IMCDA was unusually hot and with the low humidity and no water in the last 8 or more miles, you probably severly dehydrated. Do a forum search on NSAIDs and read Joe Moyas answer to a question like yours from IMUtah. One of the causes of orthostatic hypotension is dehydration. Be very careful about your hydration next time and lay of the Alleve.

Bob Sigerson

... can't be sure... but what I feel certain about is the Naxopren probably compounded/caused the Hyponatremia. In fact, if you did have Hyponatremia, the IV's complicated this issue as well. Lucky you didn't die or at least need a dialysis machine the rest of your life.

Words of wisdom... don't take Anti-inflamatories and do endurance events. Anti-inflamatories are designed for recovery. It should not be a performance enhancement.

Symptoms of Hyponatremia and Dehydration are very similar with only common delineating symptom being vomiting.

Now if your kidney's weren't damaged (and perhaps liver), you should consider yourself lucky. Doping for a race is dangerous business - people have died doing what you did - taking NSAID's prior to and/or during an endurance race or training session.

Simple rule: Never take any NSAID (OTC or Prescription) at least 24-48 hrs. before a long endurance event (depending on dosage level and length of time on NSAID's).

Take this as a learning experience and pass it on to others who think NSAID's are harmless.

FWIW Joe Moya

Not to mention that you MORE THAN DOUBLED the recommended dosage for Naproxin. The max dose is 3 per 24 hour period (1-2 initially, then 1 more, if needed, twelve hours later). You said you took 5-6 over the course of an IM! Probably a poor choice.

This is a little chilling to here. Both the naproxen intake and the hydration issue. You may have to consider that you had a volume induced hyponatremia -- hard to figure on a hot day but you said "large amounts of water" that combined with the Naproxen could have thrown off your sodium regulation. I'd recommend you do a search here on NSAIDS, hyponatremia. Then I'd have a conference with my doc who will need the records from the hospital, he/she can get them -- I have to wonder what your electrolytyes looked like. Do not take this lightly, not that you have, severe hyponatremia is a medical emergency and can result in seizure or much worse. Get your physician on board with this, you need to know what happened!

Don't know if this applies at all, but here goes...

Were you drinking very high concentration carbohydrate during or prior to the race?

The reason I ask is that it's possible to be subjectively overhydrated and objectively dehydrated (been there, done that).

In '00, finished our state TT championship under very hot/humid conditions, and then felt progressively worse and worse after the race -- paramedics checked my pulse and bp and told me in good Monolopoly Game fashion to "Go directly to ER, do not collect your (age group) winner's medal" (until later).

Though I'd downed litre after litre of water, turned out I was severely underhydrated because I'd mixed into it a way-to-strong solution of powdered CarboLoad, which the stomach simply can't absorb easily under stress in highly excessive concentrations.

So I (like you), took bag after bag of saline -- then ralphed up virtually all the "water" (read water/Carbo sludge) I'd downed all morning/afternoon. Surprised the hell out of the ER nurse, and me as well.

Sorry for the unsavory details -- but to return to the question in my second sentence above...

What I learned -- the hard way -- is that it's not just how much you drink, but also whether or not that liquid is in usable form under stress.

No slam on CarboLoad -- it's great stuff, and have won three more state TT titles using it (and/or Extran). But in proper/recommended concentration.

Hope this helps, and is not completely wide of the mark. If not relevant to your case, may be a cautionary tale for someone else.

Yikes. Glad that you're OK.

I have no medical background so am not trying to offer advice. So please don't take anything I say as anything more than anecdotal observations. That said, I'd be curious to know how long you were out on the course. The majority of cases of hyponatremia that I've heard about occur in participants of endurance events (such as marathons) who compete at a low exertion level. These people tend to sweat out less fluid yet still consume what often appears as normal to heavy amounts of water while on the course. Given that IMs by their nature tend to be low exertion events for the vast majority of participants, I'd expect Hyponatremia to be a little more common in them. Do you have any idea how much water and other fluids you ingested on the course? What else was your nutrition like? There may be other factors that slowed the absorption of the fluid until after the race whan the IVs were being pumped in as well.

oh my god......

I had no idea. I was actually told that taking some Naproxen during the race was ok.....not the amount that I took obviously. I realized at the end of the race, the amount I consumed and wondered what the damage would be. I have to say after reading your response I am thankful to be alive. This has been the most bone chilling response I have read in regards to my race. Luckily I have no liver or kidney problem and I am back to training. I have to thank you for your honesty and information. I feel ashamed for my ignorance and thank you again.

