Is overcorrection acceptable in suspected acute hyponatremia (low sodium levels)?

From the Guidelines

Over-correction of acute hyponatremia should be approached with caution, and the goal should be to raise serum sodium by 4-6 mEq/L per 24-hour period, not to exceed 8 mEq/L per 24-hour period to ameliorate the risk of osmotic demyelination syndrome (ODS). For acute hyponatremia, the management strategy should prioritize the severity of symptoms and the underlying cause of hyponatremia. According to the most recent guidelines from the American Association for the Study of Liver Diseases 1, the use of hypertonic saline is reserved for short-term treatment of patients with symptomatic or severe hyponatremia.

Key Considerations

• The goal rate of increase of serum sodium is 4-6 mEq/L per 24-hour period, not to exceed 8 mEq/L per 24-hour period to minimize the risk of ODS 1.
• Severe hyponatremia (<120 mEq/L) at the time of liver transplantation increases the risk of ODS, and multidisciplinary coordinated care may mitigate this risk 1.
• The use of vasopressin receptor antagonists can raise serum sodium during treatment but should be used with caution only for a short term (≤30 days) 1.

Management Strategy

• For symptomatic or severe hyponatremia, consider the use of hypertonic saline for short-term treatment 1.
• Monitor serum sodium levels closely during correction, every 2-4 hours, to avoid over-correction 1.
• Consider albumin infusion to improve serum sodium concentration, although more information is needed to fully understand its effects 1.

Prioritizing Patient Outcomes

• The primary goal is to alleviate severe symptoms while minimizing the risk of ODS and other complications.
• Treatment strategies should be individualized based on the severity of hyponatremia, the presence of symptoms, and the underlying cause of hyponatremia.

From the Research

Suspected Acute Hyponatremia Correction

• Overcorrection of hyponatremia is not recommended as it can cause osmotic demyelination, a rare but severe neurological condition, which can result in parkinsonism, quadriparesis, or even death 2, 3, 4.
• The correction limit for hyponatremia is 10 mEq/L within the first 24 hours, and exceeding this limit can lead to overly rapid correction 2.
• US and European guidelines recommend treating severely symptomatic hyponatremia with bolus hypertonic saline to reverse hyponatremic encephalopathy by increasing the serum sodium level by 4 mEq/L to 6 mEq/L within 1 to 2 hours 2.
• Overcorrection of hyponatremia may be preventable in many cases by recognizing common pitfalls, such as miscommunications between healthcare providers and unexpected hypoosmotic polyuria 3.
• Central pontine myelinolysis (CPM) is a rare but serious condition that can occur as a result of rapid correction of hyponatremia, and its clinical manifestation can be delayed 5.

Management of Hyponatremia

• The approach to managing hyponatremia should consist of treating the underlying cause, and urea and vaptans can be effective treatments for the syndrome of inappropriate antidiuresis and hyponatremia in patients with heart failure 2.
• Current guidelines for the treatment of hyponatremia recommend cautious correction of the serum sodium concentration, and frequent monitoring of the serum sodium concentration is necessary to prevent overcorrection 6.
• The use of vasopressin receptor antagonists, such as vaptans, can induce an excretion of increased amounts of water without altered sodium or potassium excretion, and may become important therapeutic interventions in the clinical management of osmotic myelinolysis syndrome 4.