From the Guidelines
Hypernatremia management should prioritize the use of water with dextrose, such as 5% dextrose, to correct sodium levels, avoiding salt-containing solutions like NaCl 0.9% due to their high renal osmotic load. The goal is to safely correct sodium levels without causing cerebral edema. According to the most recent expert consensus statement 1, the initial rate of fluid administration should be calculated based on physiological demand, with a routine maintenance rate used as a starting point. For example, in children, this could be 100 ml/kg/24h for the first 10 kg, 50 ml/kg/24h for the next 10-20 kg, and 20 ml/kg/24h for the remaining weight, while adults typically require 25-30 ml/kg/24h. Key considerations in hypernatremia management include:
- Avoiding rapid correction to prevent cerebral edema, aiming for a correction rate of about 0.5 mEq/L/hour
- Monitoring serum sodium levels, fluid status, and neurological signs frequently
- Addressing the underlying cause of hypernatremia, whether it be diabetes insipidus, dehydration, or another condition
- Using hypotonic fluids for correction, with oral water intake preferred when possible
- Being cautious with the use of diuretics and COX inhibitors, as they can impact fluid and electrolyte balance. As noted in the expert consensus statement 1, patients with nephrogenic diabetes insipidus are at risk of hypernatremic dehydration and should be treated with water, highlighting the importance of individualized management approaches based on the underlying condition.
From the Research
Hypernatremia Management
Hypernatremia is a condition characterized by an elevated sodium level in the blood. Management of hypernatremia involves addressing the underlying cause and correcting the fluid deficit.
- The treatment approach is based on whether the patient is hypovolemic, euvolemic, or hypervolemic 2.
- Mild hypernatremia is often caused by dehydration resulting from an impaired thirst mechanism or lack of access to water, while other causes such as diabetes insipidus are also possible 2.
- Treatment starts with addressing the underlying etiology and correcting the fluid deficit. When sodium is severely elevated, patients are symptomatic, or intravenous fluids are required, hypotonic fluid replacement is necessary 2.
Diagnostic Approach
The diagnostic approach to hypernatremia involves several steps, including:
- Excluding pseudohypernatremia 3
- Confirming glucose-corrected sodium concentrations 3
- Determining the extracellular volume status 3
- Measuring urine sodium levels and osmolality 3
- Checking ongoing urinary electrolyte free water clearance 3
- Determining arginine vasopressin/copeptin levels 3
- Assessing other electrolyte disorders 3
Treatment
Treatment of hypernatremia involves replacing water deficits, ongoing water losses, and insensible water losses.
- The amount and rate of water administration should be determined based on the severity of the hypernatremia and the patient's volume status 3.
- The type of replacement solution should be selected based on the patient's needs, and the treatment schedule should be adjusted as necessary 3.
- Additional therapy may be necessary for patients with diabetes insipidus 3.
- In cases of salt intoxication, diuretics must be given in addition to slow water replacement to avoid the development of pulmonary edema 4.
Complications
Rapid correction of hypernatremia can lead to cerebral edema and worsening of the condition 4.