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Exercise-associated hyponatremia

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The following summarized guidelines for the evaluation and management of exercise-associated hyponatremia are prepared by our editorial team based on guidelines from the Wilderness Medical Society (WMS 2020).


1.Diagnostic investigations

Assessment: obtain point-of-care testing in at-risk symptomatic patients when available. Integrate all available clinical and historical information into an assessment of the patient's hydration status (history of fluid intake, food intake, presenting signs and symptoms, body weight if available, and urine output), if testing is unavailable.
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2.Medical management

Intravenous fluids: do not administer IV hypotonic fluids in patients with suspected fluid overload exercise-associated hyponatremia.
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3.Inpatient care

Transfer of care: inform receiving caregivers about the potential diagnosis of exercise-associated hyponatremia and appropriate fluid management (withhold hypotonic fluids) when transferring care.

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  • Acute inpatient care

4.Nonpharmacologic interventions

Oral fluid restriction: advise restricting oral fluids if exercise-associated hyponatremia from fluid overload is associated with mild symptoms. Do not administer hypotonic fluids in patients with suspected exercise-associated hyponatremia.

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  • Oral sodium

5.Preventative measures

Proper hydration: advise avoiding sustained overhydration during exercise, as it is the primary risk factor for development of all variants of exercise-associated hyponatremia.
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  • Salt supplementation

6.Follow-up and surveillance

Observation: observe patients for at least 60 minutes after exercise to ensure no decompensation from delayed symptomatic exercise-associated hyponatremia occurs after cessation of exercise.