Hyponatremia

Management
Serum Sodium level: <135mEq/L
Signs and symptoms: Lethargy, thirst, weakness, irritability, confusion, coma and fits
Acute (<48 hours) or Symptomatic hyponatremia: Treat with 3% saline and increase serum
sodium level by 1-2mEq/L for 3-4 hours until the neurologic symptoms resolve or sodium level
is >120mEq/L. Max sodium correction should be 6-8mEq/L during first 24 hours.
Chronic (>48 hours) or Asymptomatic hyponatremia:
Hypovolemic: Treat with NS. Less aggressive correction rate is recommended (3-6mEq/L/day).
Max <8mEq/L/day to avoid pontine myelinolysis. Use furosemide when needed to avoid fluid
overload. Treat underlying cause. Correct max <8mEq/L/day
Euvolemic: Treat with fluid restriction of 1L/day and adjust according to urine output and set at
500ml less the daily urine output (eg if urine output is 1200ml then fluid intake should be
700ml/day). Treat underlying cause. Correct max <8mEq/L/day
Hypervolemic: Treat with fluid restriction of 1L/day and adjust according to urine output
(500ml less than daily urine output). Treat underlying cause. Correct max <8mEq/L/day
Add furosemide if CCF or nephrotic syndrome
Add spironolactone if cirrhosis and ascites. Avoid Thiazide diuretics (worsen hyponatremia)
Overcorrection: if overcorrection of more than 8-12mEq/L/day occurs, stop treatment and treat
with free water intake. Use Adrogue-Madias formula for measuring the sodium lowering effect
of 1L of fluid
Change in sodium conc. (per 1L)= (infsate sodium conc serum sodium conc)/ (TBW +1)
TBW= weight x 0.5 (women and elderly men) or 0.6 (younger men and children)

Calculations
Serum Osmolality:
2xNa + Glucose/18 + BUN/2.8
Calculation of the sodium deficit:
0.6 x weight (kg) x (desired Na+ - Actual Na+). Use 0.5 for females. Desired Na+= 120-125
mEq/l.
Example: 70kg male, Na+= 110 mEq/l Desired target= 125 mEq/l.
[0.6 x 70kg x (125-110) = 630 mEq of Na+ needed].

Corrected sodium in Hyperglycemia:

Corrected Na= Measured sodium + 0.016 x (Serum glucose - 100)
Amount needed to increase serum sodium level by 1 mEq/l/hr= 0.6 x 70kg x 1.0= 42 mEq/hr
(safe rate for this patient).
3%--hypertonic saline contains 513 mEq/liter.
Therefore: [desired rate per hr] / 513 x 1000 = infusion rate (ml/hr).
And the total infusion time= [total mEq needed] / [mEq/hr]
Desired rate= 42/513 mEq x 1000= 82 ml/hr
Infusion time= [630 mEq] / [42 mEq/hr] = 15 hrs.
Therefore: Infuse 3% saline at 82 ml/hr for 15 hours.
Preparation of Oral Hypertonic Saline:
I Mole of NaCl = 58 grams
1Equivalent of NaCl = 58 grams
1mMole = 58 mg
1 meq NaCl = 58 mg; this provides 1 mEq Na and 1 mEq Cl
Sodium Content of Common Salt
1g of salt = 17mEq of sodium
1 tsf salt = 6g NaCl = 2400 (2325)mg of sodium= 104mEq
For 3% Saline we need 5 tsf or 30g of salt = 12000 mg of sodium= 513mEq