How to manage hypernatremia resulting from overcorrection of hyponatremia?

From the Guidelines

Hypernatremia resulting from overcorrection of hyponatremia should be managed by relowering serum sodium levels with electrolyte-free water or desmopressin.

Management of Hypernatremia

To manage hypernatremia resulting from overcorrection of hyponatremia, the following steps can be taken:

• Relowering serum sodium levels: This can be achieved with electrolyte-free water or desmopressin, as recommended by a US expert panel 1.
• Monitoring serum sodium levels: Frequent monitoring of serum sodium levels is necessary to prevent overcorrection and to adjust treatment accordingly 1.
• Avoiding rapid correction: Rapid correction of serum sodium levels should be avoided to prevent central pontine myelinolysis (CPM) or osmotic demyelination syndrome (ODS) 1.

Prevention of Overcorrection

To prevent overcorrection of hyponatremia, the following guidelines can be followed:

• Goal rate of change of serum sodium: The goal rate of change of serum sodium should be 4-8 mEq/L per day, not to exceed 10-12 mEq in a 24-hour period, with average ODS risk, and a lower goal of 4-6 mEq/L per day, not to exceed 8 mEq per 24-hour period in patients at high risk of ODS 1.
• Limiting hypertonic sodium chloride administration: Hypertonic sodium chloride administration should be limited to severely symptomatic hyponatremia, and the serum sodium concentration should not increase more than 8 mmol/L per day 1.

From the Research

Managing Hypernatremia Resulting from Overcorrection of Hyponatremia

To manage hypernatremia resulting from the overcorrection of hyponatremia, it is crucial to understand the causes and risks associated with this condition. The following points highlight key considerations:

• Overcorrection of hyponatremia can lead to osmotic demyelination syndrome, a rare but severe neurological condition 2, 3, 4.
• The risk of overcorrection is higher in patients with certain characteristics, such as initial serum sodium level, chronic alcoholism, severe symptoms of hyponatremia, and initial potassium level 3.
• A novel risk score, the NASK score, has been derived to predict the risk of hyponatremia overcorrection, taking into account hypoNatremia, Alcoholism, Severe symptoms, and hypoKalemia 3.
• Treatment of symptomatic hyponatremia requires careful monitoring of the patient's clinical status and relevant serum biochemical values, as well as understanding of the targets and risks of treatment 4, 5.
• Rapid correction of chronic hypotonic hyponatremia should be avoided to prevent osmotic demyelination syndrome, and therapeutic measures to lower the serum sodium level should be undertaken if the rate increases too rapidly 4, 5.

Prevention of Overcorrection

Preventing overcorrection of hyponatremia is critical to avoid hypernatremia and its associated complications. Key strategies include:

• Careful calculation of the predicted sodium concentration based on traditional calculations for the correction of hyponatremia 2.
• Avoiding miscommunications between healthcare providers regarding the amount of saline and potassium administered to the patient 2.
• Recognizing common pitfalls, such as unexpected hypoosmotic polyuria, that can lead to overcorrection 2.
• Using the NASK score to identify patients at high risk of hyponatremia overcorrection and adjusting treatment accordingly 3.

Treatment of Hypernatremia

If hypernatremia occurs due to overcorrection of hyponatremia, treatment should focus on:

• Lowering the serum sodium level to a safe range 4, 5.
• Providing free water or desmopressin to reduce the serum sodium level, if necessary 5.
• Close monitoring of the patient's clinical status and relevant serum biochemical values to prevent further complications 4, 5.