Cool Name, Not So Cool Results

53yo WM rolls in, wee hours of the am.  C/o HA, onset around 4 days ago.  Wife says “I think he had a seizure in the middle of the night that night”    Def hit his head, has a goose egg middle of the forehead.   “Had some labs done at my primary yesterday, they called me and told me to come in”   No clue as to what labs those might be when asked.   Awesome.  Medical hx only significant for HTN and GERD.   No chronic meds.   Admits to drinking around a case of beer a day.   Probably explains the not so full history he provided.   Nothing else interesting on physical exam and normal vital signs.  So I send labs- CBC, Chem13, Mag, CT his head due to the possible seizure.

Annnnd Na 114, K 2.5, CL 75, Bicarb 32, BUN 12, Cr 1.2, Glucose 111, Ca 8.4.   CT normal.  ETOH and Tox NL.   Serum osmolality 259

So what’s going on here?   Hyponatremia and seizure- needs fixed right.   Normal saline or even hypertonic saline maybe?

Negative ghost rider

Lets look at this a little deeper.

Start with the algorithm

Image result for hyponatremia algorithm

So we will start with the asymptomatic column.   Could argue for the severe side due to the seizure, but he is now 4 days out and asymptomatic.   Went the euvolemic side of things.   No signs of fluid overload clinically and didn’t look dry.  Actually nerded out and ordered urine osmolality.  88.    So where does that land us?

Beer Potomania syndrome.

WTH is that?  Great name.   But too much physiology for my brain.

When patients have poor protein and solute (food, electrolytes) intake, such as in chronic alcoholics, they can experience water intoxication with smaller-than-usual volumes of fluid. The kidneys need a certain amount of solute to facilitate free water clearance (the ability to clear excess fluid from the body). A lack of adequate solute results in a buildup of free water in the vascular system, leading to a dilutional hyponatremia.

Free water clearance is dependent on both solute excretion and the ability to dilute urine. Someone consuming an average diet will excrete 600 to 900 mOsm/d of solute. This osmolar load includes urea generated from protein (10 g of protein produces about 50 mOsm of urea), along with dietary sodium and potassium. The maximum capacity for urinary dilution is 50 mOsm/L. In a nutritionally sound person, a lot of fluid—about 20 L—would be required to overwhelm the body’s capacity for urinary dilution.

However, when you don’t eat, the body starts to break down tissue to create energy to survive. This catabolism creates 100 to 150 mOsm/d of urea, allowing you to continue to appropriately excrete a moderate amount of fluid in spite of poor solute intake … as long as you are not drinking excessive amounts of water.

Alcoholics get a moderate amount of their calories via beer consumption and do not experience this endogenous protein breakdown or its resultant low urea/solute level. With low solute intake, dramatically lower fluid intake (about 14 cans of beer) will overwhelm the kidneys’ ability to clear excess free water in the body.   

So, we see alcoholics all the time.  Why don’t we see this all the time?   When you think about it, a pretty low percentage of our EXI all star drinkers are beer drinkers.  And most case a day beer drinkers actually have a decent oral food intake.   Making this more rare than you originally might think.

So what do we do about it?  Classic example of ‘dont just do something stand there!’

Fluid restriction, fluid restriction, fluid restriction.

Back to my case.  Admit the patient to my hospitalist, who is half asleep and currently not as excited as I am about hyponatremic management.   Orders in for fluid restriction and serial chemistries.    A few minutes later, I hear my ER nurse arguing with the floor nurse during calling of report.   They are appalled that I am not giving normal saline, and even request hypertonic saline.  I politely pick up the phone and discuss the physiology and reason for my treatment plan.   We were on the same page by the end of the call.

