#siadh

[gendernull]

syndrome of inappropriate antidiuretic hormone secretion (siadh) flag!

[mission-to-dietitian]

SIADH do not give normal saline. This exacerbates hyponatremia, as the body will just re-absorb the free water and get rid of the sodium. Treatment is fluid restriction.

[nursestudy]

SIADH Nursing Interventions Diagnosis and Care Plans

SIADH Nursing Interventions Diagnosis and Care Plans

SIADH Nursing Diagnosis Care Plan NCLEX Review Nursing Study Guide for SIADH

Syndrome of inappropriate antidiuretic hormone (SIADH) is a medical condition characterized by low serum sodium levels (hyponatremia), blood dilution, and urine concentration.

SIADH results in fluid retention in the body and imbalance of electrolytes. The volume of the blood remains stable (euvolemia), but the…

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[shuekomed-blog]

Exercise-associated Hyponatremia

Get this, ADH release can be triggered by nonosmotic stimuli (like exertion, pain, hypoglycemia, and nausea). So during intense exercise, ADH secretion is triggered. (like your body is preparing to save the water you’re about to lose to perspiration)

However, ingesting large amounts of hypotonic fluid (like water) before or immediately after a prolonged exercise COMBINED with ADH release due to nonosmotic stimuli can cause EAH.

Depending on the degree of hyponatremia, patients may be asymptomatic, mildly symptomatic (lethargy, nausea) or severely symptomatic (seizures, altered mentation)

[dustyhouseplant]

hyponatraemia

[whitecoatdiaries]

I meet Ms. G because she is “a diagnostic challenge.” She presents to our ED short of breath and chronically malnourished. She has stage IV lung carcinoma and several other diseases that make her body too weak for chemo. She tells us that the last few weeks, she just hasn’t felt like eating. 

We check her serum sodium and it’s so low that in other patients, it could cause seizures and coma. There are several disease processes that can cause low sodium, and they have opposite treatments. Every internal medicine doctor has, in the back of their head, a flowchart for diagnosis that divides patients by how hydrated or dehydrated they are, how concentrated their urine is, how much sodium they’re peeing out. The culprit can be damaged kidneys, a failing heart or liver, dysregulation of a pituitary hormone caused by lung disease, alcoholism or poor diet, or mental illness that makes patients consume liters and liters of water. To treat we replace fluids or fluid restrict patients. They key is to do it slowly: if you correct a patient’s sodium too fast, you can cause a rare but serious complication that damages a patient’s neurons (cells most sensitive to water and salt balance) irreversibly. 

Ms. G becomes my patient. I make graphs of her sodium and urine osmolarity, with hospital day # on the X axis. I ask her every morning about her breathing and appetite. She only eats fruit and salad, and even then hardly touches her food. I order a vegetarian diet for her and beg her to eat. We consult nutrition and their note says that she meets criteria for severe chronic malnourishment. They recommend adding high-fat yogurt to her meals. When I round on her in the afternoon she tells me about the foods she loves: oxtail greens, black bean burgers, strawberry shortcake. I linger, and she tells me about God and her church, how important it is to pray, how man is sinful and ugly, how man fails, but how great God is. How all things are possible through him. How all we have to do is cede control and ask Him for help. 

At first, our treatment works. Her hemoglobin is low, probably because of her cancer but also we keep drawing her blood to check her sodium, so I order a unit of blood for her. She looks a lot better when I see her the morning after she gets her blood. We’ve been talking about her on rounds, trying to decide what our ultimate goal is. We’re pretty sure her sodium is low because she hasn’t been eating and because her lung disease is causing SIADH (Syndrome of Inappropriate Antidiuretic Hormone). Every day I encourage her to eat, but her appetite isn’t great, even with the marinol pills. I’ve read her oncologist’s notes and I know that they’re no longer recommending chemo, that even if her body could stand it her lung cancer is too advanced to be cured. We agree that we ultimately won’t be able to treat what’s making her sodium low and can only treat it as best as we can while she’s here. Our goal is to get it high enough so that she’ll be safe for a while when she leaves. In this goal is an understood futility where I feel at home, that draws me to Internal Medicine. We work within the confines of death, do our debating on rounds knowing full well that there is nothing we can do to the reverse the tide. 

