In this episode of Hospital Medicine Unplugged, we tackle hypernatremia—spot it early, fix the water–salt mismatch, and keep brains safe while you correct.
We open with who’s at risk and why it matters: older adults, nursing-home residents, cognitively impaired, immobilized, and ICU patients (prevalence up to 27%). Consequences aren’t subtle: delirium, falls, functional decline, and in-/post-discharge mortality often >30–40% in severe cases—and many survivors lose independence. Iatrogenesis is common.
Diagnosis done fast and right: • History that hunts intake/losses/meds (diuretics, hypertonic infusions, tube feeds). • Exam for volume status and mental status. • Labs: serum/urine electrolytes + osmolality; urine Osm to sort renal vs. extrarenal water loss. • Calculate free-water deficit (use TBW × [(serum Na/desired Na) − 1]) to plan replacement. • Think mechanisms: thirst/AVP/renal concentrating—when any fail, Na rises.
Management—build a safe correction plan: • Treat the cause first (stop sodium loads/over-diuresis, manage DI, address GI losses). • If in shock, restore intravascular volume with isotonic saline, then switch to hypotonic therapy. • Replace with enteral water when possible; otherwise D5W or 0.45% NaCl, tailored to deficit, volume status, and ongoing losses. • Monitoring is non-negotiable: check Na q2–4h during active correction, track I/O, weight, neuro checks. • Correction targets: chronic/unknown duration ≤10–12 mmol/L/day (≤0.5 mmol/L/h); in clearly acute/admission-related severe hypernatremia, faster correction up to ~1 mmol/L/h can be reasonable and has not shown major neuro complications—individualize by chronicity, severity, and comorbids. • ICU myth-busting: with electrolyte-free water, meaningful ECFV expansion is uncommon; persistent hypernatremia tracks with worse outcomes.
Complications you’re preventing: • Cerebral edema from overly rapid correction in chronic cases; intracerebral bleeding with abrupt rises. • Delirium, falls, functional decline, and mortality if under-recognized or undertreated. • Iatrogenic harm from sodium-rich fluids and missed free-water needs (especially with feeds).
Prevention plays that work: • Protocolize: automatic free-water flushes with enteral nutrition, standardized hypernatremia order sets, and medication review for hidden sodium. • Education + dashboards to flag rising Na and prompt early intervention. • Reassess if Na isn’t improving by hospital day 3.
We close with the system bundle: (1) Screen high-risk patients daily; (2) confirm true hypernatremia and classify volume status; (3) calculate deficit + set a correction rate matched to chronicity; (4) default to enteral water/D5W or 0.45% with q2–4h Na checks; (5) avoid/stop sodium loads and fix losses; (6) use isotonic saline only for shock then pivot; (7) document and trend neuro status, I/O, CR/BUN; (8) embed prevention in tube-feed and NPO workflows.
Fast recognition, meticulous monitoring, and cause-directed, rate-aware correction—that’s how you turn a lethal, often iatrogenic problem into a controlled win.
Popular Podcasts
On Purpose with Jay Shetty
I’m Jay Shetty host of On Purpose the worlds #1 Mental Health podcast and I’m so grateful you found us. I started this podcast 5 years ago to invite you into conversations and workshops that are designed to help make you happier, healthier and more healed. I believe that when you (yes you) feel seen, heard and understood you’re able to deal with relationship struggles, work challenges and life’s ups and downs with more ease and grace. I interview experts, celebrities, thought leaders and athletes so that we can grow our mindset, build better habits and uncover a side of them we’ve never seen before. New episodes every Monday and Friday. Your support means the world to me and I don’t take it for granted — click the follow button and leave a review to help us spread the love with On Purpose. I can’t wait for you to listen to your first or 500th episode!
Cardiac Cowboys
The heart was always off-limits to surgeons. Cutting into it spelled instant death for the patient. That is, until a ragtag group of doctors scattered across the Midwest and Texas decided to throw out the rule book. Working in makeshift laboratories and home garages, using medical devices made from scavenged machine parts and beer tubes, these men and women invented the field of open heart surgery. Odds are, someone you know is alive because of them. So why has history left them behind? Presented by Chris Pine, CARDIAC COWBOYS tells the gripping true story behind the birth of heart surgery, and the young, Greatest Generation doctors who made it happen. For years, they competed and feuded, racing to be the first, the best, and the most prolific. Some appeared on the cover of Time Magazine, operated on kings and advised presidents. Others ended up disgraced, penniless, and convicted of felonies. Together, they ignited a revolution in medicine, and changed the world.
Crime Junkie
Does hearing about a true crime case always leave you scouring the internet for the truth behind the story? Dive into your next mystery with Crime Junkie. Every Monday, join your host Ashley Flowers as she unravels all the details of infamous and underreported true crime cases with her best friend Brit Prawat. From cold cases to missing persons and heroes in our community who seek justice, Crime Junkie is your destination for theories and stories you won’t hear anywhere else. Whether you're a seasoned true crime enthusiast or new to the genre, you'll find yourself on the edge of your seat awaiting a new episode every Monday. If you can never get enough true crime... Congratulations, you’ve found your people. Follow to join a community of Crime Junkies! Crime Junkie is presented by audiochuck Media Company.