Hyponatremia: What you should really know to prevent CPM and EPM.
Today has been a rough day for me. I knew that my hyponatremia was treated incorrectly when I developed Extra Pontine Myelinolysis. However, I didn’t realize to what extent my treatment of hyponatremia was mismanaged.
It is absolutely a fundamental point of this blog to try to prevent ANYONE from having to live with this injury. There is no reason anyone should.
So, in this post, I am going to try to simplify the steps of how hyponatremia should be treated.
First, it is important for you to recognize the symptoms. *Please see my earlier posts for those*
Once you realize there is a problem, seek treatment. It is an emergency.
A basic metabolic panel should be ordered to determine if your sodium levels are low.
Next, it is important for the doctor to figure out WHY you have hyponatremia, and how LONG you have had it.
If they can’t figure out the time line, then it is better for them to assume that it is chronic because it is more likely that you will develop CPM if they treat chronic hyponatremia too quickly versus acute. (Acute is when sodium has been too low for less than 48 hours. Chronic is when sodium levels have been low for more than 48 hours).
Acute hyponatremia can cause severe symptoms such as seizures, respiratory distress and coma. The severity of symptoms determines how quickly the levels should be raised. However, it is generally accepted that once your symptoms begin to improve, the treatment should be decreased or halted.
According to Dr. Sterns, an expert on hyponatremia, acute hyponatremia should be treated in the following manner, “should be treated immediately with a bolus infusion of 100 mL of 3% NaCl to acutely reduce brain edema, with up to 2 additional 100-mL 3% NaCl bolus infusions that should be given at 10-minute intervals if there is no clinical improvement.10 We believe that this is a reasonable regimen for all symptomatic patients with acute hyponatremia…” (use the link below to find the information).
According to Dr. Sterns, chronic hyponatremia should be treated with “…we suggest a goal of 6 to 8 mmol/L in 24 hours, 12 to 14 mmol/L in 48 hours, and 14 to 16 mmol/L in 72 hours.” (http://www.uphs.upenn.edu/renal/important%20pdf%20III/Sterns%20-%20The%20Treatment%20of%20Hyponatremia.pdf)
The cause of your hyponatremia is extremely important because it absolutely determines what treatment you should receive.
For instance, if a drug has caused your hyponatremia, like a diuretic, then the first course of treatment is to stop taking the diuretic. Sometimes, just discontinuing the medication is enough to reverse the low sodium.
I HIGHLY recommend the following article posted by the Cleveland Clinic that outlines in exact detail which types of treatments based on the cause of the hyponatremia.
There is little question that if you are on a 3% saline solution for treatment, that your sodium levels should be monitored every 1 to 2 HOURS. As soon as your levels start to increase to the point that your symptoms start to resolve, even BEFORE it reaches the 6 to 8 m/mol GOAL, the 3% saline should be halted. This will stop your levels from reaching the “danger zone” which is approximately 8 to 12 m/mol in the first 24 hours with chronic hyponatremia. It is generally accepted that with acute hyponatremia that you can raise the levels a bit faster and not risk CPM or EPM.
ONE OF THE MOST IMPORTANT FACTORS TO REALIZE: IF YOUR LEVELS HAVE BEEN INCREASED TOO QUICKLY, THEN THEY CAN BE DECREASED BACK TO A HYPONATREMIC STATE TO PREVENT CENTRAL PONTINE MYELINOLYSIS. IT IS BELIEVE THAT THIS DROP CAN OCCUR DURING A 5 DAY PERIOD AFTER THE RAPID CORRECTION OCCURRED.
For further information and more detailed description of these steps as well as how to treat certain types of hyponatremia, please access this article: http://www.ccjm.org/content/77/10/715.full
These simple steps could save your life!