How is a patient with a feeding tube and hypernatremia (elevated sodium level of 152) treated?

From the Guidelines

Treatment for a patient with a feeding tube and hypernatremia (sodium level of 152 mEq/L) involves careful fluid management to gradually reduce sodium levels, with the primary approach being to provide hypotonic fluids through the feeding tube or intravenously, as recommended by the most recent guidelines 1. To manage hypernatremia in a patient with a feeding tube, it is essential to address the underlying cause, which often involves inadequate free water provision, excessive electrolyte content in the formula, or increased losses through fever, diarrhea, or diabetes insipidus.

• The correction rate should not exceed 8-10 mEq/L per 24 hours to prevent cerebral edema, and regular monitoring of electrolytes (every 4-6 hours initially), urine output, and clinical status is essential 1.
• For enteral administration, free water can be given through the feeding tube at 30-50 mL/hour, with the rate adjusted based on serial sodium measurements, or the feeding formula can be diluted with water to decrease its osmolarity.
• If using IV fluids, 5% dextrose in water (D5W) or 0.45% saline may be administered, with close monitoring of weight, fluid balance, and biochemistry to inform adjustments to the rate of administration and fluid composition 1.
• Once the sodium level begins to normalize, the feeding regimen should be adjusted to prevent recurrence by ensuring adequate free water flushes (typically 200-500 mL of water 3-4 times daily) through the feeding tube.
• It is also crucial to provide ad libitum access to fluid in all patients to prevent dehydration, hypernatraemia, growth failure, and constipation, as recommended by the international expert consensus statement on the diagnosis and management of congenital nephrogenic diabetes insipidus (arginine vasopressin resistance) 1.

From the Research

Treatment of Hypernatremia

• Hypernatremia is defined as a serum sodium level above 145 mmol/L 2
• In patients with feeding tubes, hypernatremia can be treated with free water administration via the nasogastric (NG) tube and IV Desmopressin to improve the free water deficit 3
• The combination of DKA, HHS, and hypernatremia is rare and extremely challenging to manage, but the most challenging part of this condition is selecting the correct type of fluids to treat these conditions 3

Management of Hypernatremia

• A protocol using dilute vasopressin bolus can be an alternative for managing acute, central DI postoperatively, particularly in the setting of hypovolemic shock resulting in a consistent control of serum sodium 4
• Desmopressin dose requirements in adults with central diabetes insipidus can vary, with higher doses required in patients with congenital DI compared to acquired DI 5
• The primary aim of treatment is to correct the serum sodium level, with the goal of achieving a level between 135-145 mmol/L 2

Specific Treatment Approaches

• In a case report, a patient with severe hypernatremia (serum sodium level of 169 mEq/L) was treated with insulin drip, dextrose 5% in water, and ringer's lactate, as well as free water via an NG tube and IV Desmopressin 3
• Another study found that a dilute vasopressin bolus protocol can be effective in managing hypovolemic shock in acute, postoperative, central DI 4