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L’hyponatrémie chez le patient cérébrolésé en soins intensifs : étiologie et prise en charge

Hyponatremia in the neurologic patient in intensive care unit: Etiology and treatment

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Médecine Intensive Réanimation

Résumé

L’hyponatrémie est le désordre électrolytique le plus fréquent chez le patient cérébrolésé hospitalisé en soins intensifs. Elle constitue un facteur de mauvais pronostic, augmentant significativement la mortalité. Nous présentons une revue concernant les étiologies, la physiopathologie et, plus particulièrement, le traitement de cette pathologie. La majorité de ces hyponatrémies est secondaire au syndrome de sécrétion inappropriée d’hormone antidiurétique ou au « syndrome cérébral de perte de sel ». La différence entre ces deux syndromes réside principalement dans l’appréciation de l’état volémique du patient, difficilement évaluable en réanimation. L’insuffisance surrénale aiguë, l’hypovolémie et l’administration inadéquate de solutés hypotoniques sont également des étiologies fréquentes. Bien que l’approche thérapeutique puisse varier en fonction de différents facteurs tels que la pathologie neurologique sous-jacente et la vitesse d’installation de l’hyponatrémie, l’administration de sérum salé hypertonique (SSH) 3 % constitue la pierre angulaire du traitement lors d’hyponatrémie sévère. L’utilisation d’autres molécules, comme la fludrocortisone ou les antagonistes de l’hormone antidiurétique, a été étudiée et pourrait être une voie thérapeutique intéressante. La physiopathologie de l’hyponatrémie chez les patients cérébrolésés est encore mal comprise. Le SSH constitue le traitement de choix dans l’hyponatrémie sévère ou symptomatique dans cette population.

Abstract

Hyponatremia is the most prevalent electrolytic disorder found in patients with neurologic disorder hospitalized in the intensive care unit (ICU). It is a poor prognostic factor and increases mortality rates in these patients.We present a review concerning the etiology, pathophysiology, and particularly, the treatment of this pathology. Most cases of hyponatremia are caused either by the syndrome of inappropriate antidiuretic hormone secretion or by the cerebral salt wasting syndrome. The difference between them is the volemia of the patient, which is difficult to assess, especially in the ICU. Adrenal insufficiency, hypovolemia, and inadequate fluid resuscitation are also common causes of hyponatremia in the neurologic ICU. Even if the therapeutic approach varies accordingly to the concomitant neurological disorder and how fast the hyponatremia occurred, hypertonic saline solution is the cornerstone of the treatment in severe or symptomatic hyponatremia. The use of other molecules, such as fludrocortisone and antidiuretic hormone antagonist could be an interesting option in the future. The pathophysiology of hyponatremia in neurologically ill patients is not well understood. However, HSS is the treatment of choice in severe or symptomatic hyponatremia in this population.

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Authors and Affiliations

  1. Faculté de médecine et des sciences de la santé, université de Sherbrooke, département d’anesthésiologie, centre hospitalier universitaire de Sherbrooke, 3001, 12e avenue Nord Sherbrooke, J1H5N4, Sherbrooke, Québec, Canada

    P. L. Langlois

  2. Faculté de médecine et des sciences de la santé, université de Sherbrooke, centre hospitalier universitaire de Sherbrooke, 3001, 12e avenue Nord Sherbrooke, J1H5N4, Sherbrooke, Québec, Canada

    M. J. Bourguignon

  3. Faculté de médecine, UDELAR, département des soins intensifs, unité de soins intensifs de Hospital de Clínicas (hôpital universitaire), Montevideo, Uruguay

    W. Manzanares

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  1. P. L. Langlois
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  2. M. J. Bourguignon
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  3. W. Manzanares
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Correspondence to P. L. Langlois.

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Langlois, P.L., Bourguignon, M.J. & Manzanares, W. L’hyponatrémie chez le patient cérébrolésé en soins intensifs : étiologie et prise en charge. Méd. Intensive Réa 25 (Suppl 5), 203–213 (2016). https://doi.org/10.1007/s13546-016-1187-2

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