A mL IV bolus dose given over 20 minutes was found to be a safe alternative to mannitol when given for elevated ICP in patients with severe head injury. Monitor ICP, serum osmolarity, and sodium concentrations.
Titrate subsequent infusions to keep ICP below 20 mmHg. The Brain Trauma Foundation does not make recommendations regarding the use of hypertonic saline for intracranial hypertension. NOTE: Dose may be given as a single infusion through a central venous catheter. In another study that compared Administer hypertonic saline via a central line.
Of note, although the American Academy of Pediatrics states that nebulized hypertonic saline may be administered to children 1 to 23 months of age hospitalized for bronchiolitis, use in the emergency department is not recommended. Evidence suggests hypertonic saline is effective in improving symptoms of non-severe bronchiolitis after 24 hours of use and reducing hospital length of stay when the admission exceeds 3 days. Although data has been contradictory, meta-analysis suggests use in areas where the length of administration is brief e.
For sodium replacement and management of ICP, dosage must be individualized based on serum sodium concentrations and patient requirements. For sodium replacement, dosage must be individualized based on serum sodium concentrations and patient requirements. Specific guidelines for dosage adjustments in hepatic impairment are not available. Carefully consider fluid status in patients with hepatic impairment and hyponatremia.
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.
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. Typically, half the total deficit is replaced in the first eight hours after admission and the remaining fluid is given over the next 16 hours. So, this child needs ml of NS in the next eight hours for a total of ml and another ml in the next 16 hours. However, maintenance fluid must also be administered.
This needs to be given as D5NS, with our without potassium, depending on the patient's urine output. If the child is not urinating well, hold on adding potassium. Note 2: If the child continues to vomit or have significant diarrhea, the volume of ongoing fluid loss should be estimated and added to the deficit every few hours as 0.
Ideally, the diapers should be weighed. If this is not possible, then a volume of ml should be used for each stool in an infant and ml for the older child.
Dehydration and hypovolemia result in secretion of anti-diuretic hormone, which causes retention of free water, and provision of hypotonic replacement fluid can lead to potentially life-threatening hyponatremia.
Step 3: Suppose the child is well hydrated by the second hospital day, but is still feeling queasy and does not want to drink. The blood brain barrier prevents rapid movement of solutes out of or into the brain. On the other hand, water can move freely across the blood brain barrier.
Rapidly developing hyponatremia causes a shift of water into the brain; conversely, hypernatremia can lead to brain dehydration and shrinkage. Severe, acute hyponatremia may result in brain edema with neurological symptoms such as a change in sensorium, seizures, and respiratory arrest. This is a life-threatening medical emergency and requires infusion of hypertonic saline.
Acute hypernatremia results in a reduction in brain volume. This can lead to subdural bleeding from stretching and rupture of the bridging veins that extend from the dura to the surface of the brain. Given time, the brain can alter intracellular osmotic pressure to better match plasma osmolality.
With persistent or slowly developing hyponatremia, brain cells extrude electrolytes and organic osmoles and the increase in brain volume is blunted or avoided. Neurologic symptoms are absent or subtle. With persistent hypernatremia, brain cells generate organic osmoles also known as idiogenic osmoles to compensate for the increase in plasma osmolality.
Again, the change in brain volume is partially blunted. These processes take hours to become effective and leave the brain with a decreased in hyponatremia or increased hypernatremia osmolar content. Just as the adaptation takes 24 hours or more, un-adaptation also takes time.
Rapid correction of long-standing hypo- or hypernatremia has the potential for severe neurological consequences because of sudden changes in brain volume in the opposite direction. The neurologic manifestations associated with overly rapid correction of hyponatremia is called osmotic demyelination syndrome. Thus, hyper- or hyponatremia of long duration should be corrected slowly.
O ver the past four decades, oral rehydration has been demonstrated to be quite effective in replacing diarrheal fluid losses. This therapy is best reserved for the child with mild or moderate dehydration. The intestine both the small bowel and colon is remarkably efficient in its ability to absorb water. The small bowel absorbs the vast majority of the body's fluid needs. Oral Rehydration Therapy ORT is accepted as the standard of care and first line treatment for the management of acute gastroenteritis with or without mild to moderate dehydration.
Note: Patients with mild to moderate dehydration can be treated with ORT. Those with severe dehydration are not candidates and need IV infusions. Also, those patients with altered mental status who may be at risk for aspiration and those patients with intestinal diseases such as short gut or ileus are also not candidates. Vomiting is not a contraindication for ORT. During both phases, fluid losses from vomiting and diarrhea are replaced in an ongoing manner.
An age-appropriate, unrestricted diet should also be instituted after the dehydration is corrected. If the patient is breastfed, breastfeeding should continue during this phase as well as during the maintenance phase. Formula-fed infants should continue their usual formula immediately upon rehydration.
Lactose-free or lactose-reduced formulas usually are unnecessary.
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