RESUMO
Polydipsia and episodic life-threatening water intoxication remain important clinical problems for a significant portion of persons with schizophrenia. The disorders are associated with increased morbidity and mortality from a number of causes. With a basic understanding of the pathophysiology, one can easily diagnose and assess the clinical conditions. We review here the scope and pathophysiology of disordered water imbalance, including both primary and secondary polydipsia and hyponatremia. Reversible factors and possible interventions are reviewed. Treatment options for preventing water intoxication have expanded from discontinuation of offending agents, targeted fluid restriction, and clozapine therapy to the addition of oral vasopressin antagonists. The latter, however, are extremely potent and must be carefully monitored.
Assuntos
Ingestão de Líquidos , Esquizofrenia/diagnóstico , Psicologia do Esquizofrênico , Intoxicação por Água/diagnóstico , Antagonistas dos Receptores de Hormônios Antidiuréticos , Antimaníacos/efeitos adversos , Antimaníacos/uso terapêutico , Antipsicóticos/efeitos adversos , Antipsicóticos/uso terapêutico , Benzazepinas/uso terapêutico , Clozapina/efeitos adversos , Clozapina/uso terapêutico , Terapia Combinada , Diagnóstico Diferencial , Ingestão de Líquidos/fisiologia , Humanos , Hiponatremia/diagnóstico , Hiponatremia/fisiopatologia , Hiponatremia/psicologia , Hiponatremia/terapia , Carbonato de Lítio/efeitos adversos , Carbonato de Lítio/uso terapêutico , Ensaios Clínicos Controlados Aleatórios como Assunto , Receptores de Vasopressinas/fisiologia , Fatores de Risco , Esquizofrenia/fisiopatologia , Esquizofrenia/terapia , Inibidores de Simportadores de Cloreto de Sódio/efeitos adversos , Inibidores de Simportadores de Cloreto de Sódio/uso terapêutico , Tolvaptan , Privação de Água , Intoxicação por Água/fisiopatologia , Intoxicação por Água/psicologia , Intoxicação por Água/terapia , Equilíbrio Hidroeletrolítico/fisiologiaRESUMO
BACKGROUND: Irrigation of closed body spaces may lead to substantial perioperative fluid and electrolyte shifts. A syndrome occurring during transurethral resection of prostate (TURP), and a similar syndrome described in women undergoing transcervical endometrial ablation (TCEA) are both characterised by a spectrum of symptoms which may range from asymptomatic hyponatraemia to convulsions, coma, and death. Such potentially serious consequences require prompt recognition and appropriate management of this "water intoxication" syndrome. OBJECTIVES: To examine the role of a previously described core algorithm "COVER ABCD-A SWIFT CHECK", supplemented by a specific sub-algorithm for water intoxication, in the management of this syndrome occurring in association with anaesthesia. METHODS: The potential performance of this structured approach for each of the relevant incidents among the first 4000 reported to the Australian Incident Monitoring Study (AIMS) was compared with the actual management as reported by the anaesthetists involved. RESULTS: From the first 4000 incidents reported to AIMS, 10 reports of water intoxication were identified, two from endometrial ablations under general anaesthesia and eight from male urological procedures under spinal anaesthesia. The "core" crisis management algorithm detected a problem in seven cases; however, it was deficient in dealing with neurological presentations. Diagnosis of the cause of the incident would have required a specific water intoxication sub-algorithm in eight cases and a hypotension algorithm in a further two cases. Corrective strategies also required a specific sub-algorithm in eight cases, while the hypotension and cardiac arrest sub-algorithms were required in conjunction with the water intoxication sub-algorithm in the remaining two. CONCLUSION: This relatively uncommon problem is managed poorly using the "core" crisis management sub-algorithm and requires a simple specific sub-algorithm for water intoxication.