Abstract
Background and Purpose
In patients with intracerebral hemorrhage (ICH), it is not clear if hypernatremia is merely a marker of disease severity or if elevated sodium levels are harmful. We hypothesized that hypernatremia at hospital discharge in primary ICH patients would be associated with increased mortality following discharge.
Methods
We performed a two-center observational study of critically ill ICH patients in Boston. We studied 5100 patients, age ≥18 years, who were diagnosed with ICH (ICD-9 code 431), received medical or surgical critical care between 1997 and 2011 and survived hospitalization. The exposure of interest was serum sodium within 24 h of hospital discharge, categorized as Na ≤ 145 mmol/L and Na > 145 mmol/L. The primary outcome was 30-day post-discharge mortality. Odds ratios were estimated by logistic regression models adjusted for age, race, gender, Deyo–Charlson Index, patient type (medical versus surgical) and sepsis.
Results
In ICH patients who received critical care and survived hospitalization, the serum sodium at discharge was a predictor of post-discharge mortality. Patients with a discharge Na > 145 mmol/L have an OR for mortality in the 30 days following hospital discharge of 1.82 (95 %CI 1.38–2.38; P < 0.001) and an adjusted OR of 1.87 (95 %CI 1.40–2.48; P < 0.001) both relative to patients with a discharge Na ≤ 145 mmol/L. The adjusted model showed good discrimination AUC 0.77 (95 %CI 0.74–0.79) and calibration (Hosmer–Lemeshow χ 2 P = 0.68).
Conclusions
In critically ill ICH patients who survive hospitalization, hypernatremia at the time of discharge is a robust predictor of post-discharge mortality.
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References
Woo D, Broderick JP. Spontaneous intracerebral hemorrhage: epidemiology and clinical presentation. Neurosurg Clin N Am. 2002;13:265–79, v.
Hemphill JC, Bonovich DC, Besmertis L, Manley GT, Johnston SC. The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Stroke. 2001;32:891–7.
Ariesen MJ, Algra A, van der Worp HB, Rinkel GJ. Applicability and relevance of models that predict short term outcome after intracerebral haemorrhage. J Neurol Neurosurg Psychiatry. 2005;76:839–44.
Rost NS, Smith EE, Chang Y, et al. Prediction of functional outcome in patients with primary intracerebral hemorrhage: the FUNC score. Stroke. 2008;39:2304–9.
Andaluz N, Zuccarello M. Recent trends in the treatment of spontaneous intracerebral hemorrhage: analysis of a nationwide inpatient database. J Neurosurg. 2009;110:403–10.
Aiyagari V, Deibert E, Diringer MN. Hypernatremia in the neurologic intensive care unit: how high is too high? J Crit Care. 2006;21:163–72.
Qureshi AI, Suri MF, Sung GY, et al. Prognostic significance of hypernatremia and hyponatremia among patients with aneurysmal subarachnoid hemorrhage. Neurosurgery. 2002;50:749–55 discussion 55–6.
Murphy SN, Chueh HC. A security architecture for query tools used to access large biomedical databases. In: Proceedings of AMIA symposium. 2002. pp 552–6.
Zager S, Mendu ML, Chang D, et al. Neighborhood poverty rate and mortality in patients receiving critical care in the academic medical center setting. Chest. 2011;139:1368–79.
Mullen MT, Kasner SE, Messe SR. Seizures do not increase in-hospital mortality after intracerebral hemorrhage in the nationwide inpatient sample. Neurocrit Care. 2013;19:19–24.
Tirschwell DL, Longstreth WT Jr. Validating administrative data in stroke research. Stroke. 2002;33:2465–70.
Rapoport J, Gehlbach S, Lemeshow S, Teres D. Resource utilization among intensive care patients. Managed care vs traditional insurance. Arch Intern Med. 1992;152:2207–12.
Quan H, Li B, Couris CM, et al. Updating and validating the Charlson comorbidity index and score for risk adjustment in hospital discharge abstracts using data from 6 countries. Am J Epidemiol. 2011;173:676–82.
