From the Guidelines
For a patient with a sodium level of 134 mEq/L in the Emergency Department, minimal intervention is typically required as this is only mildly decreased from the normal range (135-145 mEq/L).
Management Approach
The primary approach for asymptomatic patients with sodium of 134 mEq/L is observation and identification of underlying causes rather than immediate sodium correction 1.
- If the patient is experiencing symptoms like headache, confusion, or nausea, initial management may include fluid restriction to 1-1.5 liters daily.
- For more significant symptoms, cautious administration of hypertonic (3%) saline at 1-2 mL/kg/hr may be considered while monitoring sodium levels every 2-4 hours to prevent rapid correction.
Underlying Cause Addressed
The underlying cause should be addressed, which could include medication adjustment (particularly diuretics, antidepressants, or antipsychotics), treatment of underlying conditions like SIADH, heart failure, or cirrhosis, or correction of volume status 1.
Sodium Correction
Sodium correction should not exceed 8 mEq/L in 24 hours to avoid osmotic demyelination syndrome, as recommended by the most recent guidelines 1.
Specific Considerations
A sodium of 134 mEq/L is borderline low and often doesn't require aggressive treatment unless accompanied by significant symptoms or is rapidly declining. In patients with cirrhosis, the management of hyponatremia depends on the etiology, chronicity, severity, and urgency, with the goal of correcting sodium levels gradually to avoid osmotic demyelination syndrome 1.
From the Research
Treatment of Sodium Disorders
- Sodium disorders, including hyponatremia and hypernatremia, are common findings in inpatient and outpatient settings, and are associated with an increased risk of morbidity and mortality 2.
- The treatment of sodium disorders is based on symptoms and underlying causes, and may involve fluid restriction, isotonic saline, diuresis, or a combination of these therapies 2.
Treatment of Hyponatremia
- Hyponatremia is treated with fluid restriction in the setting of euvolemia, isotonic saline in hypovolemia, and diuresis in hypervolemia 2.
- Hypertonic saline is used to treat severe symptomatic hyponatremia, and medications such as vaptans may have a role in the treatment of euvolemic and hypervolemic hyponatremia 2, 3, 4.
- The use of desmopressin and hypertonic saline has been shown to be a simple strategy for safe correction of severe hyponatremia, with a predictable response and minimal risk of overcorrection 5.
Management of Severe Hyponatremia
- The management of severe hyponatremia requires careful consideration of the underlying cause and the risk of osmotic demyelination 6.
- Infusion of hypertonic saline and desmopressin, or infusion of vasopressin inhibitors such as vaptans, may be used to correct severe hyponatremia, depending on the category of hyponatremia and the presence of concentrated or dilute urine 6.
- Monitoring of changes in serum sodium concentration is imperative to guide treatment changes and prevent overcorrection of hyponatremia 6.