Electrolytes and Fluids - Hypertonic Saline
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What are the available concentrations of hypertonic saline (HS)?
3, 7.5, 23.4% NaCl
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)
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
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
- 0% H2O 15.9 parts H2O
- =23.4 parts total
- Need 320.5ml of 23.4% NaCl, and 679.5ml H2O
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)
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
Which IV access must be used for HS? Why?
Central IV access b/c osmolarity of HS >900mOsm/L
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)
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
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
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
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
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
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.
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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