Moromizato T, Litonjua AA, Braun AB, Gibbons FK, Giovannucci E, Christopher KB. Association of low serum 25-hydroxyvitamin D levels and sepsis in the critically ill. Crit Care Med. 2014;42:97–107.
Martin GS, Mannino DM, Eaton S, Moss M. The epidemiology of sepsis in the United States from 1979 through 2000. N Engl J Med. 2003;348:1546–54.
Horkan CM, Purtle SW, Mendu ML, Moromizato T, Gibbons FK, Christopher KB. The association of acute kidney injury in the critically ill and postdischarge outcomes: a cohort study*. Crit Care Med. 2015;43:354–64.
Hoste EA, Clermont G, Kersten A, et al. RIFLE criteria for acute kidney injury are associated with hospital mortality in critically ill patients: a cohort analysis. Crit Care. 2006;10:R73.
Bellomo R, Ronco C, Kellum JA, Mehta RL, Palevsky P. Acute renal failure - definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care. 2004;8:R204–12.
Levey AS, Bosch JP, Lewis JB, Greene T, Rogers N, Roth D. A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Ann Intern Med. 1999;130:461–70.
Hug BL, Lipsitz SR, Seger DL, Karson AS, Wright SC, Bates DW. Mortality and drug exposure in a 5-year cohort of patients with chronic liver disease. Swiss Med Wkly. 2009;139:737–46.
Adeoye O, Ringer A, Hornung R, Khatri P, Zuccarello M, Kleindorfer D. Trends in surgical management and mortality of intracerebral hemorrhage in the United States before and after the STICH trial. Neurocrit Care. 2010;13:82–6.
Varhabhatla N, Zuo Z. The effects of chronic pulmonary disease on hospital length of stay and cost of hospitalization after neurosurgery. Clinical article. J Neurosurg. 2011;115:375–9.
Barell V, Aharonson-Daniel L, Fingerhut LA, et al. An introduction to the Barell body region by nature of injury diagnosis matrix. Inj Prev. 2002;8:91–6.
Cooke CR, Erickson SE, Eisner MD, Martin GS. Trends in the incidence of noncardiogenic acute respiratory failure: the role of race. Crit Care Med. 2012;40:1532–8.
Elias KM, Moromizato T, Gibbons FK, Christopher KB. Derivation and validation of the acute organ failure score to predict outcome in critically ill patients: a cohort study. Crit Care Med. 2015;43:856–64.
Purtle SW, Moromizato T, McKane CK, Gibbons FK, Christopher KB. The association of red cell distribution width at hospital discharge and out-of-hospital mortality following critical illness*. Crit Care Med. 2014;42:918–29.
Golestanian E, Liou JI, Smith MA. Long-term survival in older critically ill patients with acute ischemic stroke. Crit Care Med. 2009;37:3107–13.
Beier K, Eppanapally S, Bazick HS, et al. Elevation of blood urea nitrogen is predictive of long-term mortality in critically ill patients independent of “normal” creatinine. Crit Care Med. 2011;39:305–13.
McMahon GM, Mendu ML, Gibbons FK, Christopher KB. Association between hyperkalemia at critical care initiation and mortality. Intensive Care Med. 2012;38:1834–42.
Hemphill JC 3rd, Farrant M, Neill TA Jr. Prospective validation of the ICH Score for 12-month functional outcome. Neurology. 2009;73:1088–94.
Cheung RT, Zou LY. Use of the original, modified, or new intracerebral hemorrhage score to predict mortality and morbidity after intracerebral hemorrhage. Stroke. 2003;34:1717–22.
Acknowledgments
This manuscript is dedicated to the memory of our dear friend and colleague Nathan Edward Hellman, MD, PhD. The authors thank Shawn Murphy and Henry Chueh and the Partners HealthCare Research Patient Data Registry group for facilitating use of their database. Dr. Christopher had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
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NIH R01 NS059727.
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Boland, T., Henderson, G.V., Gibbons, F.K. et al. Hypernatremia at Hospital Discharge and Out of Hospital Mortality Following Primary Intracerebral Hemorrhage. Neurocrit Care 25, 110–116 (2016). https://doi.org/10.1007/s12028-015-0234-6
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DOI: https://doi.org/10.1007/s12028-015-0234-6