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Symptomatic hyponatraemia in home-based palliative care patients treated with subcutaneous infusions: Case reports

Authors:
  • Hospice La CIMA. Centro de Medicina Paliativa

Abstract

Hyponatraemia is the most frequently seen electrolyte disorder in palliative settings.¹ It is classified according to serum sodium levels as mild, moderate or severe (see Table 1), by time of symptom onset as acute (<48 hours) or chronic (>48 hours), and according to plasma osmolarity as hypo-, iso- or hyperosmolar².
yponatraemia is the most frequently seen
electrolyte disorder in palliative settings.1
It is classified according to serum sodium levels
as mild, moderate or severe (see Table 1), by
time of symptom onset as acute (<48 hours) or
chronic (>48 hours), and according to plasma
osmolarity as hypo-, iso- or hyperosmolar.2
Hyponatraemia is commonly associated with
drowsiness, nausea and vomiting, anorexia,
disorientation, confusion, weakness and fatigue.
Other symptoms include abdominal pain,
memory disturbance, attention deficit, gait
disturbance, agitation, hallucinations, convulsions
and coma2,3 (see Table 2).
Issues common to palliative patients, such
as renal impairment, polypharmacy and
co-morbidities, make such patients especially
vulnerable to hyponatraemia.1Medications that
can cause hyponatraemia include diuretics,
laxatives, antidepressants, opioids, anticonvulsants
and proton pump inhibitors4(see Table 3).
Hyponatraemia has been identified as a
marker of poor prognosis in the outpatient
population, with higher hospital admission
and death rates. In a study of outpatients,
Martínez observed hyponatraemia in 11%,
with 60% of cases due to the syndrome of
inappropriate antidiuretic hormone secretion
(SIADH), which has been identified as one of
the main causes of the condition.5The
vasopressin secretion in SIADH is inappropriate
because it occurs independently of effective
serum osmolality or circulating volume. It
may result from increased release by the
pituitary gland or from ectopic production.
Inappropriate antidiuresis may also result
from increased activity of vasopressin in the
kidneys’ collecting ducts.6
Hyponatraemia is a determining factor in
length of inpatient hospital stay. Timely sodium
level adjustment therefore has a positive influence
on prognosis, reducing the hospital care needed
and the associated economic costs.7
Home-based palliative patients often present
difficulties in venous access, and few services are
available to support intravenous therapy in the
community. Their physical condition also makes it
difficult to take these patients to hospital for
intravenous therapy. They may, therefore, benefit
from subcutaneous administration as an
alternative route of infusion to offer better
symptom management and quality of life.
The subcutaneous route has been shown to be
effective in rehydrating patients, using saline and
glucose solutions.8,9 In addition, we have now seen
positive results with hypertonic solution
administered via this route to adjust electrolyte
levels. Here, we present three cases of patients
receiving palliative care at home, who developed
acute symptomatic hyponatraemia, which was
successfully treated using replacement hypertonic
|www.ejpc.eu.com European Journal of Palliative Care |2018; 25(2)
78
Clinical management
Symptomatic hyponatraemia
in home-based palliative care
patients treated with subcutaneous
infusions: case reports
From El Salvador, Mario López Saca and Ancu Feng present three cases of acute hyponatraemia
that they decided to treat with home-based subcutaneous infusions, in order to avoid issues that
often arise in patients with chronic disease receiving palliative care – namely, problematic venous
access and difficulties in making hospital visits.
H
&
Mario López Saca
MD Physician,
Internal Medicine
and Palliative Care 1,2
and Professor of
Palliative Medicine 3
Ancu Feng MD
Palliative Physician 2
Assistant Lecturer in
Palliative Medicine 3
1Hospital Dr. Juan José
Fernández, San
Salvador, El Salvador
2Palliative Care Clinic,
San Salvador, El
Salvador
3Universidad Dr. Jo
Matías Delgado,
Antiguo Cuscatlán, La
Libertad, El Salvador
Table 1. Hyponatraemia classification according to sodium serum2
Mild 130–134 mmol/l
Moderate 125–129 mmol/l
Severe <125 mmol/l
Table 2. Potential symptoms presented according to sodium serum value3
130–134 mmol/l No symptoms
125–129 mmol/l Anorexia, nausea, fatigue, vomiting and abdominal pain
115–124 mmol/l Agitation, confusion, hallucinations, incontinence
and other neurological symptoms
<115 mmol/l Convulsions, coma, intracranial hypertension
Copyright © Hayward Medical Communications 2018. All rights reserved. No unauthorised reproduction or distribution. For reprints or permissions, contact edit@hayward.co.uk
solutions administered via subcutaneous infusions
in their own homes (see Boxes 1, 2 and 3).