Vanessa

hi all -

you say not to take any NAISDs (or whatever they are).... does this mean things like ibuprophen or Alleve? I don't know what NAISDs are. Thanks - trying to learn from other people's mistakes (always a first time....)

NSAID's is the anacronym for Non-Steroidal Anti-Inflamatory Drugs.

And Yep, that means ALL common OTC and prescription anti-inflamatory drug... which includes Ibuprophen.... To keep it simple, NSAID's have the potential to damage your kidney... and certain and more common OTC drugs such as Tylenol and Asprin also have a potential to damage your liver (as well as your kidneys).

Look at this thread, it has a lot of good information:

http://www.slowtwitch.com/...20dehydration;#29209

or

http://www.slowtwitch.com/...20dehydration;#34103

If you want more details... do a search of this NG - keywords "NSAID dehydration". Lot's of good posts by Taku and others.

FWIW Joe Moya

What you experienced is a combination of dilutional hyponatremia and congestive heart failure. The NSAIDs did not help either.

Hyponatremia is the condition where the concentration of Sodium drops to a too low level. People in Iron man distance races are very susceptile to this... the reason is not what you would expect... When you are in a race you are out there for a long time, which gives you a long time to drink a lot of water. Water obviously has less salt than your blood. Becasue you are out there for so long you can start diluting your blood without knowing it. The slwoer you run, the less you sweat, the more water your stomach is able to handle, and the more water you are able to absorb. Also losing salt in your sweat is not helping you any either... the kicker with waht happened to you is that the fluid of choice unless otehrwise indicated is called normal saline. Normal slaine does not have enough sodium to replace what you have lost and all you are doing is making your blood more dilute. Severe hyponatremia can lead to coma, seizure and death.

The NSAIDs are not helpign in anyway though. Drugs like NSAIDs can block the kidneys ability to regulate the filtration of fluid through the compnents of the kidneys by blokcing the production of the regulatory hormones called prostoglandins. As a result you don't get enough blood to your kidneys which makes it hard for your body to get rid of the water.

Now this combined with your heart having trouble pumping because of the excess fluid leads you to a very bad situation where you are having trouble getting rid of the water. Water is also spillign over into your lungs (congestive heart failure) making it hard to breathe...

Moral of the story
- if you feel bad it is not necessarily a sign that you are dehydrated
- Don't take NSAIDs... try some ice bags, take the NSAIDs later
- In the medical tent always try to 1st rehydrate by mouth
- Use salt, drink sports drinks, watch the water intake.

A good article on hyponatremia... http://www.rice.edu/~jenky/sports/salt.html

Taku:

If I understand correctly, a sports drink like Extran does not contain sodium and therefore salt tablets should be used by those using Extran (as opposed to say Gatorade which does contain sodium). Is this correct?

---

Gerard Vroomen
3T.bike
OPEN cycle

I really don't know much about extran but I have to say htat I am surprised that it has no sodium.

Gatorade was created by a cellular physiologist who was working with a channel in the intestinal epithelium. This channel transported glucose along with sodium accross the epithlium (allowing it to be absorbed) Water will follow wherefever sodium goes. By adding glucose (sugar) to the mixture more sodium was able to be absorbed (in addition to whatever sodium/water you are able too absorb in other manners) This works so well that this is the basis for the world health organization Oral Rehydrtation solution which is the accepted treatment for cholera.

The common misconception is that the ingredients in these drinks are designed to replace things which are lost (which it does) the primary goal is to replace water efficiently.

Which brings me to the circuitous answer... If extran is going to be used as a rehydration solution it may not be as efficient as a gatorade type drink at rehydration. If that is your goal, it may be advisable to take in some extra salt. I really don't know enough about extran to make a more inteligent answer nor am i a intestinal physiologist. I will look into it and get back to you

Taku. I did IMCDA. After the bike I had terrible cramps in my quads. Never happened before. At every 10 miles took a 25oz of gatorade and one GU packe over the 112 miles plus 3 bottles of water,so thats 11x25ozs of gatorade plus GU in 6.5hrs . I recently had someone tell me that my posssible problem was "I took in to much and could not process and that is what caused my distress. Is that possible? On the course eveyone just kept sayng "Get more salt in you.chicken broth ect...Is it possible I took in to much?I never had cramps like that before,still can not figure out what happened on race day. Thanks Kenney

You are not entirely correct. "Normal Saline" (NS)solution will correct hyponatremia. NS has a sodium concertration of about 140 which is nearly identicle to normal serum sodium concentration. If someone is severely hyponatremic with a sodium concentration of say 125, then NS with a higher sodium contration will gradually correct this, not make it worse.

