Board of Directors , Neuro Critical Care Society ( NCS). | Chairperson Asia Ocean chapter of NCS.
Past President ISCCM.
Past President SNCC.
A 45-year-old male is admitted to the ICU following a severe traumatic brain injury (TBI) with subarachnoid hemorrhage. To manage cerebral edema, he is receiving intermittent doses of mannitol and a continuous 3% hypertonic saline infusion. By day 3 post-injury, he develops polyuria and a rising serum sodium level that has now reached 164 mmol/L. Despite aggressive fluid replacement, his serum sodium continues to climb, and he develops hypotension, necessitating further fluid resuscitation. Laboratory results reveal a creatinine of 1.6 mg/dL (baseline 0.9 mg/dL), low urine sodium concentration, serum hypernatremia, and high plasma osmolality.
The ICU team is now facing a diagnostic and therapeutic dilemma: Is this Diabetes Insipidus (DI), Cerebral Salt Wasting (CSW), or a combination influenced by hyperosmolar therapies and mild renal impairment?
(Click / Tap on Questions to Reveal Content)
Explanation
In patients with acute brain injury due to traumatic brain injury or subarachnoid hemorrhage, differentiating Diabetes Insipidus (DI) from Cerebral Salt Wasting (CSW) can be challenging—especially when hyperosmolar therapies (mannitol, hypertonic saline) are used.
● Diabetes Insipidus (DI) typically presents with polyuria (large volumes of dilute urine), hypernatremia, low urine osmolality, and a marked response to desmopressin.
● Cerebral Salt Wasting (CSW) usually presents with polyuria with high urine sodium, hyponatremia, high urine osmolality, and volume depletion that is resistant to isotonic fluid replacement.
In this case, the patient’s hypernatremia and polyuria suggest DI, but CSW cannot be entirely excluded due to ongoing hyperosmolar therapy potentially masking typical hyponatremia. Urine sodium/osmolality measurements and a desmopressin trial are key to confirming DI.
Figure 1: Initial Clinical and Biochemical Assessment
Key Takeaway:
Diabetes insipidus (DI) and cerebral salt wasting (CSW) share overlapping clinical features, including polyuria and hypovolemia, particularly in patients with traumatic brain injury (TBI) or subarachnoid hemorrhage (SAH). However, their pathophysiology and biochemical profiles differ. DI commonly leads to hypernatremia due to impaired water retention, whereas CSW results in hyponatremia, though prior hypertonic therapy can sometimes obscure this finding. Urine studies offer crucial diagnostic clues: DI is characterized by low urine osmolality (<300 mOsm/kg) and low urine sodium (<20 mmol/L), whereas CSW exhibits high urine osmolality (>500 mOsm/kg) and high urine sodium (>40 mmol/L). The desmopressin (DDAVP) test aids in differentiation—a significant rise in urine osmolality (>50%) supports DI, while minimal or no response suggests CSW or nephrogenic DI. Early recognition and targeted intervention are critical to optimizing patient outcomes.
Explanation
In patients with TBI or SAH who develop polyuria and sodium imbalances, differentiating DI from CSW becomes challenging when mild renal impairment and hyperosmolar therapies (e.g., mannitol, 3% saline) coexist. Both DI and CSW can produce significant changes in urine output and electrolyte handling, and kidney dysfunction further blurs the lines by affecting the kidneys’ ability to concentrate urine and manage electrolytes.
Figure 2: Impact of Mild Renal Impairment on DI and CSW ?
Figure 3: Key Laboratory Differences in DI vs. CSW with Renal Impairment
Key Takeaway
Mild renal impairment significantly modifies the expected patterns of urine output and electrolyte handling in both DI and CSW. With concurrent hyperosmolar therapy, urine sodium and osmolality remain the most critical differentiators—alongside a DDAVP trial for suspected DI. Accurate assessment of renal function and judicious fluid/electrolyte replacement strategies are essential to avoid exacerbating either hypernatremia or sodium depletion.
