1. Weaning and De-escalation of IV Therapies

Structured tapering of hypertonic or hypotonic infusions is critical to prevent overcorrection, rebound dysnatremias, and neurologic injury like osmotic demyelination syndrome.

A. Indications and Timing Criteria for Hypertonic Saline Taper

Initiate a taper of hypertonic saline when any of the following criteria are met:

• Symptom Resolution: Acute, severe symptoms of hyponatremia (e.g., seizures, coma) have resolved.
• Correction Target Reached: Serum sodium has increased by 4–6 mEq/L in the first 24 hours (for chronic hyponatremia) or is approaching the initial target (e.g., 120 mEq/L).
• Hemodynamic Stability: The patient is hemodynamically stable with no ongoing stimuli for antidiuretic hormone (ADH) release (e.g., uncontrolled pain, nausea).

B. Stepwise De-escalation Schedule with Monitoring Checkpoints

A cautious, stepwise approach with frequent monitoring is key:

1. Rate Reduction: Halve the infusion rate of 3% NaCl once the initial sodium increment is achieved (e.g., reduce from 2 mL/kg/h to 1 mL/kg/h).
2. Frequent Monitoring: Check serum sodium every 2–4 hours. Hold or further slow the infusion if the rate of correction exceeds 0.5 mEq/L per hour.
3. Stabilization: Continue stepwise reductions until the serum sodium stabilizes within a safe, lower-normal range (e.g., 133–137 mEq/L) before discontinuation.

C. Transition to Hypotonic Maintenance Fluids

Once hypernatremia is controlled, transition to hypotonic fluids to replace the free-water deficit. The choice is often 0.45% NaCl or D5W, with the rate guided by the calculated deficit:

Free-Water Deficit (L) = Total Body Water × [(Serum Na / 140) – 1]

The infusion rate must also account for ongoing free-water losses (e.g., urine, insensible losses), with sodium and volume status monitored every 6–8 hours.

2. Oral and Enteral Sodium Management

As the patient’s condition stabilizes and enteral intake resumes, transitioning from IV to oral or enteral regimens is essential for facilitating discharge and long-term outpatient management.

A. Selection of Oral Sodium Supplements and Dietary Adjustments

• Sodium Chloride Tablets: Available as 1 g tablets (containing ~17 mEq of sodium). A typical starting dose is 2–4 g three times daily, titrated to maintain a serum sodium of 135–145 mEq/L.
• Dietary Sources: Supplement with high-sodium foods like broths, soups, and cheese. Effervescent salt preparations can also be used but may have lower patient tolerance.
• Tolvaptan: An oral vasopressin-2 receptor antagonist for euvolemic or hypervolemic hyponatremia. Start at 15 mg PO once daily, titrating up to 60 mg as needed. Requires close monitoring of sodium (daily initially) and liver function tests (LFTs). Use is generally limited to less than 30 days due to risk of hepatotoxicity.

B. Enteral Fluid Regimens and GI Tolerance

For patients with feeding tubes, sodium can be delivered via enteral fluids:

• 0.9% NaCl (Normal Saline): A continuous infusion at 20–40 mL/h delivers approximately 74–148 mEq of sodium per 24 hours.
• 0.45% NaCl (Half-Normal Saline): Suitable for milder deficits or maintenance, providing less sodium per volume.
• Administration: Use continuous rather than bolus administration to reduce the risk of diarrhea and GI intolerance from hyperosmolar loads.

3. Mitigating Post-ICU Syndrome (PICS)

Survivors of critical illness, particularly those with severe dysnatremia and associated neurologic complications, are at high risk for Post-ICU Syndrome (PICS). Proactive implementation of bundled care and early rehabilitation can optimize long-term cognitive, physical, and psychological outcomes.

A. Identification of High-Risk Patients

Key risk factors for PICS include advanced age, pre-existing frailty, prolonged mechanical ventilation (>48 hours), ICU delirium, and the severity of neurologic complications from the initial dysnatremia.

B. ABCDEF Bundle Implementation

The ABCDEF bundle is a proven, evidence-based strategy to improve ICU outcomes and reduce the incidence and severity of PICS.

• A
  Assess, Prevent, and Manage PainRegularly assess pain using validated scales and treat with a multimodal approach.
• B
  Both Spontaneous Awakening & Breathing TrialsCoordinate daily interruptions of sedation with ventilator weaning trials.
• C
  Choice of Analgesia and SedationPrioritize non-benzodiazepine sedatives like dexmedetomidine or propofol.
• D
  Delirium: Assess, Prevent, and ManageScreen for delirium daily and implement non-pharmacologic prevention strategies.
• E
  Early Mobility and ExerciseInitiate physical therapy as early as possible, from passive range of motion to ambulation.
• F
  Family Engagement and EmpowermentInvolve family in care rounds, provide education, and utilize tools like ICU diaries.

C. Neurocognitive and Physical Rehabilitation Referrals

A seamless transition from inpatient to outpatient rehabilitation is crucial. This includes initiating physical and occupational therapy (PT/OT) consults while in the ICU and ensuring referrals are in place for post-discharge programs, whether at a facility or home-based.

4. Medication Reconciliation and Discharge Counseling

Pharmacist-led medication reconciliation and tailored patient education are fundamental to ensuring adherence, preventing adverse events, and reducing readmissions after hospitalization for dysnatremia.

A. Review Inpatient Fluid and Electrolyte Therapies

A thorough review is necessary to create a safe discharge plan. This includes compiling the total doses and durations of all IV sodium therapies, explicitly discontinuing all hypertonic fluid orders, and creating a clear tapering plan for any diuretics, desmopressin, or vaptans.

B. Patient Education on Fluid Restriction and Dietary Sodium

Clear, actionable instructions are paramount. Use the “teach-back” method to confirm understanding of:

• Specific Goals: A prescribed daily fluid limit (e.g., 1.5 L/day) and sodium intake goal (e.g., 3–4 g/day).
• Practical Skills: How to measure fluid volumes in common containers, read food labels to identify high-salt foods, and recognize the early warning symptoms of both hyponatremia and hypernatremia.

C. Assessment of Health Literacy and Support Barriers

Screen for potential barriers to adherence, including health literacy, language, and social determinants of health (e.g., transportation for follow-up, financial ability to obtain medications). Provide simplified materials, pictograms, and translated documents as needed.

D. Scheduling Outpatient Follow-Up and Lab Monitoring

A robust follow-up plan is non-negotiable:

• Appointments: Arrange clinic visits within 1–2 weeks with the appropriate provider (primary care, nephrology, or endocrinology).
• Lab Monitoring: Order serial serum sodium checks (e.g., every 3–7 days) until the level is stable on the oral regimen.
• Post-Discharge Contact: A pharmacist-led telephone check-in at 48–72 hours post-discharge has been shown to clarify instructions and reduce readmissions.

5. Multidisciplinary Discharge Pathways

Coordinated efforts among pharmacists, dietitians, nurses, and social workers streamline the transition of care, enhance patient safety, and reduce the likelihood of readmission.

A. Standardized Checklists and Communication Templates

Utilize standardized electronic discharge templates and checklists to ensure all critical elements are addressed. These tools should include the etiology of the dysnatremia, the hospital course, current sodium goals, fluid orders, pending labs, and confirmed follow-up appointments. This ensures consistent communication between the inpatient team and outpatient providers.

6. Quality Metrics and Continuous Improvement

Tracking key outcomes and process measures is essential for driving iterative protocol refinement, enhancing patient safety, and ensuring the durability of the care transition program.