Umbrello Michele, Mantovani Elena S, Formenti Paolo, Casiraghi Claudia, Ottolina Davide, Taverna Martina, Pezzi Angelo, Mistraletti Giovanni, Iapichino Gaetano
Unità Operativa di Anestesia e Rianimazione, Azienda Ospedaliera San Paolo-Polo Universitario, Via A. Di Rudinì, 8, 20142, Milan, Italy.
Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy.
Ann Intensive Care. 2016 Dec;6(1):1. doi: 10.1186/s13613-015-0096-2. Epub 2016 Jan 4.
Hyponatremia is the most common electrolyte disturbance in hospitalized patients, and it represents a well-established risk factor for ICU/hospital mortality. The majority of hyponatremic states are associated with elevated arginine vasopressin levels and a preserved sodium pool. Conventional treatment is either not pathophysiologically oriented or of limited effectiveness. The aim of the present study is to investigate the use of enteral Tolvaptan in critically ill hyponatremic patients.
This is a retrospective observational study in a general ICU. Patients with preserved sodium pool hyponatremia refractory to conventional therapy were enrolled. The hemodynamic, renal, and hepatic functions, together with sodium and water balance as close as possible to the drug administration and up to 72 h thereafter, were analyzed. The main outcome was a serum sodium increase of ≥ 4 mmol/L in 24 h; secondary endpoints were the ability to maintain serum sodium at 24 and 72 h, a decrease in urine sodium concentration and an increase in sodium-free diuresis.
38 patients were enrolled. The average dose of enteral Tolvaptan was 7.5 mg. 31 patients (81.6 %) increased their serum sodium >4 mmol/l/24 h; the average increase was 6.7 ± 3.4 mmol/l during the first 24 h (p < 0.001 vs baseline), and this was sustained at 72 h. No adverse effects were reported. Plasma sodium (R = -0.622, p < 0.001), urine sodium (R = -0.345, p < 0.001), central venous oxygen saturation (R = 0.401, p = 0.013), and BUN (R = -0.416, p = 0.031) before Tolvaptan were all significantly correlated with the absolute increase in serum sodium after the administration.
Enteral administration of Tolvaptan seems effective in the treatment of hyponatremia with preserved sodium pool in critically ill patients. Even if the study was underpowered to detect significant side effects or complications of unwarranted fast corrections of hyponatremia, we report no complications.
低钠血症是住院患者中最常见的电解质紊乱，是重症监护病房/医院死亡率的既定危险因素。大多数低钠血症状态与精氨酸加压素水平升高和钠储备保留有关。传统治疗要么没有以病理生理学为导向，要么效果有限。本研究的目的是调查肠内托伐普坦在重症低钠血症患者中的应用。
这是一项在综合重症监护病房进行的回顾性观察研究。纳入对传统治疗无效的钠储备保留性低钠血症患者。分析给药时及给药后72小时内尽可能接近的血流动力学、肾脏和肝脏功能，以及钠和水平衡。主要结局是24小时内血清钠升高≥4 mmol/L；次要终点是在24小时和72小时维持血清钠的能力、尿钠浓度降低和无钠利尿增加。
纳入38例患者。肠内托伐普坦的平均剂量为7.5 mg。31例患者（81.6%）血清钠在24小时内升高>4 mmol/L；前24小时平均升高6.7±3.4 mmol/L（与基线相比，p<0.001），并在72小时维持。未报告不良反应。托伐普坦给药前的血浆钠（R=-0.622，p<0.001）、尿钠（R=-0.345，p<0.001）、中心静脉血氧饱和度（R=0.401，p=0.013）和血尿素氮（R=-0.416，p=0.031）均与给药后血清钠的绝对升高显著相关。
肠内给予托伐普坦似乎对治疗重症患者钠储备保留性低钠血症有效。即使该研究的样本量不足以检测低钠血症无端快速纠正的显著副作用或并发症，但我们未报告并发症。
