Treating profound hyponatremia


Category : Acid-Base & Lytes

Periodically we get a patient admitted with profound hyponatremia < 105.  These patients generally have a great risk for developing a demyelination syndrome.  This case report discusses a novel and logical strategy to avoid having the sodium level increase too rapidly.  They recommend a combination of 3% NS and desmopressin with a goal of 6 mEq/day.  The link is to the abstract, I recommend that all hospitalists get the article, read it and study it.  It will likely help you avoid a dreaded complication.  Treating Profound Hyponatremia: A Strategy for Controlled Correction

Comments (1)

First question should be what is the patient's mental status.
105 may cause seizures, coma or profound confusion. 
Or it may be virtually normal -I saw a patient sent home from the ER once with a sodium of 105, his mental status was normal and they didn't check the result. They called him back and went crazy treating it acutely – he got CPM.
If the patient dropped form normal to 105 in three weeks his mental status may not be bad (if it happened in three days that's another question) 
If the patient's mental status isn't bad why would you want to do this 3% and desmopressin? That might work but it seems like a lot of trouble and could lead to disaster. Just begin normal saline at a reasonable rate and his sodium will come up at about the same rate.
Even if the patient's mental status is bad, unless he is actively seizing or in coma I would not use 3% saline. Normal saline is the fluid of choice.
If his neurologic is terrible then I might consider 3% but why add desmopressin, just give 3% at small doses and intervals along with normal saline till you get to 115 in about 24 hours, then switch to normal saline.
Pretty complicated treatment for a pretty straightforward problem.

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