Hourly oral sodium chloride for the rapid and predictable treatment of hyponatremia

Hypertonic NaCl is first-line therapy for acute, severe and symptomatic hyponatremia; however, its use is often restricted to the intensive care unit (ICU). A 35-year-old female inpatient with an optic chiasm glioma and ventriculoperitoneal shunt for hydrocephalus developed acute hyponatremia (sodium 122 mEq/l) perhaps coinciding with haloperidol treatment. The sum of her urinary sodium and potassium concentrations was markedly hypertonic vis-à-vis plasma; it was inferred that serum sodium concentration would continue to fall even in the complete absence of fluid intake. Intravenous (i.v.) 3% NaCl was recommended; however, a city-wide public health emergency precluded her transfer to the ICU. She was treated with hourly oral NaCl tablets in a dose calculated to deliver the equivalent of 0.5 ml/kg/h of 3% NaCl with an objective of increasing the serum sodium concentration by 6 mEq/l. She experienced a graded and predictable increase in serum sodium concentration. A slight overshoot to 129 mEq/l was rapidly corrected with 0.25 l of D5W, and she stabilized at 127 mEq/l. We conclude that hourly oral NaCl, in conjunction with careful monitoring of the serum sodium concentration, may provide an attractive alternative to i.v. 3% NaCl for selected patients with severe hyponatremia.