Table 4.

Recommended treatment of symptomatic or severe (sodium ≤120 mEq/L) hyponatremia

ConditionAssociated SymptomsRisk of Morbidity and Mortality from Cerebral EdemaRisk of Osmotic Demyelination SyndromeTherapeutic Goal and Strategies to Achieve GoalTherapeutic Limit and Strategies to Limit Correction
Seizures and coma in any patient with serum Na <128 mEq/LVariable depending on chronicity, serum Na level, and comorbidities4–6 mEq/L within 1–2 h with bolus infusions of 3% salineVariable depending on chronicity, serum Na level, and comorbidities
 Severity of cerebral edema and risk of herniation varies
 Aggressive therapy indicated regardless of risk of herniation to relieve symptoms and avoid morbidity
High risk comorbidities for osmotic demyelination syndromeHighVariable initial therapy depending on symptoms; 4–6 mEq/L per day8 mEq/L per day; prevent excessive water losses with desmopressin
 Serum Na ≤105 mEq/L
 Alcoholism or severe malnutrition
 Hypokalemia or hypophosphatemia
 Advanced liver disease
Acute hyponatremia from self-induced water intoxication or parenteral fluids or hyponatremia with intracranial pathologyMild or moderate (nausea, vomiting, confusion, lethargy, or headache)Considerable risk of herniation and morbidity from aspiration or hypoxiaLow4–6 mEq/L within 1–2 h with bolus infusions of 3% saline10 mEq/L in first 24 h and 8 mEq/L daily thereafter; replace water losses or prevent water losses with desmopressin
Chronic severe hyponatremia (Na≤120 mEq/L) without high-risk comorbiditiesModerate (nausea, vomiting, confusion, lethargy, or headache)Minimal risk of herniation but risk of morbidity from falls or seizuresVariable depending on level of serum sodium concentration4–6 mEq/L within 6–12 h with infusion of 3% saline with or without a bolus8 mEq/L per day; replace water losses or prevent water losses with desmopressin
Chronic severe hyponatremia without high-risk comorbiditiesMild or asymptomaticNo risk of herniation but risk of morbidity from fallsVariable depending on serum sodium concentration4–8 mEq/L within 24 h8 mEq/L per day; replace water losses or prevent water losses with desmopressin
  • Na, sodium.