To calculate the sodium deficit in each of these
three cases, the following formula was used:
Sodium deficit = desired sodium level
– patient’s sodium level × total body water
The total body water is calculated as the
patient’s weight in kilograms multiplied by 0.6 for
males, 0.5 for females, 0.5 for elderly males and
0.45 for elderly females.10
We classified these cases according to their
serum sodium value, duration and clinical
symptoms in line with Spasovski et al.’s guideline
on diagnosis and treatment of hyponatraemia.11
Discussion
There are many causes of acute hyponatraemia
in patients with chronic, advanced-stage disease.
A leading cause is SIADH – due to a high
prevalence of polypharmacy and co-morbidities
in these patients – which is a common diagnosis
among hospital admissions with hyponatraemia.
Acute SIADH should be treated using sodium
replacement, while preventing sodium levels from
rising by more than 10mmol/l/24hrs to avoid the
risk of osmotic demyelination, a syndrome that
may lead to permanent brain damage. In cases of
chronic SIADH with chronic hyponatraemia,
sodium levels are corrected by means of restricted
hydration, tolvaptan or demeclocycline.13
In the cases we described in this article, we
have not used the classic hyponatraemia
classification based on plasma osmolality, since
our patients did not undergo the analyses
required to classify them in such a way. Instead,
classification was based on their serum sodium
levels and clinical symptoms. The duration of
symptoms was less than 48hours in all cases and
all were therefore considered acute.
Due to the problems with venous access that
many patients with chronic diseases have, and
the physical limitations that make hospital visits
difficult, we treated the cases of acute
symptomatic hyponatraemia presented here in
a less aggressive, more easily managed, home-
based manner by means of subcutaneously
administered sodium replacement infusions
(hypodermoclysis). Infusion zones should be the
abdomen or front of the thigh.8,14 The duration of
the subcutaneous cannula placement can be up to
15 days but on average is 2–4 days.9
A 2003 study on subcutaneous hydration
showed that the practice was well tolerated by
patients; furthermore, it was found to offer an
advantage for patients with delirium, in whom
the intravenous route is difficult to manage.15
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European Journal of Palliative Care|2018; 25(2) 79
Clinical management
Table 3. Causes of hyponatraemia in patients with chronic illness
Extracellular volume depletion • Diarrhoea
• Vomiting
• Haemorrhage
Chronic illnesses • Congestive cardiac failure
• Hepatic cirrhosis
• Nephrotic syndrome
• Renal insufficiency
• Metabolic
• SIADH due to cancer and other conditions
Medications • Diuretics
• Laxatives (lactulose)
• Anti-depressant medication
• Opioids
• Anticonvulsants
• Proton pump inhibitors (omeprazole)
• Polypharmacy
SIADH = syndrome of inappropriate antidiuretic hormone secretion
Box 1. Case report 1
The first case was a 91-year-old
chronically ill female. She was known
to have severe cardiac failure, with
N-terminal brain natriuretic propeptide
(NT-proBNP) levels of 6,120pg/ml, a
marker of poor prognosis.12 She was
on numerous medications, receiving
pantoprazole, furosemide,
spironolactone, glyceryl trinitrate,
aspirin, clopidogrel, metoprolol,
amiodarone and levothyroxine. During
monitoring, she developed somnolence
and weakness, and investigations
revealed serum sodium levels of
122mmol/l. This patient’s
hyponatraemia was classified as severe,
acute and moderately symptomatic.
After a number of failed attempts at
venous cannulation, a subcutaneous
cannula was inserted as an alternative
route for administration.
According to the calculation
noted above, the patient’s total sodium
deficit was 351mmol. Given her age,
treatment with sodium chloride
infusions was spread out over a number
of days. On the first day, an infusion of
500ml of saline solution 0.9% was
administered subcutaneously, along
with two ampoules of sodium chloride
20%, in the right anterior thigh, at a
rate of 120ml/hr, with no adverse
effects. As a result, 40% of the total
deficit was normalised on the first day,
a percentage equivalent to 142mmol.
