In chronic severe hyponatremia, avoid overcorrection, which may lead to osmotic demyelination syndrome. The rate of sodium correction depends on how quickly the hyponatremia developed.
In severe symptomatic hyponatremia e. Monitor serum sodium concentrations every 1 to 2 hours while infusing hypertonic sodium chloride and then as clinically appropriate. The rate of serum sodium correction should not exceed 0. Of note, some experts do not recommend the use of hypertonic saline in asymptomatic very low birth weight VLBW or extremely low birth weight ELBW infants with hyponatremia.
To prevent bronchospasm, administer after a bronchodilator e. For nasal sprays, 2 sprays in each nostril as needed. Drops are recommended for infants. Alternatively, this dosage may be administered enterally in patients who are not receiving TPN and require sodium chloride supplementation.
Adjust as needed based on serum sodium concentrations. Monitor sodium serum concentrations carefully and adjust dosage as needed.
Instill 1 to 2 drops onto the affected eye s every 3 to 4 hours. Instruct patients to discontinue use and seek medical advice if condition worsens or persists for more than 72 hours. Dose may be given as a single infusion. 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.
Because elderly patients are more likely to have decreased renal function, care should be taken in dose selection, and it may be useful to monitor renal function.
Reactions which may occur because of the solution or the technique of administration include febrile response, infection at the site of injection, venous thrombosis or phlebitis extending from the site of injection, extravasation, and hypervolemia. Too rapid infusion of hypertonic solutions may cause local pain and venous irritation.
Rate of administration should be adjusted according to tolerance. Use of the largest peripheral vein and a small bore needle is recommended.
Symptoms may result from an excess or deficit of one or more of the ions present in the solution; therefore, frequent monitoring of electrolyte levels is essential. Hypernatremia may be associated with edema and exacerbation of congestive heart failure due to the retention of water, resulting in an expanded extracellular fluid volume.
Reactions reported with the use of potassium-containing solutions include nausea, vomiting, abdominal pain and diarrhea. The signs and symptoms of potassium intoxication include paresthesias of the extremities, areflexia, muscular or respiratory paralysis, mental confusion, weakness, hypotension, cardiac arrhythmias, heart block, electrocardiographic abnormalities and cardiac arrest. Potassium deficits result in disruption of neuromuscular function, and intestinal ileus and dilatation.
If infused in large amounts, chloride ions may cause a loss of bicarbonate ions, resulting in an acidifying effect. The physician should also be alert to the possibility of adverse reactions to drug additives. Prescribing information for drug additives to be administered in this manner should be consulted. If an adverse reaction does occur, discontinue the infusion, evaluate the patient, institute appropriate therapeutic countermeasures and save the remainder of the fluid for examination if deemed necessary.
In the event of a fluid or solute overload during parenteral therapy, reevaluate the patient's condition and institute appropriate corrective treatment. In the event of overdosage with potassium-containing solutions, discontinue the infusion immediately and institute corrective therapy to reduce serum potassium levels.
Dosage is to be directed by a physician and is dependent upon age, weight, clinical condition of the patient and laboratory determinations. Frequent laboratory determinations and clinical evaluation are essential to monitor changes in blood glucose and electrolyte concentrations, and fluid and electrolyte balance during prolonged parenteral therapy. When a hypertonic solution is to be administered peripherally, it should be slowly infused through a small bore needle, placed well within the lumen of a large vein to minimize venous irritation.
Carefully avoid infiltration. In the average adult, daily requirements of sodium and chloride are met by the infusion of one liter of 0. Usually up to 40 mEq of potassium per liter daily is sufficient to replace normal loss in adults. Infusion rates should not exceed 10 mEq per hour or mEq per day.
A liter of fluid containing 40 mEq of potassium should be administered over an 8-hour period. Fluid administration should be based on calculated maintenance or replacement fluid requirements for each patient. There is no specific pediatric dose. The dose is dependent on weight, clinical condition and laboratory results. Some additives may be incompatible. Consult with pharmacist. When introducing additives, use aseptic techniques. Mix thoroughly. Do not store. Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit.
Exposure of pharmaceutical products to heat should be minimized. Avoid excessive heat. Protect from freezing. Storage in automated dispensing machines: Brief exposure up to 2 weeks to ultraviolet or fluorescent light does not adversely affect the product labeling legibility; prolonged exposure can cause fading of the red label. Rotate stock frequently. Caution: Do not use plastic containers in series connection. Tear overwrap down at notch and remove solution container.
Check for minute leaks by squeezing solution container firmly. If leaks are found, discard solution as sterility may be impaired. If supplemental medication is desired, follow directions below before preparing for administration. Inspect each container. Read the label.
Ensure solution is the one ordered and is within the expiration date. Invert container and carefully inspect the solution in good light for cloudiness, haze, or particulate matter.
Any container which is suspect should not be used. Use only if solution is clear and container and seals are intact. Sterile, nonpyrogenic. Single dose container. Do not use in series connection. For intravenous use only. See Package Insert.
Do not remove overwrap until ready for use. After removing the overwrap, check for minute leaks by squeezing container firmly. Additional essential electrolytes, minerals, and vitamins should be supplied as needed.
Do not use plastic containers in series connection. Laboratory Tests Clinical evaluation and periodic laboratory determinations are necessary to monitor changes in fluid balance, electrolyte concentrations, and acid-base balance during prolonged parenteral therapy or whenever the condition of the patient warrants such evaluation.
Pregnancy Teratogenic Effects Animal reproduction studies have not been conducted with Potassium Chloride in 0. Labor and Delivery The effects of Potassium Chloride in 0. Nursing Mothers It is not known whether this drug is excreted in human milk. Pediatric Use Safety and effectiveness of Potassium Chloride in Sodium Chloride Injection in pediatric patients has not been established by adequate and well-controlled studies. Geriatric Use Clinical studies of Potassium Chloride in Sodium Chloride Injection did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects.
Absorption and exchange of potassium using sodium or ammonium cycle cation exchange resin, orally and as retention enema. Hemodialysis and peritoneal dialysis. The use of potassium-containing foods or medications must be eliminated. However, in cases of digitalization, too rapid a lowering of plasma potassium concentration can cause digitalis toxicity.
Pediatric Dosage and Administration There is no specific pediatric dose. To Open Tear overwrap down at notch and remove solution container.
Note: Before use, perform the following checks: Inspect each container.
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