Continuous Versus Bolus Infusion of Hypertonic Saline in the Treatment of Symptomatic Hyponatremia Caused by SIAD

Abstract

Background Acute hyponatremia is a medical emergency that confers high mortality, attributed primarily to cerebral edema. Expert guidelines advocate the use of intravenous boluses of hypertonic saline rather than traditional continuous infusion to achieve a faster initial rise in plasma sodium (pNa) concentration. However, there is a limited evidence base for this recommended policy change. Methods We prospectively assessed the clinical and biochemical outcomes in patients treated for symptomatic hyponatremia caused by syndrome of inappropriate antidiuresis in response to intravenous bolus treatment with 3% saline (100 mL, repeated up to two more times) and compared the outcomes to retrospective data from patients treated with continuous intravenous infusion of low-dose (20 mL/h) 3% saline. Results Twenty-two patients were treated with bolus infusion and 28 with continuous infusion. Three percent saline bolus caused more rapid elevation of pNa at 6 hours [median (range) 6 (2 to11) vs 3 (1 to 4) mmol/L, P < 0.0001], with a concomitant improvement in Glasgow Coma Scale (GCS) [median (range) 3 (1 to 6) vs 1 (−2 to 2), P < 0.0001] at 6 hours. Median pNa concentration was similar at 24 hours in the two treatment groups. The administration of a third saline bolus was associated with greater need for dextrose/dDAVP to prevent overcorrection (OR 24; P = 0.006). There were no cases of osmotic demyelination in either group. Conclusion Three percent saline bolus produces faster initial elevation of pNa than continuous infusion with quicker restoration of GCS, and without osmotic demyelination. Frequent electrolyte monitoring, and judicious intervention with dDAVP is required to prevent overcorrection with bolus therapy.

MANAGEMENT OF ENDOCRINE DISEASE: Dysnatraemia in COVID-19: prevalence, prognostic impact, pathophysiology, and management

“…Evidence and clinical experience are lacking about the optimal form of hypertonic saline treatment in patients with COVID-19. In contrast to contemporary guidelines ( 30 , 32 ) and recent studies ( 48 ) favouring the use of hypertonic saline boluses, continuous infusion of hypertonic saline might be preferable in the context of COVID-19 in order to minimise the risk of pulmonary oedema due to the sudden volume increase ( 33 ).…”

The Effect of the Dose of Isotonic Saline on the Correction of Serum Sodium in the Treatment of Hypovolemic Hyponatremia

“…In 10 (33%) patients, the 24SNa showed a ∆ ≥ 8 mmol/L after a median ISSD of 32 mL/kg/24h (29)(30)(31)(32)(33)(34)(35)(36)(37). In 15 (50%) patients, the 24SNa exhibited a ∆ ≥ 6 mmol/L after a median ISSD of 31 mL/kg/24h (25)(26)(27)(28)(29)(30)(31)(32)(33). In 11 (48%) of the 23 patients with at least one risk factor for ODS, the 24SNa showed a ∆ ≥ 6 mmol/L, following a median ISSD of 31 mL/kg/24 h (23-37).…”

“…Among measures proposed to avoid overcorrection during ISS administration are the measurement of SNa every 4-6 h as well as the monitoring of diuresis [1,2,23]. Desmopressin administration can also be associated [9,14,[24][25][26]. However, in some hospital settings, all or parts of these recommendations could be difficult to apply.…”

ENDOCRINOLOGY IN THE TIME OF COVID-19-2021 UPDATES: The management of diabetes insipidus and hyponatraemia

“…Similar caution is advised in patients with severe hyponatraemia complicated by symptoms of cerebral irritation. Although guidelines recommend bolus hypertonic saline treatment to rapidly elevate plasma sodium concentration ( 29 ), and published data suggests that this is effective ( 43 ), the sudden volume load might cause pulmonary oedema. In this circumstance, the safer option might be low-dose hypertonic saline infusion, with careful control of the volume of fluid administered; the clinical experience in the COVID-19 situation is insufficient to be definitive about this, and each centre should use the method with which they are most familiar.…”