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Background: Dysnatremia occurs commonly in patients with aneurysmal subarachnoid hemorrhage (aSAH). The mechanisms for development of sodium dyshomeostasis are complex, including the cerebral salt-wasting syndrome, the syndrome of inappropriate secretion of antidiuretic hormone, diabetes insipidus. Iatrogenic occurrence of altered sodium levels plays a role, as sodium homeostasis is tightly linked to fluid and volume management. Methods: Narrative review of the literature. Results: Many studies have aimed to identify factors predictive of the development of dysnatremia, but data on associations between dysnatremia and demographic and clinical variables are variable. Furthermore, although a clear relationship between serum sodium serum concentrations and outcomes has not been established—poor outcomes have been associated with both hyponatremia and hypernatremia in the immediate period following aSAH and set the basis for seeking interventions to correct dysnatremia. While sodium supplementation and mineralocorticoids are frequently administered to prevent or counter natriuresis and hyponatremia, evidence to date is insufficient to gauge the effect of such treatment on outcomes. Conclusions: In this article, we reviewed available data and provide a practical interpretation of these data as a complement to the newly issued guidelines for management of aSAH. Gaps in knowledge and future directions are discussed. [ABSTRACT FROM AUTHOR]

Diarrhoea, vomiting, and dehydration are frequently encountered in neonatal emergency. However, it is challenging to manage resistant hypernatraemia and metabolic acidosis associated with it. Diagnosing the exact cause is even more difficult. Glucose-galactose malabsorption commonly presents with hypernatraemia and repeated dehydration. In the case described here, the baby started to have diarrhoea in the first week of life and presented in the neonatal emergency with severe dehydration and hypernatraemia. Higher sodium levels were difficult to manage throughout the course of illness. Hypernatraemia and diarrhoea worsened on feeding, whether formula or mother’s feed, which raised suspicion of glucose and galactose malabsorption. So, genetic testing was performed and fructose based formula was started which led to improvement in the condition. Later, genetic testing confirmed our diagnosis. ---Continue

Introduction: hyperchloremia and hypernatremia are common complications in critically ill children and have been associated with the development of acute kidney injury (AKI) and mortality. Objective: to estimate the incidence of hyperchloremia and hypernatremia during the first 72 hours of admission to a pediatric intensive care unit (PICU), and to evaluate their association with AKI and mortality. Material and methods: prospective cohort study, conducted over a period of 15 months. Patients with disorders in plasma levels of chloride (Cl-) or sodium (Na+), as well as with AKI at the time of admission, were excluded. Values > 110 mEq/L Cl- and > 145 mEq/L Na+ were considered as hyperchloremia and hypernatremia, respectively. A sample size of 255 patients was calculated. Statistical analysis. Odds Ratio (OR) and 95% confidence intervals (95% CI) were calculated for bivariate and multivariate analyses. Results: among 241 patients, the incidence of hyperchloremia was 12.4% (n = 30), and of hypernatremia 18.6% (n = 45). The frequency of AKI was 35.6%, and mortality was 14.1%. In logistic regression analysis, hypernatremia was associated with AKI (OR 2.7, 95% CI 1.3-5.7, p < 0.006), but not with mortality. While hyperchloremia was not identified as a risk for AKI or death. Conclusions: hyperchloremia and hypernatremia are common in critically ill pediatric patients, but only hypernatremia seems to confer a higher risk of complications. [ABSTRACT FROM AUTHOR]

A large and growing body of research suggests that the skin plays an important role in regulating total body sodium, challenging traditional models of sodium homeostasis that focused exclusively on blood pressure and the kidney. In addition, skin sodium may help to prevent water loss and facilitate macrophage-driven antimicrobial host defence, but may also trigger immune dysregulation via upregulation of proinflammatory markers and downregulation of anti-inflammatory processes. We performed a systematic search of PubMed for published literature on skin sodium and disease outcomes and found that skin sodium concentration is increased in patients with cardiometabolic conditions including hypertension, diabetes and end-stage renal disease; autoimmune conditions including multiple sclerosis and systemic sclerosis; and dermatological conditions including atopic dermatitis, psoriasis and lipoedema. Several patient characteristics are associated with increased skin sodium concentration including older age and male sex. Animal evidence suggests that increased salt intake results in higher skin sodium levels; however, there are conflicting results from small trials in humans. Additionally, limited data suggest that pharmaceuticals such as diuretics and sodium-glucose co-transporter-2 inhibitors approved for diabetes, as well as haemodialysis may reduce skin sodium levels. In summary, emerging research supports an important role for skin sodium in physiological processes related to osmoregulation and immunity. With the advent of new noninvasive magnetic resonance imaging measurement techniques and continued research on skin sodium, it may emerge as a marker of immune-mediated disease activity or a potential therapeutic target. [ABSTRACT FROM AUTHOR]

Dysnatremia after congenital heart disease (CHD) surgery is common. European guidelines on intraoperative fluid therapy in children recommend isotonic solutions to avoid hyponatremia, but prolonged cardiopulmonary bypass and administration of high sodium‐containing solutions (i.e., blood products and sodium bicarbonate) are associated with postoperative hypernatremia. The aim of the study was to describe fluid composition prior to and during the development of postoperative dysnatremia. A retrospective observational, single‐center study including infants undergoing CHD surgery. Demographics and clinical characteristics were registered. Highest and lowest plasma sodium values were recorded and associations with perioperative fluid administration, blood products, crystalloids, and colloids were explored in relation to three perioperative periods. Postoperative dysnatremia occurred in nearly 50% of infants within 48 h after surgery. Hypernatremia was mainly associated with administration of blood products (median [IQR]: 50.5 [28.4–95.5] vs. 34.5 [18.5–61.1] mL/kg; p = 0.001), and lower free water load (1.6 [1.1–2.2] mL/kg/h; p = 0.01). Hyponatremia was associated with a higher free water load (2.3 [1.7–3.3] vs. 1.8 [1.4–2.5] mL/kg/h; p = 0.001) and positive fluid balance. On postoperative day 1, hyponatremia was associated with higher volumes of free water (2.0 [1.5–2.8] vs. 1.3 [1.1–1.8] mL/kg/h; p < 0.001) and human albumin, despite a larger diuresis and more negative daily fluid balance. Postoperative hyponatremia occurred in 30% of infants despite restrictive volumes of hypotonic maintenance fluid, whereas hypernatremia was mainly associated with blood product transfusion. Individualized fluid therapy, with continuous reassessment to reduce the occurrence of postoperative dysnatremia is mandatory in pediatric cardiac surgery. Prospective studies to evaluate fluid therapy in pediatric cardiac surgery patients are warranted. [ABSTRACT FROM AUTHOR]

