1、2014 欧洲低钠血症诊疗指南解读,欧洲危重病学会（ESICM），欧洲内分泌学会（ESE）欧洲肾脏最佳临床实践（European Renal Best Practice ERBP)为代表的欧洲肾脏病协会和欧洲透析与移植协会（ERA-EDTA）共同制定了欧洲低钠血症临床诊疗指南,低钠血症,Hyponatraemia, defined as a serum sodium concentration135 mmol/l, is the most common disorder of body fluid and electrolyte balance encountered in clinical
2、practice. It occurs in up to 30% of hospitalised patients and can lead to a wide spectrum of clinical symptoms, from subtle to severe or even life threatening (10, 11),定义： 血清钠低于135mmol/L临床最常见的水盐失衡，其发生率约占住院患者的30%症状不一，从轻微到致命,6. 低钠血症诊断Diagnosis of hyponatraemia6.1. 分类：Classification of hyponatraemia,根据
3、血钠浓度分类：6111：轻度(mild)低钠血症：血钠： 130135mmol/l6112： 中度（moderate）低钠血症：血钠： 125129mmol/l6113：重度（profound）低钠血症： 血钠： 125mmol/l,依据发生时间分类：6121：急性低钠血症100mOsm/kg,尿渗透压,急性或严重症状？,100mOsm/kg:原发性烦渴盐摄入不足、嗜酒,30mmol,Y,N,有效动脉血容量不足,考虑：利尿剂肾脏疾病,如果ECF减少：呕吐，肾耗盐，脑耗盐隐匿性利尿，原发性肾上腺功能不全,如果ECF正常:SIAD,甲减，隐匿性利尿继发性肾上腺功能不全,如果ECF减少：呕吐，第三腔
4、室，远程利尿剂,如果ECF增加：心衰，肝硬化，肾病综合征,其他疾病,Y,立即开始低钠血症治疗,N,低钠血症诊断程序图示,低渗性低钠血症的治疗,症状严重程度？,中重度症状？,急性低钠血症,循环血量不足？,细胞外液量增多？,症状严重的低钠血症7.1,中重度症状的低钠血症7.2,无中重度症状的低钠血症7.3,低容量的慢性低钠血症7.4.4,高容量慢性低钠血症7.4.2,是,否,是,否,Y,N,Y,N,Y,慢性低钠血症7.4,低渗性低钠血症处理流程图,N,SIADH,7.1.1:严重低钠血症患者（慢或急性）第1小时处理First-hour management, regardless of wheth
5、er hyponatraemia is acute or chronic,7.1.1.1. We recommend prompt i.v. infusion of 150 ml 3% hypertonic over 20 min (1D).7.1.1.2. We suggest checking the serum sodium concentration after 20 min while repeating an infusion of 150 ml 3% hypertonic saline for the next 20 min (2D).7.1.1.3. We suggest re
6、peating therapeuticrecommendations7.1.1.1 and 7.1.1.2 twice or until a target of 5 mmol/l increase in serum sodium concentration is achieved(2D).7.1.1.4. Manage patients with severely symptomatic hyponatraemia in an environment where close biochemicaland clinical monitoring can be provided (not grad
7、ed).,7.1.1.1 : 推荐立即静脉输注3%高渗盐水150ml,速度20分钟以上 （1D） 71.1.2: 20分钟后检查血钠浓度并在第二个20分钟重复静脉输注3%高渗盐水150ml （2D）7.1.1.3： 建议重复以上治疗推荐两次或直到达到血钠浓度增加5mmol/L (2D)7.1.1.4: 应该在具有密切生化和临床监测的环境下对有严重症状的低钠血症患者进行治疗,7.1.2：1小时后血钠 5 mmol/L,症状改善的接续治疗,7.1.2.1. We recommend stopping the infusion of hypertonic saline (1D).7.1.2.2. W
8、e recommend keeping the i.v. line open by infusing the smallest feasible volume of 0.9% saline until cause-specific treatment is started (1D).7.1.2.3. We recommend starting a diagnosis-specific treatment if available, aiming at least to stabilise sodium concentration (1D).7.1.2.4. We recommend limit
9、ing the increase in serum sodium concentration to a total of 10 mmol/l during the first 24 h and an additional 8 mmol/l during every 24 h thereafter until the serum sodium concentration reaches 130 mmol/l (1D).7.1.2.5. We suggest checking the serum sodium concentration after 6 and 12 h and daily aft
10、erwards until the serum sodium concentration has stabilised under stable treatment (2D).,7.1.2.1：推荐停止输注高渗盐水（1D）7.1.2.2：保持静脉通道通畅，输注0.9%盐水直到开始针对病因治疗（1D）71.2.3：如果可能开始特异性诊断治疗，但至少是血钠浓度稳定（1D）7.1.2.4：第1个24h限制血钠升高超过10ml，随后每24h血钠升高8mmol. 直到血钠达到130mmol/l7.1.2.5: 第6h,12h复查血钠，此后每天复查，直到血钠浓度稳定,7.1.3：1小时后，血钠 5mmol