Probably been making the rounds in tri circles.

Middle of the paragraph covers three mechanisms of hyponatrimia.

http://www.trinewbies.com/phorum/thread-view.asp?threadid=12018&posts=7

find it here:
http://www.usatf.org/coaches/library/hydration/

Note they have recently changed their hydration guidelines due to concerns about hyponatremia. The specific incident I believe was a woman who died at the Boston marathon.

Its true that normal saline is isotonic with a Na concentration of 140 (the normal concentration of na) However there are many causes of hyponatremia (low concentration of sodium) which in clude hypovolemia (low volume) euvolemia (normal volume) and hypervolemia (which is the situation which this is)

Hypervolemic hyponatremia results when sodium is retained but retention of water exceeds that of sodium. This is seen in edematous states such as congestive heart failure (CHF), hepatic cirrhosis, and renal failure. In these conditions, decreased effective renal perfusion causes the secretion of both ADH and aldosterone. This leads to increased tubular reabsorption of both sodium and water, decreased delivery of water to the distal nephron, and inability to produce hypotonic urine.

The cornerstone of therapy for patients with hypervolemic hyponatremia is fluid restriction, which is effective in most patients. The addition of diuretics may accelerate water excretion, although this approach should be used with caution because sodium excretion is also enhanced. Dialysis may be required to remove large amounts of water in patients with advanced renal failure.

The difference in sodium is not the only problem which is seen in this patient, they have excess fluid... Excessive fluid can make things worse (depends on how bad they are) You can also make the fluid excess worse. Excess fluid can lead to some cardiac problems such as iatrogenic heart failure (caused by the doctor)

You are right that the sodium concentration will eventually comem back to normal, but you will probably run into problems before you could get back to normal

Yes, but do you think that someone would be hypervolemic after completing an Ironman in 90 degree temperatures no matter how much he drank. Almost impossible to become hypervolemic in that circumstance. I don't know what happened but I'm sure he started out dehydrated, or hypovolemic.

This is actually the counter intuitive thing that has come out within the last few years... It is actually very unusual to have a patient which is hypervolemic on their own however the iron man is not a nromal situation...

First off, you have a person who is drinking almost constantly for between 12 to 18 hours. The mantra in the past has been to drink as much as you can, then drink some more. Now what has happened in marathons and iron man events is that the popularity has drawn people who are not as fast as others, as a result they have more time to be on the course as a result they have more time to drink water, becasue they are going slower they can drink more and absorb more, and conutnerintuitively drink too much. It is definately not impossible, it is very probable. I was loooking through the medical volunteers packet for Ralp's half iron man, and the first thing that they tell you in the medical tent is not to assume that everyone needs an IV, and warnign about dilutional hyponatremia. The problem with the diltuional hyponatremia is that the symptoms are vague and easily confused with those of dehydration.

If you are interested in further reading here is a small list of ublications linking life threatening dilutional hyponatremia in Marathoners, ultra marathoners. long distance triatheltes, and army recruits. All of which have the similarity of extreme exercise for long periods of time, ample access to water, and the suggestion to drink as much as possible to stave ff dehydration... (if you need help getting copies of these just tell me.. they are all very interesting)