Fast forward to a couple days later.  I come back for another shift, and am checking on my patients from the day before (quick aside, no matter where you are in your career always save the info for 3-4 of your sicker, more interesting patients and look them up on your next shift, by far one of the most high yield learning you can get.   And will help you adjust your practice as indicated).   I look up the serial sodium results.  114, then 119, 123, then………145.   Goooooooo!!!!  Assuming I am about to hear from the Kentucky Hammer due to causing central pontine myelinolysis.  I talk to the hospitalist- apparently the next shift nurse, after the one I talked to, got her way, and they got an order to blast the guy with normal saline.  Hence the huge jump.   Patient did have some transient AMS, but was at baseline and neuro intact once levels stabilized.  Thank god.

Anyway, interesting case.  Beer potomania.   cool name, not so cool results.   Literature states that central pontine myelinolysis happens in over 20% of these patients due to too rapid correction.  So before you pull the trigger on normal saline repletion take a second and scope out the algorithm above.  Sometimes the best thing you can do is nothing.

5 thoughts on “Cool Name, Not So Cool Results

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    References:

    Steroid For Women

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    References:

    what do steroids do; posaonadlanu.de,

  3. Our pharmaceutical-grade Oxandrolone is prescribed and monitored by licensed
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    Hi, I’m Dr. Grant Fourie, a devoted medical professional enthusiastic about
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    This is as a end result of our checks present that Anavar is commonly counterfeited on the black market, being changed with Dianabol (a much cheaper steroid to produce).
    If a woman unknowingly takes Dianabol, virilization unwanted side effects are very probably.
    Anavar, primarily a type of exogenous testosterone, will improve pink
    blood cell manufacturing, thus causing superior oxygen delivery to the muscle tissue.
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    testosterone, a fat-burning hormone that increases lipolysis.
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    a potent thyroid fat-burning hormone that also has positive effects on the metabolism.
    And in terms of Anavar it all depends if you are doing an Anavar
    solely cycle, or are you stacking with another steroids.
    Anavar cycles for males often final for eight weeks, the place girls will usually cycle Anavar for
    6-8 weeks.
    Intermediate bodybuilders who have beforehand used steroids and have adequately tolerated testosterone and Anavar in standalone
    cycles usually administer the aforementioned protocol.
    The maximal testosterone dosage has been elevated from 350 mg to 500
    mg, and the cycle length has been extended from 7 to 10 weeks.
    Thus, if girls are to try and cut back the price of their Anavar cycle by drinking grapefruit juice,
    they start taking 2.5mg per day, consuming 200ml of grapefruit juice every 12
    hours to keep CYP3A4 deactivated. This successfully may give them a a lot larger dose
    (possibly the same effects as 10mg per day).

    Nonetheless, this will increase the chance of virilization and liver toxicity.
    To avoid several well being risks, female customers should monitor their cholesterol levels, liver perform, and total well-being.
    It can be advisable to follow a balanced food plan and keep a regular train routine to optimize results and reduce dangers.

    Genotropin is a human progress hormone used to treat development failure in children and adults who lack …
    Nonetheless, many women barely notice any unfavorable effects from such dosages.
    Ultimately, the liver is a very resilient and self-healing organ (8) that often takes a lot abuse in order to fail, which Anavar is unlikely to cause by itself.
    Nevertheless, precautions and common monitoring of liver enzymes remain important.

    In our experience, Anavar’s results on cholesterol are relatively mild compared to different steroids;
    nonetheless, blood strain remains to be likely to rise on-cycle.

    Ladies do not need to worry about post-cycle remedy following an Anavar cycle because they don’t need to deliver testosterone ranges again to
    normal via the usage of drugs. However, to find a way to combat potential melancholy and estrogen rebound, some women will eat “clean” (nutritional) foods
    and use mood-enhancing supplements in the weeks following a
    cycle. It’s highly really helpful that male bodybuilders run ancillaries during an Anavar cycle to prevent/minimize
    unwanted effects. This is an space the place one’s particular
    cycle will go a good distance in path of figuring out what on-cycle assist they use.

    The commonest cause the steroid is prescribed is for the aim of weight acquire necessitated because of surgery or
    infection or any kind of severe weight loss. Anavar has additionally been proven to
    be extremely effective for treating over or prolonged exposure to corticosteroids, as
    properly as for treating osteoporosis by the promotion of bone density.
    Nevertheless, such makes use of are rare in the us currently because of strict legal guidelines regardless of this steroid’s tremendously profitable and optimistic observe record.

