Advertisement
American Journal of Kidney Diseases

Hypertonic Saline and Desmopressin: A Simple Strategy for Safe Correction of Severe Hyponatremia

Published:December 26, 2012DOI:https://doi.org/10.1053/j.ajkd.2012.11.032

      Background

      Prompt correction of severe hyponatremia is important, but correction also must be limited to avoid iatrogenic osmotic demyelination. Expert opinion recommends that serum sodium level not be increased by more than 10-12 mEq/L in any 24-hour period and/or 18 mEq/L in any 48-hour period. However, inadvertent overcorrection is common, usually caused by the unexpected emergence of a water diuresis.

      Study Design

      Quality improvement report.

      Setting & Participants

      All 25 patients admitted to a community teaching hospital between October 1, 2008, and September 30, 2011, who were treated for serum sodium level <120 mEq/L with concurrently administered desmopressin and hypertonic saline solution.

      Quality Improvement Plan

      Concurrently administered desmopressin (1-2 µg parenterally every 6-8 hours) and hypertonic saline with weight-based doses adjusted to increase the serum sodium concentration by 6 mEq/L, avoiding inadvertent overcorrection of severe hyponatremia.

      Outcomes

      Rate of correction of hyponatremia, predictability of response to the combination, adverse events related to therapy.

      Measurements

      Rate of correction of hyponatremia at 4, 24, and 48 hours; administered dose of 3% saline solution, salt tablets, and potassium; predicted increase in serum sodium level.

      Results

      Mean changes in serum sodium levels during the first and second 24 hours of therapy were 5.8 ± 2.8 (SD) and 4.5 ± 2.2 mEq/L, respectively, without correction by >12 mEq/L in 24 hours or >18 mEq/L in 48 hours and without a decrease during therapy. There was no significant difference between actual and predicted increases during the first 24 hours. There was no adverse effect associated with therapy.

      Limitations

      Without concurrent controls, we cannot be certain that outcomes are improved. Balance studies were not performed.

      Conclusions

      Combined 3% saline solution and desmopressin appears to be a valid strategy for correcting severe hyponatremia, but studies comparing the regimen with other therapeutic strategies are needed.

      Index Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Kidney Diseases
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Sterns R.H.
        • Cappuccio J.D.
        • Silver S.M.
        • Cohen E.P.
        Neurologic sequelae after treatment of severe hyponatremia: a multicenter perspective.
        J Am Soc Nephrol. 1994; 4: 1522-1530
        • Verbalis J.G.
        • Goldsmith S.R.
        • Greenberg A.
        • Schrier R.W.
        • Sterns R.H.
        Hyponatremia treatment guidelines 2007: expert panel recommendations.
        Am J Med. 2007; 120 (suppl 1): S1-S21
        • Mohmand H.K.
        • Issa D.
        • Ahmad Z.
        • Cappuccio J.D.
        • Kouides R.W.
        • Sterns R.H.
        Hypertonic saline for hyponatremia: risk of inadvertent overcorrection.
        Clin J Am Soc Nephrol. 2007; 2: 1110-1117
        • Sterns R.H.
        • Hix J.K.
        • Silver S.
        Treating profound hyponatremia: a strategy for controlled correction.
        Am J Kidney Dis. 2010; 56: 774-779
        • Adrogué H.J.
        • Madias N.E.
        Hyponatremia.
        N Engl J Med. 2000; 342: 1581-1589
        • Watson P.E.
        • Watson I.D.
        • Batt R.D.
        Total body water volumes for adult males and females estimated from simple anthropometric measurements.
        Am J Clin Nutr. 1980; 33: 27-39
        • Altman D.G.
        • Bland J.M.
        Measurement in medicine: the analysis of method comparison studies.
        Statistician. 1983; 32: 307-317
        • Sterns R.H.
        • Hix J.K.
        • Silver S.M.
        Treatment of hyponatremia.
        Curr Opin Nephrol Hypertens. 2010; 19: 493-498
        • Adrogué H.J.
        • Madias N.E.
        The challenge of hyponatremia.
        J Am Soc Nephrol. 2012; 23: 1140-1148
        • Perianayagam A.
        • Sterns R.H.
        • Silver S.M.
        • et al.
        DDAVP is effective in preventing and reversing inadvertent overcorrection of hyponatremia.
        Clin J Am Soc Nephrol. 2008; 3: 331-336
        • Velez J.C.
        • Dopson S.J.
        • Sanders D.S.
        • Delay T.A.
        • Arthur J.M.
        Intravenous conivaptan for the treatment of hyponatraemia caused by the syndrome of inappropriate secretion of antidiuretic hormone in hospitalized patients: a single-centre experience.
        Nephrol Dial Transplant. 2010; 25: 1524-1531
        • Decaux G.
        • Andres C.
        • Gankam Kengne F.
        • Soupart A.
        Treatment of euvolemic hyponatremia in the intensive care unit by urea.
        Crit Care. 2010; 14: R184
        • Trissel L.A.
        Handbook on Injectable Drugs.
        16th ed. American Society of Health-System Pharmacists, Bethesda, MD2011
        • Berl T.
        • Rastegar A.
        A patient with severe hyponatremia and hypokalemia: osmotic demyelination following potassium repletion.
        Am J Kidney Dis. 2010; A55: 742-748
        • Steele A.
        • Gowrishankar M.
        • Abrahamson S.
        • Mazer C.D.
        • Feldman R.D.
        • Halperin M.L.
        Postoperative hyponatremia despite near-isotonic saline infusion: a phenomenon of desalination.
        Ann Intern Med. 1997; 126: 20-25