How to correct severe hyponatremia (low sodium level) of 114 mmol/L?

Management of Severe Hyponatremia (Sodium 114 mmol/L)

For a sodium level of 114 mmol/L, immediately hospitalize the patient and assess for severe symptoms (seizures, altered mental status, coma); if present, administer 3% hypertonic saline with a target correction of 6 mmol/L over 6 hours, but never exceed 8 mmol/L total correction in 24 hours to prevent osmotic demyelination syndrome. 1, 2

Immediate Assessment Required

Determine symptom severity first - this dictates urgency of treatment:

• Severe symptoms (seizures, coma, altered mental status, confusion): Medical emergency requiring immediate hypertonic saline 1, 3, 4
• Mild symptoms (nausea, vomiting, headache, weakness): Less urgent approach acceptable 1, 4
• Asymptomatic: Can proceed with slower correction 5

Assess volume status to guide treatment approach:

• Hypovolemic (orthostatic hypotension, dry mucous membranes, decreased skin turgor): Requires isotonic saline for volume repletion 1
• Euvolemic (no edema, normal blood pressure): Likely SIADH - requires fluid restriction 1
• Hypervolemic (edema, ascites, jugular venous distention): Cirrhosis or heart failure - requires fluid restriction 1

Treatment Protocol for Severe Symptomatic Hyponatremia

Administer 3% hypertonic saline immediately if patient has severe neurological symptoms:

• Initial target: Correct by 6 mmol/L over first 6 hours OR until symptoms resolve 1, 3
• 24-hour limit: Never exceed 8 mmol/L total correction in 24 hours 1, 2, 4
• Bolus dosing: Give 100 mL of 3% saline over 10 minutes, can repeat up to 3 times at 10-minute intervals until symptoms improve 1
• Calculate sodium deficit: Desired increase in Na (mEq/L) × (0.5 × ideal body weight in kg) 1, 6

Monitor serum sodium every 2 hours during initial correction for severe symptoms 1

Critical Safety Considerations

High-risk patients require even slower correction (4-6 mmol/L per day maximum):

• Advanced liver disease 1, 2
• Chronic alcoholism 1, 2
• Severe malnutrition 1, 2
• Hypokalemia, hypophosphatemia 1

The FDA explicitly warns that correction >12 mEq/L per 24 hours causes osmotic demyelination resulting in dysarthria, mutism, dysphagia, lethargy, seizures, coma, and death 2. For a sodium of 114 mmol/L, this means:

• If correcting 6 mmol/L in first 6 hours, only 2 mmol/L additional correction allowed in next 18 hours 1
• Watch for osmotic demyelination signs 2-7 days after correction: dysarthria, dysphagia, oculomotor dysfunction, quadriparesis 1

Treatment Based on Volume Status

For hypovolemic hyponatremia (true volume depletion):

• Administer isotonic (0.9%) saline for volume repletion 1
• Discontinue diuretics immediately 1
• Once euvolemic, reassess and adjust treatment 1

For euvolemic hyponatremia (SIADH):

• After initial emergency correction with hypertonic saline if symptomatic, implement fluid restriction to 1 L/day 1, 3
• Add oral sodium chloride 100 mEq three times daily if no response to fluid restriction 1, 6
• Consider vaptans (tolvaptan 15 mg daily) for resistant cases, but requires hospital monitoring 2

For hypervolemic hyponatremia (cirrhosis, heart failure):

• Fluid restriction to 1-1.5 L/day 1, 4
• Discontinue diuretics temporarily 1
• Consider albumin infusion in cirrhotic patients 1
• Avoid hypertonic saline unless life-threatening symptoms present - it worsens fluid overload 1

Special Considerations for Neurosurgical Patients

Distinguish cerebral salt wasting (CSW) from SIADH - treatment is opposite:

• CSW: Requires volume and sodium replacement with isotonic or hypertonic saline, NEVER fluid restriction 1
• SIADH: Requires fluid restriction 1
• CSW more common in subarachnoid hemorrhage patients 1
• Consider fludrocortisone for CSW in subarachnoid hemorrhage patients at risk of vasospasm 1

Management of Overcorrection

If sodium rises >8 mmol/L in 24 hours:

• Immediately discontinue current fluids and switch to D5W (5% dextrose in water) 1
• Consider administering desmopressin to slow or reverse rapid rise 1
• Target is to bring total 24-hour correction back to ≤8 mmol/L from starting point 1

Common Pitfalls to Avoid

• Never use fluid restriction as initial treatment for altered mental status - this is a medical emergency requiring hypertonic saline 1
• Never use normal saline for SIADH - it will worsen hyponatremia 1
• Never use fluid restriction for cerebral salt wasting - it worsens outcomes 1
• Never exceed 8 mmol/L correction in 24 hours for chronic hyponatremia 1, 2
• Never delay treatment while pursuing diagnostic workup in symptomatic patients 4

Monitoring Protocol

• Severe symptoms: Check sodium every 2 hours during initial correction 1
• After symptom resolution: Check every 4 hours 1
• Continue monitoring: Daily after stabilization 1
• Track fluid balance and daily weights meticulously 1