In this TBI and SAH patient, hyperosmolar therapy (mannitol, 3% saline) is used for cerebral edema but has led to polyuria, hypernatremia (164 mmol/L), hypotension, and renal impairment (Cr 1.6 mg/dL). These worsening fluid and electrolyte imbalances necessitate a decision on modifying or discontinuing therapy.
Key Factors in Decision-Making:
1. Serum Sodium & Osmolality
2. Urine Output & Renal Function
3. Neurological Status & ICP
4. Fluid & Electrolyte Management
5. Re-Evaluation & Alternative Strategies
Figure 4: Decision Pathway for Modifying/Stopping Hyperosmolar Therapy
Figure 5: Hyperosmolar Therapy Risks and Management Adjustments
Key Takeaway
In managing hyperosmolar therapy, dose adjustments are necessary when serum sodium exceeds 160 mmol/L despite fluid resuscitation along with worsening renal impairment (rising creatinine). Additionally, neurological deterioration due to cerebral dehydration necessitates intervention. Hypernatremia should be corrected gradually using hypotonic fluids such as D5W or 0.45% NaCl, ensuring the rate of sodium correction does not exceed 8–10 mmol/L/day to prevent cerebral edema. If hyperosmolar therapy is discontinued, alternative intracranial pressure (ICP) management strategies should be considered, including optimizing cerebral perfusion through sedation, head positioning, external ventricular drainage (EVD) and decompressive craniectomy without excessive reliance on osmotherapy. Frequent monitoring of serum sodium, osmolality, urine output, neurological status (ICP, changes in consciousness), and renal function (creatinine, urine sodium) is essential to guide therapy and prevent complications.
Explanation
This critically ill TBI/SAH patient with polyuria, hypernatremia (164 mmol/L), hypotension, and mild renal impairment (Cr 1.6 mg/dL) presents a challenging scenario for fluid management due to various combinations of possible Diabetes Insipidus (DI) or Cerebral Salt Wasting (CSW), and the effects of hyperosmolar therapy (mannitol, 3% saline).
The goals of fluid management are:
1. Restore intravascular volume while avoiding fluid overload with the help of hypotonic saline and low dose vasopressors
2. Correct hypernatremia cautiously using hypotonic fluids (D5W, 0.45% NaCl) to prevent cerebral edema
3. Discontinue hyperosmolar therapies (mannitol, 3% saline) if they worsen fluid imbalance and AKI.
4. Assess for DI and manage with desmopressin (DDAVP) if confirmed.
5. Monitor sodium, renal function, urine output, and ICP closely.
Figure 6: Decision Pathway for Fluid Management in TBI with Hypernatremia & Hypotension
Figure 7: Hypernatremia Correction and Monitoring Strategy
Key Takeaway
Managing hypernatremia in critically ill patients requires a structured approach to identifying underlying causes, restoring circulatory volume, and preventing complications. Hyperosmolar therapy, such as mannitol or 3% saline, may significantly contribute to hypernatremia and should be reassessed or discontinued if necessary. Circulatory volume should be restored using 0.45% NaCl instead of normal saline, with early vasopressor support (noradrenaline ± vasopressin) for hypotension. Dynamic hemodynamic assessments, including stroke volume variation (SVV), pulse pressure variation (PPV), passive leg raise (PLR), velocity time integral-cardiac output (VTI-CO), and inferior vena cava (IVC) distensibility, help guide fluid resuscitation. Hypernatremia correction must be gradual to prevent cerebral edema, using calculated free water replacement with D5W or 0.45% NaCl, ensuring the serum sodium reduction rate does not exceed 8–10 mmol/L per day, with frequent monitoring every 2–4 hours. Management of suspected DI includes desmopressin (DDAVP) and free water replacement for central DI, while nephrogenic DI may require hypotonic fluids and thiazide diuretics. In contrast, CSW necessitates sodium replacement via isotonic fluids and salt supplementation. Continuous neurologic and renal monitoring is essential, incorporating intracranial pressure (ICP) assessment through external ventricular drains (EVD), transcranial Doppler (TCD), and brain oxygenation metrics. Electrolyte and renal function monitoring (sodium, osmolality, creatinine, and urine output) ensures therapy adjustments based on evolving clinical status.
