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Department: CLINICAL QUERIES Sweeney, Judith MSN, RN Judith Sweeney is an associate professor and director of the prespecialty program at
Vanderbilt University School of Nursing in Nashville, Tenn. Nursing: September 2010 - Volume 40 - Issue 9 - p 63 doi: 10.1097/01.NURSE.0000387753.75852.62Managing hypernatremia
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Dextrose and Sodium Chloride Injections
Available in 250 mL, 500 mL, 1000 mL sizes in EXCEL® IV containers
Dextrose and Sodium Chloride Injections USP are sterile, nonpyrogenic and contain no bacteriostatic or antimicrobial agents. These products are intended for intravenous administration. These intravenous solutions are indicated for use in adults and pediatric patients as sources of electrolytes, calories and water for hydration.
Not made with natural rubber latex, PVC or DEHP.
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Hyponatremia, has become increasingly recognized as a cause of morbidity and mortality in hospitalized children. The main etiology of hyponatremia in these children has been attributed to the use of hypotonic maintenance IV fluids. The practice of providing IV solutions containing 20-30 mmol/L of Na is based on "physiological needs" proposed by Holliday and Segarin 1957, derived from studies of 61 adults and children. The presence of non-physiologic ADH secretion in the great majority of hospitalized children due to nausea, stress, pain, and surgical interventions, has confirmed that Holliday and Segar's recommendations are frequently inappropriately applied. To avoid the development of hyponatremia, it has been suggested that isotonic 0.9% NaCl/dextrose 5% should be the standard maintenance IV solution.
The routine use of an isotonic maintenance fluid solution has not yet been studied, and concerns exist regarding the potential for hypernatremia and salt and water overload. If isotonic solutions are to be recommended routinely, their overall safety, and specifically the occurrence of dysnatremias and volume overload, should be evaluated in a controlled prospective trial.
This information is intended for use by health professionals
Sodium Chloride 0.45 % w/v and Glucose 2.5% w/v Solution for Infusion BP
Sodium Chloride: | 4.5 g/l [0.45 % w/v] |
Glucose [as monohydrate]: | 25.0 g/l [2.5 % w/v] |
Each ml contains 25 mg glucose [as monohydrate] and 4.5 mg sodium chloride.
mmol/l: | Na+: 77 | Cl-:77 |
mEq/l: | Na+: 77 | Cl-:77 |
Nutritional value: approximately 420 kJ/l [or 100 kcal/l]
For the full list of excipients, see section 6.1.
Solution for infusion.
Clear solution, free from visible particles.
Osmolarity: 293 mOsm/l [approx]
pH: 3.5 to 6.5
Sodium Chloride 0.45 % w/v and Glucose 2.5% w/v solution is indicated for:
- Treatment of dehydration or hypovolaemia in cases where supply of water, sodium chloride and carbohydrates is required due to restriction of the intake of fluids and electrolytes by normal routes.
The choice of the specific sodium chloride and glucose concentration, dosage, volume, rate and duration of administration depends on the age, weight, clinical condition of the patient and concomitant therapy. It should be determined by a physician. For patients with electrolyte and glucose abnormalities and for paediatric patients, consult a physician experienced in intravenous fluid therapy.
Fluid balance, serum glucose, serum sodium and other electrolytes should be monitored before and during administration, especially in patients with increased non-osmotic vasopressin release [syndrome of inappropriate antidiuretic hormone secretion, SIADH] and in patients co-medicated with vasopressin agonist drugs due to the risk of hyponatraemia. Monitoring of serum sodium is particularly important for physiologically hypotonic fluids. Sodium Chloride 0.45 % w/v and Glucose 2.5% w/v solution may become extremely hypotonic after administration due to glucose metabolisation in the body [see sections 4.4, 4.5 and 4.8].
Rapid correction of hyponatraemia and hypernatraemia is potentially dangerous [risk of serious neurologic complications].
Electrolyte supplementation may be indicated according to the clinical needs of the patient.
Adults, older patients and adolescents [age 12 years and over]:
The recommended dosage is 500 ml to 3 L/24h
Administration rate
The infusion rate is usually 40 ml/kg/24h and should not exceed the patient's glucose oxidation capacities in order to avoid hyperglycaemia. Therefore the maximum acute administration rate is 5 mg/kg/min.
Paediatric population
The dosage varies with weight: | |
- 0-10 kg body weight: | 100 ml/kg/24h |
- 10-20 kg body weight: | 1000 ml + [50 ml/ kg over 10 kg]/24h |
- > 20 kg body weight: | 1500 ml + [20 ml/ kg over 20 kg]/24h. |
The administration rate varies with weight: | |
- 0-10 kg body weight: | 6-8 ml/kg/h |
- 10-20 kg body weight: | 4-6 ml/kg/h |
- > 20 kg body weight: | 2-4 ml/kg/h |
The infusion rate should not exceed the patient's glucose oxidation capacities in order to avoid hyperglycaemia. Therefore the maximum acute administration rate is 10-18 mg/kg/min, depending on the total body mass.
For all patients, a gradual increase of flow rate should be considered when starting administration of glucose containing products.
Method of administration
The administration is performed by intravenous infusion.
Sodium Chloride 0.45 % w/v and Glucose 2.5% w/v solution is hypotonic and iso-osmolar, due to the glucose content. It has an approximate osmolarity of 293 mOsm/l
Precautions to be taken before manipulating or administering the product
Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration. Do not administer unless the solution is clear and the seal is intact. Administer immediately following the insertion of infusion set. Do not remove unit from overwrap until ready for use. The inner bag maintains the sterility of the product.
The solution should be administered with sterile equipment using an aseptic technique.
The equipment should be primed with the solution in order to prevent air entering the system.
Do not use plastic containers in series connections. Such use could result in air embolism due to residual air being drawn from the primary container before the administration of the fluid from the secondary container is completed.
Pressurizing intravenous solutions contained in flexible plastic containers to increase flow rates can result in air embolism if the residual air in the container is not fully evacuated prior to administration. Use of a vented intravenous administration set with the vent in the open position could result in air embolism. Vented intravenous administration sets with the vent in the open position should not be used with flexible plastic containers.
Additives may be introduced before or during infusion through the resealable medication port.
When additive is used, verify tonicity prior to parenteral administration. Hyperosmolar solutions may cause venous irritation and phlebitis. Thus, any hyperosmolar solution is recommended to be administered through a large central vein, for rapid dilution of the hyperosmotic solution.
For further information on the product with additives, please see sections 6.2, 6.3 and 6.6.
The solution is contraindicated in patients presenting with:
• Known hypersensitivity to the product
• Extracellular hyperhydration or hypervolaemia
• Fluid and sodium retention
• Severe renal insufficiency [with oliguria/anuria]
• Uncompensated cardiac failure
• Hyponatraemia or hypochloraemia
• General oedema and ascitic cirrhosis
Clinically significant hyperglycaemia. The solution is also contraindicated in case of uncompensated diabetes, other known glucose intolerances [such as metabolic stress situations], hyperosmolar coma or hyperlactataemia.
Glucose intravenous infusions are usually isotonic solutions. In the body, however, glucose containing fluids can become extremely physiologically hypotonic due to rapid glucose metabolization [see section 4.2].
Depending on the tonicity of the solution, the volume and rate of infusion and depending on a patient's underlying clinical condition and capability to metabolize glucose, intravenous administration of glucose can cause electrolyte disturbances most importantly hypo- or hyperosmotic hyponatraemia.
Hyponatraemia
The infusion of solutions with sodium concentrations