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In general, hyponatremia is treated with fluid restriction (in the physical examination, laboratory studies, and evaluation of volume status.
Table of contents

Water intoxication and thioridazine Mellaril.

Medical Care

The agony of ecstasy: MDMA 3,4-methylenedioxymethamphetamine and the kidney. Clin J Am Soc Nephrol ; Postoperative hyponatremia despite near Palmer BF. Hyponatraemia in a neurosurgical patient: Syndrome of inappropriate antidiuretic hormone secretion versus cerebral salt wasting. Nephrol Dial Transplant ; Kilpatrick ES.

BMJ ; Osmotic and nonosmotic control of vasopressin release and the pathogenesis of impaired water excretion in adrenal, thyroid and edematous disorders.

How Should Hyponatremia Be Evaluated and Managed?

J Lab Clin Med ; Hyponatremia in marathon runners. Clin J Sport Med ; Fox BD. Crash diet potomania. Lancet ; Hyponatremia in psychogenic polydipsia. Arch Intern Med ; A double blind, placebo-controlled trial of demeclocycline treatment of polydipsia-hyponatremia in chronically psychotic patients. Biol Psychiatry ; Clinical assessment of extracellular fluid volume in hyponatremia.

Hyponatremia treatment guidelines Expert panel recommendations. Am J Med ;S Am J Med Sci ; Uric acid, anion gap and urea concentration in the diagnostic approach to hyponatremia.

Hyponatremia - Wikipedia

Age-related increase in plasma urea level and decrease in fractional urea excretion: Clinical application in the syndrome of inappropriate secretion of antidiuretic hormone. Low plasma bicarbonate level in hyponatremia related to adrenocorticotropin deficiency.


  1. Diagnosis, evaluation, and treatment of hyponatremia: expert panel recommendations..
  2. Diagnostic Approach to Hyponatremia?
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J Clin Endocrinol Metab ; The treatment of hyponatremia. Semin Nephrol ; Berl T. The Adrogue-Madias formula revisited. Danger of central pontine myelinolysis in hypotonic dehydration and recommendation for treatment. Mount DB. The brain in hyponatremia: Both culprit and victim. The pathophysiology and treatment of hyponatraemic encephalopathy: An update. Soupart A, Decaux G.

Hyponatremia Treatment

Therapeutic recommendations for management of severe hyponatremia: Current concepts on pathogenesis and prevention of neurologic complications. Am J Kidney Dis ; Greenberg A, Verbalis JG. Vasopressin receptor antagonists.

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Kidney Int ; Jovanovich AJ, Berl T. Where vaptans do and do not fit in the treatment of hyponatremia. Tolvaptan, a selective oral vasopressin V2-receptor antagonist, for hyponatremia. Oral tolvaptan is safe and effective in chronic hyponatremia. Eur Heart J ; JAMA ; Acute Card Care ; Effects of satavaptan, a selective vasopressin V 2 receptor antagonist, on ascites and serum sodium in cirrhosis with hyponatremia: A randomized trial.

Hepatology ; Effects of a selective vasopressin V2 receptor antagonist, satavaptan, on ascites recurrence after paracentesis in patients with cirrhosis. J Hepatol ; This article has been cited by. Current approaches to the management of patients with cirrhotic ascites. Hyponatremia associates with poor outcome in metastatic renal cell carcinoma patients treated with everolimus: prognostic impact. Emergency Medicine Clinics of North America. Predictors of nonresponse to fluid restriction in hyponatraemia due to the syndrome of inappropriate antidiuresis.

There are two types of hyponatremic patients: those that are dying and those that are just waiting to die. For the latter, please order the initial work-up, put away your normal saline, and wait for the medical team to see and admit the patient. For the patients that are seizing, not breathing, vomiting, or in a coma it is go time. I am a fan of the European hyponatremia recommendations outlined in the blog post. They are simple to understand; they dispense with the need for calculations and gets patients the therapy they need quickly. But understand, though you are supposed to draw the sodium after the first mL, you are not supposed to slow or stop the infusion.

One important note about the case of Marjorie. We have little information besides the fact that she is on thiazide diuretics, and has concurrent hypokalemia. The cause of the hyponatremia is release of ADH in response to the decreased perfusion from the thiazide-induced volume depletion.