Explanation
In this critically ill TBI/SAH patient with polyuria, hypernatremia (164 mmol/L), and hypotension, central Diabetes Insipidus (DI) is the most likely cause due to hypothalamic-pituitary damage.
Vasopressin/Desmopressin therapy (IV or SC) is the treatment of choice for central Diabetes Insipidus (DI).
•IV Vasopressin is preferred in ICU in view of rapid onset, easy titration, and precise control in critically ill patients.
•SC Desmopressin (DDAVP) is a selective, longer-acting agent and is suitable for stable patients. It is not ideal in acute ICU settings in view of its delayed onset of action.
Key goals of the Vasopressin/ Desmopressin therapy include:
1.Reduce polyuria to prevent excessive water loss.
2.Gradually correct hypernatremia to avoid cerebral edema.
3.Stabilize hypotension by improving intravascular volume.
Table 1: Key differences between IV Vasopressin and SC Desmopressin
Figure 8: Decision Pathway for Vasopressin Use in TBI/SAH with Hypernatremia & Polyuria
Key Takeaway
IV Vasopressin is preferred in acute ICU settings. SC Desmopressin is the agent of choice in stable patients.
Explanation
In this critically ill TBI/SAH patient with hypernatremia, polyuria, and hypotension, frequent monitoring of serum sodium, plasma osmolality, and urine electrolytes is essential to guide fluid therapy, prevent rapid shifts, and avoid complications like cerebral edema and osmotic demyelination syndrome (ODS).
Monitoring Intervals:
•Serum Sodium: Every 2-4 hours initially, then every 6-12 hours once stable.
•Plasma Osmolality: Every 6-8 hours if on mannitol or 3% saline.
•Urine Sodium & Osmolality: Every 6-8 hours to differentiate DI vs. CSW.
Correction Goals:
•Hypernatremia correction should not exceed 8-10 mmol/L per 24 hours (preferably 4-6 mmol/L in severe cases).
Rapid sodium shifts can cause:
•↓ Too fast → Cerebral edema.
•↑ Too fast → Osmotic demyelination syndrome (ODS).
•Avoid further hyperosmolar agents (mannitol, 3% saline) if osmolality rises too fast.
Figure 9: Monitoring Plan for Electrolytes & Osmolality
Figure 10: Safe Correction of Hypernatremia
Key Takeaway
In critically ill patients with traumatic brain injury (TBI) or subarachnoid hemorrhage (SAH), frequent monitoring of serum sodium, plasma osmolality, and urine studies is essential to guide safe sodium correction and differentiate diabetes insipidus (DI) from cerebral salt wasting (CSW). Hypernatremia must be corrected gradually, with a target rate of no more than 8–10 mmol/L per 24 hours (ideally 4–6 mmol/L in severe cases) to prevent the risk of cerebral edema. Overly rapid correction increases the risk of osmotic demyelination syndrome (ODS), necessitating close neurological monitoring. Ultimately, a slow, controlled approach to sodium correction, combined with vigilant electrolyte and neurological monitoring, is critical to avoiding complications and optimizing patient outcomes.
Explanation
In this TBI/SAH patient with hypernatremia (164 mmol/L), polyuria, and hypotension, early Continuous Renal Replacement Therapy (CRRT) may help gradually correct hypernatremia and stabilize plasma osmolality when fluid therapy alone is ineffective. However, hemodynamic instability is a major concern.
Benefits of Early CRRT
1.Controlled Hypernatremia Correction – CRRT slowly lowers sodium levels (<8-10 mmol/L per 24h), preventing cerebral edema & osmotic demyelination syndrome (ODS).
2.Improved Fluid Balance – facilitates free water replacement while avoiding fluid overload.
3.Neuroprotection – Prevents rapid osmolality shifts that can worsen ICP & brain edema. Also it helps in the reduction of neuroinflammation.
Risks of Early CRRT
1.Hypotension & Hemodynamic Instability – Ultrafiltration may worsen hypotension, requiring vasopressors & low UF rates.
