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Answer 4
  1. Stop IV fluids, restrict free water intake, and monitor serum sodium closely. Therapy for hyponatremia must be closely monitored because rapid correction can cause fluid shifts in the brain and result in irreversible and often fatal osmotic demyelination (central pontine myelinolysis). Clinical observations suggest that the degree of correction over the first 24 hours correlates with the development of demyelination, with the safest rate of correction being limited to 10 to 12 mEq/L over 24 hours.3 As treatment has already corrected this patient’s sodium level from 110 to 120 mEq/L over 8 hours and her neur- ologic condition has improved, therapy should be targeted to slow the rise of serum sodium. At this point, stopping hypertonic saline and restricting free water should slow the rise of sodium. If the sodium level continues to rise despite these measures, hypotonic solution must be administered. This will ensure that the target level of correction is not exceeded. Continuing current therapy would certainly cause an over- correction. Furosemide will not slow the rate of correction. IV ceftriaxone does not play a role in this case.

     Sterns RH, Cappuccio JD, Silver SM, Cohen EP. Neurologic sequelae after treatment of severe hyponatremia: a multicenter perspective. J Am Soc Nephrol 1994;4:1522-30.

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