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MINISTRY OF EDUCATION AND TRAINING MINISTRY OF DEFENSE SCIENCE RESEARCH INSTITUTE OF CLINICAL MEDICINE AND PHARMACY 108 ============ The thesis has beeb successfully completed at : SCIENCE RESEARCH INSTITUTE OF CLINICAL MEDICINE AND PHARMACY 108 Science Instructor : PGS.TS Nguyen Phuong Dong NGUYEN DINH DUNG Opponent 1: Opponent 2: STUDYING CLINICAL, SUBCLINICAL CHARACTERISTICS, ASSOCITATED FACTORS AND TREATMENT RESULTS OF HYPONATREMIA IN PATIENTS WITH CEREBRAL HEMORRHAGE Major : Anesthesia - Resusciation Major code : 62.72.01.22 Opponent 3: Thesis has been defended at Institite- level Thesis Evaluation Council held in Science Research Institute Of Clinical Medicine And Pharmacy 108 At (hour), / / 2019 This thesis may be found at: National library Library of Science Research Institute Of Clinical Medicine And Pharmacy 108 SUMMARY OF MEDICAL DOCTORAL THESIS HA NOI– 2019 CSWS SIADH CNS LIST OF ABRREVIATION Clinical symptoms:Patients with mild hyponatremia only exhibit anorexia, insensitive drowsiness, nausea, vomiting Consciousness disorders, coma, convulsions, hypothermia, acute circulatory failure, breathing disorders, decreased tendon reflexes may occur in patients with severe hyponatremia Patients with acute severe hyponatremia may have a very high risk of neurological complications: confusion, coma, convulsions, apnea Some nonspecific signs, such as loss of appetite, vomiting, apathy, nausea and fatigue, can be detected through clinical manifestations of hypotension, delayed pinches, sunken eyes, dry mucous membranes, lack of armpits sweat, tachycardia and orthostatic hypotension Subclinical: + Serum sodium concentration ✓ Normal: 135 - 145 mmol/l ✓ Mild: 130 - 134 mmol/l ✓ Moderate: 125 - 129 mmol/l ✓ Servere: < 125 mmol/l + Serum osmolality: Sodium is the main ingredient that determines the serum osmotic pressure (90%) + Urinary sodium concentration: ✓ Urinary sodium concentration 20 mmol/l:Cause ofhyponatremia is due to renal salt loss 1.2 The role and significance of sodium - osmostic pressure in the treatment of cerebral hemorrhage Hypotonic hyponatremia causes water to enter brain cells, leading to cerebral edema Because the skull surrounds the brain, the brain is limited in dilation increasing intracranial pressure occurs, thereby aggravating the brain damage inherent in patients with cerebral hemorrhage Hypovolemic hyponatremia may cause a decrease in cerebral perfusion flow, thereby aggravating the brain lesions in patients with cerebral hemorrhage Hypernatremia is always accompanied by hypertonicity, so hypernatremia causes water to be pulled out from the brain cells, leading to brain cell atrophy 1.3 Causes of hyponatremia in patients with cerebral bleeding Hyponatremia in patients with cerebral stroke and CNS lesions has begun to be studied much in the 70s of the twentieth century Hyponatremia in patients with brain damage is mainly attributed to two syndromes: SIADH, CSWS, in addition to many causes such as the use of mannitol diuretics, furosemide, multiple fluids or possibly a combination of many causes The differential diagnosis of these two syndromes is important cerebral salt wasting syndrome of inappropriate anti-diuretic hormone secretion central nervous system INTRODUCTION Hyponatremia is a common electrolyte disorder in patients with cerebral hemorrhage, accounting for 30-60%.Hyponatremia in patients with cerebral hemorrhage increases the rate of complications, mortalityand prolongsthe duration of treatment Clinical symptoms of hyponatremia are poor, especially in patients with cerebral hemorrhage, they easily confused with symptoms of central nervous system (CNS)damage caused by cerebral hemorrhage such as confusion, seizure, coma…The reasons of hyponatremia and associatedfactors have not been clearly defined, but the results of many studies often suggest that the causes of hyponatremia are two syndromes: syndrome of inappropriate anti-diuretic hormone secretion (SIADH) and cerebral salt wasting syndrome (CSWS) Clinically, these two syndromes have many similar and easily confused symptoms, but the pathogenesis mechanisms are completely different and treatment principles are also different Some studies suggest that it is possible to determine