From the Guidelines
The target for hypernatremia correction should be to reduce serum sodium at a controlled rate of 10-15 mmol/L per 24 hours. This is based on the most recent and highest quality study available, which recommends this rate to avoid rapid correction that may induce cerebral oedema, seizures, and neurological injury 1.
Key Considerations
- The correction rate should be based on the aetiology of hypernatremia, which should be ascertained by assessment of the infant's intravascular volume and hydration status.
- In case of symptomatic hypovolaemia, plasma volume should be replaced.
- A reduction rate of 10-15 mmol/L per 24 hours is recommended to avoid complications.
Treatment Approach
- Therapeutic measures should be based on the aetiology of hypernatremia.
- Treatment may involve administration of fluids, but the type and rate of administration should be carefully considered to avoid rapid correction.
- The underlying cause of hypernatremia should be addressed simultaneously, which may include correcting fluid and electrolyte imbalances.
Monitoring and Adjustments
- Careful monitoring of serum sodium levels is essential during initial correction.
- The correction plan should be adjusted based on the patient's response to treatment and any ongoing fluid losses. As recommended by the espghan/espen/espr/cspen guidelines on pediatric parenteral nutrition: fluid and electrolytes 1, this approach prioritizes the patient's safety and minimizes the risk of complications.
From the Research
Hypernatremia Correction Targets
- The optimal target for hypernatremia correction is not clearly defined, but some studies suggest a reduction rate not to exceed 0.5 mmol/L per hour 2.
- A study published in 2019 found that rapid correction of hypernatremia (>0.5 mmol/L per hour) was not associated with a higher risk of mortality, seizure, alteration of consciousness, and/or cerebral edema in critically ill adult patients 2.
- However, another study published in 2013 recommended that serum sodium level should not be increased by more than 10-12 mEq/L in any 24-hour period and/or 18 mEq/L in any 48-hour period to avoid iatrogenic osmotic demyelination 3.
- A systematic review published in 2024 found that the present recommendations for treating acute and chronic hypernatremia in resuscitated patients do not stem from high-quality research 4.
- The diagnosis and treatment of hypernatremia require an understanding of body fluid compartments and concepts of normal body water balance, and the management of hypernatremia focuses on resolving the underlying cause, replenishing free water deficit, and preventing further losses while closely monitoring serum sodium concentration 5.
Risk Factors for Hypernatremia
- A study published in 2014 found that the use of normal saline to dilute parenteral drugs and to keep catheters open is a major and preventable source of hypernatremia acquired in the intensive care unit 6.
- High sodium input from 0.9% saline used to dilute drugs and keep catheters open is a modifiable risk factor for ICU-acquired hypernatremia 6.
- Dissolving drugs in dextrose 5% may partially prevent potentially harmful sodium overloading and hypernatremia 6.