Management of Osmotic Demyelination Syndrome

Prevention of ODS

The American Association for the Study of Liver Diseases recommends identifying patients at high risk for ODS: those with advanced liver disease, alcoholism, malnutrition, severe hyponatremia, hypophosphatemia, hypokalemia, hypoglycemia, low cholesterol, and prior encephalopathy 1, 2
Patients with chronic hyponatremia (present >48 hours) require more cautious correction than those with acute hyponatremia 1, 2
For patients with average risk: limit correction to 4-8 mEq/L per day, not exceeding 10-12 mEq/L in 24 hours 1, 2
For high-risk patients (including those with advanced liver disease): limit correction to 4-6 mEq/L per day, not exceeding 8 mEq/L in 24 hours 1, 2
Monitor serum sodium every 2-4 hours during active correction to prevent overcorrection 2

ODS typically presents 2-7 days after rapid sodium correction with dysarthria, dysphagia, oculomotor dysfunction, and quadriparesis 1
Confirm diagnosis with brain magnetic resonance imaging 1
Some case reports suggest potential benefit from plasmapheresis (though evidence is limited) 2
Some case reports suggest potential benefit from high-dose corticosteroids (limited evidence) 2
Some case reports suggest potential benefit from intravenous immunoglobulin (limited evidence) 2

ODS is rare in liver transplantation, occurring in approximately 0.5%-1.5% of recipients 1
Multidisciplinary coordinated care may mitigate the risk of ODS in transplant patients 1
Consider using tromethamine to reduce the risk of ODS in transplant patients 1

Failing to identify patients at high risk for ODS 2
Inadequate monitoring during active correction 2
Using fluid restriction in cerebral salt wasting (which can worsen outcomes) 2
Failing to recognize and treat the underlying cause of hyponatremia 2
Using hypertonic saline in hypervolemic hyponatremia without life-threatening symptoms 2