Hypo natremia Normonatremia Hyper natremia Hypo volemia - Isotonic bicarbonate is mainstay of treatment. (May add some hypertonic bicarbonate if hyponatremia or acidosis are severe) - Isotonic bicarbonate - Isotonic bicarbonate & - Free water Euvolemia - Hypertonic bicarbonate (initially, until the sodium concentration increases) - Isotonic bicarbonate & - Diuresis (loop diuretic +/ - thiazide) (or, limited use of hypertonic bicarbonate) - Isotonic bicarbonate & - Diuresis (loop diuretic plus thiazide) & - Free water Hyper volemia - Diuresis with only a loop diuretic (May add some hypertonic bicarbonate if hyponatremia or acidosis are severe) - Diuresis (loop diuretic +/ - thiazide) (or, limited use of hypertonic bicarbonate) - Diuresis (loop diuretic plus thiazide) & - Free water Optimal treatment of NAGMA depends on sodium & water balance NAGMA may be treated in a holistic fashion, allowing multiple problems to be managed simultaneously . Further clarification of the interventions listed above: - Isotonic bicarbonate: 150 mEq/L solution of sodium bicarbonate (typically 3 amps bicarb in a liter of D5W) - Hypertonic bicarbonate: 1 mEq/ml solution of sodium bicarbonate (concentrated ampules of bicarbonate) - Loop diuretic: Intravenous furosemide or bumetanide - Thiazide diuretic: Usually oral metolazone or indapamide as an adjunctive diuretic to enhance sodium excretion. In more severe cases, IV chlorothiazide may be useful. - The Internet Book of Critical Care, by @PulmCrit