What is the primary approach for a patient requiring sodium 124 treatment?

Treatment of Sodium 124 mEq/L (Moderate Hyponatremia)

For a patient with sodium 124 mEq/L, immediately assess symptom severity: if severely symptomatic (seizures, altered consciousness, respiratory distress), administer 100 mL boluses of 3% hypertonic saline (2 mL/kg) up to three times to raise sodium by 4-6 mEq/L within 1-2 hours; if asymptomatic or mildly symptomatic, determine volume status (hypovolemic, euvolemic, or hypervolemic) and treat the underlying cause while restricting free water and ensuring sodium correction does not exceed 10 mEq/L in 24 hours. 1, 2, 3

Step 1: Assess Symptom Severity Immediately

The rapidity and aggressiveness of treatment depends entirely on symptom severity, not the absolute sodium value. 2, 3

Severe symptoms requiring emergency treatment: 1, 2

• Seizures
• Altered consciousness, somnolence, obtundation, or coma
• Cardiorespiratory distress
• Severe confusion or delirium

Mild symptoms (less urgent): 1, 2

• Nausea, vomiting
• Headache
• Weakness
• Mild cognitive impairment

Step 2: Emergency Treatment for Severely Symptomatic Patients

Administer 3% hypertonic saline as 100 mL boluses (approximately 2 mL/kg) over 10 minutes, up to three boluses maximum. 1, 2, 3 This approach raises sodium by approximately 2 mEq/L per bolus, targeting a 4-6 mEq/L increase within 1-2 hours to reverse hyponatremic encephalopathy. 2, 3

Critical correction limits to prevent osmotic demyelination syndrome: 1, 2, 3

• Do not exceed 10 mEq/L correction in the first 24 hours
• Monitor sodium levels every 2-4 hours during active treatment
• Stop hypertonic saline once symptoms resolve or target increase achieved

The bolus approach provides immediate, controllable correction and is safer than continuous infusions for preventing overcorrection. 3

Step 3: Determine Volume Status for Non-Emergency Cases

Categorize the patient to guide definitive treatment: 1, 2

Hypovolemic hyponatremia (dehydration signs present): 1

• Treat with 0.9% normal saline infusions
• Look for causes: diuretics, vomiting, diarrhea, excessive sweating

Euvolemic hyponatremia (normal volume status): 1, 2

• Restrict free water to <1000 mL/day
• Consider salt tablets (1-2 g three times daily)
• Evaluate for SIADH, hypothyroidism, adrenal insufficiency
• Vaptans may be considered but risk overly rapid correction 2

Hypervolemic hyponatremia (edema, ascites present): 4, 1

• Restrict free water to <1000 mL/day
• Restrict sodium to <2000 mg/day (88 mmol/day) 4
• Treat underlying condition (heart failure, cirrhosis, nephrotic syndrome)
• Diuretics may be needed but monitor sodium closely

Step 4: Identify and Address Underlying Causes

Common reversible causes at sodium 124 mEq/L: 1, 2

• Medications: thiazide diuretics, SSRIs, carbamazepine, NSAIDs
• Excessive alcohol consumption
• Very low-salt diets combined with high water intake
• Excessive free water intake during exercise
• Postoperative state with hypotonic IV fluids

Do not delay treatment while pursuing diagnosis, but identifying the cause prevents recurrence. 1

Step 5: Special Considerations

If hyperglycemia is present (glucose >100 mg/dL): 5

• Calculate corrected sodium: add 1.6 mEq/L for every 100 mg/dL glucose above 100 mg/dL
• A measured sodium of 124 with glucose of 400 mg/dL corrects to approximately 129 mEq/L
• Use corrected value to guide fluid selection (0.45% saline if corrected sodium normal/high, 0.9% saline if corrected sodium low) 5

Fluid restriction thresholds: 4, 6

• Only restrict fluids if sodium <120-125 mEq/L 4
• At sodium 124 mEq/L, fluid restriction to approximately 1000-1500 mL/day is appropriate for euvolemic/hypervolemic cases 6
• Avoid restriction in hypovolemic patients 1

Critical Pitfalls to Avoid

Overcorrection is the most dangerous complication: 2, 3

• Osmotic demyelination syndrome can cause permanent neurological damage (parkinsonism, quadriparesis, death)
• Risk is highest in chronic hyponatremia (>48 hours duration), alcoholism, malnutrition, liver disease
• If sodium rises >10 mEq/L in 24 hours, consider re-lowering with hypotonic fluids or desmopressin 3

Do not use hypotonic fluids (0.45% saline, D5W) in patients with hyponatremia unless specifically correcting overcorrection. 4, 6 Isotonic (0.9%) saline is appropriate for hypovolemic hyponatremia; 3% saline only for severe symptoms. 1, 2

Monitor sodium every 4-6 hours during active treatment and every 12-24 hours once stable. 2, 3 More frequent monitoring (every 2 hours) is needed during hypertonic saline administration. 3

Recognize that even mild chronic hyponatremia at this level increases fall risk, fracture risk, and cognitive impairment. 2 Correction improves these outcomes but must be done gradually over days in asymptomatic patients.