Background The patient described in this case received a diagnosis of severe head trauma that resulted in death. Imaging findings, along with discrepancies in the parental explanation of the incident, aided the forensic investigators to identify the case as nonaccidental trauma (NAT). Discussion Identifying demographic risk factors and performing proper clinical evaluations can serve an important role in the diagnosis of pediatric NAT. Imaging modalities such as radiography, computed tomography, and magnetic resonance imaging can help determine the extent of trauma. Conclusion: Abuse is frequent in the pediatric population. To help prevent future cases of abuse, medical professionals should be fluent in identifying differences between accidental and NAT. Using multiple imaging modalities, NAT in pediatric patients can be identified and treated adequately. [ABSTRACT FROM AUTHOR]

Hypernatremia is a frequent and potentially life-threatening condition in hospitalized patients. It is a disorder of water metabolism and is usually defined as a plasma sodium concentration above 145 mEq/L. The treatment of severe cases of hypernatremia might be challenging in patient with feeding jejunostomy. The average person’s GI tract secretes and reabsorbs around 7 L of gastrointestinal fluid (including 3-5 L originating above the pylorus alone). These 7 L of gastrointestinal fluid will significantly dilute whatever we consume or infuse. However, this dilution of enteral feed may be bypassed in by feeding jejunostomy. There are very few cases reported on extreme hypernatremia. We present a case of severe hypernatremia in patient with feeding-jejunostomy, managed successfully with the recommended correction.

Abstract Aims The effect of changes in serum sodium levels on the survival of patients with heart failure (HF) is unclear. We aimed to analyse the impact of serum sodium level trajectories on survival in intensive care unit (ICU) patients with HF. Methods A total of 4760 patients diagnosed with HF between 2001 and 2012 from the Medical Information Mart for Intensive Care III (MIMIC‐III) database were extracted. Of these patients, 1132 patients who died within 48 h of ICU admission were excluded, and 3628 patients were included in this retrospective cohort study. Sodium levels were measured at baseline, 6, 12, 18, 24, 30, 36, 42, and 48 h. Patients were divided into hyponatremia, normal, and hypernatremia groups based on baseline sodium levels, and trajectory modelling was performed for each group separately. Group‐based trajectory model (GBTM) method was utilized to identify serum sodium levels trajectories. Results The number of patients with hyponatremia (145 mmol/L) at baseline were 594 (16.37%), 2,738 (75.47%), and 296 (8.16%), respectively. A total of seven trajectory groups were identified, including hyponatremia‐slow rise group [initial levels (IL), 128.48 ± 5.42 mmol/L; end levels (EL), 131.23 ± 3.83 mmol/L], hyponatremia‐rapid rise to normal group (IL, 132.13 ± 2.18 mmol/L; EL, 137.46 ± 3.68 mmol/L), normal‐slow decline group (IL, 137.65 ± 2.15 mmol/L; EL, 134.50 ± 2.54 mmol/L), normal‐steady‐state group (IL, 139.20 ± 2.26 mmol/L; EL, 139.04 ± 2.58 mmol/L), normal‐slow rise group (IL, 140.94 ± 2.37 mmol/L; EL, 143.43 ± 2.89 mmol/L), hypernatremia‐rapid decline to normal group (IL, 146.31 ± 1.98 mmol/L; EL, 140.71 ± 3.61 mmol/L), and hypernatremia‐slow decline group (IL, 148.89 ± 5.54 mmol/L; EL, 146.28 ± 3.90 mmol/L). The results showed that hyponatremia‐slow rise group [hazard ratio (HR) = 1.35; 95% confidence interval (CI), 1.01–1.80, P = 0.040], hyponatremia‐rapid rise to normal group (HR = 1.37; 95% CI, 1.11–1.71, P = 0.004), hypernatremia‐rapid decline to normal group (HR = 1.46; 95% CI, 1.08–1.97, P = 0.014), and hypernatremia‐slow decline group (HR = 1.49; 95% CI, 1.07–2.07, P = 0.018) trajectories were associated with an increased risk of 1‐year mortality in HF patients compared with normal‐steady‐state group. After adjustment for all confounders, hyponatremia‐rapid rise to normal group (HR = 1.26, 95% CI; 1.01–1.57, P = 0.038) and hypernatremia‐rapid decline to normal group (HR = 1.36; 95% CI, 1.01–1.84, P = 0.047) trajectories were still related to an increased risk of 1‐year mortality in patients with HF. Conclusions Serum sodium level trajectories were associated with mortality in patients with HF. Association between serum sodium level trajectories and prognosis in patients with HF deserve further study.

Objective Hyponatremia and hypernatremia are common electrolyte disorders. Few studies to date have focused on patients presenting to the emergency department (ED) with sodium (Na) disorders. Our objective was to determine the incidence and outcomes of hyponatremia and hypernatremia in ED patients. Methods This study was a retrospective, single-center review of electronic medical records at an academic suburban ED with approximately 100,000 annual visits. Subjects included consecutive adult ED patients with Na levels measured while in the ED in 2019. Demographic, clinical, and laboratory data were recorded. Outcomes data, including hospital admission, intensive care unit (ICU) admission, mortality, and length of stay (LOS), were recorded. The primary outcome was inhospital death. Secondary outcomes were hospital admission, ICU admission, ED LOS, and hospital LOS. Univariable and multivariable linear and logistic regression analyses were performed to explore the association of candidate predictor variables and outcomes. Results Na was measured in 57,427 adults (54%) among a total of 106,764 assessed ED visits in 2019. The mean±standard deviation age was 54±21 years, and 47% of participants were male. Mild, moderate, and severe hyponatremia and hypernatremia occurred in 8%, 2%, and 0.1% of patients and 1%, 0.2%, and

