I posted this on Med surg but want more opinions:
I had a pt. come in with a critical low sodium level, altered LOC, seizure, etc. The docs orders were: Give bolus 3% saline (done in ed), then give 500 cc@ 66/hr (hanging when she came up), then give 500 CC @ 100 ml. hr. (I hung and it finished at 6 am). After bag two we did a BMP and her sodium was up from 115 to 117.
After the last bag early the next morn., I did the draw and it came back at 130. Im thinking good, its back up and the pt was now alert, oriented, etc.
However,being a new RN, I stopped the infusion after the last bag and asked the NTL if I should call the doc. She said since the pt. was doing well and the doc would be in soon anyway, just report off the results and that I had S/L her iv.
Well as I was charting to leave, the RN mgr came to me and asked if I had given more 3% solution than had been ordered. I said no, I gave it exactly as ordered. She stated the sodium was corrected too fast and that was very dangerous and did I know what to look for s/s of overcorrection??
She said to look for seizures, coma,LOC changes from cerebral edema. I said okay, they put the pt. on Tele and kept her another night. She was fine and ended up going home.
As I did research I found there are many factors to correction. If a pt is chroninc low sodium, there is a lot of danger in correcting too fast and it can lead to a demylinization of the pontines or something. If it is a less than 48 hr acute onset, it is not as likely to have an overcorrection consequence and you have to weigh what is best, usually getting the levels up quickly.
I know this is all the docs call, and there is also a huge consideration as to what caused this in the first place, she had pituitary and thyroid probs and she put out a TON of urine during the night suggestive of her having SIADH or DI or something.
So, I wonder, would not overcorrection cause "shrinkage" of brain cells rather than cerebral edema? My colleagues said a young man had died from heart failure r/t overcorrection awhile back and the floor was ever vigilant about it. Will I EVER understand my fluid and electrolytes??
Oct 3, '06
Okay I look at things simply some times, but it does the trick in trying to add the pieces of the puzzle together.
Remember from Chem and even Bio that WATER FOLLOWS SODIUM. Now you have a patient that may have more water than sodium...so the cellular compartments in the body and blood are low...and the orders pretty much rushed in sodium...so first..the sodium is in the bloodstream right? Okay...so first reaction...if there isn't enough fluid in the bloodstream to handle that...you get water pulled from the cells...but this tends to be a very quick lived deal...
THEN it stablizes and the sodium starved cells grab that sodium because it is pleanty now in the bloodstream! WATER FOLLOWS SODIUM! So now you have rushes of water following the sodium into the cells...Kinda like a wave...first it goes into the ocean..then crashes full force back! Now you have edema...cells holding to much water!!!
This is very serious when it comes to the brain, puts strain on the heart big time, and hit the lungs hard! Hard to exchange all these different gasses when you are waterlogged! That is why this must be done slowly so this doesn't happen!
ALSO, is this patient a renal patient? That plays a huge part in electrolyte loss, and some medicines! I won't go into renal because it would take a book or meds either....but apply this simple fact of WATER FOLLOWS SODIUM and you can figure it out!
Also remember that sodium and potassium are in a "love hate relationship" and stick/work together...so you can have serious consequences with potassium too! I like having those pts on heart monitor and frequent blood tests for electrolytes!
For a good source of info about fluid and electroyles, check out treatment of burn victims! With so much cellular damage replacement must be very accurate and timed...that is how I learned about it! Also dialysis tx too!
Last edit by Antikigirl on Oct 3, '06
Oct 3, '06
Wow! Thank you for that great detailed response. I have a much better understanding of sodium imbalance and wasn't even sure until just now that I was lacking understanding lol
Oct 3, '06
Geez.....all those times I tried to explain things like this to students and pts, and someone slaps me in the face with a much simpler way to do it! Thanks!
Oct 4, '06
Thanks Triage RN. I still hunger for more info. She was NOT a renal pt, however, she DID have Hypo-pituitaryism. (sp). I figured during the admin of the sodium,that is why even NPO she "peed out" about 4000 CC of dilute urine and went from 115 to 130 NA in about 11 hrs., however her potassium and sodium remained constant after the infusion stopped... Lucky her huh?
Oct 4, '06
was ths patient on DDAVP? where did she come in from? LTC? have had experience with this med being "missed" because it req refrigeration....the exp is old however......interesting
Oct 4, '06
Hello- at my facility the for patient's who are hyponatremic our goal to correct is 12 (mg/dl) in a 24 hour period due to the severe complications of correcting too fast as were mentioned by other posters. We usually never infuse 3%saline for more than 1 liter before switching to a less hypertonic fluid. We check lytes every 4 hours to make sure that we are not correcting to fast. For our patients that are chronically low NA we usually give them NaCl tabs with each meal and at bedtime. Hope this helps-
Oct 4, '06
Thanks to the OP. This question intrigued me and I couldn't stop thinking about it. I got out my nursing books and did some research on the net. I learned something new today. Thanks Triage, I really have a better understanding of the negative process of over correcting the hyponatremia. Most of the info that I found on the subject was very complicated to understand. You broke it down very nicely. LOVE THIS SITE!!!!!!!
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