    Thus, the hormonal lipolytic results of Anavar could additionally be
    preserved even if an individual is sedentary post-Anavar
    cycle. Analysis indicates that if a person administers Anavar
    and doesn’t raise weights, any improvements in muscular
    strength or mass could also be short-term (29).
    Therefore, any enhance in muscle hypertrophy diminishes
    following cycle cessation. Some bodybuilders state that they require Anavar doses of 40 mg so as to see notable results.

    At the identical time, the depth and duration of your training considerably improve as a result of your physique recovers extra efficiently.

    In the end, all this implies better, sooner outcomes due to the wide-ranging effects of Anavar.
    Anavar will increase your endurance to an extent, with a noticeable ability
    to work out for longer and at the next intensity22.

    In this article, we will focus on what Anavar is
    strictly, why it’s known as one of the best anabolic steroid for ladies, the
    really helpful anavar dosage and the varied potential well being dangers concerned.

    Okay, Anavar comes filled with pretty superior features such
    as energy and fat loss gains; Anavar is considered the safest steroid on the market.
    Let’s face it, Anavar too might be toxic and can include a really serious life-threatening side-effect which in severe instances would possibly end in even sudden dying.

    In these instances, a medicine like oxandrolone (also generally
    recognized as Anavar) is prescribed and a food plan program to assist people get back to
    a healthier weight. By studying on, you probably can study everything that you need to learn about oxandrolone so as to see if this is the best treatment possibility for you.

    The commonest side effect of all AAS is liver
    toxicity and cholestatic jaundice, among others. Such opposed results on the liver are demonstrated
    in patients using excessive dosages of Oxandrolone for greater
    than 1 yr and concomitant use with other anabolic agents.

    This is indicative of the product being underdosed, as 20 mg is more than enough to
    experience vital modifications in physique composition. Regardless Of the above protocol being efficient, DHEA is the official medical treatment prescribed to
    women for low androgen ranges. Over half a century later, quite a few
    girls have used Anavar anecdotally and in analysis.
    Now it is broadly considered that doses in the vary of 5–10 mg produce noticeable results while inhibiting virilization. Others use capsule cutters
    to split 10 mg drugs in half, giving them four x 5 mg doses.
    If 2.5 mg pills are obtained, this reduces the need to reduce any
    of the drugs.
    When it comes to the Winstrol vs. Anavar debate, some bodybuilders
    go for Anavar, and others choose Winstrol (for various reasons that
    we’ll cover). Nevertheless, when it comes to the advantages of
    every compound, most of our patients report Winstrol
    as being stronger. Oxandrolone is also used to lower muscle loss caused by utilizing steroid
    medicines, and to scale back bone ache in people with osteoporosis.
    Thus, Anavar isn’t strongly hepatotoxic in comparison with other oral steroids.
    This reduction in visceral fats mass is especially beneficial for girls, as they’re
    extra prone to storing stomach fat.

    References:

    steroids at 20 (Felicia)

  4. Both these AAS are slower-acting, so patience is required to see results.
    Optionally, you could think about adding an oral AAS like Dianabol for the
    first few weeks to kick things off sooner. Dianabol may cause significant stress to the liver, so it’s solely used
    for a quantity of weeks.
    As I’ve mentioned Anavar and Winstrol cycles, it’s important to
    mention the significance of Submit Cycle Remedy (PCT).
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    Lastly, remember that a clear food regimen and a correct
    strength coaching program are crucial for maximizing the
    outcomes of this cycle. Without a proper nutrition and
    exercise plan, no complement stack will provide the specified consequence.
    Regarding the size of the cycle, it’s typically finest
    to keep it between 6 to 8 weeks.
    Enhanced muscle hardness and density with muscular lines changing into a bit
    extra pronounced are the early signs of Anavar’s muscle shaping capabilities.
    Moreover, Anavar use usually ends in significantly enhanced vascularity, with veins turning into extra noticeable
    owing to reduced subcutaneous fats. While particular person outcomes could vary, this
    noticeable vascularity is a standard statement amongst Anavar users.
    It included a big and varied pattern of participants with current or
    remitted psychopathology and healthy controls, and a excessive variety of measurements
    per participant. The EMA method used on this study is particularly useful in the assortment of data for
    personalised networks, as it is prepared to generate
    a great amount of data at a low price to the patient
    or participant. The high variety of measurement points facilitates mapping a nuanced image of short-term interaction between temper states.
    Nonetheless, the DTW technique may outperform mlVAR in analyzing sparse panel data.

