What happens if you overcorrect for hypernatremia (elevated sodium levels)?

From the Guidelines

Overcorrecting sodium levels can lead to a life-threatening condition called osmotic demyelination syndrome (ODS), which is why sodium correction should always be done gradually under medical supervision. The risk of ODS is particularly high in patients with chronic hyponatremia, where rapid correction of sodium levels can cause water to shift out of brain cells too quickly, leading to damage to the protective myelin sheath around nerve cells 1. According to the 2021 practice guidance by the American Association for the Study of Liver Diseases, patients with chronic hyponatremia require more gradual and measured correction to avoid overcorrection and mitigate the risk of ODS 1.

Key considerations for sodium correction include:

• The recommended correction rate for sodium is no more than 8-10 mEq/L in 24 hours and no more than 18 mEq/L in 48 hours
• Sodium correction should be carefully monitored with regular blood tests to avoid overcorrection
• Patients with chronic hyponatremia or risk factors like alcoholism, malnutrition, or liver disease require closer monitoring and more gradual correction
• Treatment for sodium imbalance should always be individualized and based on the underlying cause of the imbalance, as outlined in the 2021 practice guidance 1

Symptoms of ODS can appear 2-6 days after rapid sodium correction and may include confusion, difficulty speaking or swallowing, paralysis, seizures, coma, and in severe cases, death. Prevention is crucial, and sodium correction should always be done under medical supervision to minimize the risk of ODS and other complications 1.

From the Research

Overcorrection of Sodium

• Overcorrection of hyponatremia can occur due to various reasons, including miscommunications between healthcare providers, unexpected hypoosmotic polyuria, or excessive administration of saline and potassium 2.
• The consequences of overcorrection can be severe, including the risk of fatal osmotic demyelinating syndrome (ODS) 2, 3.
• ODS can result in central and extrapontine myelinolysis, leading to symptoms such as pseudobulbar palsy and spastic quadriparesis 3.
• The rate of correction of chronic hyponatremia should not exceed 8 mmol/l per 24 hours to prevent ODS 3.
• Even with appropriate correction of hyponatremia, ODS can still occur, especially in patients with underlying risk factors such as malnutrition, alcohol dependence, or malignancy 4.
• Close monitoring of serum sodium correction and the use of 5% dextrose with or without desmopressin can help prevent or reverse overcorrection in patients with chronic hyponatremia 5.
• Central pontine myelinolysis (CPM) can occur even in patients with normal serum sodium levels, suggesting that the mechanism of demyelination is not fully understood 6.

Risk Factors and Prevention

• Certain medical disorders, such as large-volume polyuria, can increase the risk of rapid correction of serum sodium concentration 5.
• Early identification of risk factors and close monitoring of serum sodium correction can help prevent overcorrection 5.
• The use of 5% dextrose with or without desmopressin can help prevent or reverse overcorrection in patients with chronic hyponatremia 5.
• Recognizing common pitfalls, such as miscommunications between healthcare providers, can help prevent overcorrection 2.