On the second day, the patient showed a
slight clinical improvement. A decision
was taken to administer the same
regimen for another two days.
Symptoms disappeared completely
on the third day and repeat sodium
levels showed that these had risen
to a value of 133mmol/l (see Figure 1).
Subcutaneous administration was
suspended at that stage and the
patient was prescribed sodium
2g/day orally.
The sodium level sent after 17
days was 137mmol/l. She died after
a further three months of home care,
due to respiratory failure.
Copyright © Hayward Medical Communications 2018. All rights reserved. No unauthorised reproduction or distribution. For reprints or permissions, contact edit@hayward.co.uk
Subcutaneous infusion allows the patient
increased independence and gives family
members and carers peace of mind. It also has
the advantage that family and carers can be
trained in its administration.
Guidelines from the Spanish Palliative Care
Society on the use of the subcutaneous route in
palliative care do not recommend the
administration of hypertonic infusions.8
Specifically, the guidelines note that
Box 2. Case report 2
The second case was a 78-year-old
female with chronic renal failure. Her
usual medications were omeprazole,
nifedipine, atenolol and lorazepam.
Relatives requested a palliative care
review after noticing episodes of
disorientation and muddled speech.
Three days prior to her palliative
care appointment, she had been
admitted to hospital with a diagnosis of
hyponatraemia and, after treatment, had
been discharged with normal serum
sodium levels. The palliative care
physician reviewing her therefore
suspected that she had developed a
further episode of hyponatraemia.
This was confirmed, with serum
sodium levels again found to be very
low, at 117mmol/l. Her condition was
classified as severe, acute, moderately
symptomatic hyponatraemia.
As requested by the patient’s family,
home-based management was adopted,
as she did not wish to be admitted for a
further inpatient stay. A history of difficult
venous access led to a decision to
administer treatment for sodium
adjustment subcutaneously.
The sodium deficit was calculated as
486mmol. Treatment involved infusion of
1,000ml of saline solution, along with
two ampoules of sodium chloride20%,
administered subcutaneously in the
abdominal wall, at a rate of 120ml/hr,
with no adverse effects. An adjustment
of 42.5% of the total deficit was achieved
on the first day, which is equivalent to
206.6mmol sodium. The same regimen
was administered for three days.
The patient responded with early
clinical resolution – her clinical
disorientation resolved within 24 hours –
and improvement of serum sodium levels
after four days to 126mmol/l (see
Figure1), allowing for oral administration
of sodium thereafter. She currently
continues to be monitored at home.
|www.ejpc.eu.com European Journal of Palliative Care |2018; 25(2)
80
Clinical management
Box 3. Case report 3
The third case was an 87-year-old
woman with a history of cancer of the
colon, treated with a left hemicolectomy.
Co-morbidities included hypothyroidism,
atrial fibrillation and vascular dementia.
She was on a number of regular
medications, including amiodarone,
spironolactone, donepezil, levothyroxine,
as well as iron and vitamins. She had had
a recent hospital admission for sepsis
and anaemia and had been referred to
the palliative care team when she was
discharged home. During her time at
home, she presented with hypoactive
delirium, with subsequent investigations
showing a normal white cell count and
urine culture, slightly elevated TSH levels
at 7.4IU/ml and serum sodium levels of
128mmol/l. The hyponatraemia was
classified as moderate, acute and
moderately symptomatic.
The dose of levothyroxine was
increased because hypothyroidism can
stimulate antidiuretic hormone
production.11 The sodium deficit was
calculated as 189mmol. An increased
dose of levothyroxine was administered,
leading to a correction of 75% of the
total sodium deficit on the first day,
which is equivalent to 142mmol. In
addition, a 500ml saline solution was
administered subcutaneously, along
with two ampoules sodium chloride
20%, at a rate of 120ml/hr via the
abdominal wall.
On Day 2, after initiating sodium
replacement, her state of alertness
improved. Sodium infusion was
continued for another two days,
after which she was prescribed 2g of
salt with meals. On the sixth day of
therapy, serum sodium levels had risen
to 136.3mmol/l (see Figure1). The
patient currently continues to be cared
for at her home.
