I also understand what
@CFS_for_19_years is saying, that I can demand certain tests or refuse saline but it doesn't mean anyone will listen to me.
Yes, the doctor is simply going to order the tests that he or she thinks are necessary. But if you come in with the signs of hyponatremia, they're going to test your electrolytes. That's what's most important.
As for refusing the saline, you can always do that; you did that yesterday. Refusing treatments is a lot easier than getting tests done.
@zzz @halcyon I wanted to add that I read the Medscape link you mentioned and it said that hyponatremia is if your blood sodium level is below 135 meq and is severe is below 125 meq. The range from the test at the ER last night was slightly different in which normal was 134 to 144.
Those are essentially the same ranges. Ranges for everything vary slightly from place to place and from lab to lab. The reason for this is that the ranges are for the population as a whole, and they're derived statistically. The numbers in these ranges are only approximations. That's why if you're just a little bit outside a range, your doctor will often ignore the reading; the difference often isn't significant. However, for PWME, these differences tend to be more significant than for other people.
My sodium level was 137 which seems well within the range even though on the lower side. Would this have been enough for the ER doctor to assess that it was not hyponatremia?
Yes; your doctor would take one look at that number and say that you did not have hyponatremia. And it appears that at that point he would have been right; your symptoms appear to be coming and going. This is characteristic of autonomic dysfunction. (Generally, they don't know much about autonomic dysfunction in the ER.)
1) If I had acute hyponatremia, wouldn't the most severe be during & after the bad reaction in which the sodium test was 137 meq. Or could it worsen a day later?
Certainly, it would be most severe during the bad reaction. But your sodium wasn't measured then. By the time your sodium was measured, your symptoms had abated. Again, this is a strong sign of dysautonomia. And yes, it could worsen a day later - that's exactly what appears to have happened. There are two explanations for this that come to mind: Your autonomic nervous system may still be traumatized from yesterday, and as a result it is continuing to fluctuate back and forth. This could deteriorate, which is where going to the ER makes sense. Or you could have what is essentially hyponatremic PEM. This could get better on its own, or it could deteriorate. If you're asymptomatic now, you can wait a few hours and see if symptoms return. If they do, you'd need to go to the ER. If they don't, going to the ER wouldn't tell you anything, and you should be safe staying home.
2) If I go back to the ER and they do the basic metabolic panel and sodium is still in the normal range, does this indicate that I do not have hyponatremia?
It means that you don't have hyponatremia at the time they do the test. But again, your situation is fluctuating, and may continue to fluctuate. Hyponatremia is the most common adverse reaction to a saline infusion, and you had definitive symptoms for it. You need to be sure that it's not coming back.
Here is a definitive list of common hyponatremia symptoms from
MedlinePlus, which is under the NIH. Like most symptom lists, the symptoms are rarely all present, but if you have hyponatremia, you would have at least some of them.
So see how you feel as the evening progresses. You can always contact me directly for a quick answer to any question; I'll be available all evening. It's the fastest way to get a response, as it takes me forever to write these posts.
Meanwhile, I hope you continue to feel better and gradually improve, and that this whole episode will soon be completely behind you.
With a sodium of 137, you did not have hyponatremia last night.
All we can say for sure is that she did not have hyponatremia at the time the test was taken. The dysautonomia component here means that things can change rapidly.
I believe your problems stemmed from too much magnesium and possibly too much fluid in general.
I must strongly disagree here, and I'll elaborate in a later post, but I want to get this done so
@Gingergrrl can see it. Her symptoms are completely consistent with a diagnosis of dysautonomic hypervolemia with accompanying hyponatremia and hypokalemia, with complications of acute pulmonary edema and hypoxemia. All her symptoms can be explained by this. I can show that the magnesium explains none of her symptoms, with the exception that there is a very remote possibility that it contributed somewhat to her flushing. But the main symptoms of hypermagnesemia are often the
opposite of what she experienced - for example, bradycardia as opposed to tachycardia. I'll have more later.
In answer to your questions:
1. It's doubtful it would worsen a day later.
Again, the combination of dysautonomia and PEM make such worsening very possible. The PA she talked to thought she had hyponatremia; the symptoms she described were those of hyponatremia.
This might be more advice than you want to hear at the moment, but IMHO, your IV yesterday should have been plain saline (no added Mg) until the reason for your reaction to the previous saline IV had been sorted out. When you change or add medications or treatments, it is best to change or add one thing at a time. If there is a problem with a new med/treatment (saline IVs), that problem should be sorted out before adding one more thing (adding Mg to the mix).
I agree completely here. Additionally, I would have decreased the saline amount to a half liter, as I mentioned before the infusion. There would still have been a reaction, but it would have been much milder, and it would still have been clear that the saline should be discontinued.
It seems real unlikely that your sodium would have gotten worse compared to last night. I'm saying this as my understanding of human physiology, the way the body handles fluid and electrolyte balance.
Normally, this is true. But dysautonomia can mess up things in very unusual ways. Consider this quote from Professor Edwards:
What people call hypovolaemia often means relative hypovolaemia, which could easily be absolute hypervolaemia, I think.
The only way that saline IV could have caused you hyponatremia is if it was hypotonic, i.e. purposely having a lower amount of saline than what is in plasma.
Not true; for example, see
this quote from Medscape:
Note that normal saline can exacerbate hyponatremia in patients with SIADH, who may excrete the sodium and retain the water.
This is just one way this could happen. There is a different mechanism in dysautonomia, but it's a bit complicated to get into right now.
But since you received 0.9% normal saline, this is what kept your sodium in the normal range last night. The overall volume (1 liter) for someone at 110 lbs with a weak heart could have been too much for you, and your doctor will have to make the call on that one.
I have to stress that this is not what happened, because this line of thinking ignores a potentially dangerous case of hyponatremia. If what you say were true, trying a half liter of saline might be reasonable. It's not, and the results could be expected to be at least as bad as yesterday's.
But you clearly had a high magnesium, which could have accounted for some of your symptoms.
When you look at the situation closely, you'll see that there's really no evidence for this, as I'll show. Also, what about the other symptoms? What other explanation ties them all together in a sensible way? But I'll have to get to this in another post. For now, I'll have to get this one up...