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THe Cycle of Cerebral Salt Wasting and SIADH
Timing
- This process starts between day 5-10
Monitoring
- They only need daily blood work
Duration
- Runs a course over a couple of weeks
- You will know when to back off on supplements because their sodium will start climbing on blood work
Cautions
- You cannot and should not volume restrict these patients as it runs contrary to the pathophysiologic process and they also often have obligatory fluids running
- Make sure that they are not dry. For example, patients with cerebral vasospasm from SAH (see section on SAH) will often either spike their own blood pressure or we will purposely induce hypertension. This is sensed by the Juxtaglomerular apparatus in the kidney (our other blood pressure dependent organ besides the brain) resulting in diuresis
- If you overshoot their sodium DO NOT correct it with free water
Cerebral Salt Wasting and siadh
- The process begins with an abrupt increase in ICP causing release of circulating catecholamines
- Meanwhile, the increase in ICP also causes a release of BNP which is a physiologic response to raised ICP (where salt goes water will follow), causing a naturesis.
- Juxtaglomerular apparatus in the kidney senses the hyperdynamic respose
- Mild diuresis occurs and mild volume depletion occurs
- volume depletion causes an appropriate rise in ADH (although we call it SIADH)
- ADH binds to is aquaporin receptor in the kidney which causes the reabsorption of free water
- A vicious cycle of salt wasting and free water conservation has been birthed and bestowed
Treatment of CSW/SIADH
They simply need plenty of salt and mineralocorticoids
Salt is best
- If they are awake and swallowing and can tolerate these massive tablets, dry salt tabs are best
- You can give anywhere between 1g bid to 5g tid depending on how severe
- Err on the side of giving too much and then back off
- If the patient has a feeding tube, all the better as the tablets can be dissolved in water and put down the tube
3% saline
- For patients who won't tolerate PO
- It is not quite as effective because it also provides up to an extra liter of water a day but it still works
Mineralocorticoids
- Larger than average doses
- 200ug twice daily
- Recall that the normal adrenal replacement dose is 50ug daily