Zhili Qi,1,&ast; Jiaqi Lu,2,&ast; Pei Liu,1 Tian Li,1 Ang Li,3 Meili Duan1 1Department of Critical Care Medicine, Capital Medical University, Beijing, People’s Republic of China; 2Department of Critical Care Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, People’s Republic of China; 3Beijing Ditan Hospital, Capital Medical University, Beijing, People’s Republic of China&ast;These authors contributed equally to the articleCorrespondence: Ang Li, Beijing Ditan Hospital, Capital Medical University, Beijing Ditan Hospital 8 Jing Shun East Street, Beijing, People’s Republic of China, Email liang@ccmu.edu.cn Meili Duan, Department of Critical Care Medicine, Beijing Friendship Hospital, Capital Medical University, No. 95 Yong’an Road, Xicheng District, Beijing, 10005, People’s Republic of China, Email dmeili@ccmu.edu.cnObjective: To investigate the value of hypernatremia in the intensive care unit (ICU) for the risk prediction of mortality in severe patients.Methods: Clinical data of critically ill patients admitted to the ICU of Beijing Friendship Hospital, were collected for retrospective analysis. Univariate and multivariate logistic regression analyses were employed to analyze the influencing factors. Nomograms predicting the mortality were constructed with R software and validated with repeated sampling.Results: A total of 442 cases were eligible for this study. Hypernatremia within 48 hours of ICU admission, change in sodium concentration (CNa+) within 48 hours, septic shock, APACHE II score, hyperlactatemia within 48 hours, use of continuous renal replacement therapy (CRRT) within 48 hours, and the use of mechanical ventilation (MV) within 48 hours of ICU admission were all identified as independent risk factors for death within 28 days of ICU admission. These predictors were included in a nomogram of 28-day mortality in severe patients, which was constructed using R software.Conclusion: The nomogram could predict the individualized risk of 28-day mortality based on the above factors. The model has better discrimination and accuracy and has high clinical application value.Keywords: intensive care unit, 28 day mortality, serum sodium, hypernatremia

The article presents a case study of a 57-year-old male with uncontrolled diabetes mellitus who developed central pontine myelinolysis (CPM) despite the absence of significant electrolyte disturbances. It states that the patient's condition, characterized by ataxia and dysarthria, improved significantly with proper glycemic control, highlighting the rare association between chronic hyperglycemia and CPM.

The article presents a case study of a 21-year-old man with cerebral palsy who experienced severe hypercalcaemia due to hypervitaminosis A. It highlights how this rare condition led to significant health issues, including acute kidney injury and nephrogenic diabetes insipidus, and emphasizes the need for careful monitoring of vitamin A levels to prevent such toxicity.

In hyperglycemia, the serum sodium concentration ([Na]S) receives influences from (a) the fluid exit from the intracellular compartment and thirst, which cause [Na]S decreases; (b) osmotic diuresis with sums of the urinary sodium plus potassium concentration lower than the baseline euglycemic [Na]S, which results in a [Na]S increase; and (c), in some cases, gains or losses of fluid, sodium, and potassium through the gastrointestinal tract, the respiratory tract, and the skin. Hyperglycemic patients with hypernatremia have large deficits of body water and usually hypovolemia and develop severe clinical manifestations and significant mortality. To assist with the correction of both the severe dehydration and the hypovolemia, we developed formulas computing the fractional losses of the body water and monovalent cations in hyperglycemia. The formulas estimate varying losses between patients with the same serum glucose concentration ([Glu]S) and [Na]S but with different sums of monovalent cation concentrations in the lost fluids. Among subjects with the same [Glu]S and [Na]S, those with higher monovalent cation concentrations in the fluids lost have higher fractional losses of body water. The sum of the monovalent cation concentrations in the lost fluids should be considered when computing the volume and composition of the fluid replacement for hyperglycemic syndromes.

Background: Sodium fluctuation is independently associated with clinical deterioration. We developed and validated a prognostic index based on sodium fluctuation for risk stratification and in-hospital monitoring. Methods: This study included 33,323 adult patients hospitalized at a tertiary care hospital in 2014. The first 28,279 hospitalizations were analyzed to develop the model and then the validity of the model was tested using data from 5044 subsequent hospitalizations. We predict in-hospital mortality using age, comorbidity, range of sodium fluctuation, and duration of sodium fluctuation, abbreviated as CARDS. Results: In-hospital mortality was similar in the derivation (0.6%) and validation (0.4%) cohorts. In the derivation cohort, four independent risk factors for mortality were identified using logistic regression: age (66–75, 2 points; >75, 3 points); Charlson comorbidity index (>2, 5 points); range of sodium fluctuation (7–10, 4 points; >10, 10 points); and duration of fluctuation (≤3, 3 points). The AUC was 0.907 (95% CI: 0.885–0.928) in the derivation cohort and 0.932 (95% CI: 0.895–0.970) in the validation cohort. In the derivation cohort, in-hospital mortality was 0.106% in the low-risk group (0–7 points), 1.076% in the intermediate-risk group (8–14 points), and 8.463% in the high-risk group (15–21 points). In the validation cohort, in-hospital mortality was 0.049% in the low-risk group, 1.064% in the intermediate-risk group, and 8.403% in the high-risk group. Conclusions: These results suggest that patients at low, intermediate, and high risk for in-hospital mortality may be identified by CARDS mainly based on sodium fluctuation.

Hyperchloremia and hypernatremia are associated with higher mortality in ischemic stroke, but it remains unclear whether their influence directly contributes to ischemic injury. We investigated the impact of 0.9% sodium chloride (154 mM NaCl), 0.9% sodium acetate (167 mM CH3COONa), and their different combinations (3:1, 2:1, and 1:1) on microglial (HMC-3) and neuronal (differentiated SH-SY5Y) survival during oxygen–glucose deprivation/reperfusion (OGD/R). Further, we assessed the effect of hyperchloremia and hypernatremia-treated and OGD/R-induced HMC-3-conditioned media on differentiated SH-SY5Y cells under OGD/R conditions. We performed cell viability, cell toxicity, and nitric oxide (NO) release assays and studied the alteration in expression of caspase-1 and caspase-3 in different cell lines when exposed to hyperchloremia and hypernatremia. Cell survival was decreased in 0.9% NaCl, 0.9% CH3COONa, combinations of HMC-3 and differentiated SH-SY5Y, and differentiated SH-SY5Y cells challenged with HMC-3-conditioned media under normal and OGD/R conditions. Under OGD/R conditions, differentiated SH-SY5Y cells were less likely to survive exposure to 0.9% NaCl. Expression of caspase-1 and caspase-3 in HMC-3 and differentiated SH-SY5Y cells was altered when exposed to 0.9% NaCl, 0.9% CH3COONa, and their combinations. A total of 0.9% NaCl and 0.9% CH3COONa and their combinations decreased the NO production in HMC-3 cells under normal and OGD/R conditions. Both hypernatremia and hyperchloremia reduced the survival of HMC-3 and differentiated SH-SY5Y cells under OGD/R conditions. Based on the OGD/R in vitro model that mimics human ischemic stroke conditions, it possibly provides a link for the increased death associated with hyperchloremia or hypernatremia in stroke patients.

