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- EBM term coined by Guyatt in 1991
- “Conscientious, explicit, and judicious use of current best evidence in
making decisions about the care of individual patients”
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3
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- Historically based on expert consensus - GOBSAT
- Now EBM methodology applied to a population
- “systematically developed statements to assist practitioner and patient
decisions about appropriate health care for specific clinical
circumstances”
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4
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- Assure best chance of achieving acceptable outcome
- Reduce wide range of variation in tx options
- Reduce costs of delivery
- Balance of risks, benefits & costs
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- Neurosurgery - WAF, SNR, neurosurgical ARNPs
- CCM - Bihorac
- Endocrinology - Kennedy
- Nephrology - Tantravahi, Segal
- Pharmacy - Leclaire
- Nursing - multiple
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6
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- When should hyponatremia be further evaluated and treated? (what lab
values and/or clinical symptoms require intervention)
- What is the optimal evaluation paradigm, clinical and laboratory, for
hyponatremia in the neurosurgical setting?
- What is the optimal treatment paradigm for hyponatremia in the
neurosurgical setting?
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7
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- Literature search for clinical trials, meta-analyses, prospective
studies, case control, case reports & reviews
- English
- PubMed & Cochrane database
- Hyponatremia
- Over 75 articles reviewed
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8
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- Literature on prognosis
- 14 studies
- 6 retrospective studies - considered invalid for prognostic questions
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9
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- Class I: Well-designed clinical trial, population followed from uniform
point in disease process, no bias, multivariate analysis
- Class II: Data on restricted population, prospective, complete
follow-up, multivariate analysis
- Class III: Expert opinion, other prospective studies
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10
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11
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- Recommendation:
- Hyponatremia should be further investigated and treated when Na
<131mmol/L. (II)
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12
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- Literature on diagnosis
- 37 studies
- 17 prospective
- 14 reviews
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13
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- Class I: Well-designed clinical study, diverse population, “gold
standard” test in blinded eval, sensitivity, specificity, pos and neg
predictive values
- Class II: Restricted pop, reference test in blinded eval, sensitivity,
specificity, pos and neg predictive values
- Class III: Expert opinion, studies w/o above criteria
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14
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15
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16
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- Recommendation:
- Evaluation of hyponatremia should include a combination of physical exam
findings, basic lab studies and invasive monitoring when available.
(III)
- Obtaining levels of hormones such as ADH and natriuretic peptides is not
supported by the literature. (III)
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17
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- Literature reviewed
- Consensus recommendations for the paradigm for evaluation of
hyponatremia at UF
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18
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19
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20
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- 35 Studies
- 3 Randomized controlled trials
- 11 Prospective
- 7 Retrospective/case reports
- 15 Reviews
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- Class I: Randomized controlled trial
- Class II: Comparative study, cohort study, case-control
- Class III: Case series, comparative study with historical controls, case
reports and expert opinion
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22
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23
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24
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- Recommendation:
- Sodium should not be corrected by more than 10mmol/day. (III)
- Treatment of hyponatremia should be based on severity of symptoms. (III)
- CSW should be treated with replacement of Na and IVF. (III)
- Fludrocortisone may be considered in the treatment of hyponatremia in
SAH patients at risk for vasospasm. (I)
- Hydrocortisone may be used to prevent natriuresis in SAH patients. (II)
- SIADH may be treated with urea, diuretics, lithium, demeclocycline
and/or fluid restriction. (III)
- Hyponatremia in SAH patients at risk for vasospasm should not be treated
with fluid restriction. (II)
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Notes
