1.

Determine serum sodium: 135-145 mEq/L

Hyponatremia: Na < 135
Hypernatremia: Na > 145 mmol/L

2. Confirm true hyponatremia w/:

Normal plasma osmolality: 280-295 mOsm/kg
 True hyponatremia: <275 mOsm/kg/H20
- Posm = (2 x plasma Na) + (plasma glucose in mg/dL / 18) + (BUN in mg/dL / 2.8)
- Effective plasma osmolality = (2 x plasma Na) + (plasma glucose in mg/dL / 18)
Urine osmolality: 300-800 mmol/L
 <100: primary polydipsia
 100-400 AVP excess with inc water intake
 >400: AVP excess

3. Assess volume status: hypovolemic, euvolemic, hypervolemic w/:

 Hypovolemia: DEC H20 & Na (sodium loss > water loss)
 Euvolemia: INC water; NO CHANGE in Na
 Hypervolemia: INC H20 & Na

4. Determine cause w/:

Urine sodium: 20 mEq/L

Hyponatremia
Acute: <48 hrs
 Emergency correction with hypertonic saline (3%) at 1-2 mL/kg/hr
 Coadminister furosemide (not given with hypovolemia)

Chronic: >48 hrs

 Hypertonic saline
 Furosemide
 Water restrict upon reaching 10% increase of sodium
 Do not correct if serum Na > 12 mmol/L in 24 hrs
 Goal: 8 mmol/L in 24 hrs or <18 mmol/L in 48 hrs

Signs of chronic hyponatremia

 Plasma Na: <125 mmol/L
 Vomit, nausea, confusion, seizures
 Subtle gait, cognitive defects
 Inc risk of fall and bony fractures

Total Body Water

 Male: 0.6 x body weight (kg)
 Female: 0.5 x body weight (kg)
Na deficit = TBW x (target plasma Na – starting plasma)
 Recommended rate (1-2 mmol/L per hour for up to 4-6 mmol/L)
 Plasma Na raised or lowered by no more than 8-10 mmol/L per day

Free water deficit = TBW x (Actual sodium – 140)/140]

 Replace water deficit over 48-72 hours