and clinical signs of herniation appears, hemorrhagic venous infarction presenting with herniation uncal subfalcine and then being realized urgently left frontal lobectomy. The patient develops severe intracranial hypertension requiring decompressive craniotomy, with a torpid evolution (hygroma collections, transtentorial herniation.), tetraventricular dilatation persists and carries ventriculoperitoneal shunt catheter. When she goes to our hospital she is awake, and responds to verbal commands gaze.

In the specific case of hyperosmolar treatment such as mannitol and saline solution prolonged, elevated serum sodium levels represent whole-body sodium accumulation. Anecdotal evidence and pilot studies suggest that elevated serum sodium targets are attainable, safe, and an early goal of targeted hypernatremia treatment in selected patients lead better outcomes.

This management principle should be the subject of future study to analyze its effect on the frequency of cerebral edema formation, subsequent crises intracranial pressure, and mortality rate, especially in patients undergoing neurosurgical procedures of long duration.

References

  1. Ryu H Justine, Walcott Brian P, Kahle Kristopher, Sheth Sameer, Peterson Randall T, et al. (2013) Induced and sustained hypernatremia for the prevention and treatment of cerebral edema following brain injury. Neurocrit Care 19(2): 222-231.
  2. Bajwa SJ, Haldar R (2014) Endocrinological disorders affecting neurosurgical patients: An intensivists perspective. Indian J Endocrinol Metab 18(6): 778-783.
  3. Spatenkova V, Bradac O, Skrabalek P (2015) The Impact of a Standardized Sodium Protocol on Incidence and Outcome of Dysnatremias in Neurocritical Care. J Neurol Surg A Cent Eur Neurosurg 76(4): 279-290.
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