Electrolytes and Fluids - Hypertonic Saline

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Snooze
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293030
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Electrolytes and Fluids - Hypertonic Saline
Updated:
2015-01-14 21:37:07
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Fluids
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Hypertonic saline
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  1. What are the available concentrations of hypertonic saline (HS)?
    3, 7.5, 23.4% NaCl
  2. What are the 2 common uses of HS?
    • 1. Traumatic brain injury with elevated ICP (esp if ICP>20mmHg)
    • 2. Symptomatic hypoNatremia (usually Na<120mEq/L)
  3. What are 3 common inappropriate uses of HS? What can be done to fix each ailment?
    • 1. SIADH - treat with fluid restriction <800ml/day
    • 2.HypoNa asso'd w/severe hyperglycemia (diabetic ketoacidosis) - treat with insulin. FYI: Na dec by 2.4mEq/L for q100mg/dL GLU elevation above 400mg/dl
    • 3. HypoNa asso'd w/hypervolemia (I.e. HF leading to tissue hypoperfusion, triggering ADH secretion, thus water reabsorption via kidneys) - treated with fluid restriction
  4. Using alligation, how would one make 1000ml of 7.5% HS from 23.4% NaCl vial? (Hint: How much volume)
    • 23.4%NaCl                        7.5 parts NaCl
    •                      7.5%
    • 0% H2O                            15.9 parts H2O
    •                                         =23.4 parts total
    • Need 320.5ml of 23.4% NaCl, and 679.5ml H2O
  5. What are 2 dosing options of HS for traumatic brain injury?
    • 1. 3% HS 250ml OR 2-4ml/kg IV over 1-15 mins
    • 2. 23.4% HS 30 ml IV over 30mins
    • (FYI standing orders not rec'd)
  6. For the dosing of HS in symptomatic hyponatremia, what is the general infusion rate? What is the max rate if MUST use in asymptomatic hypoNa?
    • 3% HS 1-2ml/kg/hr
    • Max: 0.5ml-1ml/kg/hr
  7. Which IV access must be used for HS? Why?
    Central IV access b/c osmolarity of HS >900mOsm/L
  8. If peripheral line must be used for HS as an emergency, what are the 2 conditions that MUST be abided by?
    • Use 2% HS
    • Monitor for phlebitis
    • (Obtain central access asap)
  9. What is the "safe" serum Na range to avoid neurological outcomes? What is the max safe amt of change in serum Na in 24hrs?
    • 120-125mEq/L of Na
    • Max safe change is 10-12mEq/L (some suggest 8mEq/L) per DAY
  10. What complication, caused by HS, is mainly caused by rapid changes in serum Na? How can one avoid this?
    • Osmotic demyelination syndrome
    • Avoid changes of 10-12mEq/L Na in 24 hours, or 18 mEq/L Na in 48 hours
  11. What are 8 complications that may be caused by HS?
    • 1. Osmotic demyelination syndrome
    • 2. HyperNa
    • 3. Hyperchloremic acidosis
    • 4. HypoK
    • 5. Phlebitis if using peripheral line
    • 6. HF (esp over time, HS can have a diuretic effect and thus  intravascular vol depletion)
    • 7. Coagulopathy caused by platelet dysfunction
    • 8. Hypotension if HS administered rapidly
  12. What are two scenarios that must be in consideration before using HS?
    1. Rule out hypoK as cause of HypoNa. Treat K depletion 1st.

    2. If 150mEq NaHCO3 must be used, avoid adding to NS (850ml NS added will make 3% HS). If need infusion of NaHCO3, add it to D5W or sterile water
  13. What are two IV fluids, when reconstituted, may cause cell hemolysis?
    1. Albumin 25% diluted with water to make albumin 5% - has osmolarity of 60mOsm/L

    2. 0.225% NaCl (quarter NS) with osmolarity of 68mOsm/L
  14. At what osmolarity should IV fluids be avoided to avoid cell rupture? What should patients receive instead if they have hypernatremia?
    • 1. Avoid osmolarity <150mOsm/L
    • 2. Instead of IV sterile water (which should be avoided), administer water enterally. If that route is unavailable, use D5W IV.
  15. To prevent a potential fatal error by using 0.225% NaCl (quarter NS), what are three methods or alternatives that can be used? (HINT: esp if one is considering that for hyperNa)
    • 1. Changing quarter NS to D5W alone or combo of D5W and quarter NS
    • 2. Alternatively, one may use 2.5% dextrose and quarter NS if there is concern for hyperglycemia
    • 3. Administer water enterally by mouth or feeding tube

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