Dosage should be modified based on clinical response, but no quantitative recommendations are available. Avoid or use systemic therapy with great caution in patients with severe renal impairment. If use is necessary, monitor serum sodium concentrations and renal function carefully to avoid sodium retention.
Sodium chloride injection solution may be administered enterally if necessary. In general, hypertonic solutions should be utilized to minimize volume. If a Visually inspect parenteral products for particulate matter and discoloration prior to administration whenever solution and container permit.
Use of a final filter is recommended during administration of all parenteral solutions when possible. When administering sodium chloride from flexible plastic containers, do not connect in series, pressurize without fully evacuating the container's residual air, or use a vented intravenous administration set with the vent in the open position. Such use could result in air embolism. Central access should be obtained for continued use.
Monitor peripheral administration of hypertonic solutions carefully for potential extravasation and local tissue damage. Additional solutes such as dextrose or other electrolytes e. Do not mix or administer hypotonic or hypertonic sodium chloride injection solutions through the same administration set with whole blood or cellular blood components. IV Push 0. Intermittent IV Infusion 0. Intraosseous Administration For emergent fluid resuscitation, 0.
Inhalation Solution for Nebulization To minimize or prevent bronchospasm, administer a bronchodilator e. Inhaled hypertonic sodium chloride has been administered via jet and ultrasonic nebulization. Hold bottle upright. Give short, firm squeezes into each nostril. Do not aspirate nasal contents back into bottle. Small Children and Infants: Use drops. Put drops in each nostril and have the child remain on their back for 1 to 2 minutes.
Rinse bottle tip with hot water and wipe with a clean towel after each administration. To avoid contamination and prevent the spread of infection, do not use the bottle dispenser for more than 1 person to prevent the spread of infection. Ophthalmic solution Do not use if solution changes color or becomes cloudy. Apply to affected eye and replace cap after use. To avoid contamination, do not touch the tip of the dispenser to any surface e.
Ophthalmic ointment Do not use if ointment is difficult to dispense or if particles are visible in the product. Generic: - Discard product if it contains particulate matter, is cloudy, or discolored - Discard unused portion.
Do not store for later use. Saljet Rinse: - Discard product if it contains particulate matter, is cloudy, or discolored - Discard unused portion. Hypersensitivity and infusion reactions may occur with intravenous sodium chloride infusion. Immediately stop the infusion and institute appropriate therapeutic countermeasures if signs or symptoms of hypersensitivity occur. Use sodium chloride with great caution in patients with preexisting hypernatremia, hyperchloremia, metabolic acidosis, or risk factors for such conditions.
Intravenous solutions should be used with particular care in patients at risk for hypervolemia or other conditions that may cause sodium retention and fluid overload such as patients with primary or secondary hyperaldosteronism.
In patients with cardiac disease, sodium chloride administration and subsequent sodium retention may exacerbate hypertension, edema, and heart failure. In addition, because sodium chloride is primarily excreted by the kidney, administration to patients with renal disease, including renal artery stenosis, nephrosclerosis, renal impairment, or renal failure may result in significant sodium and chloride retention.
Additionally, patients with diabetic ketoacidosis may be at risk for cerebral edema after rapid administration of a crystalloid e. It is recommended to avoid routine volume expansion in newborns without evidence of acute blood loss. In patients with organ dysfunction, monitor respiratory status and tissue perfusion, as well as changes in clinical condition. In addition, central pontine myelinolysis CPM , a noninflammatory demyelinating condition, can occur when hyponatremia is corrected too quickly.
Patients with severe malnutrition, alcoholism, or advanced liver disease may be more susceptible to CPM and sodium replacement therapy should be tailored to stay well below established limits. Risk for developing hyponatremia is also increased in those with psychogenic polydipsia and those who are receiving concurrent medications that increase the risk of low serum sodium. Patients with hypoxemia and those with underlying central nervous system disease are at risk for developing hyponatremic encephalopathy.
Females particularly premenopausal are also at higher risk. Carefully consider fluid status in hyponatremic patients with hepatic disease e. Water retention and dilutional hyponatremia are common in patients with advanced disease and should be treated with sodium and fluid restriction, as well as diuretics.
Sodium supplementation may aggravate edema. In addition, patients with advanced liver disease may be more susceptible to central pontine myelinolysis CPM ; sodium replacement therapy should be tailored to stay well below established limits.
Hemolysis of red blood cells can occur during the infusion of hypotonic solutions. In the presence of a hypotonic fluid, water enters the red blood cells across a diffusion gradient, causing the cells to swell and burst. After lysis, the intracellular contents of the cells e.
