From the Guidelines
Lactated Ringer's (LR) solution is not the ideal choice for treating hyponatremia due to its lower sodium concentration compared to normal serum sodium levels. The management of hyponatremia depends on the severity of the condition, the presence of symptoms, and the underlying cause. According to the most recent guidelines, for patients with cirrhosis, mild hyponatremia (Na 126-135 mEq/L) does not require specific management apart from monitoring and water restriction 1. For moderate to severe hyponatremia, the use of hypertonic saline is reserved for short-term treatment of patients with symptomatic or severe hyponatremia or those with imminent liver transplant (LT) 1. Some key points to consider when treating hyponatremia include:
- 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 ameliorate the risk of osmotic demyelination syndrome (ODS) 1.
- Severe hyponatremia (<120 mEq/L) at the time of LT increases the risk of ODS with LT, 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. It's essential to address the underlying cause of hyponatremia and to avoid correcting sodium levels too quickly to prevent ODS. In general, normal saline (0.9% NaCl) with 154 mEq/L of sodium or hypertonic saline (3% NaCl) with 513 mEq/L of sodium are more appropriate options for treating hyponatremia than LR solution, depending on the severity and symptoms of the condition 1.
From the Research
Treatment of Hyponatremia
- Hyponatremia is a common electrolyte disorder that can be associated with poor outcomes, and its treatment depends on the underlying cause and the patient's volume status 2, 3, 4.
- For patients with hypovolemic hyponatremia, treatment with normal saline infusions is recommended 3, 4.
- For patients with euvolemic hyponatremia, treatment includes restricting free water consumption or using salt tablets or intravenous vaptans 2, 3, 4.
- For patients with hypervolemic hyponatremia, treatment is primarily focused on managing the underlying cause (e.g., heart failure, cirrhosis) and restricting free water intake 2, 3, 4.
Use of Hypertonic Saline
- Hypertonic saline is reserved for patients with severely symptomatic hyponatremia, and its use should be guided by the patient's symptoms and volume status 2, 3, 5.
- The goal of treatment with hypertonic saline is to increase the serum sodium level by 4-6 mEq/L within 1-2 hours, but not to exceed a correction limit of 10 mEq/L within the first 24 hours 2, 5.
- Rapid correction of hyponatremia can cause osmotic demyelination, a rare but severe neurological condition, and should be avoided 2, 4, 5.
Specific Considerations
- In patients with severe hyponatremia, intravenous hypertonic saline solution can be used to rapidly correct the serum sodium concentration, but this should be done with caution and close monitoring 6.
- The use of desmopressin concomitantly with hypertonic saline may be considered to prevent rapid correction of serum sodium, but this requires careful consideration of the patient's individual needs and circumstances 5.