Critical Care Doctor Discusses Brain Injury Following Volume Resuscitation Treatment

This case involves a middle-aged male patient who had a past medical history significant for alcohol abuse as well as cirrhosis who presented to the emergency room with bleeding esophageal varices. In order to treat his loss of fluid volume and low levels of sodium, the man was started on a very aggressive regimen of volume resuscitation. The man received a large amount of fluid, which caused his blood sodium levels to skyrocket. Following treatment, the patient was found to have worsening neurological symptoms, including involuntary movements and difficulty speaking. Eventually, the patient was diagnosed with brain damage due to central pontine myelinolysis, which was caused by his significantly elevated sodium levels.

Question(s) For Expert Witness

Expert Witness Response E-115014

Treatment of acute hyponatremia depends on several things, including the type and cause of hyponatremia, how long it took to develop (acute vs. chronic), and the symptoms the patient is having. Typically, alcoholics have hypoosmotic, chronic hyponatremia. If they are not having seizures, you can typically correct with saline solution, aiming to correct about 4-6 points/day, with no more than 8-9 in any 24 hour period. This is because they are at higher risk for having demyelination with a faster correction. If the patient was symptomatic with hyponatremia, then faster correction is warranted as levels as low as the ones described have significant mortality. In addition, when you do over-correct and develop symptoms of demyelination, you can treat that by lowering the sodium back down, giving desmopressin, and re-raising the sodium more slowly.

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