Because of this phenomenon, isotonic or near-isotonic solutions are preferred for fluid administration. Normal saline 0. In contrast, 0. Hypotonic solutions should never be used for fluid resuscitation or rehydration; however, they are sometimes used in patients with high serum osmolarity e.
Additionally, hypotonic saline solutions offer a maintenance infusion option with less sodium content, which may be desirable in specific circumstances e. However, the most hypotonic fluid that can be safely administered is 0. The risk of hemolysis increases as the tonicity decreases ; of the commercially available saline products, 0. Mixing hypotonic saline solutions with dextrose increases their tonicity and makes the overall solution approach isotonicity, making it feasible to administer an intravenous infusion with a lower sodium content.
For example, 0. Because hemolysis is accentuated by an increased ratio of hypotonic solution to blood and prolonged cell contact time with the solution, it has been suggested that administering hypotonic solutions at a slower rate or through a central line may decrease the risk of cell lysis; however, hemolysis can still occur with such precautionary measures and use of any hypotonic solution in patients should be used with extreme caution.
According to the manufacturer, it is not known whether sodium chloride can cause fetal harm or affect reproduction capacity; only administer sodium chloride during pregnancy if it is clearly needed. However, normal saline 0. Saline nasal preparations and topical solutions are safe for use during pregnancy.
According to the manufacturer, it is not known whether sodium chloride is excreted in human milk. Because 0. Use caution when using sodium chloride bacteriostatic injection, as the benzyl alcohol preservative is associated with the development of metabolic acidosis, kernicterus, and intraventricular hemorrhage in the neonatal population; bacteriostatic injection is contraindicated for direct use in the neonatal population.
Consider the benefits of breast-feeding, the risk of potential infant drug exposure, and the risk of an untreated or inadequately treated condition. If a breast-feeding infant experiences an adverse effect related to a maternally ingested drug, healthcare providers are encouraged to report the adverse effect to the FDA. Bacteriostatic sodium chloride products contain benzyl alcohol and are contraindicated in neonates and premature neonates. Gasping syndrome is characterized by central nervous depression, metabolic acidosis, and gasping respirations.
If a sodium chloride solution is required for preparing medications or intravascular flush, only preservative-free injection should be used. Many physiological changes occur during the first weeks of life that affect the neonate's handling of fluid and sodium, especially in premature neonates. Carefully assess fluid and sodium status and adjust therapy as appropriate.
In general, volume expansion in neonates should only be used when clearly needed e. Premature neonates younger than 30 weeks gestational age should receive fluid resuscitation with 0. Children, including neonates and infants, are at increased risk of developing hyponatremia and hyponatremic encephalopathy.
Rapid correction of hypo- or hypernatremia requires an experienced clinician. Due to the risk of serious neurologic complications, dosage, rate, and duration of administration should be determined by a physician experienced in intravenous fluid therapy. Sodium chloride ophthalmic formulations i. There are no data to determine if geriatric patients respond differently to sodium chloride compared to younger patients. However, sodium chloride is excreted by the kidney, and elderly patients are more likely to have decreased renal function.
In general, dose selection for the elderly should be cautious and start at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, and cardiac function as well as concomitant disease or drug therapy. Monitor renal function in the elderly when receiving sodium chloride. Azelastine; Fluticasone: Moderate Concomitant use of systemic sodium chloride, especially at high doses, and corticosteroids may result in sodium and fluid retention.
Assess sodium chloride intake from all sources, including intake from sodium-containing intravenous fluids and antibiotic admixtures. Carefully monitor sodium concentrations and fluid status if sodium-containing drugs and corticosteroids must be used together. Beclomethasone: Moderate Concomitant use of systemic sodium chloride, especially at high doses, and corticosteroids may result in sodium and fluid retention.
Benzalkonium Chloride: Major Sodium chloride saline solutions should not be used to dilute benzalkonium chloride as saline solutions may decrease the antibacterial potency of the antiseptic. Stored tap water should also not be used for dilution since it may contain microorganisms. Resin deionized water may also contain pathogens and it may inactivate benzalkonium chloride. Betamethasone: Moderate Concomitant use of systemic sodium chloride, especially at high doses, and corticosteroids may result in sodium and fluid retention.
Budesonide: Moderate Concomitant use of systemic sodium chloride, especially at high doses, and corticosteroids may result in sodium and fluid retention. Budesonide; Formoterol: Moderate Concomitant use of systemic sodium chloride, especially at high doses, and corticosteroids may result in sodium and fluid retention. Ciclesonide: Moderate Concomitant use of systemic sodium chloride, especially at high doses, and corticosteroids may result in sodium and fluid retention.
