Hypertonic Saline is Required for Severe Hyponatremia with Acute Delirium
Yes, a patient with sodium 110 mmol/L and acute delirium requires immediate hypertonic saline correction. This represents severe symptomatic hyponatremia, which is a medical emergency requiring urgent intervention 1, 2.
Immediate Management Protocol
Administer 3% hypertonic saline immediately with the following parameters 1, 2:
- Initial correction goal: Increase sodium by 6 mmol/L over the first 6 hours OR until severe symptoms (delirium) resolve 1, 2
- Administration method: 100 mL boluses of 3% saline over 10 minutes, which can be repeated up to three times at 10-minute intervals until symptoms improve 1
- Maximum 24-hour limit: Total correction must not exceed 8 mmol/L in 24 hours to prevent osmotic demyelination syndrome 1, 2
Critical Safety Parameters
After achieving the initial 6 mmol/L correction, only 2 mmol/L additional correction is permitted in the following 18 hours 2. This strict limitation prevents osmotic demyelination syndrome, a devastating neurological complication that can cause parkinsonism, quadriparesis, or death 3.
Monitor serum sodium every 2 hours during the initial correction phase 1. Once severe symptoms resolve, transition to monitoring every 4 hours and switch from hypertonic saline to protocols for mild symptomatic or asymptomatic hyponatremia 2.
Why Hypertonic Saline is Essential
Acute delirium at sodium 110 mmol/L indicates severe hyponatremic encephalopathy with brain edema and increased intracranial pressure 4, 5. Without prompt correction, this can progress to seizures, respiratory arrest, coma, or death 4, 6. The mortality risk with sodium <130 mmol/L is 60-fold higher (11.2% vs 0.19%) compared to normonatremic patients 1, 4.
Fluid restriction alone is completely inappropriate for severe symptomatic hyponatremia—this is a medical emergency requiring hypertonic saline, not conservative management 1, 2.
Post-Acute Management
Once delirium resolves (typically after 6 mmol/L correction), discontinue 3% saline and transition to 2:
- Fluid restriction to 1 L/day 2
- Determine underlying etiology (SIADH vs cerebral salt wasting vs hypovolemic) 1
- Continue monitoring to ensure total 24-hour correction stays ≤8 mmol/L 2
Common Pitfall to Avoid
Never use fluid restriction as initial treatment for altered mental status from severe hyponatremia—this delays life-saving therapy 1. The rapid correction rate (>1 mmol/L/hour) is appropriate and safe for severely symptomatic acute hyponatremia, as the risk of osmotic demyelination is primarily with chronic hyponatremia (>48 hours duration) 2, 5, 7.
If the hyponatremia is chronic (>48-72 hours), the same initial aggressive correction is still indicated for severe symptoms, but the 8 mmol/L/24-hour limit becomes even more critical 5, 7.