Introduction
Case Presentation
MJ is a 56 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.
o
MJ denies shortness of breath, chest or abdominal pain, cough, pain or swelling in her legs, other
neurological symptoms, fever, vomiting, or diarrhea.
o
Her medical history is significant for hypothyroidism, hypercholesterolemia, and hypertension.
o
According to family, she was hospitalized for three days a few months ago due to “dehydration,” at
which time she was given “fluids.”
o
While transporting MJ to the CT scanner, she has a witnessed prolonged tonic-clonic seizure.
o
POC labs are unremarkable, except a serum sodium of 118 mEq/L
How would you manage this patient?
o
3% Sodium Chloride STAT!
Clinical Detail
Clinical Detail
Pharmacology of 3% Sodium Chloride (NaCl) for management of symptomatic hyponatremia:
| 3% Sodium Chloride (NaCl) | Detail |
|---|---|
| Dose* | 2 mL/kg or 50–150 mL • Max of 3 boluses of 3% NaCl preferably 10–30 minutes apart • Option to dose based on calculated sodium deficit |
| Administration* | IV bolus recommended administration for symptomatic hyponatremia • Administered over 10–60 minutes • May be given through peripheral (PIV) access while central access obtained |
| Adverse Effects | Hypernatremia • Fluid or solute overload • Hypokalemia • Acidosis • Overcorrection of hyponatremia |
| Monitoring | BMP (Na+, K+, Cl-) • Symptoms of hyponatremia • Serum osmolality • Volume status • Neurological exam |
| Compatibility | Not compatible with blood products or drugs incompatible with normal saline |
| Comments | Critical to establish IV access with largest bore at most proximal point • During emergencies it’s acceptable to administer through peripheral IV |
*Check institutional guidelines.
Evidence
Evidence
Overview of evidence supporting 3% hypertonic saline in symptomatic hyponatremia:
| Author, Year | Design, Sample Size | Intervention & Comparison | Outcome |
|---|---|---|---|
| Dillon, 2018 | Observational, N=66 | 3% NaCl through PIV | Max rate= 50 mL/hr • Mean duration infusion= 14 hrs (IQR 4–30) • Infusion-related phlebitis= 3% |
| Perez 2017 | Observational, N=28 | 3% NaCl through PIV | Max rate= 50 mL/hr • Mean duration infusion= 36 hrs (range 1–124) • Infusion-related phlebitis= 3% |
| Jones, 2016 | Observational, N=213 | 3% NaCl through PIV | Max rate= 30 mL/hr • Mean duration infusion= 0.85 hr (IQR 0.4–1.3) • Infusion-related phlebitis= 4% |
| Ayus, 2015 | Case Series, N=47 | 3% NaCl 500mL over 6 hrs via PIV | ↑ serum sodium level by 1.26 mEq/L/hr • Improvement in symptoms in 97% of cases |
| Hew-Butler, 2015 | Exercise-Induced Hyponatremia Guideline (EAH) | Recommendation for Severe EAH | “100 mL bolus of 3% NaCl, repeated twice if there is no clinical improvement (10 min intervals have been recommended)” |
| Spasovski G, 2014 | European Renal Best Practice (ERBP) Hyponatremia Guidelines | Recommendation for Severe Hyponatremia | “We recommend prompt IV infusion of 150 mL 3% hypertonic saline or equivalent over 20 minutes. (1D)” |
| Verbalis JG, 2013 | Expert Panel Recommendations for Hyponatremia | Recommendation for Symptomatic Acute Hyponatremia | “For severe symptoms, 100 mL of 3% NaCl infused IV over 10 minutes x 3 as needed.” |
Conclusions
- 3% sodium chloride (NaCl) is the recommended therapy for severe symptomatic hyponatremia, given as an IV bolus of 2 mL/kg or 50–150 mL (max of 3 boluses, preferably 10–30 minutes apart) or dosed to the calculated sodium deficit.
- It can be administered through peripheral IV access while central access is being obtained; published observational data report low rates of infusion-related phlebitis with peripheral 3% NaCl.
- Guideline and expert-panel recommendations support 100–150 mL boluses of 3% NaCl over 10–20 minutes for severe symptoms, repeated as needed (e.g., ERBP 150 mL over 20 minutes; Verbalis 100 mL x 3 over 10 minutes each).
- Overcorrection of hyponatremia is a key adverse effect, so monitor closely with serial BMP (Na+, K+, Cl-), serum osmolality, volume status, neurologic exam, and resolution of hyponatremia symptoms.
References
Sodium chloride. Micromedex [Electronic version]. Greenwood Village, CO: Truven Health Analytics. Retrieved December 21, 2019, from http://www.micromedexsolutions.com/
Rogers IR, et al. Clin J Sport Med. 2011 May;21(3):200-3. PMID: 21519296
Dillon RC, et al. J Intensive Care Med. 2018 Jan;33(1):48-53. PMID: 28372499
Perez CA, et al. J Neurosci Nurs. 2017 Jun;49(3):191-195. PMID: 28471928
Jones GM, et al. Am J Crit Care. 2016 Dec;26(1):37-42. PMID: 27965228
Ayus JC, et al. Am J Kidney Dis. 2015 Mar;65(3):435-42. PMID: 25465163
Hew-Butler T, et al. Clin J Sport Med. 2015 Jul;25(4):303-20. PMID: 26102445
Spasovski G, et al. Nephrol Dial Transplant. 2014 Apr;29 Suppl 2:i1-i39. PMID: 24569496
Verbalis JG, et al. Am J Med. 2013 Oct;126(10 Suppl 1):S1-42. PMID: 24074529
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