Υπονατραιμία

Κείμενο : Γιάννης Ψαρέλης Στους αγώνες Τριάθλου όλων των αποστάσεων ένα από τα θέματα που έχει μάθει να προσέχει ο αθλητής είναι η σωστή ενυδάτωσή του κατά την διάρκεια ώστε να αποφύγει μία πολύ δυσάρεστη κατάσταση η οποία ακούει στο όνομα αφυδάτωση. Ομως το να πίνω όσο περισσότερο μπορώ δεν είναι απαραίτητα και τα καλύτερο. Αυτό έγινε ακόμα πιο ξεκάθαρο όταν ερευνητές (η κλασσική έρευνα των Speedy, Noakes et al)  το 1999 δημοσίευσαν έρευνα που  έκαναν το 1998 στο Ironman της Νέας Ζηλανδίας και έφεραν στο φως της δημοσιότητας το θέμα της Υπονατραιμίας.  Μέχρι τότε αυτό που ακούγαμε ήταν η οδηγία «πίνετε όσο περισσότερο μπορείτε» στο ποδήλατο και το τρέξιμο. Ας δούμε τί βρήκαν οι ερευνητές στο Ironman της Νέας ζηλανδίας. Το 18% από τους 330 αθλητές που τερμάτισν το Ironman ήταν υπονατραιμικοί και οι ερευνητές εικάζουν ότι στο 73% αυτών των περιπτώσεων αυτό οφειλόταν σε υπερβολική δόση νερού/ υγρών/ ενυδάτωσης. Ομως και σε άλλες περιπτώσεις αγώνων Ironman είχαμε έντονη καταγραφή του φαινομένου

 

 

 

Ας δούμε αρχικά τί είναι αυτό το φαινόμενο. Ως υπονατραιμία έχει οριστεί η περίπτωση όπου η συγκέντρωση κατιόντων νατρίου (Να+) είναι μικρότερη από 136mmol/L.  Μπορεί να προκληθεί για δύο λόγους : είτε λόγω της εξάντλησης/ αποσυμφόρησης (depletion) του Νατρίου του σώματος είτε λόγω της παρατεταμένης συσσώρευσης ύδατος κάτι που δημιουργεί την λεγόμενη αραιωτική (dilutional) υπονατραιμία.

H αποσυμφορητική προκαλείται λόγω διαιτητικής έλλειψης νατρίου, την απώλεια του νατρίου από το γαστροεντερικό σύστημα, την απώλεια νατρίου από το νεφρικό σύστημα και την χορήγηση διουρητικών. Αντίστοιχα η αραιωτική υπονατραιμία προκαλείται από χορήγηση περίσσειας υγρών, την οξεία νεφρική ανεπάρκεια, την συμφορητική βλάβη της καρδιάς και τις πρωτείνες ορού (υποαβουμιναιμία). Αυτές όμως είναι οι γενικές αιτίες της πρόκλησης της υπονατραιμίας.

Στο Τρίαθλο η μη σωστή χορήγηση ηλεκτρολυτών, η υπεβολική  και η υπερβολική εφυδάτωση με νερό (τις προηγούμενες ημέρες, κατά την διάρκεια του αγώνα ή μετά) είναι αυτή που μπορεί να προκαλέσει την υπονατραιμία σε συνδυασμό την απώλεια του νατρίου λόγω εφίδρωσης.

 

Τί προκαλεί η υπονατριαμία ; Είναι αυτοννόητο ότι ανάλογα με την ένταση του φαινομένου, δηλαδή πόσο χαμηλά θα πέσει η συγκέντρωση των κατιόντων νατρίου, έχουμε και αντίστοιχα συμπτώματα. Παρατηρούνται όμως μεταξύ άλλων τα εξής : Κράμπες, ναυτεία, ανορεξία, λήθαργος και σύγχυση και ακόμα περαιτέρω με παροξυσμό σπασμών, κώμα….και ακόμα και θάνατο. Για να εξηγήσουμε απλά γιατί έχουμε τα σημαντικά συμπτώματα να πούμε απλοικά ότι η μείωση της συγκέντρωσης κατιόντων νατρίου στα πλάσμα δημιουργεί οσμωτικές ανισορροπίες και έτσι έχουμε την εισροή νερού στον εγκέφαλο. Αυτό το φαινόμενο προκαλεί τις σημαντικές νευρολογικές διαταραχές, όπως η ναυτία, η ζαλάδα και …δυστυχώς και τον θάνατο. Αναφέροντας παραπάνω για τη σημασία της πτώσης να αναφέρουμε ότι όταν η συγκέντρωση είναι μεταξύ 125-135 mmol/l τότε έχουμε πιο πολύ γαστροεντερικές διαταραχές, βλ ναυτία. Από εκεί και κάτω έχουμε τις σοβαρές επιπλοκές που αναφέραμε και στις οποίες λόγω του αθλητικού ενδιαφέροντος του άρθρου να προσθέσουμε την αδυναμία συγχρονισμού των κινήσεων καθώς την ασυνήθιστη αίσθηση κόπωσης. Κάτω από τα 120mmol/ lt έχουμε περιπτώσεις όπου ο αθλητής πέφτει σε κώμα ή πεθαίνει.