A few days into her stay I try and have what we call a “Goals of Care” conversation, which translates roughly to: we don’t think we can fix you, so where do you want to go from here? These conversations are always challenging but essential. Part of the reason healthcare costs are so high is that doctors do not like this conversation, where we admit medical defeat, and patients’ and their families are so desperately afraid of death that they will “do everything,” lengthy ICU stays that still end in death, the patient spending their last week sedated and suffering, stuck with lines, bucking the vent. So every time we admit a patient to our service, during the intake interview, we ask, if something were to happen, and your heart stopped beating, what would you want? CPR? Your heart shocked? A tube pushing air into your lungs? Every patient can say yes or no to each treatment individually, can change their mind whenever they want. It’s a hard thing to ask a terrified family in the ED, to think about the possibility of their loved one’s death, but I am not one to let things go unsaid. I am not a big believer in shielding patients and families from the reality of death. In this way I stand in full opposition to the superstitions of my mothers’ family, who say that naming death is to bring it, that the possibility only exists when we speak of it. To speak in circles around my fears has never brought me good luck, only left me unprepared. 

So I ask Ms. G what she wants to do next. She wants more chemo, says that her cancer is gone because God healed it. The note in our EMR says that her chemo was palliative, which means her oncologist has no hope of cure. When I say, gently, that the chemo probably won’t make the cancer go away, her pleasant face wrinkles at me in disgust and she yells, “you’re wrong! God can do anything! Man can’t do it but God can do it! I’ve been praying and he took my cancer away.”

I’m startled but I try not to show it. I smile at her, backpedaling, “Yes ma’am, anything is possible!” I think one of my key healthcare virtues is being able to smile genuinely when I’m sad or angry. She yells to/at me for a while, eventually calming, and I turn the conversation towards her son’s two poodles, which always makes her face light up

“Ooh! I love them dogs,” she says. “They’re so pretty. I love pretty dogs and pretty horses,” and her face wrinkles in delight as she laughs up at the ceiling. She watches ESPN almost exclusively and there’s a horse race on. We watch the horses tear around the track and she cheers, but she enjoys most the shots of the horses in the paddock, nosing each other. 

Her sodium stalls. In the last week we’ve fluid restricted her, stopped and then added back IVF fluids, dosed her 3 times a day with salt tabs. My graph of blood sodium and urine concentration grows longer and longer, a scroll I tuck into my white coat pocket. I’m not sure whether to drop one treatment or double-down on both. My team helps me think through it, but no one has a right answer for me. I don’t go by her room on my afternoon rounds because I’m embarrassed to have no news for her, and I think she’s getting tired of me anyway. 

Moments later I get a text from my upper level. “Ms. G is threatening to leave AMA (against medical advice). Please go see her.” I square my shoulders and run through what I’ll say to her on my way up to the floor. I’ve been yelled at by patients plenty of times before and I’m not afraid of it. My tactic is simple: to realize that it’s almost never about me and to take none of it personally. There is no sense in arguing or trying to reason people out of their anger. Every time I prepare by envisioning myself as bamboo, able to bend almost flush against the ground and not break. I apologize for what can be apologized for, concede what is reasonable to concede, let people spend themselves: their anger, their sadness, but what mostly boils down to fear. The only way to calm the frightened it to be gentle and unafraid, to absorb what they give you and refuse to let it reverberate around the room. 

This is no small feat and takes all my energy. 

I stop by the nursing station on the way, and her nurse tells me that Ms. G has called her son to come get her. Her nurse has spoken to him, and he seems to understand that she is not well enough to leave, and will not take her unless we, her doctors, think it is so safe for her to go. I step into the room and into Ms. G yelling, mid-sentence. She is saying that we have tricked her, that we can’t keep her here, that we’re bad people, that she needs to go. I apologize to her, say that I understand that’s she’s frustrated to be in the hospital for so many days, that we’re working hard to get her out but that her sodium is still low, that it still isn’t safe for her to go. I turn to my son and introduce myself, but it is hard to hear over her yelling. We step into the hallway. 

