Should I admit a patient with hyponatremia?

Management of Hyponatremia with Sodium of 124 mEq/L

Yes, a patient with a serum sodium of 124 mEq/L should be admitted to the hospital for evaluation and management, as this level of hyponatremia requires close monitoring and may lead to serious neurological complications if not properly treated. 1, 2

Assessment and Triage

When evaluating a patient with hyponatremia (Na 124 mEq/L), consider:

1. Symptom severity:

   • Severe symptoms: Mental status changes, seizures, coma
   • Mild symptoms: Nausea, vomiting, headache, weakness
   • Asymptomatic: No apparent symptoms

2. Volume status assessment:

   • Hypovolemic: Signs of dehydration, orthostatic hypotension
   • Euvolemic: No obvious volume abnormalities
   • Hypervolemic: Edema, ascites, signs of heart failure

3. Duration of hyponatremia:

   • Acute: <48 hours
   • Chronic: >48 hours (more common)

Treatment Protocol

For Symptomatic Patients:

• Admit to ICU or intermediate care unit 1
• Administer 3% hypertonic saline with the goal of:
  • Correcting sodium by 6 mmol/L in first 6 hours or until severe symptoms improve
  • Total correction not exceeding 8 mmol/L in 24 hours 1, 2
• Monitor serum sodium every 2-4 hours initially 2

For Asymptomatic Patients:

• Still require admission for:
  • Workup including serum and urine osmolality, urine electrolytes, uric acid
  • Evaluation of volume status 1
  • Close monitoring of sodium levels (every 4-6 hours)
  • Treatment of underlying cause

Etiology-Specific Management

For Cerebral Salt Wasting (CSW):

• Normal saline infusion
• Consider fludrocortisone (class I evidence for SAH patients) 1, 2
• Avoid fluid restriction as it can worsen cerebral perfusion 1, 2

For SIADH:

• Fluid restriction to 1 L/day
• Consider hypertonic saline if symptoms persist or sodium <120 mEq/L 2
• For refractory cases, consider vasopressin receptor antagonists (vaptans) in a hospital setting 3

For Hypervolemic Hyponatremia (e.g., heart failure):

• Fluid restriction (<1 L/day)
• Diuretics as appropriate
• Consider vasopressin antagonists for persistent hyponatremia 1, 3

Important Precautions

1. Avoid overly rapid correction (>8-10 mmol/L/24 hours) to prevent osmotic demyelination syndrome, especially in:

   • Chronic hyponatremia
   • Malnourished patients
   • Alcoholics
   • Patients with advanced liver disease 1, 2

2. Monitor for complications:

   • Neurological status changes
   • Signs of volume depletion
   • Electrolyte imbalances

3. Discontinue causative medications if applicable 2

Special Considerations

• Tolvaptan (vasopressin antagonist) should only be initiated in a hospital setting where serum sodium can be closely monitored 3
• FDA warning: Too rapid correction of hyponatremia with tolvaptan can cause osmotic demyelination 3
• Women and elderly patients are more sensitive to hyponatremic injury 2, 4

Discharge Criteria

Patients can be considered for discharge when:

• Serum sodium is >130 mmol/L or stable
• Symptoms have resolved
• Underlying cause has been identified and addressed
• Follow-up plan is established

In conclusion, a serum sodium of 124 mEq/L warrants hospital admission for proper evaluation, monitoring, and treatment to prevent serious neurological complications and address the underlying cause of hyponatremia.