2.Electrolyte Imbalances – May cause hypokalemia, hypocalcemia, or hypomagnesemia
3.Coagulopathy & Clotting Issues – Severe TBI/SAH patients may have increased bleeding risks.
When to Consider Early CRRT?
•Persistent hypernatremia (>160 mmol/L) despite fluid therapy.
•Worsening AKI with impaired sodium/water handling.
•Increased ICP requiring controlled osmolality adjustments.
Figure 11: Decision Pathway for Early CRRT in TBI/SAH with Hypernatremia
Figure 12: CRRT Benefits vs. Risks
Key Takeaway
In critically ill patients with traumatic brain injury (TBI) or subarachnoid hemorrhage (SAH) and persistent hypernatremia, continuous renal replacement therapy (CRRT) offers a controlled approach to correcting sodium imbalances while maintaining osmotic stability. CRRT helps prevent rapid sodium shifts, reducing the risk of cerebral edema, and effectively manages fluid overload and acute kidney injury (AKI). Early initiation of CRRT should be considered when hypernatremia remains above 160 mmol/L despite fluid therapy, plasma osmolality is critically elevated due to hyperosmolar agents, or conventional fluid management poses risks of cerebral edema or volume overload. Given the complexity of care, CRRT initiation should be a multidisciplinary decision involving ICU, nephrology, and neurology teams, ensuring an individualized approach that aligns with the patient’s fluid status, renal function, and intracranial pressure (ICP) management needs.
Managing hypernatremia (164 mmol/L) in a critically ill TBI/SAH patient with polyuria, renal impairment, and cerebral edema is challenging and requires a multidisciplinary approach to optimize neurological, renal, and hemodynamic outcomes while preventing osmotic demyelination syndrome (ODS) and acute kidney injury (AKI).
Figure 13: Multidisciplinary Approach to Hypernatremia in TBI/SAH
Elder Protection Planning protected family assets successfully.
Эстетика и функциональность: стеклянные душевые ограждения от производителя
душевые ограждения из стекла на заказ [url=https://steklo777777.ru/]https://steklo777777.ru/[/url] .
Лучшие корпоративные сувениры с логотипом под ключ
сувенирная продукция [url=https://www.suvenirnaya-produktsiya-s-logotipom-1.ru/]https://www.suvenirnaya-produktsiya-s-logotipom-1.ru/[/url] .
Лечение алкоголизма у пожилых: особенности и методы терапии
лечение алкоголизма стационар [url=http://spb-lechenie-alkogolizma.ru/]http://spb-lechenie-alkogolizma.ru/[/url] .
Аренда яхты — это просто: от звонка до отплытия за один день
яхта в сочи аренда [url=https://www.arenda-yahty-sochi323.ru/]https://www.arenda-yahty-sochi323.ru/[/url] .
Этапы строительства деревянных домов от подготовки участка до сдачи
деревянное строительство [url=https://stroitelstvo-derevyannyh-domov178.ru/]деревянное строительство[/url] .
Рокли от естествени материи за комфорт през целия ден
ежедневни рокли [url=http://www.rokli-damski.com]http://www.rokli-damski.com[/url] .
Деревянные дома под ключ из качественного материала и по разумной цене
строительство деревянных домов под ключ проекты и цены [url=http://www.derevyannye-doma-pod-klyuch-msk.ru]http://www.derevyannye-doma-pod-klyuch-msk.ru[/url] .
Dubai balloons tailored to your brand, color and message
birthday balloons [url=http://www.balloons-and-helium.com]http://www.balloons-and-helium.com[/url] .
Dubai balloons for festive vibes and Instagram-ready scenes
helium balloon [url=https://dubai-balloons-uae.com/]helium balloon[/url] .
Online stamp maker compatible with laser and traditional rubber stamps
stamp creator online free [url=https://mystampready-constructor1.com/]https://mystampready-constructor1.com/[/url] .
Create office rubber stamps online with ease and flexibility
stamp creator online free [url=https://stamps-creator-online1.com]https://stamps-creator-online1.com[/url] .
