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QJM Advance Access originally published online on July 29, 2005
QJM 2005 98(9):691-703; doi:10.1093/qjmed/hci101
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© The Author 2005. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For Permissions, please email: journals.permissions@oupjournals.org

Masterclasses in medicine

Acute and fatal hyponatraemia after resection of a craniopharyngioma: a preventable tragedy

D. Bohn1, M.R. Davids2, O. Friedman3 and M.L. Halperin3

From the 1Department of Critical Care Medicine, Hospital for Sick Children and Departments of Anaesthesia and Medicine, University of Toronto, Toronto, Canada, 2Nephrology Unit and Department of Internal Medicine, Stellenbosch University, Cape Town, South Africa, and 3Division of Nephrology, St Michael's Hospital, University of Toronto, Toronto, Canada

Address correspondence to Professor M.L. Halperin, University of Toronto, St Michael's Hospital Annex, Lab #1, Research Wing, 38 Shuter Street, Toronto, Ontario, M5B 1A6, Canada. email: mitchell.halperin{at}utoronto.ca

Central diabetes insipidus developed for the first time in a 14-year-old female during the resection of a craniopharyngioma. The water diuresis persisted until a vasopressin analogue (dDAVP) was given. Professor McCance was asked to explain why hypernatraemia developed, to anticipate dangers that might develop in the salt and water area with therapy, and to provide insights into why this patient died, due to the subsequent development of hyponatraemia that caused a lethal rise in intracranial pressure. The team specifically wanted Professor McCance's opinions as to why a PNa of 124 mmol/l was uniquely dangerous for this patient, and this was a particularly challenging conundrum. Nevertheless, with the aid of a mini-experiment, a careful chart review, and creative thinking, he was able to offer a novel solution, and to suggest ways to prevent its occurrence in other patients.


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