How to correct a free water deficit of 200 milliliters (mL) with hypernatremia (elevated sodium levels) of 154 milliequivalents per liter (mEq/L)?

From the Guidelines

To correct a free water deficit of 200 cc with a sodium level of 154 mEq/L, administer 200 cc of free water orally or as D5W intravenously over 4-6 hours while monitoring sodium levels, as this approach allows for careful correction and minimizes the risk of rapid changes in serum sodium 1. The use of D5W is recommended because the glucose is metabolized, leaving free water, which is essential for correcting the free water deficit without adding to the renal osmotic load 1.

Key Considerations

• Monitor sodium levels every 2-4 hours during correction, aiming for a decrease of no more than 8-10 mEq/L in 24 hours to prevent cerebral edema 1.
• Assess for clinical improvement in symptoms of hypernatremia such as thirst, confusion, or irritability.
• Address the underlying cause of the hypernatremia simultaneously, whether it's inadequate water intake, excessive water loss, or diabetes insipidus.
• Ensure ongoing maintenance fluids after correction to prevent recurrence, typically 30-35 mL/kg/day for adults, adjusted for any abnormal losses 1.

Administration Details

• For oral administration, provide plain water or very dilute juice.
• For IV administration, use D5W, and avoid salt-containing solutions like NaCl 0.9% due to their large renal osmotic load 1.
• Calculate the initial rate of fluid administration based on physiological demand, considering the routine maintenance rate for adults as 25-30 ml/kg/24h 1.

Ongoing Care

• Close observation of clinical status, including neurological condition, fluid balance, weight, and electrolytes, is crucial in hospitalized patients 1.
• Placement of a urinary catheter should be considered to ensure proper monitoring of diuresis 1.
• Regular follow-up, as outlined in recommendations for minimal frequency of follow-up, should include tests and measurements such as weight, height, blood sodium, potassium, chloride, bicarbonate, creatinine, and uric acid levels, as well as urine osmolality 1.

From the Research

Correction of Hypernatremia

To correct hypernatremia with a free water deficit of 200 cc and sodium levels of 154, the following steps can be taken:

• Replenish the free water deficit to lower serum sodium levels 2
• The choice of treatment can be either enteral free water or parenteral dextrose 5% in water (D5W), with parenteral D5W being slightly more effective in lowering serum sodium levels 3
• The rate of correction should be carefully monitored to avoid overcorrection, which can lead to complications such as seizures or cerebral edema 4

Treatment Options

The treatment options for hypernatremia include:

• Enteral free water: effective in treating ICU-acquired hypernatremia, but may have a slower effect on lowering serum sodium levels compared to parenteral D5W 3
• Parenteral dextrose 5% in water (D5W): slightly more effective than enteral free water in lowering serum sodium levels, but requires careful monitoring to avoid overcorrection 3
• Desmopressin: can be used as an adjunct treatment to limit urine output and prevent an unpredictable rise in serum sodium levels 4

Monitoring and Precautions

When correcting hypernatremia, it is essential to:

• Closely monitor serum sodium levels to avoid overcorrection or undercorrection 2
• Monitor for signs of cerebral edema or seizures, which can occur with rapid changes in serum sodium levels 4
• Adjust the treatment plan as needed to ensure a safe and effective correction of hypernatremia 3