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Table 3 Summary of recommendations for approaches to treatments for hyponatremia by included guidance documents

From: Diagnosis and treatment of hyponatremia: a systematic review of clinical practice guidelines and consensus statements

 

Guideline Organization/Societies

Criteria/categories

NIV [16]

NHS [17]

GAIN [22]

AEEH [23]

EHN [25]

ERBP/ESE/ESICM [20]

UF [18]

HEP [19]

RCHM [21]

EAH-ICD [24]

Symptoms

          

Acute Onset (<48 h)

NaCl >1% Infusion speed may be guided by Adrogué-Madias

NaCl 3%

NaCl 2.7% 200 mL over 30 min

 

NaCl 3% 100 mL/10 min up to 3× or infused at 0.5–2 mL/kg/h

NaCl 3% 150 mL/20 min up to 4×

NaCl >1%

NaCl 3% 100 mL/10 min up to 3× or infused at 0.5–2 mL/kg/h

NaCl 3% 4 mL/kg over 30 min

NaCl 3% 100 mL bolus

Hypovolemia

       

NaCl 0.9% until blood pressure restored

  

Euvolemia

  

Fluid restriction

      

No hypotonic fluids

   

Stop offending drugs

       
   

Stop hypotonic fluids

       

Hypervolemia

  

Furosemide

    

Furosemide

  

Chronic onset (>48 h)

NaCl >1% Infusion speed calculation may be guided by Adrogué-Madias

NaCl 3%

Only if severe symptoms NaCl 2.7% 200 mL over 30 min infusion speed by may be guided Adrogué-Madias

 

NaCl 3% 100 mL/10 min up to 3× or infused at 0.5–2 mL/kg/h

NaCl 3% 150 mL/20 min up to 4×

NaCl >1%

NaCl 3% 100 mL/10 min up to 3× or infused at 0.5-2 mL/kg/h

  

Hypovolemia

  

NaCl 0.9% 1 L over 2–4 h infusion speed may be guided by Adrogué-Madias

    

NaCl 0.9% until blood pressure restored

  

Euvolemia

  

Fluid restriction

       
   

Stop offending medications

       
   

Stop hypotonic fluids

       

Hypervolemia

  

Fluid restriction

    

Furosemide

  
   

Salt restriction

       

No symptoms

         

Acute onset (<48 h)

NaCl >1% Infusion speed by Adrogué-Madias

 

Treat underlying condition

  

Stop offending fluids and medications, treat underlying condition NaCl 3% 150 mL/20 min

 

Treat underlying condition

 

Chronic onset (>48 h)

Treat underlying condition

 

Treat underlying condition

  

Stop non-essential fluids Stop offending medications Treat underlying condition

 

Treat underlying condition

  

Hypovolemia

NaCl 0.9%

NaCl 0.9% until blood pressure restored

NaCl 0.9% infusion speed may be guided by Adrogué-Madias

  

NaCl 0.9% or balanced crystalloid 0.5–1 mL/kg/h

NaCl 0.9%

NaCl 0.9% until blood pressure restored

Nasogastric rehydration

 
 

NaCl tablets

      

No VPA

NaCl 0.9%

 

Euvolemia

Fluid restriction, dose dependent on serum and urinary electrolytes

Fluid restriction, 500–1,000 mL/d

Fluid restriction

 

Fluid restriction <500–1,000 mL/d

Fluid restriction

Fluid restriction

Fluid restriction 500 mL below average daily urine output

Fluid restriction, no hypotonic fluids

 
  

No salt restriction

Salt restriction

 

Salt 5–8 g/d

  

No salt restriction

  
 

Loop diuretics

   

Furosemide 20–60 mg/d + oral NaCl

Loop diuretics, low dose + oral NaCl

Diuretics

   
 

Demeclocycline

Demeclocycline

   

No demeclocycline

Demeclocycline

Demeclocycline, 600–1,200 mg/d

  
 

Urea

   

Urea 30 g/d

Urea, 0.25–0.5 g/kg/d

Urea

Urea, 15–60 g/d

  
 

Vasopressin receptor antagonist

Vasopressin receptor antagonist

 

Tolvaptan 15–60 mg/d

No vasopressin receptor antagonists

    

Hypervolemia

 

Treat underlying condition

        
 

Fluid restriction, dose dependent on serum and urinary electrolytes

Fluid restriction

Fluid restriction

Fluid restriction <1,000 mL/d

 

Fluid restriction

 

Fluid restriction, <insensible losses + urine output

Fluid restriction

 
 

Loop diuretics

Salt restriction

Salt restriction

No NaCl >0.9%

   

Salt restriction

  
  

Demeclocycline

 

Stop diuretics

 

No demeclocycline

 

Possibly vasopressin receptor antagonist

  
  

Vasopressin receptor antagonist

   

No vasopressin receptor antagonist

    
  1. NIV, Nederlandse Internisten Vereniging [16]; NHS, National Health Service [17]; GAIN, Guidelines and Audit Implementation Network [22]; AEEH, La Asociación Española para el Estudio del Hígado [23]; EHN, European Hyponatremia Network [25]; ERBP, European Renal Best Practice; ESE, European Society of Endocrinology; ESICM, European Society of Intensive Care Medicine [20]; UF, University of Florida [18]; HEP, Hyponatremia Expert Panel [19]; RCH Melbourne, the Royal Children’s Hospital Melbourne [21]; EAH-ICD, International Exercise-Associated Hyponatremia Consensus Development Conference [24].