Avoid adding insult to injury - correct management of sick female endurance athletes

Tamara Dawn Hew-Butler, Jeremy Boulter, Rehana Bhorat, Timothy D Noakes


Objectives. To evaluate the efficacy of Ringer’s lactate, isotonic saline and hypertonic saline on the clinical and biochemical recovery of athletes with exercise-associated hyponatraemic encephalopathy caused by fluid overload.

Methods. We retrospectively reviewed serial blood sodium concentrations (Na+) and qualitative signs of recovery and time to recovery in two healthy menstruant females hospitalised with dilutional exercise-associated hyponatraemic encephalopathy after withdrawal from the 2011 Comrades Marathon (89 km) and Argus Cycle Tour (109 km).

Results. Improvements in blood Na+ did not occur with intravenous administration of Ringer’s lactate solution, but did occur with administration of isotonic and hypertonic saline. Qualitative improvements in mental status were not quantitatively related to the biochemical value of blood Na+ or subsequent return to normonatraemia.

Conclusions. Hyponatraemia should be suspected in all female athletes presenting to the medical area of endurance races with vomiting, altered mental status and a history of high fluid intake. If a diagnosis of exercise-associated hyponatraemia with cerebral encephalopathy is confirmed, the treatment of choice is administration of an intravenous bolus of hypertonic saline. Administration of Ringer’s lactate should be discouraged, as this does not correct Na+ and appears to delay recovery.

Authors' affiliations

Tamara Dawn Hew-Butler, School of Health Science, Oakland University, Rochester, MI, USA

Jeremy Boulter, Chief Medical Officer, Comrades Marathon, Scottsville, Pietermaritzburg

Rehana Bhorat, Vincent Pallotti Hospital, Cape Town

Timothy D Noakes, MRC/UCT Research Unit for Exercise Science and Sports Medicine and Department of Biology, University of Cape Town

Full Text



hyponatraemia; hypertonic saline

Cite this article

South African Medical Journal 2012;102(12):927-930. DOI:10.7196/SAMJ.6156

Article History

Date submitted: 2012-07-23
Date published: 2012-10-22

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