How to manage a patient with corrected hyponatremia (low sodium level) from 132 to 150 after treatment with 3% Sodium Chloride (NaCl) Three Times a Day (TDS)?

Management of Iatrogenic Hypernatremia After Hyponatremia Correction

Immediately discontinue 3% NaCl and implement a controlled sodium reduction strategy to prevent osmotic demyelination syndrome in this patient with overcorrected hyponatremia.

Assessment of Overcorrection

• The patient's sodium has increased from 132 mmol/L to 150 mmol/L, representing an increase of 18 mmol/L, which significantly exceeds the maximum recommended correction rate of 8 mmol/L in 24 hours 1, 2
• This rapid correction puts the patient at high risk for osmotic demyelination syndrome (ODS), a potentially devastating neurological complication 1, 3

Immediate Management Steps

• Discontinue all ongoing 3% NaCl infusions immediately 2
• Administer 5% dextrose in water (D5W) to relower sodium levels 1, 4
• Consider administering desmopressin (DDAVP) to prevent further water diuresis and help control the sodium reduction 1, 5
• Calculate the target sodium reduction using the formula: Desired decrease in Na (mEq/L) × (0.5 × ideal body weight in kg) 1

Target Correction Rate

• Aim to reduce sodium concentration by 4-6 mmol/L per day until reaching a safer level (around 140 mmol/L) 1, 3
• Monitor serum sodium levels every 2-4 hours during the initial relowering phase 1, 2
• Adjust fluid therapy based on frequent sodium measurements to ensure controlled reduction 1

Monitoring for Complications

• Closely monitor for neurological symptoms that might indicate developing ODS (dysarthria, dysphagia, altered mental status, quadriparesis, movement disorders) 1, 6
• Watch for signs of volume overload during fluid administration, especially if the patient has underlying heart or liver disease 1
• Monitor urine output carefully, as excessive diuresis can complicate management 4

Special Considerations

• If the patient has liver disease, alcoholism, malnutrition, or other risk factors for ODS, even more cautious management is required 1, 6
• ODS typically manifests 2-7 days after rapid correction, so continued vigilance is necessary even after initial management 1
• Supportive care should be continued for several weeks if ODS develops, as it may be reversible even in severe cases 3

Prevention of Future Episodes

• For future management of hyponatremia in this patient:
  • Use slower correction rates (maximum 8 mmol/L in 24 hours, or 4-6 mmol/L for high-risk patients) 1, 7
  • Implement frequent monitoring of serum sodium during correction 1
  • Consider fluid restriction (1-1.5 L/day) rather than hypertonic saline for chronic management if appropriate 1, 7
  • Address the underlying cause of the original hyponatremia 8, 6

Common Pitfalls to Avoid

• Failing to recognize the urgency of treating overcorrection - delay increases risk of permanent neurological damage 1, 4
• Inadequate monitoring during relowering therapy can lead to excessive or insufficient correction 1
• Not considering desmopressin to prevent further water diuresis during treatment 5
• Assuming ODS is irreversible - aggressive supportive care may lead to recovery even in severe cases 3