What is included in the emergency department (ED) care of severe symptoms of chronic hyponatremia?

Updated: Aug 24, 2020
  • Author: Kartik Shah, MD; Chief Editor: Romesh Khardori, MD, PhD, FACP  more...
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Patients with chronic hyponatremia and severe symptoms (eg, severe confusion, coma, seizures) should receive hypertonic saline, but only enough to raise the serum sodium level by 4-6 mEq/L and to arrest seizure activity. After this, we recommend no further correction of the sodium for the first 24 hours. Reports suggest that therapeutic relowering of the serum sodium level with hypotonic fluids and desmopressin (DDAVP) may help avert neurologic sequelae in patients whose chronic hyponatremia is inadvertently corrected too quickly. [31]

In treating patients with chronic hyponatremia and mild to moderately severe symptoms, consider the cause of the hyponatremic state. Patients are classified as having hypovolemic, euvolemic, or hypervolemic hyponatremia based on historical clues and physical examination. Regardless of the therapeutic approach, serum sodium must be monitored closely and corrected no faster than 6 mEq/L in the first 24 hours.

Patients with hypovolemic hyponatremia who are hypotensive and have signs of decreased end-organ perfusion may need IV fluid volume repletion in addition to sodium correction. Careful treatment with isotonic saline may be considered, but monitor serum sodium levels frequently to ensure that the serum sodium level increases slowly, with a maximum rise of 6 mEq/L in the first 24 hours. Be aware that as isotonic saline is given, large-volume diuresis of dilute urine may occur, causing overcorrection of sodium. As such, some practitioners will give low-dose (1-2 μg) DDAVP, continued every 6-8 hours, before administering IV fluids, thereby proactively decreasing urine output and preventing the overcorrection of sodium. [20, 32]

Patients with hypervolemic hyponatremia have increased total body sodium stores. Treatment consists of sodium and water restriction and attention to the underlying cause. The vasopressin receptor antagonists conivaptan (Vaprisol) and tolvaptan (Samsca) are now approved for use in hospitalized patients with hypervolemic hyponatremia, though clinical experience is scant. [33]

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