HYPONATREMIA

Volume status : hypovolemia ( urinary or GIT losses, check Na urine )/ normovolemia SIADH, low
dietary Na intake, advanced renal failure , primary polydipsia/ hypervolemia CHF, advanced liver
failure ( decreased effective arterial tissue perfusion/volume depletion, reduced card output)

PseudohypoNa : hyperlipidemia, hyperglucemia, mannitol, hyperproteinemia from multiple

myeloma ,post urology/uterine surgery, hysteroscopia from irrigation with hypotonic solutions that
get absorbed ( post TURP)

Serum osmolality < 280 : hyposmolar : SIADH ( CNS pathology , malignancy, lung diseases, drugs,
recent surgery) , effective arterial volume depletion / ectopic atrial natriuretic peptide production
from small cell cancer / exercise induced hyponatremia/ ectasis use / advanced renal failure/
primary polydipsia, compulsive water drinking , the urine is max diluted ( U osm<100 ) but pt drinks
more water than the amount the body is able to excrete

Increase ADH release : nausea, stress, antipsychotic meds, sertraline, fluoxetine, carbamazepine

Low dietary Na intake : beer drinking, malnourish, low protein high water diets

Normal /increased osmolality: alcohol, advanced renal failure, mannitol, hyperglycaemia ,iv Ig

Normal serum Osm: irrigation solutions during TRUP prostate, bladder, hysteroscopy, laparoscopic
surgery: acute severe hypoNa

ACUTE < 48 h : marathon runners, exercise induced, self induced water intoxication, ecstasy, post
surgery when hypotonic fluids are infused in pt that have increased ADH release from nausea, stress

CHRONIC > 48 h or unknown time

Severe ,<120/ Moderate 120-129 / Mild >130-34

SYMPTOMS Acute marked hypoNa – no time for adaptation- cerebral edema . When Ns<125-130
usually nausea, malaise. When Na<120 headache, lethargy, obtundation, coma, seizures, coma, resp
arrest . Mild to moderate symptoms in acute hypoNa (even if Na>120) may evolve without warning
to seizures and resp arrest

Chronic hypoNa may be asymptomatic or non specific symp weak, lethargy, gait abnormal, fatigue,
muscle cramps,

Risk for brain herniation : acute hypoNa from massive water ingestion , women and children with
acute post op hypoNa, intracranial pathology that develop hypoNa

Risk for ODS : overly rapid correction of severe chronic hypoNa, high risk if Ns<105 , presence of
alcoholism, low K, malnutrition, liver disease . Low risk in acute hypoNa that develops in few hours

Goal of correction: Initial tx should be increase serum Na by 4-6 meq in 24 h period and less than 16
in a 48 h period . Max rate 8 mEq in 24 h . If severe symptomatic acute hypoNA , this goal can be
achieved quickly in 6 h or less but the Na should be maintained at a constant level for the remainder
of the 24 h period

Treatment FIRST 6 HOURS

ACUTE HYPONATREMIA . high risk for cerebral edema. Medical emergency .

1,1 No symptoms + Na <130 = 50 ml 3% saline to prevent further fall in Na .Monitor NA q 1 hour.Do
not give hypertonic saline if Na is already autocorrecting from water diuresis

1.2 Symptoms ( even if mild symptoms) Na <130 + any sympt of potentially increase intracranial
pressure—headache, N, V, confusion, tremor, gait disturbances, seizures, coma --- 100 ml 3 % saline
and if symptoms persists repeat x 2 times over 30 minutes. Goal is serum increase Na by 4-6 mmol
over a period of few hours .Usually an increase in 2 mmol Na should be enough to improve cerebral
edema

1.3 Mild hypoNa 130-134 , should have no symptoms, low risk for cerebral herniation but limit
intake hypotonic fluids / monitor Na q 1 hour to detect if Na lowers/ stop medications that can lower
Na .No need for 3% saline

Measure urinary output hourly, urine Na, K , urine osmol. If increase urinary output and decreased
Na.K urine, the rate of correction serum Na may be accelerating

CHRONIC >48 h /unknown duration

When symptoms are severe ( coma, obtundation, resp arrest) stat bolus 100 ml 3% and if still symp
repeat bolus 100 ml 3% x 2 over 30 min .Goal increase Na by 4-6 mmol in few hours

2.1 asymp or mild (130-134) – no need for 3%, fluid restriction <800 ml/d, below urinary output ,
bery important in CHF, cirrhosis , SIADH, advanced renal failure / if urine is highly concentrated U
osm > 500 , fluid restriction alone may not be sufficient . Do urine/serum cation ratio

Urine (Na+k) / serum Na <0.5 fluid restric will work, >1 it will not

regular diet , stop iv hypotonic fluids including ringer lactate, review medications

