Hypertonic saline for fluid resuscitation is best performed with an institution-approved protocol. One such protocol for buffered 3 % hypertonic (half sodium acetate and half sodium chloride) which closely follows the protocol used in the surgical ICUs at Johns Hopkins Hospital (where it is largely the only resuscitation fluid used other than isotonic saline) is described below. Generally, the treatment philosophy is an aggressive and early use to ameliorate sepsis and other critical illness. Often, hypertonic saline and isotonic fluids are given concomitantly.
To resuscitate patients with any of the following:
1) MAP < 75 mmHg (off pressors)
3)Â acute renal failure patients
4) clinical assessment of impending or active sepsis
5) Â clinical conditions where large volume of intravenous fluid is contraindicated – e.g., elderly patients with low EF
6) traumatic brain injury or increased intracranial pressure
1) sickle cell patients
2) diabetes insipidus
1) patients must be in the ER, ICU, OR, or PACU and administration of therapy must be per protocol, unless change is approved by an ICU or other experienced attending.
2) use can be initiated in the step down units if transfer is imminent to one of the above patient care areas
3)Â buffered 3% hypertonic saline (sodium content is actually2.7-2.95%) Â must be infused into a central line or a centrally placed PICC line.
4) buffered 2% hypertonic saline may be administered into a peripheral line judged to be of a sufficient caliber for vigorous isotonic fluid resuscitation.
1) blood pressure and heart rate prior to administration, no less then every 30 minutes during infusion and within 1 hour after completion of infusion
2) serum sodium and serum chloride prior to infusion, every 2 hours during continuous infusion if the rate is > 50 cc/hr and within 1 hour after completion of infusion.
3) if rate of hypertonic saline infusion is < 50 cc/hr, sodium and chloride should be checked every four hours.
4) signs/symptoms of side effects of hyperchloremia, severe pulmonary edema, hypokalemia, or acute renal failure
5) serum ICa and potassium should be checked often and calcium repleted as needed as the sodium load will typically cause these electrolytes to be excreted
6) magnesium repletion empirically if calcium and potassium repletion is required or long QT is seen on ECG. Serum magnesium is notoriously unreliable Â as test for magnesium levels and it is not checked routinely.
1) 3% hypertonic saline to be administered as a continuous infusion to start at 1-3 mL/kg/hr, not to exceed 3 mL/kg/hr (ideal body weight).
2) 2% buffered hypertonic saline to be administered as continuous infusion not to exceed 5 mL/kg/hr (ideal body weight)
1) orders for hypertonic saline may NOT be placed as recurring, PRN, or titrate
2) discontinue infusion if: serum sodium > 150 mEq/L or increases > 10 mEq/L over a 24 hour period unless continuation is approved by an experienced attending
3) serum chloride > 125 mEq/L unless approved by an experienced attending; attending must be notified if serum chloride is > 120 mEq/L
4) signs/symptoms of CHF or intravascular volume overload develop
5) patient’s blood pressure, vitals and/or condition improves
6) Â strong consideration must be given to active diuresis after condition has stabilized to prevent vascular volume overload when capillary leak has healed – commonly a furosemide gtt is used to facilitate volume off load.
7) to avoid contraction alkalosis during active diuresis, Diamox is usually given on a daily basis.