Publication: Disorders of sodium balance after traumatic brain injury in adult patients: A prospective study in a single centre
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Date
2019
Authors
Han, Tan Zi
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Abstract
Background and Objective Traumatic brain injury (TBI) is the leading cause of death and disability in young adults remain a major public health concern (1–3). Post-traumatic endocrinopathy has been reported as one of the complications TBI which causes serious physical and mental deficit (4–6). While many studies focus on anterior pituitary insufficiency, the function of posterior pituitary in survivors of TBI remains poorly investigated. Hence, the aim of this study is to evaluate the sodium abnormality in patients in the acute and chronic phase of TBI and a proposed protocol that was developed for the early identification of sodium abnormality for prompt treatment. Methods This was a single centre longitudinal cohort study. A total of 270 patients aged between 18 to 65-year-old with Glasgow Coma Scale (GCS) 3-13 who fulfilled the inclusion criteria admitted to the Department of Neurosurgery, Hospital Sultanah Aminah (HSAJB) from 1st January 2018 to 31st December 2018 were included. Patients were managed based on the proposed protocol. Demographic data: age of patients, gender, mechanism of injury, types of head injury and types of intervention were evaluated. Serum and urine Osmolality were obtained if the patients developed hypernatremia with polyuria (serum Na >145). If the patients developed hyponatremia (serum Na < 130), serum and urine osmolality, urine Na, serum cortisol and thyroid function test was obtained. All the patients who were diagnosed with acute diabetes insipidus (DI) and who developed symptoms of DI during clinic follow-up, were subjected for water deprivation test at 6 months post TBI Results In all 36 patients (13.3%) developed DI in the acute phase of TBI, with a mean age 31.4 (± 12.6) year old with 35 patients suffering severe head injury. The median GCS was 6. The mean onset of DI in the acute phase of TBI was 2.0 days (±1.0), the range of serum sodium during onset of DI was 149-162 mmol/l with mean sodium 153.5 mmol/l (±3.3). For the day of normalization of sodium level, the mean was 4.5 days (±1.7). From the multiple logistic regression (Table 6), base of skull fracture (p<0.001), cerebral oedema (p=0.040) and GCS score (p=0.009) were significant. This indicated that the base of skull fracture, cerebral oedema and GCS score are associated factor towards DI regardless of the existence of polytrauma and SAH at basal cistern. Two patients had abnormal WDT at 6 months post TBI. The overall mortality rate for acute DI is 13% A total of 24 patients (8.9%) developed Syndrome of Inappropriate Antidiuretic Hormone secretion (SIADH) in the acute phase of TBI with all patients suffering severe head injury with adrenal and thyroid sufficiency being ruled out. The median GCS was 6. The mean onset of sodium abnormality was 7.7 days (±3.4), the range of serum sodium during onset of SIADH was 114-128 mmol/l with mean sodium 125.3 mmol/l (±2.9). Only one factor associated with SIADH, which is cerebral oedema (p=0.018) when adjusted OR for both factors using multivariate logistic regression test (table 8). All SIADH resolved prior discharge and there was no new case of SIADH being diagnosed. Cerebral salt wasting (CSW) syndrome was seen in 3 patients with serum sodium 120 or less with natriuresis. Conclusion Study results showed significant frequency of sodium disorder in acute and chronic phase of TBI and it was possible to determine the significant factors that were associated with DI and SIADH at the acute phase of TBI. Hence, early recognition and prompt treatment with proper treatment protocol is extremely important in order to reduce the morbidity and mortality of sodium imbalance. Water deprivation test (WDT) is a gold standard for differentiation of cranial DI from nephrogenic and identification of partial or severe cranial in chronic phase of TBI
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Keywords
raumatic brain injury , diabetes insipidus