Syndrome of inappropriate antidiuretic hormone secretion
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Syndrome of inappropriate antidiuretic hormone secretion
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Syndrome of inappropriate antidiuretic hormone secretion (SIADH) is a condition in which excess anti-diuretic hormone (ADH) - also known as vasopressin - is produced. Downstream effects include 1. retention of excess water which can lead to cerebral edema/seizures/coma/death, 2. hyponatremia which can lead to arrhythmias and - if sodium corrected is attempted - potentially iatrogenic Osmotic demyelination syndrome (OSD)/Central pontine myelinolysis (CPM).
Anesthetic implications
Preoperative optimization
- Evaluate overall sodium trend
- Most anesthesiologists would consider delaying case if sodium x<130
- Ideally sodium should be corrected to normal limits or at least stabilized or trending towards correction prior to surgery
- Uncorrected sodium levels merits discussion with internal medicine and surgery.
Intraoperative management
- Serial ABG to monitor serum sodium
- concern for overly rapid correction - potentially leading to OSD or CPM.
- Maintain sodium correction to 0.5mmol/L/hr with goal of 4-8mmol/L in 24 hours[1]
- concern for overly rapid correction - potentially leading to OSD or CPM.
- Avoid hypotonic fluids
- half normal saline
- dextrose in water
- LR - can consider but requires very close monitoring of sodium levels
- Preferred fluids
- Hypertonic saline
Postoperative management
Related surgical procedures
Pathophysiology
General Mechanism of Action of ADH
- ADH is a hormone produced by the hypothalamus, then stored and released via the posterior pituitary gland
- ADH is responsible for mechanisms pertaining to water retention via upregulation of aquaporin channels in renal nephrons to increase water re-absorption. ADH's main effect leads to increased fluid volume while decreasing serum sodium concentration and decreasing urinary output volume.
Consequences
Causes
- Cancer
- Brain tumors
- Small Cell Lung Cancer
- Lymphoma
- Central Nervous System
- Brain Surgery - especially pituitary gland surgery
- Brain tumors
- Meningitis
- Encephalitis
- Brain trauma
- Hypopituitarism
- Stroke
- Guillain-Barre
- Heart Failure
- Lung Pathology
- Pneumonia
- Medications
- SSRIs
- Anti-neoplastic drugs
- Anti-psychotics
- Acute stressors
- pain
- Nausea
- Hypothoridism
- HIV infection
Signs and symptoms
Symptoms
- Cerebral
- Altered mental status
- Seizures
- Loss of balance/coordination
- Coma
- GI
- Nausea
- Emesis
- Musculoskeletal
- Muscle cramps
- Muscle weakness
Diagnosis
- Hyponatremia (serum) x< 135 mEq/L
- High urine osmolality: 100+ mOsm/kg
- High Urine sodium levels 40+ mEq/L
- Euvolemic or fluid overload state
Treatment
- Overall treatment is to remove excess water from the body
- Diuretics
- H20 restriction
- Demeclocycline (off-label)
- a tetracycline antibiotic that is used off-label to treat SIADH by decreasing renal response to ADH
- Treat inciting etiology
Epidemiology
Risk factors for SIADH
- Increasing age
- Hospitalization
- Lung cancer
- Cerebral pathology/manipulation
References
- ↑ "The Resuscitationist's Approach to Severe Hyponatremia". www.acep.org. Retrieved 2025-06-29.
- ↑ Leung, Alexander A.; McAlister, Finlay A.; Rogers, Selwyn O., Jr; Pazo, Valeria; Wright, Adam; Bates, David W. (2012-10-22). "Preoperative Hyponatremia and Perioperative Complications". Archives of Internal Medicine. 172 (19): 1474–1481. doi:10.1001/archinternmed.2012.3992. ISSN 0003-9926.
Top contributors: Jessica Leung and Olivia Sutton