Validation study of a central venous pressure-based protocol for the management of neurosurgical patients with hyponatremia and Natriuresis

OBJECTIVE: We had previously suggested a protocol for the management of neurosurgical patients with hyponatremia and natriuresis that was based on their volume status as determined by actual blood volume measurements. All patients in that study were found to be hypovolemic or normovolemic and responded, within 72 hours, to salt and fluid replacement. In the present study, the validity of that protocol was tested using central venous pressure as the sole measure of volume status of patients with hyponatremia and natriuresis. METHOD: Twenty-five consecutive patients (26 cases) who fulfilled the inclusion criteria typically used to diagnose the syndrome of inappropriate secretion of antidiuretic hormone were included in the study. Central venous pressure was used to classify patients as hypovolemic (<5 cm of water) normovolemic (6-10 cm of water), or hypervolemic (>11 cm of water). Hypovolemic patients were given fluids (50 ml/kg/d) and salt (12 g/d). Normovolemic patients were given normal fluid with 12 g of salt per day. In addition, patients with anemia (hematocrit <27%) were administered whole blood. The end point was a serum sodium of more than or equal to 130 mEq/L measured in two consecutive samples 12 hours apart or 72 hours after entry into the study. If the serum sodium was less than 130 mEq/L at the end of 72 hours, the clinical condition of the patient determined further management. RESULTS: Nineteen of 25 patients (26 cases) were hypovolemic, the rest were normovolemic. No patient was hypervolemic. Nineteen of 25 patients (26 cases) attained normal serum sodium values within 72 hours and an additional 3 responded within the next 36 hours (108 h after entry into the study). One patient who was discharged on request had normalized her serum sodium a week later. Among the three nonresponders, two were severely hypovolemic, as revealed by blood volume measurement, and responded to increased fluid and salt administration. One was normovolemic and responded to increased salt administration. There were no complications related to the therapy. CONCLUSION: Hyponatremia with natriuresis in the neurosurgical setting responds to salt and fluid replacement guided by the patients' volume status as determined by the central venous pressure. This study also offers further indirect evidence to suggest that the syndrome of hyponatremia with natriuresis is most often caused by ''cerebral salt wasting'' rather than by the syndrome of inappropriate secretion of antidiuretic hormone.