4/n the threshold for very sever hypoNa needs to be 4-6 meq vs the old <12 to make sense based on evidence or pragmatic feasibility

3/n that said. I don’t think any of the recent studies address whether it’s safe to abandon slow correction of <10-12/day for eg a sodium of 105 but they are compelling that 4-6 meq day is probably not helpful and may be harmful for a sodium of > 115ish and I’ve never found the argument that

2/n-as far as I can tell there was 0 evidence for increased conservativism-but I’ve frequently witnessed residents correcting someone back down because they corrected from 120-128. This leases to prolonged icu stay more blood draws etc ….all based on crap evidence and bad assumptions

1/nthe issue is that in last 20 years guidelines moved from correction <12 meq/day to 10 then 8 then 6-on the basis of rare cases of cpm with slower rates—ignoring that these cases likely relate to Hyponatremia severity not correction rate and that cpm can also occur with Uber slow correction of <6