Corticosteroids: Moderate Concomitant use of systemic sodium chloride, especially at high doses, and corticosteroids may result in sodium and fluid retention. Corticotropin, ACTH: Moderate Concomitant use of systemic sodium chloride, especially at high doses, and corticosteroids may result in sodium and fluid retention. Cortisone: Moderate Concomitant use of systemic sodium chloride, especially at high doses, and corticosteroids may result in sodium and fluid retention.
Deflazacort: Moderate Concomitant use of systemic sodium chloride, especially at high doses, and corticosteroids may result in sodium and fluid retention.
Dexamethasone: Moderate Concomitant use of systemic sodium chloride, especially at high doses, and corticosteroids may result in sodium and fluid retention. Fludrocortisone: Moderate Concomitant use of systemic sodium chloride, especially at high doses, and corticosteroids may result in sodium and fluid retention.
Flunisolide: Moderate Concomitant use of systemic sodium chloride, especially at high doses, and corticosteroids may result in sodium and fluid retention. Fluticasone: Moderate Concomitant use of systemic sodium chloride, especially at high doses, and corticosteroids may result in sodium and fluid retention.
Fluticasone; Salmeterol: Moderate Concomitant use of systemic sodium chloride, especially at high doses, and corticosteroids may result in sodium and fluid retention. Fluticasone; Umeclidinium; Vilanterol: Moderate Concomitant use of systemic sodium chloride, especially at high doses, and corticosteroids may result in sodium and fluid retention. Fluticasone; Vilanterol: Moderate Concomitant use of systemic sodium chloride, especially at high doses, and corticosteroids may result in sodium and fluid retention.
Formoterol; Mometasone: Moderate Concomitant use of systemic sodium chloride, especially at high doses, and corticosteroids may result in sodium and fluid retention. Hydrocortisone: Moderate Concomitant use of systemic sodium chloride, especially at high doses, and corticosteroids may result in sodium and fluid retention.
Lithium: Moderate Moderate to significant dietary sodium changes, or changes in sodium and fluid intake, may affect lithium excretion. Systemic sodium chloride administration may result in increased lithium excretion and therefore, decreased serum lithium concentrations.
In addition, high fluid intake may increase lithium excretion. For patients receiving sodium-containing intravenous fluids, symptom control and lithium concentrations should be carefully monitored. It is recommended that patients taking lithium maintain consistent dietary sodium consumption and adequate fluid intake during the initial stabilization period and throughout lithium treatment.
Supplemental oral sodium and fluid should be only be administered under careful medical supervision. Methylprednisolone: Moderate Concomitant use of systemic sodium chloride, especially at high doses, and corticosteroids may result in sodium and fluid retention. As a child grows, minute ventilation does not rise in direct proportion to the weight so neither does lung water loss. Transcutaneous evaporative water loss is dependent on body surface area BSA.
In summary, the water loss per kg body weight from these two routes is highest in the newborn. As the child grows, the increase in the rate of water loss is less than the increase in weight. Putting it all together, the rate of water loss from all three routes is highest in the smallest children and does not rise in direct proportion to increase in body weight. I t is clinically useful to begin fluid therapy by estimating normal maintenance requirements using the estimated caloric expenditure method.
The commonly used method for approximating water loss and therefore the water requirement is based off of the Holliday-Segar nomogram. Holliday and Segar collated information from a number of studies, including their own, and concluded the following:. The diagram below is taken from their original publication "The maintenance need for water in parenteral fluid therapy", Pediatrics Holliday and Segar determined how many calories a patient burns as a factor of weight.
The Holliday-Segar nomogram approximates daily fluid loss, and therefore the daily fluid requirements, as follows:. Even though it is correct to think about fluid requirements on a hour basis, the delivery pumps used in hospitals are designed to be programmed for an hourly infusion rate.
The hour number is often divided into approximate hourly rates for convenience, leading to the "" formula. I t is clear that there is no strict daily sodium requirement since, in the normal individual, homeostatic mechanisms will instruct the kidney to conserve or excrete sodium and keep total body sodium content within the normal range. Holliday and Segar decided on this number by looking at the sodium content of human and cows' milk. Click for flashback to chemistry.
When we speak about adding sodium to IV fluids, we talk about it in terms of normal saline. Normal saline is isotonic to plasma. Note that all of these are considered hypotonic to plasma. Based on current research, it is determined that giving hypotonic solutions as maintenance IV fluids is associated with severe morbidity and even mortality due to hyponatremia. We know that kids in the hospital are stressed.