11、/l，但症状无改善,7.1.3.1. We recommend continuing an i.v. infusion of 3%hypertonic saline or equivalent aiming for an additional 1 mmol/l per h increase in serum sodium concentration (1D).7.1.3.2. We recommend stopping the infusion of 3% hypertonic saline or equivalent when the symptoms improve, the serum
12、sodium concentration increases 10 mmol/l in total or the serum sodium concentration reaches 130 mmol/l, whichever occurs first (1D).7.1.3.3. We recommend additional diagnostic exploration for other causes of the symptoms than hyponatraemia (1D).7.1.3.4. We suggest checking the serum sodium concentra
13、tion every 4 h as long as an i.v. infusion of 3% hypertonic saline or equivalent is continued (2D).,7.1.3.1：继续静脉输注3%高渗盐水，使血钠浓度增加1mmol/l. （1D）7.1.3.2：有下列之一者停止输注高渗盐水： 症状改善， 血钠升高幅度达10mmol/l 血钠达到130mmol/l, （1D）7.1.3.3: 建议寻找存在症状的低钠血症以外的原因(1D)7.1.3.4: 只要继续3%高渗盐水输注，建议每隔4小时检测一次血钠（2D）,7.2. 中重度低钠血症（Hyponatrae
14、mia with moderately severe symptoms）,7211:立即开始诊断评估7212:如果可能，停止引起低钠血症的所有治疗7214:立即单次输注3%盐水（或等量）150ml,20分钟以上7215：每24h血钠升高5mmol/l7216:第1个24h血钠 10mmol/l 之后每日血钠 10mmol/l，单次静脉输注3%盐水150ml7316: 4 h后用同样技术检测血钠。,7.4 ：无中重度症状的慢性低钠血症：,7411：去除诱因7412：针对病因治疗7423：轻度低钠血症，不建议将增加血钠作为唯一治疗7424：中度或重度低钠血症，第1个24h应避免血钠增加10mmol
15、/l,随后每24h 100 ml/h,提示血钠有快速增加危险。若低容量患者经治疗血容量恢复，血管加压素活性突然被抑制，游离水排出会突然增加，则使血钠浓度意外升高。如尿量突然增加，建议每2h测血钠。作为增加溶质摄入的措施，推荐每日摄入0.250.5 /kg尿素,添加甜味物质改善口味。药学家可制备如下袋装尿素口服剂：尿素10g+碳酸氢钠2g+柠檬酸1.5g+蔗糖200mg, 溶于50100ml水中。,7.5:如低钠血症被过快纠正需注意什么？,7.5.1.1：如果第1个24h血钠增加幅度10mmol/l,第2个24h8mmol/l，建议立即采取措施降低血钠7.5.1.2：建议停止积极的补钠治疗7.5
16、.1.3：建议有关专家会诊以讨论是否可以开始在严密尿量及液体平衡监测下以1小时的时间，10ml/kg的速度输注不含电解质液体（如葡萄糖溶液）7.5.1.4：建议专家会诊，讨论是否可以静注去氨加压素（desmopressin）2ug, 间隔时间不低于8h.,For demeclocycline and lithium, there is some evidence of possible harm, so we advise against their use for management of any degree of chronic hyponatraemia in patients wi
17、th SIAD.Although vasopressin receptor antagonists do increase serum sodium, the guideline development group judged that based on current evidence, these drugs cannot be recommended.,地美环素和锂可抑制ADH释放。但有证据表明对机体有害。指南制定小组反对将其用于SIAD患者任何程度的慢性低钠血症虽然加压素受体拮抗剂确有增加血钠作用，但是指南制定小组认为根据目前资料，不推荐加压素受体拮抗剂临床用于低钠血症。,Indee
18、d, the risk benefit ratio seems to be negative: there is no proven outcome benefit aside from increase in serum sodium concentrations, while there are increasing concerns on safety. The most prominent safety related factor is the increased risk for overly rapid correction of hyponatraemiaAs this ris
19、k is greatest in patients with profound hyponatraemia, the guideline development group wanted to recommend against the use of vasopressin receptor antagonists in this specific patient group.,应用加压素受体拮抗剂的危益比（risk benefit ratio）似乎呈负性：除其增加血钠外，未见其对预后有益。但增加安全担忧。最大的隐患是可能快速升高血钠（而导致渗透性脱髓鞘）。因在中毒低钠血症患者其危险最大，故指南制定小组不推荐将其用于重症低钠血症患者。,谢谢,谢谢,
