How to manage overcorrection of hyponatremia (low sodium)?

From the Guidelines

To manage overcorrection of hyponatremia, the goal is to limit the total correction to no more than 8 mEq/L per 24-hour period to ameliorate the risk of Osmotic Demyelination Syndrome (ODS). When overcorrection occurs, consider relowering with electrolyte-free water or desmopressin 1. The use of tromethamine may also reduce the risk of ODS 1.

Key Considerations

• The risk of ODS is higher in patients with advanced liver disease, alcoholism, severe cases of hyponatremia, malnutrition, and severe metabolic derangements 1.
• Multidisciplinary, coordinated care may mitigate the risk of ODS, and liver transplantation need not be prohibited by hyponatremia alone 1.
• Patients should be monitored in an ICU setting during this treatment, with attention to fluid status, neurological symptoms, and electrolyte levels.

Management Approach

• For patients with chronic hyponatremia, slower correction is safer, with a goal rate of increase of serum sodium of 4-6 mEq/L per 24-hour period 1.
• If overcorrection occurs, consider administering D5W (dextrose 5% in water) and possibly desmopressin to re-lower sodium levels.
• The underlying cause of hyponatremia should also be addressed simultaneously to prevent recurrence.

Monitoring and Prevention

• Monitor serum sodium levels every 2-4 hours during treatment 1.
• Be aware of the potential for rapid correction to cause ODS, a potentially devastating neurological complication 1.
• Consider the use of tromethamine to reduce the risk of ODS 1.

From the Research

Managing Overcorrection of Hyponatremia

To manage overcorrection of hyponatremia, the following strategies can be employed:

• Monitor serum sodium levels closely to avoid rapid changes 2
• Use desmopressin to minimize water excretion during correction of hyponatremia 3, 2
• Avoid discontinuing desmopressin in patients with symptomatic DDAVP-associated hyponatremia, as this can lead to rapid correction of serum sodium and resultant severe neurological injury 4
• Continue desmopressin while administering intravenous hypertonic saline solution to manage desmopressin-associated hyponatremia with neurologic symptoms 4, 3
• Limit correction of serum sodium to 8 mEq/L/day in chronic hyponatremia, and 4-6 mEq/L/day in high-risk patients to avoid osmotic demyelination 2

Common Pitfalls to Avoid

Common mistakes that can lead to overcorrection of hyponatremia include:

• Miscommunications between healthcare providers regarding the amount of saline and potassium administered to the patient 5
• Unexpected hypoosmotic polyuria 5
• Overly rapid correction of hyponatremia due to "too much salt (Na+ + K+) gained" or "too much water lost" 5

Treatment Approaches

Treatment approaches for managing overcorrection of hyponatremia include:

• Withholding desmopressin and providing intravenous saline 4
• Continuing desmopressin and providing intravenous hypertonic saline 4, 3
• Using desmopressin to reduce free-water losses and prevent overly rapid "autocorrection" of serum sodium level 3