They are vomiting, or have respiratory illness, or require surgery, or have fever. All of these things cause an increase in ADH release. The more ADH, the more water is reabsorbed from the collecting duct of the kidneys.
Combine this with hypotonic IV fluids, and you have a perfect formula for hyponatremia. This was estimated by Holliday and Segar to again reflect the composition of human and cow milk and has remained the same since then. In children who have a condition that might predispose to renal failure, such as dehydration, K is not added to intravenous fluids until the presence of renal function has been established.
This means that there is 0. You can apply this conversion factor to any other amount. There are two reasons for this:. Any solution that has less salt will be hypo-osmolar.
Rapid infusion of a hypo-osmolar solution can cause osmotically induced water shift into the cells, and this can lead to detrimental effects such as hemolysis. Ringer's lactate LR is a composite fluid that is available with and without dextrose. The lactate is metabolized in the liver to bicarbonate.
LR provides a source of base, as well as some Ca. M aintenance fluid calculations assume that fluid loss from sensible and insensible routes is taking place at a normal rate.
But a febrile infant will be having a much greater transcutaneous evaporative water loss than one with a normal body temperature. Similarly, a child with tachypnea will lose excess water from the lungs - unless she is receiving humidified oxygen, in which case she will lose none! Also consider patients with kidney disease who have anuria, oliguria, or polyuria. Maintenance IV fluids for these patients will not be written with the standard formula because their urinary losses are not taking place at a normal rate.
Maintenance fluids using the standard formula would be too much for an anuric child with no urinary losses and too little for those with a concentrating defect in their kidneys causing polyuria. Important : Before using a standard formula for calculating maintenance fluids, ensure that the child is not having higher or lower losses than usual! When we prescribe maintenance fluid for a 10 kg child for 24 hours as ml, we are assuming that loss from the various routes is occurring at a normal rate.
However, adjustments are sometimes necessary:. What is the hour fluid requirement for a 10 kg child who has a fever of 40 degrees C. Presuming the child is not receiving humidified O 2. What volume of maintenance fluid would you order for the next 12 hours for a 10 kg child with oliguria whose measured urine output in the previous 12 hours has been 50 ml?
I n children, the most common cause of dehydration is diarrheal fluid loss. This is known as isotonic dehydration. Electrolyte losses from diarrhea and vomiting range from iso- to hypo- osmolar. The tendency to have hypernatremia from loss of hypo-osmolar fluid is partially countered by movement of fluid from the ICF to the ECF driven by the increase in ECF osmolality.
This also helps maintain intra vascular volume. One potential scenario for hyponatremic dehydration is replacement of fluid loss by electrolyte-free water such as apple juice or iced tea, or with hypotonic fluids such as D5 0. Because of anti-diuretic hormone ADH secretion stimulated by hypovolemia, water will be retained even in the face of a falling serum sodium level. For example, a child who is on gavage feeding with a fixed daily fluid intake and develops excessive fluid loss from tachypnea or fever will gradually develop hypernatremia.
Hypernatremia is also seen in a small proportion of children with gastroenteritis and dehydration, presumably from excessive loss of water in relation to solute. C linical assessment of dehydration is always approximate, and the child should be frequently re-evaluated for continuing improvement during correction of dehydration. If you have an accurate pre-illness weight, you may use that weight.
Alternatively, the pre-illness weight can be calculated as follows:. The child's current dehydrated weight can be used for calculation of dehydration and maintenance fluids. After all, clinical assessment of dehydration, and therefore the volume needed for correction, is approximate! T he initial goal of treating dehydration is to restore intravascular volume resuscitative phase. The simplest approach is to replace dehydration losses with 0. This ensures that the administered fluid remains in the extracellular intravascular compartment, where it will do the most good to support blood pressure and peripheral perfusion.
Therapy may be started with a rapid bolus of 0. But correction of dehydration must be accompanied by provision of maintenance fluid. After all, the child is breathing, losing free water through the skin, and is urinating!
As discussed earlier, maintenance fluid is provided as D5NS. The blood pressure is low and the heart rate is very high. This child is in shock. The goal is to rapidly stabilize the vital signs; maintenance fluid is not a consideration at this time. The vital signs stabilize the bolus can be repeated if necessary. Step 2: The patient is transferred to the inpatient unit. By this time, serum electrolyte levels are available and the serum sodium concentration is within the normal range.
Subsequent fluid therapy is calculated as follows:. Of this, ml has already been infused in the ER, so the remaining deficit is ml.
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