Initial serum sodium levels Follow-up serum sodium levels after corrective treatment
Case 1 Case 2 Case 3
140
130
120
110
100
mmol/l
Figure 1. Initial
sodium serum values
and control sodium
for the three cases
Copyright © Hayward Medical Communications 2018. All rights reserved. No unauthorised reproduction or distribution. For reprints or permissions, contact edit@hayward.co.uk
hypodermoclysis is inappropriate in emergency
situations, including in the management of
hypovolemic shock, for example, when large
quantities of solutions are required.16 This was
not the case for any of the patients we have
described here.
We have not found any references in the
current literature that describe experiences using
hypertonic saline solutions via the subcutaneous
route. We also found no bibliographic evidence
on the use of 0.9% saline solution with added
sodium chloride for patients with acute
symptomatic hyponatraemia.
Our cases were all treated at home in the
context of palliative care for advanced chronic
diseases, with the compassionate use of
hypodermoclysis to achieve rapid symptomatic
improvement. There was no evidence of oedema or
other complications at the infusion site; the
patients’ neurological symptoms improved and
they were able to interact with their families again.
Based on our experience, home care teams
may feel more confident in helping other patients
experiencing acute symptomatic hyponatraemia,
with the aim of developing standardised
management protocols8
Declaration of interest
The authors declare that there is no conflict of interest.
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www.ejpc.eu.com |
European Journal of Palliative Care|2018; 25(2) 81
Hyponatraemia is a frequent condition in
palliative care patients and is associated with
adverse effects on prognosis and quality of life.
Hyponatraemia is common in chronic
illnesses, such as cancer, cardiac failure and
hepatic and renal insufficiency, and can also
be caused by polypharmacy.
Cannulation of peripheral veins is often
difficult in these patients; the subcutaneous
route for infusion is an alternative.
Acute cases of symptomatic hyponatraemia
in patients receiving palliative care may be
successfully treated by administering
hypertonic saline at home.
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Background Hyponatraemia is a very common medical condition that is associated with multiple poor clinical outcomes, and is often managed suboptimally because of inadequate assessment and investigation. Previously published guidelines for its management are often complex and impractical to follow in a hospital environment, where patients may present to divergent specialists, as well as to generalists.DesignA group of senior, experienced UK clinicians met to develop a practical algorithm for the assessment and management of hyponatraemia in a hospital setting. The latest evidence was discussed and reviewed in the light of current clinical practicalities to ensure an up-to-date perspective. An algorithm was largely developed following consensus opinion, followed up with subsequent additions and amendments that were agreed by all authors during several rounds of review.ResultsWe present a practical algorithm which includes a breakdown of the best methods to evaluate volume status, simple assessments for the diagnosis of the various causes, and a straightforward approach to treatment to minimise complexity and maximise patient safety.Conclusion The algorithm we have developed reflects the best available evidence and extensive clinical experience, and provides practical, useable guidance to improve patient care.This article is protected by copyright. All rights reserved.
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Introducción: La vía subcutánea se emplea con frecuencia en enfermos de cáncer avanzado o ancianos para administrar medicación por vía parenteral. Sin embargo, la hidratación por vía subcutánea es excepcional en nuestro medio aunque ya se está utilizando en algunos centros. Pretendemos conocer si es factible administrar hidratación subcutánea en enfermos oncológicos, las características de la técnica y las dificultades que se pueden presentar en su aplicación. Pacientes, material y métodos: Se incluyeron pacientes oncológicos con cáncer avanzado con deshidratación o riesgo de padecerla de la Unidad de Medicina Paliativa del Hospital Grey Nuns, Edmonton (Canadá) y del Hospital Universitario de Valladolid que recibieron hidratación subcutánea con volumen y ritmo de infusión adaptados a cada enfermo. Resultados: Se realizaron 101 punciones en 33 pacientes (Edmonton 24; Valladolid 9), con un total de 314 días de infusión. El volumen fue 1.000 cc/día durante una mediana de 10 días (1 a 21 días) y un ritmo de 20 a 400 cc/hora. El punto de infusión se cambió cada tres días (1 a 15 días), principalmente por acumulación en zona de punción. Solo dos enfermos precisaron asociar hialuronidasa a la solución utilizada por absorción deficiente. Hubo diferencias entre Hospitales en las características de los pacientes (peor pronóstico: grupo español) y tipo de infusión (mayor volumen y duración: grupo canadiense). La incidencia de complicaciones fue similar similares en ambos grupos y en general de carácter leve. Conclusión: La vía subcutánea para la hidratación de pacientes oncológicos terminal es sencilla y parece exenta de complicaciones importantes.
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