Introduction. Acute diarrhea caused by group A rotavirus (RVA) is a leading cause of morbidity and mortality globally in children less than 5 years old. Acute diarrhea caused by RVA is often manifested by loose/watery stool leading to different degrees of dehydration. The detection of risk factors, diagnosis, and prompt treatment of acute diarrhea caused by RVA is critical. We aimed to describe clinical epidemiological features of acute diarrhea caused by RVA and its associated risk factors. Subjects and Method. We conducted a cross-sectional study that included 321 children under 5 years old with acute diarrhea at Haiphong Children's Hospital, Vietnam, from 1 August 2019 to 31 July 2020. Results. Among the 321 children included in our analysis, 221 (68.8%) children were positive for RVA. Males represented 61.1% of cases, 41.2% of children were in the 12-<24-month age group, and the majority of cases were among children in suburban areas (71.5%). Clinical manifestations included loose and watery stool (100%), vomiting-fever-loose/watery stool (57.9%), vomiting-loose/watery stool (83.2%), fever-loose/watery stool (58.8%), dehydration (30%), hyponatremia (22.1%), hypernatremia (1.4%), and hypokalemia (15%). Risk factors for acute diarrhea caused by RVA included history of diarrhea, not exclusive breastfeeding in the first 6 months, living area, maternal education, and income. Conclusions. Acute diarrhea due to RVA was very prevalent in children under 5 years old. Clinical manifestations included a high prevalence of loose/watery stools/day and dehydration with electrolyte disorder. Mothers should exclusively breastfeed their children for the first 6 months to avoid the risk of acute diarrhea caused by RVA. [ABSTRACT FROM AUTHOR]

COVID-19 may induce short- and long-term cognitive failures after recovery, but the underlying risk factors are still controversial. Here, we investigated whether (i) the odds of experiencing persistent cognitive failures differ based on the patients' disease course severity and sex at birth; and (ii) the patients' electrolytic profile in the acute stage represents a risk factor for persistent cognitive failures. We analysed data from 204 patients suffering from COVID-19 and hospitalised during the first pandemic wave. According to the 7-point WHO-OS scale, their disease course was classified as severe or mild. We investigated the presence of persistent cognitive failures collected after hospital discharge, while electrolyte profiles were collected during hospitalisation. The results showed that females who suffered from a mild course compared to a severe course of COVID-19 had a higher risk of presenting with persistent mental fatigue after recovery. Furthermore, in females who suffered from a mild course of COVID-19, persistent mental fatigue was related to electrolyte imbalance, in terms of both hypo- and hypernatremia, during hospitalisation in the acute phase. These findings have important implications for the clinical management of hospitalised COVID-19 patients. Attention should be paid to potential electrolyte imbalances, mainly in females suffering from mild COVID-19. [ABSTRACT FROM AUTHOR]

Background: Multi-chamber bag with electrolytes (MCB-E) parenteral nutrition (PN) formulations are gaining acceptance for nutritional support for safety and economic advantages. However, their use is hampered by serum electrolyte abnormalities. No data exist regarding MCB-E PN interruption due to high serum electrolyte levels. We assessed the rate of MCB-E PN discontinuation in surgical patients secondary to persistently high serum electrolyte levels. Methods: This prospective, cohort study included surgical patients (aged ≥18 years) who received MCB-E PN at King Faisal Specialist Hospital and Research Centre-Riyadh, from February 28, 2020, until August 30, 2021. Patients were followed for 30-day for the discontinuation of MCB-E PN secondary to persistent hyperphosphatemia, hyperkalemia, hypermagnesemia, or hypernatremia for two consecutive days. The association of discontinuing MCB-E PN with various factors was assessed using univariable and multivariable Poisson regression analysis. Results: Seventy-two patients were enrolled in the study, 55 (76.4%) completed MCB-E PN, whereas 17 (23.6%) patients discontinued MCB-E PN due to a persistent hyperphosphatemia (n = 13, 18%) and persistent hyperkalemia (n = 4, 5.5%). Hyperphosphatemia and hyperkalemia were observed at a median of 9 (IQR 6-15) days and 9.5 (IQR 7-12) days of MCB-E PN support, respectively. According to adjusted multivariable analysis, developing an episode of hyperphosphatemia or hyperkalemia was associated with MCB-E PN discontinuation (RR 6.62, 1.95-22.49; P =.002) and (RR 4.73, 1.30-17.24; P =.018), respectively. Conclusion: In surgical patients receiving short-term MCB-E PN, developing hyperphosphatemia was the most frequent high electrolyte abnormality assocaited with MCB-E PN discontinuation, followed by hyperkalemia. [ABSTRACT FROM AUTHOR]

Aim: To explore the relationship between the serum sodium level on admission and all‐cause mortality in HF patients. Design: A single‐center retrospective cohort study. Methods: Patients hospitalized with HF at the Heart Failure Center, Fuwai Hospital, from November 2008 to November 2018 were enrolled. Results: A total of 3649 patients were included, and the mean sodium level was 137.19 ± 4.36 mmol/L, with a range from 115.6 to 160.9 mmol/L. During a median follow‐up of 1101 days, mortality occurred in 1413 (38.7%) hospital survivors. After adjustment for age, sex, and other potential confounders, patients with sodium levels <135 mmol/L (hazard ratio [HR]: 1.67; 95% confidence interval [CI]: 1.29–2.16) and 135–137 mmol/L (HR: 1.34; 95% CI: 1.01–1.78) had an increased risk of all‐cause mortality compared to those with sodium levels of 139–141 mmol/L. [ABSTRACT FROM AUTHOR]

Disturbances in serum sodium concentration (dysnatremia) are common following aneurysmal subarachnoid hemorrhage (aSAH), but its direct impact on outcomes is not well understood. This study aimed to examine the association between dysnatremia following aSAH and patient outcomes. A retrospective cohort study of consecutive patients with aSAH who were admitted to an academic referral center between 2015 and 2021 was performed. Multivariate logistic regression was used to test the association of dysnatremia and outcomes including modified Rankin Scale score at 3 months after discharge and vasospasm. Multiple linear regression was used to test the association of hospital length of stay and dysnatremia. We included 320 patients with confirmed aneurysmal etiology (mean [SD] age = 57.8 [14.3] years; 61% female; 70% White). No independent associations were found between hyponatremia or hypernatremia and functional outcome or vasospasm. However, hospital length of stay was longer in patients with hypernatremia (7 more days; 95% confidence interval = 4.4–9.6, P < 0.001) independent of age, Hunt and Hess grade, modified Fisher score, delayed cerebral ischemia, and other hospital complications. Although dysnatremia may not directly impact functional outcome or vasospasm risk, hypernatremia may prolong hospital length of stay. Judicious use of hypertonic saline solutions and avoidance of unnecessary dysnatremia in patients with aSAH should be considered. [ABSTRACT FROM AUTHOR]

