Hypernatremia — Management Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Volume assessment
   Sodium >145 — is the patient hemodynamically stable? (Hypernatremia = serum sodium >145 mmol/L, usually from water deficit (inadequate intake / losses > solute), occasionally sodium excess, rarely diabetes insipidus. Assess volume and hemodynamics first.)
   • Hypovolemic/unstable → Restore volume first
   • Hemodynamically stable → Acute or chronic
2. [End] Restore volume first
   Hypovolemic/unstable: first restore intravascular volume with isotonic crystalloid (normal saline or a balanced solution) until vitals are stable, then switch to free-water replacement (see the stable pathway). Concurrently find and treat the cause.
3. [Decision] Acute or chronic
   Acute (<48 h) or chronic (>48 h)? (Water deficit (L) = 0.5 (men)/0.45 (women) × weight (kg) × [Na/140 − 1]; replace the deficit + ongoing/insensible losses (~500–1000 mL/day). Oral water is preferred, otherwise 5% dextrose or 0.45% saline.)
   • Chronic (>48 h) or unknown → Chronic → correct slowly
   • Acute (<48 h) → Acute → may correct faster
4. [End] Chronic → correct slowly
   Correction rate ≤10–12 mmol/L/day (~0.5 mmol/L/h), to avoid cerebral edema and seizures; recheck sodium every 2–4 h then 4–6 h, adjust for urine output. Treat the cause (central diabetes insipidus → desmopressin). Refractory/critical cases may need dialysis.
5. [End] Acute → may correct faster
   Acute (<48 h) may be corrected faster, ~1 mmol/L/h in the first 6–8 h; still monitor closely to avoid over-correction. Replace free water (oral/D5W/0.45% saline), recheck every 2–4 h, treat the cause.

Source guidelines & references

• Management of hypernatremia (Adrogue/Madias; electrolyte disorder reviews)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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