Πρακτικά η υπονατραιμία στους τριαθλητές προκαλείται στις εξής περιπτώσεις :

  • Μεγάλη απώλεια ιδρώτα, και κατά συνέπεια νατρίου, και ταυτόχρονη ενυδάτωση (συνεπώς περαιτέρω μείωση της συγκέντρωσης των κατιόντων νατρίου)
  • Πολύ μεγάλη συγκέντρωση νατρίου στον ιδρώτα που παράγει ο αθλητής
  • Πολύ γρήγορη απορρόφηση του νερού
  • Μεγάλη ποσότητα νερού για να γίνει αραίωση σε ουσίες ντόπινγκ και να πέσει η συγκέντρωσή τους.
  • Μεγάλη λήψη γλυκερόλης
  • Εντονη υπεργλυκαιμία, υψηλό ποσοστό σακχάρου αίματος.
  • Υπερβολική ανυδάτωση τις προηγούμενες μέρες, πολύ μεγαλύτερη από αυτή που μπορεί να αποβάλλει με τα ούρα ο αθλητής.
  • Μικρόσωμοι τριαθλητές και γυναίκες έχουν μεγαλύτερες πιθανότητες να υποστούν υπονατραιμία.

Ομως πρέπει να εξηγήσουμε ότι αντίστοιχα έχουμε και την υπερνατραιμία, δηλαδή την περίπτωση όπου η συγκέντρωση των κατιόντων νατρίου στον ορό είναι μεγαλύτερη από 148mmol/L και συνήθως αυτό είναι το αποτέλεσμα της αφυδάτωσης όμως και η χορήγηση υπερτονικών διαλυμάτων μπορούν να οδηγήσουν σε αυτή την κατάσταση όπου τα κλινικά συμπτώματα είναι πάλι πολύ σιβαρά : λήθαργος, παροξυσμός σπασμών, απώλεια συνειδήσεως, κώμα και δυστυχώς κι πάλι θάνατος.

 

Πρακτικές συμβουλές

Προτίμηση των διαλυμάτων ηλεκτρολυτών έναντι του νερού. Γενικά προτείνεται να λαμβάνουμε 0,5 έως 0,7 γραμμάρια αζώτου για κάθε ώρα άσκησης να και πολύ ειδική προτείνουν το 1γραμμάριο ανά ώρα άσκησης. Εάν έχουμε σημαντικό πρόβλημα απώλειας αζώτου από τον ιδρώτα μας τότε μπορούμε να επιλέξουμε κατάλληλο διάλυμα διάλυμα. Στην αγορά υπάρχουν σκευάσματα που δίνουν συγκεντρώσεις μέχρι και 60 mmol. Σε κάποιες περιπτώσεις οι ταμπλέτες νατρίου ίσως είναι καλή περίπτωση καθώς μπορούμε να τις λάβουμε ανά πάσα στιγμή.

Ναι μεν σωστή ενυδάτωση τις προηγούμενες μέρες αλλά όχι υπερβολές, πάνω από 1000 Ml την ώρα (δηλαδή την μέγιστη ποσότητα που μπορεί να αποβάλλει μέσω ούρων ο αθλητής)

Ζύγισμα πριν από αγώνα, η προπόνηση, και μετά για υπολογισμό της απώλειας υγρών.

Εάν τυχόν ζυγιστούμε μετά τον αγώνα και έχουμε πάρει κιλά αυτό φανερώνει την υπερβολική ενυδάτωση. Χαρακτηριστικά θυμάμαι ξένη εθνική ομάδα η οποία για την προετοιμασία της για τους ΟΑ της Αθήνας ζυγζίζονταν οι αθλητές συνεχώς μετά την προπόνηση για να δούν τις απώλειες ιδρώτα και αντίστοιχα να υπολογίσουν την ποσότητα των υγρών που θα λάβουν.

Δεν πρέπει να αγωνιζόμαστε έχοντας λάβει φαρμακευτική αγωγή, από την απλή ασπιρίνη ως και μη στεροειδή αντιφλεγμονώδη.

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