Hypernatremia Protocol the difficulty: volume and

sodium loss could not be

controlled precisely

eg . Affect by renal
function/ hormonal status

Conceptual framework
meds
Increased Na intake/ citrate accumulation
reabsorption
steroid
DI
fever
Decreased body fluid Persistent inflammation
volume
Tend to promote diuresis https://emcrit.org/ibcc/
Lasix with a diluted urine diurese/#loop_diuretics
Causes
Combined

Hypernatremia

Dehydrated Euvolemic Edematous

Extra free water needed?

Yes Should Not Should Not

by calculation

Volume loss desired No need No / equal to Free water (BW-DW) +/- Free water
given given

1. Current body weight-

dry weight(BW-DW)

2. clinical assessment
less accurate

No need Yes Yes

urine Na loss desired

Aim ~ current serum [Na]

by diuretic adjustment

But turnover time of urine

[Na] too slow to be useful

K replacement No need Probably Probably

by monitoring As diuretic used

More Practical Way

DI treatment
Treat sepsis/inflammation
fever mx
wean off steroid, or to one
1. Treat the cause
with less
mineralocorticoid effect
Use antibiotic with less
Na load eg D5 version

avoid too rapid correction

2.Rate of correction
<= 12mmol/day

monitor serum [Na]

Calculate and administer

Just need to replace the Utilize formula/app
the free water needed over
Volume depleted? free water a certain period

2. Determine volume
status

ALERT: Diuretics use

can induce acute kidney
Possible starting options injury
Volume overload? Adjust diuretics to achieve
the Na loss

Hydrochlorothiazide 25mg Alert for hypoK

BD

NB. Patient may not may

not already on Lasix, which
is the most effective Aldactone 25mg BD
diuretics for fluid removal, Alert for hyperK
but itself may induce
hyperNa

Aldactone 25-50mg BD +
May avoid hyper/hypoK
hydrochlorothiazide 25mg
effect
BD

If Na does not drop as

May need to replace free
desired even with diuretics
water

Alert that the cause may

be treated inadequately eg
occult sepsis not dealt with

Associated with various

3. Replace K loss diuretic use

4. Correct contraction
By Diamox
alkalosis if needed

Eg. NG water 100ml q4h

5. Remind to set the end-
till Na <=140
time for treatment

Eg. remarks “off when

Na<=140” in IPMOE
under the diuretics used

As they may be forgotten

in general ward
Eg. Set a 2-3 days course
only for these diuretics