Objective: The present study aimed to investigate the clinical characteristics of electrolyte imbalance in patients with moderate to severe traumatic brain injury (TBI) who underwent craniotomy and its influence on prognosis. Methods: A total of 156 patients with moderate to severe TBI were prospectively collected from June 2019 to June 2021. All patients underwent craniotomy and intracranial pressure (ICP) monitoring. We aimed to explore the clinical characteristics of electrolyte disturbance and to analyze the influence of electrolyte disturbance on prognosis. Results: A total of 156 patients with moderate and severe TBI were included. There were 57 cases of hypernatremia, accounting for 36.538%, with the average level of 155.788±7.686 mmol/L, which occurred 2.2±0.3 days after injury. There were 25 cases of hyponatremia, accounting for 16.026%, with the average level of 131.204±3.708 mmol/L, which occurred 10.2±3.3 days after injury. There were three cases of hyperkalemia, accounting for 1.923%, with the average level of 7.140±1.297 mmol/L, which occurred 5.3±0.2 days after injury. There were 75 cases of hypokalemia, accounting for 48.077%, with the average level of 3.071±0.302 mmol/L, which occurred 1.8±0.6 days after injury. There were 105 cases of hypocalcemia, accounting for 67.308%, with the average level of 1.846±0.104 mmol/L, which occurred 1.6±0.2 days after injury. There were 17 cases of hypermagnesemia, accounting for 10.897%, with the average level of 1.213±0.426 mmol/L, which occurred 1.8±0.5 days after injury. There were 99 cases of hypomagnesemia, accounting for 63.462%, with the average level of 0.652±0.061 mmol/L, which occurred 1.3±0.4 days after injury. Univariate regression analysis revealed that age, Glasgow coma scale (GCS) score at admission, pupil changes, ICP, hypernatremia, hypocalcemia, hypernatremia combined with hypocalcemia, epilepsy, cerebral infarction, severe hypoproteinemia were statistically abnormal (p<0.05), while gender, hyponatremia, potassium, magnesium, intracranial infection, pneumonia, allogeneic blood transfusion, hypertension, diabetes, abnormal liver function, and abnormal renal function were not statistically significant (p>0.05). After adjusting gender, age, GCS, pupil changes, ICP, epilepsy, cerebral infarction, severe hypoproteinemia, multivariate logistic regression analysis revealed that hypernatremia or hypocalcemia was not statistically significant, while hypernatremia combined with hypocalcemia was statistically significant (p<0.05). Conclusion: The incidence of hypocalcemia was the highest, followed by hypomagnesemia, hypokalemia, hypernatremia, hyponatremia and hypermagnesemia. Hypocalcemia, hypomagnesemia, and hypokalemia generally occurred in the early post-TBI period, hypernatremia occurred in the peak period of ICP, and hyponatremia mostly occurred in the late period after decreased ICP. Hypernatremia combined with hypocalcemia was associated with prognosis. [ABSTRACT FROM AUTHOR]

The number of elderly patients with acute decompensated heart failure (ADHF) is increasing, and it is often difficult to treat. This study aimed to evaluate the efficacy and safety of using tolvaptan early after hospitalization in elderly patients with ADHF and the prognosis one year after hospitalization. This study enrolled 185 patients with ADHF who were admitted for the first time. Tolvaptan was administered within 24 h after admission. These patients were assigned to two groups: over 80 years old (n = 109) and under 80 years old (n = 76). There were no significant differences between the two groups in the occurrence of MACCE within one year (25% vs. 20%, p = 0.59). All-cause mortality was significantly higher in the over-80 group (12% vs. 2%, p = 0.01). There were no significant differences in the incidence of worsening renal failure (11% vs. 7%, p = 0.46) and hypernatremia (5% vs. 9%, p = 1.0), and in the duration of hospitalization (19.2 days vs. 18.8 days, p = 0.8). Tolvaptan might be effective and safe in elderly patients with ADHF, and there was no difference in the incidence of MACCE within one year. [ABSTRACT FROM AUTHOR]

Background: sodium disorders are the most common and least understood in patients with acute brain injury due to the major role played by the central nervous system in regulating sodium and water homeostasis, which can lead to serious complications and adverse outcomes, including death. Objective: to determine the hypernatremia contribution to mortality in patients with neurological conditions in critical state. Methods: longitudinal analytical observational study on 55 patients who were admitted to the acute care units at the Arnaldo Milián Castro University Hospital, between October 2020 and May 2022, regardless of the plasma sodium value upon admission to the service, as well as during their stay in the critical care units. Univariate and bivariate statistical methods were used in data analysis. Results: the average age was 60 ± 16 years. The most relevant diagnoses were intraparenchymal hemorrhage (56.37%), head trauma, and ischemic stroke (both 30%). Plasma sodium concentrations showed significant differences (pX2= 0.000), with the highest average at 24 hours of admission (174.2 ± 133.6) and the lowest at the 5th day (102.9 ± 72.9). There was a significant correlation between plasma sodium concentrations at admission, 24h and 72h with the state at discharge. In the individual bivariate analysis by period, there was only a significant relationship after 24 hours. In this period, hypernatremia contributed 1.78 times more to mortality than in those who did not have elevated sodium (OR=1.78 with CI: 1,39-3,4). Conclusions: hypernatremia in critically ill patients with neurological conditions is associated with increased mortality. [ABSTRACT FROM AUTHOR]

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There have been recent advances assessing copeptin levels in adults with suspected disorders of vasopressin release. Very limited data exits on copeptin levels in children and infants, especially in a critically-ill hospitalized population where hyper- and hypo-natremia are very common. Our objective is to describe the institutional experience assessing copeptin levels in hospitalized infants and children with hyper- or hypo-natremia. We performed a single-center retrospective case series of all infants, children, and adolescents who had an ultrasensitive plasma copeptin level obtained between 2019-2021. A total of 29 critically ill patients (6 infants) were identified with 38 % of patients having copeptin levels after neurosurgical procedures for tumors or trauma. Approximately 13/17 children with hypernatremia had central diabetes insipidus (central diabetes insipidus) to diagnose CDI, A copeptin level ≤ 4.9 pmol/L resulted in an 88 % sensitivity (95 % CI 47–99 %), and 66 % specificity (95 % CI 30–93 %). Amongst those with hyponatremia levels were more variable, 8/12 children had syndrome of inappropriate antidiuresis (SIAD) with copeptin levels ranging 4.7–72.6 pmol/L. While difficult to conclude due to multiple limitations, this case series highlights that typical copeptin cutoffs used to diagnose DI in adults in an ambulatory setting may also translate to a critically-ill pediatric population. Large prospective studies are needed to confirm this observation. In addition, postoperative copeptin levels could potentially be utilized as an additional marker to predict permanent from transient DI, but much larger studies are needed. Further work is needed to establish normative copeptin levels in infants and patients with SIAD. [ABSTRACT FROM AUTHOR]

