Key Points
- Use the highest‑yield diagnostic test early; do not let testing delay time‑critical therapy.
- Set objective targets (hemodynamic, neurologic, respiratory) and reassess frequently.
- Plan definitive source control or disease‑specific therapy when indicated; document follow‑up and patient education.
Algorithm
- Identify severe symptoms; give 3% saline 100 mL IV bolus, up to 3 boluses, reassessing after each.
- Start desmopressin clamp in high‑risk patients or when water diuresis emerges.
- Set correction targets (≤8 mEq/L/24 h; ≤18 mEq/L/48 h); monitor Na+ q2–4 h.
- Treat underlying cause (e.g., SIADH, hypovolemia, adrenal insufficiency); adjust fluids and solute intake.
- If overcorrection occurs, give DDAVP and D5W to relower safely; continue controlled correction.
Clinical Synopsis & Reasoning
Severe symptoms (seizures, coma) require immediate 3% saline boluses to raise Na+ by 4–6 mEq/L quickly; then maintain controlled correction using a desmopressin clamp and tailored fluids to avoid overcorrection and osmotic demyelination. Aggressively treat the underlying cause.
Treatment Strategy & Disposition
Stabilize ABCs. Initiate guideline‑concordant first‑line therapy with precise dosing and continuous monitoring. Escalate to advanced/procedural interventions based on explicit failure criteria. Define ICU, step‑down, and ward disposition triggers; involve specialty teams early.
Epidemiology / Risk Factors
- Risk varies by comorbidity and precipitants; see citations for condition‑specific data.
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|---|---|---|
| Serum/urine osmolality and sodium | Etiology | Hypotonic vs non‑hypotonic; hypovolemic/euvolemic/hypervolemic | Guide therapy |
| Glucose, lipids, protein | Pseudohyponatremia | Corrected Na+ | — |
| Serial Na+ every 2–4 h | Safety | Monitor correction rate | Target ≤8 mEq/L in 24 h |
Pharmacology
| Medication/Intervention | Mechanism | Onset | Role in Therapy | Limitations |
|---|---|---|---|---|
| Hypertonic saline 3% 100 mL IV bolus (repeat up to 3) | Osmotic | Minutes | Rapidly raise Na+ by ~4–6 mEq/L | Central line not required for small boluses |
| Desmopressin 2–4 µg IV/SC q6–8 h (clamp) | V2 agonist | Hours | Stabilize water diuresis to prevent overcorrection | Monitor Na+ and urine output |
| D5W relowering (if overshoot) | Hypotonic fluid | Minutes | Relower Na+ with DDAVP to safe trajectory | Frequent checks |
Prognosis / Complications
- Outcome depends on timeliness of diagnosis and definitive therapy; monitor for complications.
Patient Education / Counseling
- Provide red‑flag education, adherence guidance, and explicit return precautions; arrange timely specialty follow‑up.
References
- European Clinical Practice Guideline on Hyponatraemia (2014) with updates; expert reviews on DDAVP clamp — Link