Further Outpatient Care
See the list below:
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The outpatient follow-up care of these patients is individualized, depending on the endocrine problem under treatment and the patient's metabolic stability.
Further Inpatient Care
See the list below:
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The clinical response of the patient after treatment has been instituted is the most important factor in determining the necessity of additional treatment. Follow-up endocrine studies (ie, hormonal levels) are necessary at least weekly until homeostasis has been achieved. Serum electrolytes, BUN, and creatinine levels need to be assessed at least daily until normalized, and then these levels should be monitored at routine intervals.
Inpatient & Outpatient Medications
See the list below:
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As stated previously, medication management consists primarily of hormone replacement until clinical response and normal serum levels have been achieved. In most cases, the HRT continues on a long-term outpatient basis. Most inpatients with associated electrolyte disorders are stabilized with intravenous electrolyte therapy before hospital discharge, and no further medication management is necessary.
Deterrence
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No deterrence/prevention program exists for endocrine complications following traumatic brain injury (TBI). Early recognition of these problems through a high index of suspicion, close monitoring of serum electrolyte balance, and prompt corrective treatment minimizes any negative impact these complications have on the rehabilitation outcome.
Complications
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The most significant complication is failure to recognize these treatable endocrine complications, ultimately prolonging the rehabilitation program and decreasing the patient's functional outcome following traumatic brain injury (TBI).
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Osmotic demyelination of the CNS, caused by an excessively rapid correction of hyponatremia with IV hypertonic saline, is an unusual complication of TBI, albeit a serious and sometimes lethal one.
Prognosis
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The prognosis for the patient with endocrine complications following traumatic brain injury (TBI) is good to excellent, assuming these sometimes subtle problems are diagnosed and treated promptly. Failure to recognize and treat these problems negatively affects the rehabilitation progress and eventually the long-term functional outcome. [24, 25]
Patient Education
See the list below:
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Depending on the level of patient cognitive impairment, the patient and his or her caregivers/guardians are advised to be aware of any changes exhibited by the patients, such as unexplained patient lethargy, decreased tolerance to activity, or cold intolerance. These particular problems require immediate notification of the attending physician. The patient should undergo physician reevaluation and, if necessary, an endocrine workup. Rapid corrective hormonal replacement therapy then can be initiated and monitored at a follow-up session with the treating physician.
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For excellent patient education resources, visit eMedicineHealth's Thyroid and Metabolism Center. Also, see eMedicineHealth's patient education article Anatomy of the Endocrine System.
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Effects of hyponatremia on the brain and adaptive responses. Within minutes after the development of hypotonicity, water gain causes swelling of the brain and a decrease in osmolality of the brain. Partial restoration of brain volume occurs within a few hours as a result of cellular loss of electrolytes (rapid adaptation). The normalization of brain volume is completed within several days through loss of organic osmolytes from brain cells (slow adaptation). Low osmolality in the brain persists despite the normalization of brain volume. Proper correction of hypotonicity reestablishes normal osmolality without risking damage to the brain. Overly aggressive correction of hyponatremia can lead to irreversible brain damage.
Tables
Formula* |
|
Clinical Use |
Change in serum Na+ = |
Infusate Na+ — serum Na+ —————————— total body water +1 |
Estimate the effect of 1 L on any infusate serum Na+ |
Change in serum Na+ = |
(Infusate Na+ + infusate K+)—serum Na+ ———————————————— total body water +1 |
Estimate the effect of 1 L of any infusate containing Na+ and K+ on serum Na+ |
|
|
|
Infusate |
Infusate Na+ |
Extracellular—Fluid Distribution |
|
mmol/L |
% |
5% sodium chloride in water |
855 |
100† |
3% sodium chloride in water |
515 |
100† |
0.9% sodium chloride in water |
154 |
100 |
Ringer lactate solution |
130 |
97 |
0.45% sodium chloride in water |
77 |
73 |
0.2% sodium chloride in 5% dextrose in water |
34 |
55 |
5% dextrose in water |
0 |
40 |
*The number in formula 1 is a simplification of the expression (infusate Na+ —serum Na+) X 1 liter, with the value yielded by the equation in mmol/L. The estimated total body water (in liters) is calculated as a fraction of body weight. The fraction is 0.6 in children; 0.6 and 0.5 in nonelderly men and women, respectively; and 0.5 and 0.45 in elderly men and women, respectively.†In addition to its complete distribution in the extracellular compartment, this infusate induces osmotic removal of water from the intracellular compartment. |
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