Abstract

Iatrogenic Hypernatremia; Still Not Uncommon

Author(s): Asheesh Kumar, Ram Singh and Sanjay Vikrant

Background: We are aware that hemodialysis is a routine outpatient treatment for millions of patients with a proven safety record, accidents and errors do occur from time to time. Hypernatremia in CKD 5D is although rare and is often caused by technical failure.

Case presentation: We report the case of 50 year old male with symptomatic hypernatremia which manifested as altered level of consciousness immediately after dialysis. The hypernatremia was caused by technical error conductivity reading. Patient improved without any neurological deficit after hemodialysis treatment of the patient.

Conclusions: We should never ignore conductivity alarm and there should be urgent examination of the dialysate if the patient develops rapid onset altered sensorium.