Frizzell RT, Lang GH, Lowance DC, et al: Hyponatremia and ultramarathon running. JAMA 1986;255(6):772-774
Noakes TD, Norman RJ, Buck RH, et al: The incidence of hyponatremia during prolonged ultraendurance exercise. Med Sci Sports Exerc 1990;22(2):165-170
Surgenor S, Uphold RE: Acute hyponatremia in ultra-endurance athletes. Am J Emerg Med 1994;12(4):441-444
Wolfson AB: Acute hyponatremia in ultra-endurance athletes. Am J Emerg Med 1995;13(1):116-117
Clark JM, Gennari FJ: Encephalopathy due to severe hyponatremia in an ultramarathon runner. West J Med 1993;159(2):188-189
Irving RA, Noakes TD, Buck R, et al: Evaluation of renal function and fluid homeostasis during recovery from exercise-induced hyponatremia. J Appl Physiol 1991;70(1):342-348
Davis D, Marino A, Vilke G, et al: Hyponatremia in marathon runners: experience with the inaugural Rock 'n' Roll Marathon. Ann Emerg Med 1999;34(4):S40
Ayus JC, Varon J, Arieff AI: Hyponatremia, cerebral edema, and noncardiogenic pulmonary edema in marathon runners. Ann Intern Med 2000;132(9):711-714
Speedy DB, Rogers I, Safih S, et al: Hyponatremia and seizures in an ultradistance triathlete. J Emerg Med 2000;18(1):41-44
Speedy DB, Noakes TD, Rogers IR, et al: A prospective study of exercise-associated hyponatremia in two ultradistance triathletes. Clin J Sport Med 2000;10(2):136-141
Speedy DB, Noakes TD, Rogers IR, et al: Hyponatremia in ultradistance triathletes. Med Sci Sports Exerc 1999;31(6):809-815
Montain SJ, Latzka WA, Sawka MN: Fluid replacement recommendations for training in hot weather. Mil Med 1999;164(7):502-508
Garigan TP, Ristedt DE: Death from hyponatremia as a result of acute water intoxication in an Army basic trainee. Mil Med 1999;164(3):234-238
Galun E, Tur-Kaspa I, Assia E, et al: Hyponatremia induced by exercise: a 24-hour endurance march study. Miner Electrolyte Metab 1991;17(5):315-320
Zelingher J, Putterman C, Ilan Y, et al: Case series: hyponatremia associated with moderate exercise. Am J Med Sci 1996;311(2):86-91
Shopes EM: Drowning in the desert: exercise-induced hyponatremia at the Grand Canyon. J Emerg Nurs 1997;23(6): 586-590
Backer HD, Shopes E, Collins SL, et al: Exertional heat illness and hyponatremia in hikers. Am J Emerg Med 1999;17(6):532-539

I see your point. It would be hard to do bu I suppose if you are walking and chugging for 15 hours it could happen. Got to be carefull out there.

This is a great thread. Thanks to all who participated.

-Robert

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"How wonderful it is that nobody need wait a single moment before starting to improve the world." ~Anne Frank

As a side note to what's already been mentioned by others is this:

Hyponatremia is not a normal problem of endurance events unless (so it seems) this condition is complicated/created by the use of NSAID's. While it is possible to become Hyponatremia without the help of NSAID's, It just not common (although I know of no research that quantifies my observation) without outside help from drugs.

When you think about Hyponatremia it counter intuitive to comfort. Hydrating while demands for fluids decline because of reduced effort doesn't seem to make sense. On the otherhand, I can see how an athlete who's trained consuming X amount of fluids may perceive that if he wants to increase his performance for the training session/race then he would want to drink more fluids (specially if he has ran out of sodium replacement drink). This would result in dilutional hyponatremia.

However, it's been my experience that most athlete's will naturally cut back on fluids as dehydration becomes less of an issue - except in situations where the athlete has trained themselves to the point they drink with the perception this will "give them the energy to go further or faster". This is an unusual situation. However, could a person become Hyponatremic if he is going slow and has a "lot of time on his hands" to simply add water to his system. Possibly... but, I think the body would also have the ability to realize it's over drinking. But then (again), urination should also help remidy the over-hydration problem (UNLESS, the kidney's are not working properly - ah... NSAID's rears it ugly head again).

When does this problem not seem to follow the norm... when NSAID's are introduced into the equation. In which case, the body is reacting to a bodies inability to process fluids (keeping the explanation simple simple). (IMHO) This why NSAID's are the primary culprit for Hyponatremia (And, what research I have read seem to also indicate this correlation between NSAID's and Hyponatremia). Hyponatremia doesn't seem to "just" happen as a part of endurance racing and/or training.

In short, it's when the kidneys are not functioning properly is when problems develop. It's less likely for dilutional Hyponatremia to develop because an athlete drank to much fluids (water). While it is possible... still, my intuition says otherwise. Most athletes just can't (nor want to) drink themselves to the point of illness. In fact, the bodies natural reaction is to vomit when excess fluids build up in the stomach. If not, the stomach fills to point of discomfort that it's been described as like "running with a bowling ball in your stomach". This natural reaction occurs long before hyponatremic reaction develops.

FWIW Joe Moya

BTW, as per my original post (and as Taku mentioned) adding Fluid to the athletes system complicated the issue. That's is why it's important for medical personal to understand that not all athlete's may need an IV. And, this knowledge is slowly moving into med. tent evaluation process (specially as more (and younger) athlete's don't realize the problems of what common OTC anti-inflamatories can cause).

I have a great idea...

If you dont have a really serious physical problem that requires you do take something... DONT!!!

Try a good breakfast and a good nights sleep... That will push your performance way further then a drug... Be care.... Dont kill yourself by mistake you silly monkeys....