causes of hyponatremia based on BNP, NT - ProBNP concentrations Treatment of hyponatremia in patients with cerebral hemorrhage to ensure efficiency and safety is based not only on sodium levels even as mild but also on clinicalcharateristics , associated factors, and causes of hyponatremia Currently, the consented recommendations is that3% NaCl solution is appropriate concentration, ensure treatment goals, minimize complications Therefore we conducted the research:"Studying clinical and subclinical characteristics, asociated factors and treatment results of hyponatremia in patients with cerebral hemorrhage" with twoobjectives: Comment on clinical, subclinical characteristics and factors associated with hyponatremia in patients with cerebral hemorrhage Evaluation of the treatment results of hyponatremia in patients with cerebral hemorrhage Chapter LITERATURE OVERVIEW 1.1 Definition of hyponatre mia Hyponatremia is defined as a serum sodium concentrationof less than 135 mEq/L While hypernatremia is always associated with increasedserum osmolality, hyponatremia may be associated with low, normal or high blood osmolality 3 because they differ in their nature and treatment SIADH syndrome is an unreasonable secretion of ADH, leading to hyponatremia due to dilution (excess fluid volume) so treatment should limit infusion CSWS syndrome is hyponatremia due to an increase in loss of sodium and water through the kidneys, so treatment needs to compensate for sodium and water The syndrome of inappropriate antidiuretic hormone secretion (SIADH) includes: ✓ Serum sodiumconcentration ≤ 135mmol/l ✓ Urinary sodiumconcentration> 20 mEq/l ✓ CVP> 6cmH2O ✓ Blood osmotic pressure Blood osmotic pressure ✓ Decreased A uric, albumin, protein, Hb, Hct ✓ Kidney function, thyroid, adrenal gland normal ✓There are no signs of peripheral edema, no signs of dehydration Principles of treatment Treat underlying disease Restrict fluid - fluid restriction is the main treatment in most SIADH patients, with a proposed goal of less than 800 - 1000 ml /day Fluid restriction may promote cerebral vasoconstriction in patients with subarachnoid hemorrhage because it is usually treated with an increase in circulating volume As well as related to blood pressure, intracranial pressure is a very important factor in monitoring the treatment of patients with cerebral or subarachnoid hemorrhage Therefore, hyponatremia in patients with cerebral or subarachnoid hemorrhageshould be treated with hypertonic saline (3%) to preserve cerebrospinal fluid and prevent cerebral edema complications of hyponatremia Cerebral salt wasting syndrome (CSWS) includes: ✓ Serum sodium concentration ≤ 135mmol / l ✓ Urinary sodium concentration> 20 mEq / l ✓ CVP 150mmol), patients increased blood osmotic pressure,at the time of hyponatremia and after treatment: 334mosmol / kg, 342 mosmol / kg, respectively) The reason is that at the beginning of treatment, we did not have the result of blood osmotic pressure, and patients with diabetes During treatment with NaCl 3% solution, no clinical manifestations of complications were noted Blood sodium concentration also quickly returned to normal when stopped using NaCl 3% solution patient increased blood osmotic pressure due to hypernatremia (Na = 163mmol / l), this patient also stopped infusion, adjusted to normal and the patient was discharged from hospital with good status (Glasgow: 15 points), our complication rate was similar to Carolyn Woo and much lower according to Froelich M et al This is due to that infusion NaCl3% did not have a suitable reference and adjustment process 4.4.2 Change of cognition before and after treating hyponatremia with NaCl 3% solution 42/79 patients had a good improvement in perception after treatment accounted for 53.16%, 31/79 patients (39.24%) did not have any change in perception after treatment Post-treatment perceptions of patients (7.59%) worsened The average value of Glasgow at the beginning of treatment was 12.84 ± 2.89 point and 13.01 ± 2.86 point in the end Among them, CSWS patients have the most obvious improvement in perception Figure 3.10 In addition to treating hyponatremia, NaCl 3% solutionhas antiedematous effect and is the most effective in hyponatremia patients in the acute phase of brain bleeding (