Her son is tall and dressed in dusty work clothes. He has one of those handsome faces that seems ageless, and he smiles wearily at me. I tell him what we’ve been doing all week, about how it’s hard to know exactly what is causing this problem. All week we’ve been trying to figure out dispo (where Ms. G will go after she’s discharged from the hospital. This is a huge part of our job, and the bane of many residents’ existence).  Ms. G has been refusing to go to a nursing home. We don’t think it’s safe for her to go home alone, given that she can hardly walk without assistance and she was admitted because she stopped eating. Her son says he’s spoken to his wife and that she will come home with him. I’ve only half-removed my plastic gown and gloves but we stand in the hallway for a long time, talking about his mother and her care, how things have gone the last year. We talk about her favorite foods and the poodles that she loves. My attending shows up, adds a few supporting statements, but lets me do most of the talking. 

In a lull, I ask him the question I’ve scared to: what is your mother’s understanding of her illness? It’s a little outside of my expertise to be having this conversation with the family. Usually it’s the upper level resident and the attending who have ‘the family meeting,’ but I think I know her and her medical care the best and I’m eager to hone this skill, one that seems fundamental to an Internal Medicine doctor. 

His face falls and eyes rim with tears as soon as I say it. She knows, he says. He and I speak in the coded language of death. She didn’t want to come to the hospital... I called 911. Because she was hardly breathing. But ... we know. It’s just... I let his pauses settle around me, envelop us. Nurses and nursing assistants walk by us down the hall, machines clatter and beep, but in this moment not a part of me is elsewhere. He tells me what he needs to. We repeat ourselves. We smile throughout the conversation but it’s a a whole assortment of smiles. Grief, understanding, concession. 

We return to the room where Ms. G is still furious. I kneel down by her chair where she sits with the IV line in her arm. “I’m getting out of here! I’m leaving!” She’s on the phone with her sister, calling anyone who will listen.” When I try to explain what’s keeping her here, she yells to her son, “She’s not a doctor! She doesn’t care! SHE DOESN’T EVEN KNOW GOD!!” I am wearied by this, think of how much time I’ve spent listening to her talk about the Christian God that I’m estranged from, how I’ve never derailed or sidestepped the conversation. Her son apologizes for her and tells her to be nice. I tell her that she’s always treated me well and that I don’t hold it against her because she’s frustrated. I can tell that I am only winding her up more and beat a quick retreat, satisfied that I’ve accomplished what I need to. 

The next morning she is grumpy so I do not stay long to talk. The morning after that she is contrite and sweet. Medicine is playing a long game, which I do not mind. She apologizes for being nasty over and over, but I tell her that it’s okay, that we all have our moments. Her nurse is also an Indian woman, and she eyes us both, asks who is my doctor? When I raise my hand, she seems satisfied enough with my reply. That afternoon she tells me about how she used to play basketball in high school, and when I ask her if she was good she exclaims “of course!” and we both laugh. She tells me what it was like to travel throughout the South, how the Ku Klux Klan would show up at their away games, blocking her team’s path. I notice that her flowers are wilting and water them, getting myself firmly back on Ms. G’s good side. 

Her sodium never gets high enough to be considered ‘normal,’ but it’s outside of seizure and coma range and she’s made it clear she has no interest in being in the hospital, so we compromise with stubborn Ms. G and her family, we compromise with God, with the salt in her blood and the hospital administrators and the futility of our own role, we admit a certain defeat for victory of a different sort and send the wild and lovely, gravelly-voiced and sharp-boned Ms. G home. 

[medicowesome]

Medicowesome: Diabetes insipidus and SIADH mnemonics

"Do you have any mnemonics on vasopressin related disorders? I always mix up diabetes insipidus and syndrome of inappropriate anti-diuretic hormone!"

Related posts: Drugs causing SIADH mnemonic Normal sodium, potassium and serum osmolality values mnemonic

[medicowesome]

Drugs causing SIADH mnemonic

Hello!

Because ADH makes you retain water, the mnemonic goes: "SIADH Causes Poor Voiding"

S: SSRIs (Sertaline) I: Indomethacin (Analgesics) A: Antidepressants (Tricyclics) D: Diuretics (Thiazides) Desmopressin H: Hello :D

Causes: Cyclophosphamide Chlorpromazine Carbamazepine

Poor: Phenothiazines

Voiding: Vincristine Vinblastine

If you want a smaller mnemonic, one of the awesomites told me she uses "ABCD" for drugs causing SIADH A: Analgesics B: Barbiturates C: Cyclophosphamide, Chlorpromazine, Carbamazepine   D: Diuretics (thiazides)

That's all! Smile. -IkaN