As soon as the volume is restored the hypothalamus will shut down ADH and the patient will start pouring out copious amounts of maximally dilute urine. This will cause the serum sodium to rush upwards and could cause osmotic demyelination syndrome. The Case Marjorie, an year-old female, presents to the ED with a chief complaint of progressively worsening weakness and fatigue over the past week, associated with a loss of appetite, nausea, and occasional confusion. Investigations are ordered and results reviewed.

Severe : cardiorespiratory arrest, seizures, coma, deep somnolence Moderate : nausea, confusion, headache, vomiting In adults, the most common causes of hyponatremia include thiazide use, SIADH, primary polydipsia, and water intoxication intentional or unintentional. Why does this matter?

Pathophysiology and Complications of Hyponatremia Left untreated, hyponatremia can be a life-threatening condition. Signs and symptoms The signs and symptoms of hyponatremia depend on the level of sodium deficiency and whether the hyponatremia developed acutely or over a longer period of time 5. Signs and symptoms include 2 : Nausea, vomiting Headache Confusion Seizures Abnormal somnolence, coma Cardiorespiratory distress Hiccups Ataxia, falls Slow decision making Brain cells adjust to hyponatremia within hours by reducing intracellular concentration of other solutes.

Investigations The presence of hyponatremia is established by the standard serum electrolyte test.


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  • About This Item.
  • Key Points.
  • Diagnosis and Management of Sodium Disorders: Hyponatremia and Hypernatremia.
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  • Caution must be taken of other plasma abnormalities or sampling errors that can mimic hyponatremia: Pseudohyponatremia — an elevation in non-osmolar plasma proteins or lipids, leading to a falsely low sodium reading. If pseudohyponatremia is suspected, direct ion detection can be used through the ABG lab. These patients have no clinical manifestations of hyponatremia because they do not have hypoosmolar plasma. Hyponatremia and Volume Status Additional testing can be performed to identify whether the hyponatremia is hypo-, hyper-, or euvolemic. Hypovolemic Euvolemic Hypervolemic Definition Loss of sodium and relatively lesser loss of body water Normal total body sodium and excess total body water Increased sodium with relatively greater increase in body water Etiologies Vomiting, diarrhea, diuretic use Syndrome of inappropriate anti diuretic hormone secretion SIADH , drugs most frequently SSRIs , hypothyroidism, adrenal insufficiency, primary polydipsia, Water intoxication e.

    In case of cerebral salt wasting, do NOT restrict fluids See guidelines for recommended treatment by specific underlying pathology 4 Chronic SIADH most common cause, in which case isotonic saline is not effective and fluid restriction is first line therapy. Treatment If the decision is made to go ahead with treatment, keep the following principles in in mind. Decide whether treatment is required in the ED at all.

    Treatment should be focussed on the individual patient, not lab values. Not all patients presenting to the ED with hyponatremia require rapid treatment, particularly in cases where the hyponatremia is thought to have developed gradually, with effective patient compensation, manifesting with no or sub-acute symptoms. Set up for success — if possible, weigh your patient in order to have as accurate an estimate of total body water as possible. Also, have an idea of what tonicity saline is available at your site.

    Overly rapid increase in sodium levels, particularly in patients with chronic hyponatremia, can lead to osmotic demyelination syndrome ODS , a profoundly debilitating condition. In , a patient successfully sued her physician and nurse for overcorrection of sodium levels, leading to ODS and lifelong disability 6. Water diuresis i. The development of water diuresis should prompt careful monitoring for a rising serum sodium Cue up medicine — while treatment for moderate to severe hyponatremia starts in the ED, patients may have to be admitted until symptoms regress.

    However, patients with asymptomatic, mild, and sometimes even moderate hyponatremia often do not require admission. Moderately symptomatic 1,2 Where possible, discontinue use of medications that can worsen hyponatremia Treat underlying condition, if known. Some causes e. Check sodium concentration at hours 1, 6, and Treat underlying condition, if possible.

    Check serum sodium every 6 hours. Appendix 1 — Calculating infusion rates I have found calculating infusion rates challenging.

    Differential Diagnosis of Hyponatremia

    The fluid you would like to use. Hyponatremia in the Emergency Department. AHC Media. Published Clinical practice guideline on diagnosis and treatment of hyponatraemia. Eur J Endocrinol. Diagnosis, evaluation, and treatment of hyponatremia: expert panel recommendations. Am J Med. Henry D. In The Clinic: Hyponatremia.