    And the most well-liked injectable steroids will
    all the time be cheaper – typically less expensive than Anavar.

    Positive reviewers will state that Anavar is essentially the most well-tolerated steroid they’ve used.

    Still, it’s necessary to verify out what
    dosage they’ve used so you presumably can determine how the dose might affect your results and (lack of) unwanted aspect
    effects. It’s fun to take a look at earlier
    than and after photographs of individuals who’ve used Anavar, however this tells us
    nothing about any positive aspects in energy they’ve experienced on the cycle.

    Nevertheless, this should not be conflated with a drastic rise in muscle mass.
    The true strength of Oxandrolone lies in boosting fat loss, promoting
    lean muscle preservation and growth, and improving muscle hardness and density.
    A well-structured Take A Look At Anavar cycle can offer quite a
    few benefits for individuals looking to optimize their
    features whereas minimizing side effects. By understanding the suitable dosages and durations, each women and men can tailor their cycles to swimsuit their
    particular goals. Beginners ought to method steroid utilization with warning, steadily increasing dosages and carefully monitoring
    their progress. Superior users can explore greater dosages
    and stacking choices, however must prioritize well being and mitigate unwanted side effects.
    Individuals over 40 ought to consider age-related factors
    and modify their cycles accordingly.
    I wouldn’t run this cycle for greater than six weeks
    or eight at the most. This is a pleasant contest prep
    stack fitted to hardcore customers and competitors.
    Females can get hold of energy and lean positive aspects at low
    doses, and stacking Anavar with one other kind
    of compound called Ostarine (a SARM) can result in excellent results with minimal unwanted
    facet effects. Winstrol poses a better liver toxicity and side effect risk than Anavar, so
    we can keep this stack quick. Doses are around half that of what we’d normally use for each compound because they are each oral steroids.
    One Other Anavar stack for men is a pure slicing cycle and
    contains one other cutting-specialist steroid in Winstrol.
    Winstrol is among the finest chopping compounds available,
    and when combined with Anavar, it proves to be a potent
    duo for final shredding.
    By embracing these optimal dosages, both men and women can expertise the optimistic results of Anavar while mitigating potential dangers.
    Men aiming for enhanced physique and performance commonly uncover that a every day dosage
    ranging from 20 to one hundred mg proves highly efficient over a period of 6 to 12
    weeks. Can you take Anavar and Winstrol collectively without the
    rest in the mix? Sure, you possibly can, but taking Testosterone
    (even if it’s just TRT dosage circa 150mg per week) is at all times advisable.

    Nevertheless, it is important for girls to carefully manage dosages to avoid virilization effects.

    Consulting with a healthcare skilled or experienced coach is really helpful for personalised guidance.
    Alcohol should be averted when using oral anabolic steroids, as we have discovered it to exacerbate liver values.

    Clenbuterol has potent results on the central nervous system,
    causing the physique to lift adrenaline manufacturing.

    At this stage, you’ll almost actually be taking a glance at stacking, which lets you maintain Testosterone Propionate at lower doses.
    Elevated protein synthesis results in elevated lean mass gains, probably the
    most potent effect of Testosterone Propionate for any bodybuilder.

