With Special Guest Dr. Bianca Farley

In this episode of Inpatient Update, Dr. Mason Turner is joined by hospitalist Dr. Bianca Farley to examine two practices driven largely by fear of rare but devastating complications:

• Are we correcting severe hyponatremia too cautiously? 
• Does pharmacologic DVT prophylaxis improve outcomes that actually matter to patients? 

Two common hospitalist decisions. Two deeply ingrained habits. Two areas where the evidence may be more nuanced than many of us were taught. 

Articles & PubMed Links

Sodium Correction Rates and Outcomes Among Patients With Severe Hyponatremia

Annals of Internal Medicine (2026)

Retrospective cohort study of nearly 14,000 hospitalized patients with severe hyponatremia (Na ≤120 mEq/L). 

Compared:

• Slow correction: <8 mEq/L per 24 hours 
• Moderate correction: 8–12 mEq/L per 24 hours 
• Fast correction: >12 mEq/L per 24 hours 

Primary Outcome

• Composite of: 
   
  • 90-day mortality 
• 
  
  • Delayed neurologic complications 
• 
  

Key Findings

• Slow correction had the worst outcomes 
• Moderate correction reduced adverse outcomes 
• Fast correction reduced adverse outcomes even further 
• Primary outcome occurred in 21% of patients overall 
• Faster correction was associated with significantly lower risk of death or delayed neurologic events compared with slow correction. 

What About Osmotic Demyelination Syndrome?

The traditional fear of overcorrection continues to matter, particularly in high-risk populations, but this study suggests that aggressively avoiding correction may also cause harm. 

Takeaway

→ Avoiding overcorrection remains important.
 → But correcting severe hyponatremia too slowly may also worsen outcomes.
→ A reasonable target may be 8–10 mEq/L/day rather than reflexively aiming for the lowest possible correction rate.

Pubmed: https://pubmed.ncbi.nlm.nih.gov/41587479/

Pharmacologic Thromboprophylaxis in Medical Inpatients

JAMA Network Open (2026)

Systematic review and network meta-analysis of 22 randomized trials involving 43,840 medical inpatients. 

Compared:

• Low-molecular-weight heparin (LMWH) 
• Unfractionated heparin (UFH) 
• Direct oral anticoagulants (DOACs) 
• No pharmacologic prophylaxis 

Key Findings

Symptomatic VTE

Baseline risk without prophylaxis:

• 1.7% at 90 days 

LMWH:

• Reduced symptomatic VTE 
• RR 0.68 (95% CI 0.49–0.94) 

Clinically Relevant VTE

• LMWH RR 0.57 
• DOAC RR 0.58 
• UFH RR 0.66 

Mortality

• No mortality benefit with any regimen. 

Major Bleeding

• DOACs increased major bleeding 
• UFH increased major bleeding 
• LMWH showed no statistically significant increase in major bleeding. 

Interpretation

Pharmacologic prophylaxis reduces VTE events, but:

• Absolute VTE risk is relatively low 
• Mortality is unchanged 
• Bleeding risk must be considered 
• Patient selection matters 

Takeaway

→ DVT prophylaxis works, but mostly by preventing relatively uncommon events.
 → Benefits are greatest in appropriately selected high-risk patients.
 → LMWH appears to offer the best balance of efficacy and safety.

Pubmed: https://pubmed.ncbi.nlm.nih.gov/42138924/

Practice-Changing Takeaways

Severe Hyponatremia

• Fear of osmotic demyelination has likely pushed many clinicians toward overly conservative correction. 
• Emerging evidence suggests slow correction may itself be harmful. 
• Consider targeting meaningful correction rather than simply avoiding overcorrection. 

DVT Prophylaxis

• Prevents VTE. 
• Does not appear to reduce mortality. 
• Absolute benefit is smaller than many clinicians assume. 
• Risk-benefit assessment remains essential. 

Clinical Pearls

• The most feared complication is not always the most common complication. 
• Many hospital practices persist because of rare catastrophic outcomes rather than aggregate patient outcomes. 
• The best question is often not "Can this happen?" but "What happens most often?" 

Bottom Line

If you change nothing else this week:

• Reconsider whether your severe hyponatremia patients are being corrected too slowly. 
• Remember that DVT prophylaxis prevents clots, but has never clearly been shown to save lives in general medical inpatients. 

Sometimes the greater danger isn't doing too much—it's doing too little.

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