Отдых в Абхазии у моря с проживанием, питанием и экскурсиями
абхазия отдых 2025 [url=https://otdyh-v-abhazii-01.ru/]абхазия отдых 2025[/url] .
Роскошные бокалы для вина с тонкими стенками и идеальной формой для раскрытия аромата
бокалы для вина купить [url=https://bokaly-dlya-vina.website.yandexcloud.net/]https://bokaly-dlya-vina.website.yandexcloud.net/[/url] .
Фарфоровая посуда от Императорского завода: актуальные дизайны и классические формы
императорский фарфор интернет магазин [url=http://imperatorskij-farfor.website.yandexcloud.net/]http://imperatorskij-farfor.website.yandexcloud.net/[/url] .
Espectaculo aereo con drones 100% personalizado y dinamico
compañía de exhibición de drones [url=http://www.show0-de-drones.com/]http://www.show0-de-drones.com/[/url] .
Строим теплые каркасные дома в любое время года
каркасные дома цена под ключ [url=https://karkasnye-doma-msk-pod-kluch.ru/]каркасные дома цена под ключ[/url] .
Выгодный лизинг на коммерческий транспорт с быстрой доставкой по России
лизинг коммерческого транспорта для ип [url=http://www.lizing-kommercheskogo-transporta1.ru/]http://www.lizing-kommercheskogo-transporta1.ru/[/url] .
Кредит без отказа: полный список банков с лучшими условиями
взять кредит без отказа [url=investrost1.ru]investrost1.ru[/url] .
http://terios2.ru/forums/index.php?autocom=gallery&req=si&img=4747
http://terios2.ru/forums/index.php?autocom=gallery&req=si&img=4745
Выгодные условия рефинансирования кредита без потери льготных ставок
как рефинансировать кредит [url=https://kapitalinfo-team.ru]https://kapitalinfo-team.ru[/url] .
Проверьте кредитный рейтинг бесплатно и получите консультацию эксперта
как узнать свой кредитный рейтинг [url=https://dengivperedservice.ru/]https://dengivperedservice.ru/[/url] .
Быстрый калькулятор досрочного погашения для экономии на процентах
калькулятор досрочного погашения [url=http://finanspro24.ru/]http://finanspro24.ru/[/url] .
Espectaculo con drones de alta tecnologia y precision visual
empresa de espectáculos de drones [url=http://www.show0-de-drones.com/]http://www.show0-de-drones.com/[/url] .
Лизинг коммерческого транспорта с налоговыми преимуществами для бизнеса
лизинг оборудования [url=lizing-kommercheskogo-transporta1.ru/oborudovanie]lizing-kommercheskogo-transporta1.ru/oborudovanie[/url] .
Каркасный дом с продуманным зонированием и большой кухней-гостиной
каркасные дома санкт петербург [url=https://www.karkasnye-doma-spb-pod-kluch0.ru/]https://www.karkasnye-doma-spb-pod-kluch0.ru/[/url] .
Строим тёплые каркасные дома по современной технологии без задержек
каркасный дом [url=karkasnye-doma-pod-kluch-spb1.ru]karkasnye-doma-pod-kluch-spb1.ru[/url] .
Сравните цены на строительство каркасных домов с разными комплектациями
каркасный дом в спб [url=http://www.karkasnye-doma-spb-pod-kluch.ru/]http://www.karkasnye-doma-spb-pod-kluch.ru/[/url] .
Каркасный дом с утеплением и внутренней отделкой — заезжай и живи
дома каркасные спб [url=http://karkasnye-doma-pod-kluch-spb1.ru/]http://karkasnye-doma-pod-kluch-spb1.ru/[/url] .
Контрактные двигатели с гарантией работоспособности и технической проверки
купить мотор [url=https://www.kontraktnye-dvigateli1-minsk.ru/]https://www.kontraktnye-dvigateli1-minsk.ru/[/url] .
Авторазборки с быстрой доставкой автозапчастей по всей России
авторазбор [url=http://www.avtorazborka1-minsk.ru/]http://www.avtorazborka1-minsk.ru/[/url] .