2.1 Mild-mod sympt : fatigue, nausea, headache, confusion , NA <130 . If intracranial pathology,
recent cranial surgery give 100ml 3% saline bolus. If sympt persists repeat x 2 over 30 min

2.3 If no intracranial pathology : tx depends on severity of hypoNa a) If severe <120 give 3% at

15-30 ml/h +/- desmopressin or furosemide . If high risk for ODS or high risk for water diuresis add
desmopressin to prevent overly correction at the beginning of the treatment before the 3%

Use 1-2 mcgr desmopressin q 6-8 h iv/sc x 24-48 h or until Na>125 + simultaneous 3% saline. Achieve
rate 3% saline to achieve the desired goal . Desmopressin prevents un unexpected water diuresis
from occurring during the course the tx . This approach cannot be used when water restriction
cannot be achieved ( polydipsia, psychosis. It can be used in SIADH if fluid restriction can be
guaranteed ( very important !) . Another approach is to use desmopressin only if water diuresis
occurs

If the cause of hypoNa is not rapidly reversible, they are unlikely to develop water diuresis , so do
not use desmopressin , for example cirrhosis, heart failure, chronic SIADH secretion

b) no severe , mod 120-129 , no 3% saline , fluid restriction 800ml/day , monitor urinary output,

FIRST SEVERAL DAYS CHRONIC HYPONA

AVOID ISOTONIC SALINE IN SYMPTOMATIC OR SEVERE HYPONA

Check Na q 1 h in acute hypoNa, q 4-6 in chronic hypoNa. Once Na has increased 4-6 mmol , stop 3%
saline for the rest of the 24 h period
Do urine/ serum cation ratio . If ratio >1 : loop diuresis may be useful to achieve water diuresis.

SIADH with Na> 120/ mild sympt : oral salt tablets + fluid restriction

Oral salt tablets can substitute hypertonic saline in non urgent situations. 1 gr oral salt = 35 ml
3% saline. Do not give them in edematous pt , cirrhosis, CHF

Potassium supplements are osmoticament active and increase Na , so monitor for overcorrection. Iv
KCl 10 mmol in 100 ml water are not osmotically active but 20 mmol in 50 ml water will increase Na
as much as 40 ml of 3% saline

Impending overcorrection : watch urinary output . An increase in urine volume and a decrease in
urine Na, K signify water diuresis and will accelerate the rate of correction . Seen more often in
adrenal insuf being corrected, hypothyroid , correction of hypovolemia , post op , when rugs that
cause SIADH are stopped( sertraline, fluoxetine)

Do not use isotoninc saline in severe hypoNa , SIADH ,acute hypoNa, edematous states,

In true volume depletion ( diarrhea, vomit, diuretic) isotonic saline 1 liter will increase Na serum 1
mmol , removes the stimulus for ADD stimulus and pt excretes water

SIADH

Retention of ingested or infused water. Seen in CNS, pulmonary, drugs, malignancy. Initial tx fluid
restriction <800 ml/d, avoid in subarachnoid haemorrhage ( in this case 20ml/h 3% saline)

a) Severe ,sympt, resistant hypoNa : use 3% .if urine Na+k >154 , do not use isotoninc saline . If
urine is very concentrated ( urine osm> 500) , hypertonic saline will increase na but then it
will be excreted in the urine and N will fall again. Add loop diuretics and/or oral tablets or
high salt high protein diet .

Salt plus loop diuretic ( furosemide 20 mg bid) .A loop diuretics will be effective if U osm > 2 x plasma
Osm , usually U osm > 500

Hypertoninc 3% in severe hypona , symptoms with intracranial disease. Use 3 % saline. A 100 ml of
3% will increase na by 1.5 meq in men, 2 mmol in women. If neuro symp persist repeat x 2 q 10 min

If symp resolve but Na rise is still less than 6-8 mmol in 24 h , futher tx is fluid restriction +/- slow 3%
infusion 10-30 ml/h . Monitor Na q 2-4 h to avoid overly correction . if Urine osm>500, add loop
diuretic

b) Mild -mod symp + Na > 120 , do not need aggressive tx, fluid restr, salt tablets
c) Maintenance tx , chronic SIADH nn reversible , fluid restr<800 ml/d, oral salt tablets 3 gr/8h ,
oral urea . If urine Osm > 2x plasma Osm increase water excretion with furosem 20 mg bid

PREDICTIVE FORMULAS aprox 1ml/kg 3% saline will increase Na by 1 mmol

Serum Na deficit = TBW x ( Na desired – Na actual) .

Increase in Na serum by infusing 1 liter of the chosen fluid = Infusate (Na+K) – serumNa

TBW + 1