Key Points
- Use the highest‑yield diagnostic test early; do not let testing delay time‑critical therapy.
- Set objective targets and reassess frequently.
- Plan definitive source control or disease‑specific therapy when indicated; document follow‑up and patient education.
Algorithm
- Assess and treat hypovolemia first; switch to hypotonic fluids to correct free water deficit.
- Determine cause (DI, osmotic diuresis, insensible losses) via urine studies.
- Limit correction to ≤10–12 mEq/L/day (≤8 if high-risk); monitor sodium and neuro status; adjust plan.
Clinical Synopsis & Reasoning
Hypernatremia reflects hypertonicity, usually from water deficit. Restore intravascular volume with isotonic fluids first, then replace free water based on deficit and ongoing losses, limiting correction to ≤10–12 mEq/L/day (≤8 in high-risk) to avoid cerebral edema.
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 |
|---|
| Volume status assessment and hemodynamics | Etiology | Hypovolemic vs euvolemic vs hypervolemic | Guides fluids |
| Serum/urine osmolality, urine volume | Mechanism | Diabetes insipidus vs osmotic diuresis | DDAVP response |
| Serial sodium q4–6 h | Safety | Prevent overcorrection | Adjust infusion rates |
High-Risk & Disposition Triggers
| Trigger | Why it matters | Action |
|---|
| Na+ ≥160 or severe neuro symptoms | Severe hypertonicity | ICU; slow correction ≤10–12/d |
| Shock or ongoing high losses | Persistent rise | Resuscitate; replace ongoing losses |
Pharmacology
| Medication/Intervention | Mechanism | Onset | Role in Therapy | Limitations |
|---|
| Isotonic saline for shock, then hypotonic fluids (D5W/0.45% NaCl) | Fluids | Hours | Restore volume then correct tonicity | Calculate and replace free water deficit |
| Desmopressin (central DI) | AVP analog | Hours | Reduce polyuria and correct hypernatremia | Monitor Na+ closely |
| Loop diuretics (hypervolemic) with hypotonic replacement | Adjunct | Hours | Net free water gain | — |
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
- Hypernatremia reviews and nephrology guidance — Link