Реальные примеры построенных каркасных домов с отзывами клиентов
дома каркасные под ключ проекты и цены [url=http://www.karkasnye-doma-msk-pod-kluch0.ru/]http://www.karkasnye-doma-msk-pod-kluch0.ru/[/url] .
Экспресс-доставка цветов в любую точку города
букет хризантем купить [url=cvety-s-dostavkoi.ru/rubric/khrizantemy]cvety-s-dostavkoi.ru/rubric/khrizantemy[/url] .
Каркасные дома в современном стиле с энергоэффективными решениями
дома каркасные под ключ москва [url=https://karkasnye-doma-msk-pod-kluch.ru/]https://karkasnye-doma-msk-pod-kluch.ru/[/url] .
Анонимный вывод из запоя без постановки на учет в СПб
вывод из запоя диспансер [url=http://www.vyvod-iz-zapoya-spb-1.ru/]http://www.vyvod-iz-zapoya-spb-1.ru/[/url] .
Are you refresh your look with genuine dreadlocks? Discover our collection of handmade dreadlocks at this link – dreads real hair, offering the highest quality options for achieving a flawless, natural look.
Crafted from ethically sourced hair, these dreadlocks are ideal for self-expression through hair. Whether you’re into clip-ins, we have options that suit curly, coily, or straight textures.
Find your fit with:
– human hair dreadlock extensions
– handmade dreadlocks
Get the look you love with premium-quality extensions that look and feel real. Smooth checkout available across the USA and beyond!
Claim yours today – you were meant to stand out.
https://mazda-demio.ru/forums/index.php?autocom=gallery&req=si&img=6335
Пластиковые окна с ламинацией под дерево для стильного интерьера
пластиковые окна монтаж [url=https://www.plastikovye-okna-master.ru/]https://www.plastikovye-okna-master.ru/[/url] .
Помощь при депрессии, тревоге и панике — психиатрическая клиника СПб
психиатрическая клиника санкт петербург [url=https://www.klinika-psikhiatrii-spb.ru]https://www.klinika-psikhiatrii-spb.ru[/url] .
Ready to elevate your hairstyle with real dreadlocks? Check out this range of dreadlock extensions at this link – dread natural, offering the highest quality options for achieving a flawless, natural look.
Expertly hand-crafted with premium natural hair, these dreadlocks are a great match for your unique personality. Whether you’re into clip-ins, we have options that match your exact texture.
Express yourself with:
– dread natural
– dreadlock extensions
Achieve that natural dreadlock vibe with premium-quality extensions that look and feel real. Top-rated customer service available across the USA and beyond!
Shop now – your dream style awaits.
Услуги сантехника с выездом и расчетом на месте
сантехник на дом недорого красносельский район [url=https://vyzov-santekhnika-0.ru/krasnoselskij-rajon/]https://vyzov-santekhnika-0.ru/krasnoselskij-rajon/[/url] .
Проведение выездной поверки манометров без задержек и бюрократии
поверка манометра с выездом на объект [url=https://www.poverkamanomterov.ru]https://www.poverkamanomterov.ru[/url] .
Услуги сантехника по замене труб, радиаторов и сантехнических узлов
сантехник мурино вызов на дом [url=http://www.vyzov-santekhnika1-spb.ru/murino/]http://www.vyzov-santekhnika1-spb.ru/murino/[/url] .
Современное оборудование и методики в платной наркологической клинике
наркоклиника спб [url=https://platnaya-narkologicheskaya-klinika-0.ru/]наркоклиника спб[/url] .
Варианты комфортного отдыха в Абхазии для пар и семей
отдых в абхазии без посредников [url=https://otdyhabhazia01.ru/]отдых в абхазии без посредников[/url] .
Клининг Москва: рейтинг компаний с лучшими ценами на рынке
клининговые компании москвы рейтинг [url=http://www.kliningovye-kompanii-msk1.ru]http://www.kliningovye-kompanii-msk1.ru[/url] .
Клининг в Москве: рейтинг лучших компаний с лицензией и страховкой
лучшие клининговые компании [url=https://kliningovye-kompanii-msk.ru/]https://kliningovye-kompanii-msk.ru/[/url] .
