How to correct severe hyponatremia (low sodium level) of 107 meq/L?

Management of Severe Hyponatremia (107 mEq/L)

For severe hyponatremia with a sodium level of 107 mEq/L, initiate treatment with 3% hypertonic saline boluses in a hospital setting with close monitoring of serum sodium levels every 2-4 hours initially to prevent osmotic demyelination syndrome. 1, 2

Initial Assessment and Treatment Approach

1. Hospital Admission Required:

   • All patients with severe hyponatremia (sodium <125 mEq/L) must be treated in a hospital setting where serum sodium can be monitored closely 3
   • Monitor serum sodium every 2-4 hours initially, then every 4-6 hours once stabilized 1
   • Monitor vital signs every 1-2 hours initially 1

2. Symptom-Based Treatment Strategy:

   • For severe neurological symptoms (seizures, coma, altered mental status):

     • Administer 3% hypertonic saline as 100-150 mL boluses 4
     • Target initial increase of 4-6 mEq/L within 1-2 hours to reverse severe symptoms 2

   • For mild/moderate symptoms (nausea, headache, weakness):

     • More gradual correction with 3% hypertonic saline infusion
     • Calculate initial infusion rate (mL/kg per hour) = body weight (kg) × desired rate of increase in sodium (1-2 mEq/L per hour) 5

Critical Rate of Correction Guidelines

• Maximum correction rate: Do not exceed 8 mEq/L in 24 hours 1
• Total correction limit: No more than 12 mEq/L in 24 hours or 18 mEq/L in 48 hours 5, 2
• For high-risk patients (alcoholism, malnutrition, liver disease): Use slower correction rates 1, 3
• Target: Initially correct to safe range (around 125-130 mEq/L), not to normal levels 6

Volume Status-Based Management

Determine volume status to guide specific treatment:

1. Hypovolemic Hyponatremia:

   • Administer normal (0.9%) saline infusion 1, 7
   • Discontinue any diuretics 1
   • Monitor for fluid overload

2. Euvolemic Hyponatremia (e.g., SIADH):

   • 3% hypertonic saline for symptomatic cases 2
   • Consider tolvaptan (starting at 15 mg once daily) after initial stabilization 1, 3
   • Fluid restriction to 1-1.5 L/day 1

3. Hypervolemic Hyponatremia (heart failure, cirrhosis):

   • Fluid restriction to 1-1.5 L/day 1
   • Treat underlying condition
   • Consider combination therapy with aldosterone antagonists 1

Monitoring and Preventing Complications

• Check electrolytes with each sodium measurement 1
• Daily renal function tests 1
• Avoid rapid correction to prevent osmotic demyelination syndrome (dysarthria, mutism, quadriparesis, seizures, coma) 3
• If correction is too rapid, consider administering 5% dextrose or desmopressin to re-lower sodium 1, 4
• Avoid water restriction in cases with sodium >126 mmol/L as it may exacerbate central hypovolemia 1

Special Considerations

• For patients with liver disease: Consider albumin infusion (1 g/kg body weight for two consecutive days, maximum 100 g) 1
• For patients with heart failure: Consider combination therapy with aldosterone antagonists rather than increasing loop diuretic dose 1
• Avoid nephrotoxic agents including contrast media in patients with AKI and liver failure 1

Follow-up Management

• Once stabilized, continue monitoring sodium levels every 6-8 hours
• If using tolvaptan, do not administer for more than 30 days to minimize risk of liver injury 3
• Upon discontinuation of treatment, resume fluid restriction and monitor for changes in sodium and volume status 3