Background: Sodium imbalance is one of the most common electrolyte disturbances encountered in the medical practice, and it may present with either hyponatremia or hypernatremia. Both sodium abnormalities are related with unfavorable outcomes. Objective: Elucidation of the prevalence of dysnatremia among COVID-19 patients and its impact on 30- and 90-day mortality and need for ICU admission was the goal. Design and participants: A single-center, retrospective, observational study was conducted. A total of 2026 adult, SARS-CoV-2 positive patients, admitted to Wroclaw University Hospital between 02.2020 and 06.2021, were included. On admission, patients were divided into groups: normonatremic (N), hyponatremic (L), and hypernatremic (H). Acquired data was processed, and Cox hazards regression and logistic regression were implemented. Key results: Hyponatremia on admission occurred in 17.47% (n = 354) of patients and hypernatremia occurred in 5.03% (n = 102). Dysnatremic patients presented with more comorbidities, used more drugs, and were statistically more often admitted to the ICU. Level of consciousness was the strongest predictor of ICU admission (OR = 1.21, CI: 1.16–1.27, p < 0.001). Thirty-day mortality was significantly higher in both the L and H groups (28.52%, p = 0.0001 and 47.95%, p < 0.0001, respectively), in comparison to 17.67% in the N group. Ninety-day mortality showed a similar trend in all study groups: 34.37% in the L group (p = 0.0001), 60.27% (p < 0.0001) in the H group, and 23.32% in the N group. In multivariable analyses, hypo- and hypernatremia were found to be independent predictors of 30- and 90-day mortality. Conclusions: Both hypo- and hypernatremia are strong predictors of mortality and disease severity in COVID-19 patients. Extraordinary care should be taken when dealing with hypernatremic, COVID-positive patients, as this group exhibits the highest mortality rates. [ABSTRACT FROM AUTHOR]

Backgrounds: To investigate the relationship between obesity and 30-day mortality in a cohort of older hospitalized COVID-19 inpatients. Methods: Included patients were aged 70 years or more; hospitalized in acute geriatric wards between March and December 2020; with a positive PCR for COVID-19; not candidate to intensive care unit admission. Clinical data were collected from patients electronic medical records. Data on 30-day mortality were retrieved from the hospital administrative database. Results: Patients included (N = 294) were on average 83.4 ± 6.7 years old, 50.7% were women, and 21.7% were obese (BMI > 30 kg/m2). At 30-day, 85 (28.9%) patients were deceased. Compared to survivors in bivariable analysis, deceased patients were older (84.6 ± 7.6 vs 83.0 ± 6.3 years), more frequently with very complex health status (63.5% vs 39.7%, P <.001), but less frequently obese (13.4% vs 24.9%, P =.033) at admission. Over their stay, deceased patients more frequently (all P <.001) developed radiologic signs of COVID-19 (84.7% vs 58.9%), anorexia (84.7% vs 59.8%), hypernatremia (40.0% vs 10.5%), delirium (74.1% vs 30.1%), and need for oxygen (87.1% vs 46.4%) compared to survivors. In multivariable analysis that controlled for all markers of poor prognosis identified in bivariable analysis, obese patients remain with 64% (adjOR 0.36, 95%CI 0.14–0.95, P =.038) lower odds to be deceased at 30-day than non-obese patients. Conclusions: In this population of older COVID-19 inpatients, an inverse association between obesity and 30-day mortality was observed even after adjusting for all already-known markers of poor prognosis. This result challenges previous observations in younger cohorts and would need to be replicated. [ABSTRACT FROM AUTHOR]

Introduction: Sodium levels should be between 135 and 145mEq/L. A cell's ability to maintain homeostasis is necessary for proper operation. An imbalance in the body's general water control may be the cause of abnormal sodium levels. High sodium levels caused by irregular water balance are present in chronic liver illness that is not yet fully reversible. Aims: To assess the correlation among serum sodium imbalance and prognosis in decompensated liver disease patients and its clinical relevance. Materials and Methods: It was a prospective hospital based observational study of 75 patients with biochemical and clinical evidence of chronic liver disease (CLD), who were admitted in the medical ward of Katihar Medical College, Katihar, since December 2020 to May 2022. Result: In present study, 69 (92%) patients were alcoholic, 1 (1.33%) had HCV, 5 (6.67%) had HBV, and none had primary biliary cirrhosis, cryptogenic cirrhosis, and autoimmune hepatitis. There was abdominal distension in 75 patients (100%), jaundice in 22 (29.33%), lower limb swelling in 75 (100%), GI bleed in 19 (25.33%), and altered sensorium in 15 patients (20%). Conclusion: It has been shown that low serum sodium is a poor prognostic marker and increases the risk of early mortality. The few available treatments for hyponatremia currently consist of appropriate free water restriction, stopping diuretics, and may be short-term vaptan (eg; Tolvaptan) usage. [ABSTRACT FROM AUTHOR]

Changes in serum sodium concentrations are frequently encountered by anesthesiologists, are complex and are often inadequately treated. Feared consequences include neurological complications, such as cerebral hemorrhage, cerebral edema and coma. Dysnatremia is always accompanied disturbances in the water balance. Accordingly, these are routinely classified based on the tonicity; however, in the daily routine and especially in the acute setting, the volume status and extracellular volume are often difficult to assess. Severe symptomatic hyponatremia with impending cerebral edema is treated by administration of hypertonic saline solution. If the rise in serum sodium is too rapid, there is a risk of central pontine myelinolysis. In a second step, the cause of the hyponatremia can be investigated and the appropriate treatment can be initiated. In the case of hypernatremia, the etiology of the disorder must be clarified before treatment. The goal is to compensate for the water deficiency by correcting the cause, specific volume therapy and, if necessary, drug support. A slow and controlled compensation must be closely monitored in order to avoid neurological complications. An algorithm has been developed that provides an overview of the dysnatremias, aids with making the diagnosis and gives recommendations for treatment measures in the clinical routine. [ABSTRACT FROM AUTHOR]

