Hyponatremia Treatment: Improving the Rate of Overcorrection

Background: Hyponatremia, an electrolyte disorder resulting from impaired free water excretion, requires tailored treatment based on its etiology and severity. The goal of treatment is to raise serum sodium (Na+) levels safely to avoid osmotic demyelination syndrome (ODS). The object of this study was to institute a protocol in the emergency department (ED) that would decrease the incidence of overcorrection. Methods: A prospective, single-center study was conducted at Westchester Medical Center (WMC) between January and April 2024. Adult patients presenting to the ED with Na+ ≤125 mmol/L were included. A protocol was initiated requiring the ED physician to assess urine Na and osmolality (osm), implement cautious use of intravenous (IV) fluids, and consult nephrology. Overcorrection was defined as a serum Na+ correction exceeding 8 mmol/L within the first 24-hours. Excluded from the study were transfer patients, patients with hyperglycemia induced hyponatremia, and patients who didn't stay a full 24 hrs. Data was collected on patient comorbidities, urine and serum osm, use of IV fluids, and efforts to slow overcorrection. The data was compared to retrospective data of adult patients presenting to the WMC ED between 2019 and 2022 with serum Na+ ≤125 mmol/L. Results: Between 2019-2022, 89 out of 477 patients (19%) experienced overcorrection. Notably, 42% were on medications associated with hyponatremia (thiazides or psychiatric drugs), and 15% had cirrhosis or congestive heart failure. Most patients (76%) received empiric IV fluids, and 68% had urine osmolality <300 mmol/L. After implementing the protocol (January to April 2024), 11 patients had a Na+ ≤125 mmol/L. Four patients were excluded. Among the remaining 7 patients, 2 (29%) were on hyponatremia-associated medications, and 3 (42%) had cirrhosis or CHF. Only 1 patient (14%) overcorrected, and that patient had received empiric IV fluids and had an initial urine osm<300. This patient corrected by 9 mmol/L, and D5W was administered to rectify the overcorrection. Conclusion: Our retrospective data highlights a 19% overcorrection rate in hyponatremia, a potentially significant risk for ODS. Early renal intervention, as observed in our prospective study, improved the overcorrection rate through collaboration between the ED and the nephrology division. Further investigation is warranted to further analyze the benefits of the hyponatremia protocol.