Ready to transform your vibe with real dreadlocks? Browse the best selection of handmade dreadlocks at the site – real dreadlock extensions, offering the highest quality options for achieving a flawless, natural look.
Carefully designed using real human hair, these dreadlocks are perfect for natural styling. Whether you’re into permanent styles, we have options that blend with curly, coily, or straight textures.
Choose your vibe with:
– dread natural
– handmade dreadlocks
Get the look you love with premium-quality extensions that look and feel real. Fast shipping available across the USA and beyond!
Claim yours today – you were meant to stand out.
Обновленный рейтинг компаний по ремонту квартир – только проверенные мастера
лучшие компании по ремонту квартир [url=remont-kvartir-reiting.ru]remont-kvartir-reiting.ru[/url] .
ППРК для сложных объектов – от промышленных площадок до городских стройплощадок
разработка ппрк [url=https://www.pprk-msk.ru]https://www.pprk-msk.ru[/url] .
Оконные компании с лучшими отзывами – рейтинг популярных производителей
пластиковые окна рейтинг компаний в москве [url=http://www.top-okon.ru]http://www.top-okon.ru[/url] .
Универсальные экраны для проекторов – модели для любого типа проекторов
экран для проектора настенные [url=https://www.proekcionnye-ehkrany0.ru/proekcionnye-ekrany/nastennyj-ekran-dlya-proektora]https://www.proekcionnye-ehkrany0.ru/proekcionnye-ekrany/nastennyj-ekran-dlya-proektora[/url] .
Срочный сантехник СПб – стоимость работ без переплат
сантехник спб цены [url=https://santeh1-montazh-price.ru/]сантехник спб цены[/url] .
Современная спецтехника Unisteam com – надежность, проверенная временем
заводы по производству спецтехники в россии unisteam com
Never miss a verification code – receive SMS online with 24/7 availability
receive sms [url=http://www.rskswap.com/]http://www.rskswap.com/[/url] .
Услуги по оформлению пропуска в центр Москвы для Газелей с разными параметрами
оформить пропуск на газель в центр москвы [url=https://propusk-v-centr-dlya-gazeli.ru/]https://propusk-v-centr-dlya-gazeli.ru/[/url] .
Производство светодиодных светильников для промышленных объектов и складов
светильник светодиодный прожекторный [url=https://proizvodstvo-svetodiodnih-svetilnikov.ru]https://proizvodstvo-svetodiodnih-svetilnikov.ru[/url] .
Spotify подписка для студентов — экономь на любимых треках
подписка премиум спотифай [url=http://www.podpiska-spotify-1.ru]http://www.podpiska-spotify-1.ru[/url] .
Hello! I hope you’re having a great day. Good luck 🙂
Si eres fanatico de los juegos de azar en Espana, has llegado al lugar indicado. Aqui encontraras analisis completos sobre los casinos mas confiables disponibles en Espana.
Ventajas de jugar en casinos de Espana
Casinos regulados para jugar con seguridad garantizada.
Bonos de bienvenida exclusivos que aumentan tus posibilidades de ganar.
Ruleta, blackjack, tragaperras y mas con premios atractivos.
Transacciones confiables con multiples metodos de pago, incluyendo tarjetas, PayPal y criptomonedas.
Lista de los casinos mas recomendados
En nuestra guia hemos recopilado las valoraciones detalladas sobre los casinos con mejor reputacion en Espana. Consulta la informacion aqui:
casinotorero.info
Empieza a jugar en un sitio seguro y descubre una experiencia de juego unica.
Very nice and very informative and helpful
Iam nephro and interesting to dialysis and transplantation.
Pocus is needed for good mangment of critical cases.
Thanks so much for presenting this clinical reasoning masterclass. I’m an Endocrinology trainee and we (thankfully) see all dyselectrolytemias here in our trust and that was surely plenty of robust learning. Thanks again.
I hope someday in the future you would consider a masterclass on bedside POCUS to assess volume status of a patient. With a real case as presented above.
Sincere thanks again