Management of Hyponatremia with Sodium Level of 117 mmol/L
Stop diuretics immediately and implement volume expansion with colloid or saline, while avoiding increasing serum sodium by >12 mmol/L per 24 hours. 1
Initial Assessment
- Serum sodium <120 mmol/L represents severe hyponatremia requiring immediate intervention 1
- Determine volume status (hypovolemic, euvolemic, or hypervolemic) to guide appropriate treatment 2
- Check urine osmolality and sodium concentration to help distinguish between SIADH and other causes 2
- Assess for symptoms: mild (nausea, weakness, headache) vs. severe (seizures, coma, cardiorespiratory distress) 3
Treatment Algorithm Based on Symptom Severity
For Severe Symptoms (seizures, coma, cardiorespiratory distress):
- Administer 3% hypertonic saline with goal to correct 6 mmol/L over 6 hours or until severe symptoms resolve 2
- Consider ICU admission for close monitoring during treatment 2
- Monitor serum sodium every 2 hours during initial correction 2
For Mild/No Symptoms:
- Stop diuretics 1
- Implement volume expansion with colloid (haemaccel, gelofusine, or voluven) or saline 1
- For hypervolemic hyponatremia (e.g., cirrhosis), implement fluid restriction to 1-1.5 L/day 1
- Consider albumin infusion for patients with cirrhosis 2
Correction Rate Guidelines
- Do not exceed correction of 8 mmol/L in 24 hours to prevent osmotic demyelination syndrome 2
- For patients with advanced liver disease, alcoholism, malnutrition, or prior encephalopathy, use more cautious correction rates (4-6 mmol/L per day) 2
- Avoid increasing serum sodium by >12 mmol/L per 24 hours 1
Monitoring and Follow-up
- Monitor serum sodium levels every 4-6 hours during correction 2
- Watch for signs of osmotic demyelination syndrome (dysarthria, dysphagia, quadriparesis) typically occurring 2-7 days after rapid correction 2
- If overcorrection occurs, consider relowering with electrolyte-free water or desmopressin 2
Special Considerations for Different Types of Hyponatremia
Hypovolemic Hyponatremia:
- Discontinue diuretics and administer isotonic saline for volume repletion 2
- Once euvolemia is achieved, reassess sodium levels 2
Euvolemic Hyponatremia (SIADH):
- Fluid restriction to 1 L/day is the cornerstone of treatment 2
- Consider oral sodium chloride supplementation if no response to fluid restriction 2
Hypervolemic Hyponatremia (cirrhosis, heart failure):
- Fluid restriction to 1-1.5 L/day for serum sodium <125 mmol/L 2
- Consider albumin infusion for patients with cirrhosis 2
- Avoid hypertonic saline unless life-threatening symptoms are present 2
Common Pitfalls to Avoid
- Overly rapid correction exceeding 8 mmol/L in 24 hours can lead to osmotic demyelination syndrome 2
- Inadequate monitoring during active correction 2
- Using fluid restriction in cerebral salt wasting instead of volume replacement 2
- Failing to recognize and treat the underlying cause 2
- Using hypertonic saline in hypervolemic hyponatremia without life-threatening symptoms 2