    Testosterone Propionate will provide quicker positive aspects than most different
    types of testosterone simply because it detaches from the ester very quickly
    and begins attending to work to stimulate protein synthesis.
    Check Deca Anavar cycle may be an effective approach to
    increase power and endurance. By following these tips, bodybuilders
    can optimize the results of the cycle and decrease any potential negative effects.

    In this article, we’ll discover where you ought to buy Test Deca
    Anavar in your cycle. Maintaining a wholesome, balanced food regimen and
    incorporating regular train into one’s routine are equally crucial in reaching sustainable success with these compounds.
    Sufficient relaxation and hydration, as nicely
    as correct supplementation, might help minimize any potential
    side effects and make sure that the user’s
    general health stays a precedence. Elements like genetics, diet,
    and coaching routines certainly play a job in how effective these compounds
    might be for each individual.
    The weight loss brought on by Anavar is often skilled as a
    slow but constant lower in unwanted fats, especially in downside areas
    just like the abdomen. The progress into a leaner physique additionally initiails inside the first two
    weeks. Though not extremely dramatic at this point, the onset of fats burning course of can be seen. Particularly extra cussed fat, like these around the
    abdomen, may start reducing, indicating Anavar’s promising start.

    First and maybe most noticeable, is the elevated muscle definition and power.
    Anavar, identified for its anabolic properties, aids in making a well-defined muscular structure.

    References:

    bodybuilders Before and after Steroids

  5. Nonetheless, if newbies do not wish to experience
    vital muscle features but as a substitute milder increases in hypertrophy (size), the above cycle could also
    be taken. We find that HGH just isn’t sometimes taken by beginners however by
    extra skilled PED users, making an attempt to boost their muscle features.
    When used for efficiency enhancement purposes, 2-4 IU per
    day are taken, with a maximum dosage of 6 IU used by elite bodybuilders to promote additional mass achieve.
    Combining the strategic intake of Anavar with a well-balanced food regimen, common train, and proper
    relaxation is important for reaching your fitness goals.
    All The Time consult with a healthcare professional or
    health skilled before incorporating Anavar or any complement into your routine to make sure personalised
    and secure usage. It was fairly costly, especially in comparison with other anabolic steroids that have been in the stores on the time.
    In conclusion, whether or not you want to take Anavar 7 days
    a week or not is dependent upon your targets, dosage, and tolerance.

    It’s all the time a good suggestion to seek the assistance of with a healthcare skilled earlier than beginning any new supplement or medicine regimen to
    ensure it aligns along with your particular well being wants and goals.
    Anavar is a popular steroid amongst bodybuilders and athletes as a outcome of it
    helps with the synthesis of proteins, increases muscle mass, and prevents
    nitrogen loss throughout train. Nonetheless, it’s necessary
    to notice that Anavar just isn’t a magic tablet that
    will provide you with instant outcomes. It needs to be taken constantly and at the aspect of a
    correct food regimen and exercise routine. Our exams have proven that testosterone, similar to Anavar, is amongst the
    most well-tolerated anabolic steroids.
    It is important to closely monitor your body’s response to the drug
    and seek the advice of with a healthcare skilled to make sure that you’re using the optimum dosage
    in your individual wants. In conclusion, timing triumphs in relation to optimizing your Anavar
    routine for enhanced fat loss. By splitting the day by day dosage into two separate doses and strategically timing your workouts, you probably can maximize the advantages of this highly effective
    steroid. With correct timing considerations, you’ll be able to unlock the
    full potential of Anavar and achieve your health goals extra effectively.

    Common monitoring, together with blood work, is crucial when using
    anabolic steroids. Monitoring liver operate, lipid profiles, and hormone ranges may
    help establish any potential points early on and ensure your health
    and well-being all through the cycle. When it involves an Anavar cycle, the outcomes
    can range tremendously based mostly on a quantity of elements.
    Careful planning helps form up the perfect regimen to fulfill your health
    objectives.
    Anavar is something newbies can use, because the side effects are fairly
    low. You will still need to deal with the drug respectfully, as the unwanted
    side effects can creep on you. Regardless, most individuals really feel Anavar throughout the first 2 – three weeks of utilizing it.
    The amount of time it takes for any drug to kick in is decided by varied variables such as dosage, age, and digestion. That being said, it does
    deliver into dialogue one of many side effects of all oral Steroids – loss of urge for food.
    Whereas extremely small, Anavar will nonetheless cause
    a rise in blood stress. They will increase
    LDL and Total Cholesterol while additionally lowering HDL levels.

