Use of 3% Hypertonic Saline for Severe and Symptomatic Hyponatraemia: A Five-Year Single-Centre Audit — ASN Events
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Use of 3% Hypertonic Saline for Severe and Symptomatic Hyponatraemia: A Five-Year Single-Centre Audit (#328)

Alexander Bald 1 , Yi Ming Chiang 2 , Maya Kashiwagi 2 , Karl Winckel 2 , Elizabeth Currey 2 , Lisa Hayes 1 , Benjamin Sly 1 , Katherine Isoardi 3 , Amanda Holford 3 , Jack Lockett 1 4
  1. Department of Diabetes and Endocrinology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
  2. Pharmacy Department, Princess Alexandra Hospital, Brisbane, Queensland, Australia
  3. Emergency Department,, Princess Alexandra Hospital, Brisbane, Queensland, Australia
  4. PA-Southside Clinical Unit, The University of Queensland, Brisbane, Queensland, Australia

Aims:

We aimed to assess adherence to recommended practice for 3% hypertonic saline (HTS) treatment of severe or symptomatic hyponatraemia, focusing on indication, dosing, monitoring, excessive hyponatraemia correction and relowering therapy.

Methods:

This retrospective audit included all 112 patients who received HTS outside of the intensive care unit from January 2021-December 2025 at a quaternary hospital in Brisbane. Venous blood gas sodium was used preferentially over serum values. Excessive correction was defined as a sodium rise >10mmol/L within 24 hours (>8mmol/L in patients at high osmotic demyelination syndrome (ODS) risk) or >18mmol/L within 48 hours.

Results:

Median baseline sodium was 115mmol/L (IQR 112-117, range 100-126). Neurological symptoms were present in 100 (89.3%), and 72 (64.3%) had at least one ODS risk factor. Median bolus dose was 100mL (range 20-250), no patients received a continuous infusion. Fifty-four received subsequent boluses, sodium was rechecked beforehand in 42 (77.8%). Monitoring was fully compliant in only 41 (36.6% of total) cases. Median sodium increases were 8mmol/L at 24 hours and 13mmol/L at 48 hours. The individualised 24-hour limit was exceeded in 45 (40%), with 18 cases exceeding the 48-hour limit. Relowering therapy was used in 44 cases, most commonly dextrose with desmopressin (63.6%). Excessive 24-hour correction occurred less often when endocrine was consulted prior to treatment initiation than when consultation was later or did not occur at all: 6/38 (15.8%) vs 47/74 (63.5%), p<0.001. Twelve participants had suspected ODS based on new symptoms, 5 (41.2%) had overly rapid correction. MRI excluded ODS in all, and none had long-term neurological sequelae at follow-up.

Conclusion:

Hypertonic saline was indicated in all episodes, but monitoring was inconsistent and excessive correction was common. Early endocrine involvement was associated with less overcorrection, supporting a standardised pathway with risk-based limits, mandatory monitoring, clear relowering criteria and early specialist review.