I laid out my thoughts on the management of hyponatremia way back in Podcast 39. Josh has weighed in here on the dDAVP clamp as well. I'd been continuing my readings on this matter, especially with some great posts from the renal fellow network (below). Then, fortuitously, I was approached by Nand Wadhwa, one of our amazing nephrologists at Stony Brook. He wanted to partner with my unit to create a euvolemic hyponatremia protocol. So in this episode, we'll discuss the use and basis of the new Euvolemic Hyponatremia Guideline.
The Protocol
Included Patients
- Euvolemic or Hypovolemic
- Na <=125 (we changed this to <=120)
Evidence for dDAVP Clamp with 3%
from this post
http://renalfellow.blogspot.com/2014/10/severe-chronic-hyponatremia_20.html
Clin J Am Soc Nephrol 2007;2:1110
Modified Edelman Equation
Video on Why Androgue Madias Equation doesn't work and how to use the Edelman Equation from Hashim Mohmod
Causes of Hyponatremia
See this Deranged Physiology Page and the LitFL Page
The Renal Fellow Network Hyponatremia Series by Hashim Mohmand
Key Points from the Series
Severe hyponatremia is multifactorial
Three issues that will screw your plans up:
- Subclinical Volume Depletion: Because we suck at assessing this
- Solute Depletion Hyponatremia: For instance, “Tea and Toast Diet ” hyponatremia and “Beer Potomania.”
- Hypokalemia Repletion [case report]
- Read a Review Article by Dr. Mohmand on these issues
Review Articles
Peripheral 3% Hypertonic Saline is Safe
Things to think About
- Oral K repletion math-am I on the right track?
- Why doesn't SIADH lead to edema
Update
- Let's add Tramadol to the list of culprit meds
- UK Endocrine Society Guidelines (DOI 10.1530/EC-16-0058)
- European Hyponatremia Guidelines
- NephJC and a New Article
- History of Hyponatremia Management
SALSA Trial
-
- Rapid Intermittent Bolus was better in terms of overshoot and getting Na up.
- Jama Intern Med 10.1001/jamainternmed.2020.5519
Additional New Information
More on EMCrit
- PulmCrit wee: DDAVP Clamp-Bolus technique for severe hyponatremia(Opens in a new browser tab)
- Hyponatremia(Opens in a new browser tab)
- Taking control of severe hyponatremia with DDAVP(Opens in a new browser tab)
- EMCrit Podcast 39 – Hyponatremia
Additional Resources
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- EMCrit 373 – Mike Weinstock with another Critical Care Bounceback: “Asymptomatic Hypertension” - April 18, 2024
- EMCrit Wee – Ross Prager on 10 Heuristics for the New ICU Attending - April 13, 2024
- EMCrit 372 – FoundStab Intubation SOP - April 5, 2024
There is a lot of hand-waving and dogma around hyponatremia, and I think it generally serves to overcomplicate a conceptually simple problem. The key is categorization: Hypovolemic hyponatremia: The biggest concern is balancing the imperative to fluid resuscitate and maintain vascular tone against the imperative not to spike the serum sodium. That said, it’s frequently acute and rapid correction is generally pretty safe. Hypervolemic hyponatremia: Fairly difficult (although not impossible) to overcorrect because the underlying causes (cirrhosis, heart failure) are similarly difficult to correct. Euvolemic hyponatremia is the real problem. I like to break it into two categories: Stupid Patient/Clinician… Read more »
Eric, This reductionism is likely part of the problem. What you have outlined seems to be the exact dogma that has been taught to all of us as we have come up through training. If it was so simple and categorization so clean cut, I (and I am sure you as a crit care director) would not see it botched so very often by the folks around you. The whole point the new thinking on hyponatremia is attempting to address is almost never does the patient fit into just one category. It is a dirty picture with many different etiologies.… Read more »
Scott, I am not remotely qualified to “peer review” this, so I have a couple of questions. Mostly regarding potassium repletion independent of sodium management. Many hospitals have limits or rates of potassium repletion. I.e. 10 meq/hr on a floor/tele bed through a peripheral IV or 20 meq/hr in the ICU with a central line. I have become a fan of avoiding the mandatory tele/ICU bed by using the oral route. In the ED, on a monitor, I will replete with 25 meq of Potassium Citrate/bicarbonate ORALLY q 30 minutes. This has never caused a problem that I have been… Read more »
Hi Scott, I am a great fan of your show and I did enjoy the hyponatremia podcast. I would like to make the following comments: 1. The Edelman equation and its derived formulas are really essential to the understanding of the pathogenesis of all hypo- and hypernatremias. They are also central in designing the right treatment. As you rightly stated it is not enough to only look at the impact of a certain amount of a certain type of infusion on the sodium concentration. You have to do a complete “tonicity balance”, that is assessment of the sodium, potassium and… Read more »
I’m sorry..but the vídeo from Hashim its very complicated and not for practical daily use