    Taking Anavar before a exercise may improve vitality, focus, and muscle pump,
    whereas consuming it after a workout might help muscle restoration and
    restore. However, it is crucial to do not neglect that responsible utilization, correct dosage, and particular person health considerations should all the time be prioritized when utilizing any anabolic steroid.
    In phrases of dosage, it is necessary for ladies to begin with a low
    quantity and steadily increase it if wanted. A frequent starting dose for female customers is 5mg per day, and this might be increased to 10mg after
    a couple of weeks if no adverse results are experienced.

    Thus, by spiking HGH, users might effectively be
    growing their very own threat for most cancers or worsening any
    present (unknown) tumors. We have also seen HGH having cardiovascular advantages when used within the remedy of sufferers deficient in endogenous growth hormone (5),
    having a paradoxical effect and inflicting cardiac atrophy.
    HGH also increases cognitive capability as a result of progress hormone
    receptors being expressed in mind regions, including the cerebral cortex, choroid plexus, and hippocampus (2).
    This concern faced is that whenever you take the medicine your body can acknowledge the necessity to cease
    producing testosterone, this is very clever and really environment friendly.
    Due To This Fact, there seems little level attempting to stimulate natural test when steroids flood your system with
    more than you can produce synthetically.
    Anavar is a broadly most popular anabolic steroid used by individuals globally
    who train or are particularly into bodybuilding. It appeals explicitly due
    to its propensity to help enhance muscle mass and promote a robust body.

    The comfort of this steroid is that it presents minimal unwanted effects, making
    it a beautiful choice for both men and women.
    The use of Winstrol suppresses your natural testosterone manufacturing and sometimes shuts it down completely.
    Whereas Winstrol is frequently used for cutting purposes, it is not thought-about a fats
    burner.
    Note that this doesn’t necessarily imply it’s authorized to import or promote AAS in such countries
    – legal guidelines differ. While private possession won’t trigger you legal points, you could end up in bother if you’re caught making an attempt to promote Anavar to someone.

    Most individuals would find that the value
    of pharmaceutical-grade Anavar would just not be price
    it, as it’s considerably costlier than most other, more
    extensively obtainable steroids. Very little Oxandrolone is produced for human medical use nowadays, so there’s hardly any provide of
    pharma-grade merchandise.
    Continual alcoholics abuse their livers every day for years and heaps of are simply
    fantastic. Nevertheless, if you’re just making an attempt to cut down on physique fats, then a shorter cycle of four to 6 weeks should suffice.
    The most typical signs of an Anavar kick in time embrace feeling extra energetic, having extra motivation, and seeing a rise in muscle mass.
    The normal technique for detecting Anavar within the system
    is thru urine testing, which is usually used in sports doping exams.
    Extra sophisticated checks, such as blood or hair follicle
    checks, can detect hint amounts of steroids for an extended
    duration after use has ceased.
    Also people who find themselves worried about steroid’s
    unwanted facet effects are extra inclined to take anavar as the risks are lower.
    It helps the body use saved fat for power, which might lead to
    a discount in body fats, particularly when combined with a correct food regimen and exercise routine.

    This is why Anavar is often used throughout slicing cycles, where the goal is to lose fats whereas
    preserving muscle mass.
    With these components harmoniously aligned, the dosage fine-tuned to your routine can unlock new levels in your physique
    and efficiency. Stanozolol is a synthetic steroid
    that’s much like natural testosterone, which has been derived from dihydrotestosterone.
    DHT can be an endogenous androgen intercourse steroid produced
    naturally within the body by way of the conversion of testosterone.

    References:

    Is jay cutler on steroids

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