A 34-year-old woman who underwent elective laparos - pacemaker

[ArchivalUser]

A 34-year-old woman who underwent elective laparoscopic bilateral tubal ligation 1 day ago develops severe headache and nausea the next morning. During the surgery, 5% dextrose in ¼ strength normal saline therapy is initiated and maintained at 125 mL/h. She remains in recovery until late in the afternoon because she is too sedated to be discharged. Intravenous meperidine is administered with adequate relief of her pain.

Laboratory Studies
Glucose

115 mg/dL (6.38 mmol/L)
Blood urea nitrogen

12 mg/dL (4.29 mmol/L)
Creatinine

1.0 mg/dL (88.42 μmol/L)
Sodium

126 meq/L (126 mmol/L)
Potassium

3.9 meq/L (3.9 mmol/L)
Chloride

96 meq/L (96 mmol/L)
Bicarbonate

22 meq/L (22 mmol/L)

Which of the following is the most appropriate next step in the management of this patient?

A Discontinue 5% dextrose in ¼ strength normal saline; begin 3% saline via infusion pump
B Discontinue 5% dextrose in ¼ strength normal saline; begin intravenous 0.9% saline at 200 mL/h
C Emergent CT scan of the head
D Administer naloxone
E Switch meperidine to fentany

[ArchivalUser]

B..

[ArchivalUser]

BB

[ArchivalUser]

Answer and Critique (Correct Answer = A)
Key Points

* Hypotonic fluids should not be used postoperatively.
* Normal saline (0.9%) is the most appropriate intravenous fluid when fluid therapy is indicated in the postoperative setting.

The most appropriate next step in this patient's management is discontinuing 5% dextrose in ¼ strength normal saline and initiating therapy with 3% saline via infusion pump. This patient developed iatrogenic hyponatremic encephalopathy because of hypotonic fluid use in the postoperative setting. She is at high risk for mortality or the development of permanent neurologic injury if not treated expeditiously and appropriately. Children, menstruant women, and hypoxic patients have a particularly high risk for a poor outcome in hyponatremic encephalopathy. In this setting, therapy with 3% saline would raise the serum sodium level to a mildly hyponatremic level. Early intervention is important in mild cerebral edema to prevent seizures and respiratory arrest.

Therapy with 0.9% saline would not increase this patient's serum sodium level. Because she is euvolemic, volume expansion is not indicated to correct her condition. However, this treatment would be appropriate therapy in a volume-depleted patient who is not acutely symptomatic. This patient's clinical scenario strongly suggests a diagnosis of hyponatremic encephalopathy. This condition warrants treatment with hypertonic saline, which is safe only in the setting of close monitoring. CT scanning is not likely to yield useful information and would cause a dangerous delay in therapy. Therapy with hypertonic saline is safe if proper monitoring occurs. Initiation of naloxone therapy or switching meperidine with fentanyl is not indicated because this patient's symptoms are not associated with narcotic use and would delay treatment of her condition.

[ArchivalUser]

oh i miss this...hypo na,,iwas thinking hyper na.

[ArchivalUser]

bdj done with CK.

[ArchivalUser]

the above message should've been posted underneath row message.....lol.

[ArchivalUser]

[ArchivalUser]