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Hypertonic Saline for Hyponatremia: Risk of Inadvertent Overcorrection

Hashim K. Mohmand^*, Dany Issa, Zubair Ahmad, Joseph D. Cappuccio, Ruth W. Kouides, and Richard H. Sterns

^* Department of Medicine, University of Cincinnati Medical Center, Cincinnati, Ohio; Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and Department of Medicine, Rochester General Hospital, Rochester, New York

Correspondence: Dr. Hashim K. Mohmand, 8072 Plantation Drive, West Chester, OH 45069. Phone: 513-280-1191; Fax: 513-558-4399; E-mail: hashimkm{at}yahoo.com

Background and objectives: Data regarding dosage–response relationships for using hypertonic saline in treatment of hyponatremia are extremely limited. Objectives of this study were to assess adherence to previously published guidelines (limiting correction to <12 mEq/L per d and <18 mEq/L per 48 h) in treating hyponatremia with hypertonic saline and to determine the predictive accuracy of the Adrogué-Madias formula.

Design, setting, participants & measurements: A retrospective review was conducted of all 62 adult, hyponatremic patients who were treated with hypertonic saline during 5 yr at a 528-bed, acute care, teaching hospital.

Results: Median infusion rate was 0.38 ml/kg per h, increasing serum sodium concentration by 0.47 ± 0.05 mEq/L per h, 7.1 ± 0.6 mEq/L per 24 h, and 11.3 ± 0.7 mEq/L per 48 h. In 11.3% of cases, the increase was >12 mEq/L per 24 h and in 9.7% was >18 mEq/L per 48 h. No patient's rate was corrected by >25 mEq/L per 48 h. Among patients with serum sodium <120 mEq/L, the observed increase in sodium exceeded the rise predicted by the Adrogué-Madias formula in 74.2%; the average correction in overcorrectors was 2.4 times the predicted. Inadvertent overcorrection was due to documented water diuresis in 40% of cases.

Conclusions: The Adrogué-Madias formula underestimates increase in sodium concentration after hypertonic saline therapy. Unrecognized hypovolemia and other reversible causes of water retention pose a risk for inadvertent overcorrection. Hypertonic saline should be infused at rates lower than those predicted by formulas with close monitoring of serum sodium and urine output.

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The Adrogue-Madias Formula Revisited

Tomas Berl
Clin. J. Am. Soc. Nephrol. 2007 2: 1098-1099. [Full Text] [PDF]

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				A. Perianayagam, R. H. Sterns, S. M. Silver, M. Grieff, R. Mayo, J. Hix, and R. Kouides DDAVP Is Effective in Preventing and Reversing Inadvertent Overcorrection of Hyponatremia Clin. J. Am. Soc. Nephrol., March 1, 2008; 3(2): 331 - 336. [Abstract] [Full Text] [PDF]

				T. Berl The Adrogue-Madias Formula Revisited Clin. J. Am. Soc. Nephrol., November 1, 2007; 2(6): 1098 - 1099. [Full Text] [PDF]