HDCN Abstract:  ASN Annual Meeting -- San Diego  

Mohmand HK, Issa D, Ahmad Z, et al.

Hypertonic Saline for Hyponatremia: The Risk of Inadvertent Overcorrection

ASN Annual Meeting -- San Diego
J Am Soc Nephrol (Nov) 17:219A 2006

Clinicians have little data to guide them in the optimal use of hypertonic saline in the treatment of hyponatremia. Fear of neurological complications often makes clinicians avoid its use. Formulas for predicting correction have not been extensively validated.

We report on all 62 adult patients treated for hyponatremia with 3% NaCl solution over a five year period in a 528 bed acute care, teaching hospital. In 84% of all patients, and in 100% of patients with a serum sodium <120 mEq/L, a nephrologist supervised the infusion, intending to limit correction to <12 mEq/L/day and <18 mEq/L/48 hours. 3% saline was started in ED in 19 (32%) and in the ICU in 9 (15%) cases; clinical setting did not affect outcomes. The average rate of infusion was 27.4 2.3 ml/hr resulting in an average rise in serum sodium of 0.47 0.05 mEq/L/hr. The average daily correction was 7.15 0.56 mEq/L/day and 11.33 0.69 mEq/L/48 hrs. In 11.3% of cases, correction was >12 mEq/L/24 hrs and in 9.7%, correction >18 mEq/L/48 hrs. In 78% of the patients whose serum Na was < 120 mEq/L, the observed correction exceeded the correction predicted by the Adrogue-Madias formula. Patients who were overcorrected received significantly less hypertonic saline (339 85 ml) than patients whose correction rates remained within guidelines (646 74 ml; p=0.04) and their actual correction averaged 2.54 times their predicted correction. Inadvertent overcorrection was due to a documented water diuresis in 40% of cases. Three patients were given D5W after 3% NaCl to slow correction and 1 patient received DDAVP. The degree of hypokalemia did not affect rate of correction. There was no occurrence of correction by >25 mEq/L/48 hours, worsening of neurological condition during or after hypertonic saline infusion or respiratory arrest.

We conclude that popular formulas underestimate correction after 3% NaCl therapy. Even when hypertonic saline is given in conservative doses, close monitoring of serum sodium levels and urine output is essential, and replacement of urinary water losses and/or administration of DDAVP are often needed to avoid inadvertent overcorrection.

© Copyright 2006-2007, American Society of Nephrology. Reproduced with permission.
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