Introduction: Ichthyosis is an epidermal disruption that increases insensible water loss. Hypernatremic dehydration is a consequence of skin disruption. This study reviewed the treatment of hypernatremic dehydration in patients with ichthyosis comparing to patients with intact skin. Case Presentation: We studied five neonates with hypernatremia, including three ichthyosis cases and two normal-skin neonates. This case-series study showed that the sodium correction rate is slower in infants with ichthyosis than in infants with normal skin. The first and second neonates needed less sodium than fluid intake than normal skin infants, although fluid requirement was lower in the third ichthyosis infant than in others due to less skin disruption in this infant. Conclusions: Fluid therapy in hypernatremic dehydration in ichthyosis patients is different from neonates with intact skin because of excessive insensible water loss in these patients. It may be needed to give more fluid and less sodium depending on the degree of skin disruption, which may not be determined by physical examination. [ABSTRACT FROM AUTHOR]

Serum osmolality is the sum of the osmolalities of every single dissolved particle in the blood such as sodium and associated anions, potassium, glucose, and urea. Under normal conditions, serum sodium concentration is the major determinant of serum osmolality. Effective blood osmolality, so-called blood tonicity, is created by the endogenous (e.g., sodium and glucose) and exogenous (e.g., mannitol) solutes that are capable of creating an osmotic gradient across the membranes. In case of change in effective blood osmolality, water shifts from the compartment with low osmolality into the compartment with high osmolarity in order to restore serum osmolality. The difference between measured osmolality and calculated osmolarity forms the osmolal gap. An increase in serum osmolal gap can stem from the presence of solutes that are not included in the osmolarity calculation, such as hypertonic treatments or toxic alcoholic ingestions. In clinical practice, determination of serum osmolality and osmolal gap is important in the diagnosis of disorders related to sodium, glucose and water balance, kidney diseases, and small molecule poisonings. As blood hypertonicity exerts its main effects on the brain cells, neurologic symptoms varying from mild neurologic signs and symptoms to life-threatening outcomes such as convulsions or even death may occur. Therefore, hypertonic states should be promptly diagnosed and cautiously managed. In this review, the causes and treatment strategies of hyperosmolar conditions including hypernatremia, diabetic ketoacidosis, hyperglycemic hyperosmolar syndrome, hypertonic treatments, or intoxications are discussed in detail to increase awareness of this important topic with significant clinical consequences. [ABSTRACT FROM AUTHOR]

Background: Acute gastroenteritis is one of the common causes for which pediatric patients are admitted. The present study was conducted to assess clinical profile and pattern of water and sodium disturbances in children suffering from diarrhoea with dehydration. Materials & Methods: 110 children of age 6 months to 5 years admitted in Pediatric ward with diarrhoea with dehydration of both genders were selected. Children were managed as per standard WHO protocol, adequately hydrated and serum electrolytes were repeated as and when required. Hyponatremia was defined as serum sodium 145 meq/L. Results: The mean serum sodium level at admission was 135.6mEq/L, duration of diarrhoea was 14.2days, number of loose stools per day was 11.5, duration of vomiting episodes was 2.9 days, number of vomiting episodes per day was 3.4 and duration of hospital stay was 3.8days. Hyponatremia was seen in 14 male and 16 females. Hypernatremia in 16 males and 9 females and isonatremia in 37 males and 18 females. Age group 6 months- 1 year had 10, 10 and 20 and 1 year- 5 years had 20, 15 and 35. Nutritional status was normal seen in 16, 12 and 22, grade I PEM in 6, 4 and 5, grade II PEM in 4, 5 and 4, grade III PEM in 3, 3 and 2 and grade IV PEM in 2, 1 and 2 having hyponatremia, hypernatremia and isonatremia respectively. The difference was significant (P< 0.05). Conclusion: The incidence of hyponatremia and hypernatremia in children is quite high (nearly 40%). Malnourished children and children taking improperly diluted WHO ORS were at a significantly higher risk of developing hyponatremia or hypernatremia. [ABSTRACT FROM AUTHOR]

Background: Salt-sensitive hypertension in humans and experimental models is associated with higher plasma and cerebrospinal fluid sodium chloride (NaCl) concentrations. Changes in extracellular NaCl concentrations are sensed by specialized neurons in the organum vasculosum of the lamina terminalis (OVLT). Stimulation of OVLT neurons increases sympathetic nerve activity (SNA) and arterial blood pressure (ABP), whereas chronic activation produces hypertension. Therefore, the present study tested whether OVLT neuronal activity was elevated and contributed to SNA and ABP in salt-sensitive hypertension. Methods: Male Dahl salt-sensitive (Dahl S) and Dahl salt-resistant (Dahl R) rats were fed 0.1% or 4.0% NaCl diets for 3 to 4 weeks and used for single-unit recordings of OVLT neurons or simultaneous recording of multiple sympathetic nerves during pharmacological inhibition of the OVLT. Results: Plasma and cerebrospinal fluid Na+ and Cl− concentrations were higher in Dahl S rats fed 4% versus 0.1% or Dahl R rats fed either diet. In vivo single-unit recordings revealed a significantly higher discharge of NaCl-responsive OVLT neurons in Dahl S rats fed 4% versus 0.1% or Dahl R rats. Interestingly, intracarotid infusion of hypertonic NaCl evoked greater increases in OVLT neuronal discharge of Dahl S versus Dahl R rats regardless of NaCl diet. The activity of non–NaCl-responsive OVLT neurons was not different across strain or diets. Finally, inhibition of OVLT neurons by local injection of the gamma-aminobutyric acid agonist muscimol produced a greater decrease in renal SNA, splanchnic SNA, and ABP of Dahl S rats fed 4% versus 0.1% or Dahl R rats. Conclusions: A high salt diet activates NaCl-responsive OVLT neurons to increase SNA and ABP in salt-sensitive hypertension. [ABSTRACT FROM AUTHOR]

This study was performed to assess the effect of baseline Preoperative Laboratory Values (PLV) on post-operative Brain Tumor Resection (BTR) outcomes in a large national registry. We extracted data from the National Surgical Quality Improvement Program (NSQIP) database for BTR patients 2015–2019 (n = 3 0,951). Uni- and multivariate analyses were performed for PLV and key surgical outcomes. The most significant PLV predictors of 30-day mortality after BTR included hypernatremia (odds ratio, OR 4.184, 95% CI, 2.384–7.343, p < 0.001), high serum creatinine (OR 2.244, 95% CI 1.502–3.352, p < 0.001), thrombocytopenia (OR 1.997, 95% CI 1.438, 2.772, p < 0.001), and leukocytosis (OR 1.635, 95% CI 1.264, 2.116, p < 0.001). The most significant predictors of Clavien IV complications were increased INR (OR 2.653, 95% CI 1.444, 4.875, p < 0.01), thrombocytopenia (OR 1.514, 95% CI 1.280, 1.792, p < 0.001), hypoalbuminemia (OR 1.480, 95% CI 1.274, 1.719, p < 0.001), and leukocytosis (OR 1.467, 95% CI 1.306, 1.647, p < 0.001). The most robust predictors of eLOS were increased INR (OR 1.941, 95% CI 1.231, 3.060, p < 0.01) and hypoalbuminemia (OR 1.993, 95% CI 1.823, 2.179, p < 0.001), and those for non-routine discharge included increased INR (OR 1.897, 95% CI 1.196, 3.008, p < 0.01) and hypernatremia (OR 1.565, 95% CI 1.217, 2.012, p < 0.001). Several PLV independently predicted worse outcomes in BTR patients. Baseline labs should be routinely used for the pre-operative risk stratification of these patients. [ABSTRACT FROM AUTHOR]

All other usual causes of encephalitis had been ruled out by Film Array® Meningitis/Encephalitis panel (Biofire Diagnostics) and additional testing for Japanese encephalitis virus, West nile virus, and Nipah virus (Table 1). The world has witnessed the emergence of mpox virus (mpoxv) from multiple countries in 2022.[1] The mpox case fatality rate of 3%-6%[2] is far lower than smallpox (30%).[3] Till now, India has reported 25 confirmed mpox cases from Kerala ( I n i = 10) and New Delhi ( I n i = 15) during July 2022 to February 2023.[[4]] Here, we report the first fatal mpox case imported from UAE to Kerala, India. [Extracted from the article]

Hypernatremia (>145 mmol/L) is a relatively rare event, and the data regarding its role in the outcome of inpatients on an oncology ward are weak. The aim of this study was to describe the prevalence, prognosis, and outcome of hospitalized cancer patients with hypernatremia. We performed a retrospective case-control study of data obtained from inpatients with a solid tumor at the St. Claraspital, Basel, Switzerland, who were admitted between 2017 and 2020. The primary endpoint was overall survival. Hypernatremia was found in 93 (3.16%) of 2945 inpatients bearing cancer or lymphoma. From 991 eligible normonatremic control patients, 93 were matched according to diagnosis, age, and sex. The median overall survival time (OS) of patients with hypernatremia was 1.5 months compared to 11.7 months of the normonatremic controls (HR 2.69, 95% CI 1.85–3.90, p < 0.0001). OS of patients with irreversible compared to reversible hypernatremia was significantly shorter (23 versus 88 days, HR 4.0, 95% CI 2.04–7.70, p < 0.0001). The length of hospital stay was significantly longer for the hypernatremic than for the normonatremic group (p < 0.0001). Significantly more patients with hypernatremia died in the hospital (30.1% versus 8.6%, p < 0.001). These results suggest hypernatremia to be associated with an unfavorable outcome and a very short OS.

Jiaqi Lu,1 Zhili Qi,2 Jingyuan Liu,1 Pei Liu,2 Tian Li,2 Meili Duan,2 Ang Li3 1Department of Critical Care Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, People’s Republic of China; 2Department of Critical Care Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China; 3Beijing Ditan Hospital, Capital Medical University, Beijing, People’s Republic of ChinaCorrespondence: Meili Duan, Department of Critical Care Medicine, Beijing Friendship Hospital, Capital Medical University, No. 95 Yong’an Road, Xicheng District, Beijing, 10005, People’s Republic of China, Email dmeili@ccmu.edu.cn Ang Li, Beijing Ditan Hospital, Capital Medical University, #8 Jing Shun East St, Chaoyang, Beijing, 100015, People’s Republic of China, Email liang@ccmu.edu.cnPurpose: This study aims to investigate the effect of serum chloride and sodium ions on AKI occurrence in ICU patients, and further constructs a prediction model containing these factors to explore the predictive value of these ions in AKI.Methods: The clinical information of patients admitted to ICU of Beijing Friendship Hospital Affiliated to Capital Medical University was collected for retrospective analysis. Logistic regression analysis was used to analyzing the influencing factors. A nomogram for predicting AKI risk was constructed with R software and validated by repeated sampling. Afterwards, the effectiveness and accuracy of the model were tested and evaluated.Results: A total of 446 cases met the requirements of this study, of which 178 developed AKI during their stay in ICU, with an incidence rate of 39.9%. Hypernatremia, heart failure, sepsis, APACHE II score, and initial creatinine value and BE value at ICU admission before the diagnosis of AKI were identified as independent risk factors for developing AKI during ICU stay. These predictors were incorporated into the nomogram of AKI risk in critically ill patients, which was constructed by using R software. Receiver operating characteristic curve analysis was further used and showed that the area under the curve of the model was 0.7934 (95% CI 0.742– 0.8447), indicating that the model had an ideal value. Finally, further evaluated its clinical effectiveness. The clinical effect curve and decision curve showed that most areas of the decision curve of this model were greater than 0, indicating that this model owned a certain clinical effectiveness.Conclusion: The nomogram based on hypernatremia, heart failure, sepsis, APACHE II score, and initial creatinine and BE value in ICU can predict the individualized risk of AKI with satisfactory distinguishability and accuracy.Keywords: intensive care unit, acute kidney injury, hypernatremia, hyperchloremia

Abstract Introduction Gangrene is the death of an organ or tissue due to lack of blood supply or bacterial infection. In neonates, gangrene is usually caused by sepsis, dehydration, maternal diabetes, asphyxia, or congenital anticoagulant deficiency. It commonly occurs in the extremities. Gangrene may lead to death or amputation of the limb. Early diagnosis and prompt management of the underlying cause halts the progression of the disease. Case presentation A 12-day-old neonate presented with a complaint of black discoloration of the nose and feet for 2 days. He was breastfeeding poorly and had signs of dehydration. Upon physical examination, he was tachycardic (pulse rate = 182 beats per minute), tachypneic (respiratory rate = 62 breaths per minute), and hypothermic (temperature = 35.0 oC). He lost 33.3% of his birth weight. He had demarcated cold, dry, and dark discoloration of the entire nose, nasal septum; upper lip; palate; bilateral distal lower limbs; and the left fifth finger. Dorsalis pedis arteries were not palpable on either side. On investigation, the baby had pancytopenia, hypernatremia, elevated creatinine, elevated coagulation profiles, and absent arterial flow in bilateral dorsal pedis arteries. He was treated for hypernatremic dehydration and possible sepsis. He was transfused with whole blood, platelets, and fresh frozen plasma, but finally, the patient passed away on the 7th day of admission. Conclusion The entire nose, upper lip, soft and hard palate, symmetric lower limb, and fifth finger gangrene due to severe hypernatremic dehydration complicated by disseminated intravascular coagulation may occur in the same patient. To avoid such serious neonatal problems, mothers should be properly educated about optimal breastfeeding techniques and schedule well-child visits 3–5 days after birth.