All Pharmacy Pearls

Introduction

    Case Presentation

    • MJ is a 56 year-old female, presents to the ED with a chief complaint of progressively worsening weakness and

    fatigue over the past week, associated with a loss of appetite, nausea, and occasional confusion.

    o

    MJ denies shortness of breath, chest or abdominal pain, cough, pain or swelling in her legs, other

    neurological symptoms, fever, vomiting, or diarrhea.

    o

    Her medical history is significant for hypothyroidism, hypercholesterolemia, and hypertension.

    o

    According to family, she was hospitalized for three days a few months ago due to “dehydration,” at

    which time she was given “fluids.”

    o

    While transporting MJ to the CT scanner, she has a witnessed prolonged tonic-clonic seizure.

    o

    POC labs are unremarkable, except a serum sodium of 118 mEq/L

    • How would you manage this patient?

    o

    3% Sodium Chloride STAT!

Clinical Detail

    3% Sodium Chloride (NaCl)

    Dose*

    • 2 mL/kg or 50-150 mL

    o Max of 3 boluses of 3% NaCl preferably 10-30 minutes apart

    • Option to dose based on calculated sodium deficit

    Administration*

    • IV bolus recommended administration for symptomatic hyponatremia

    • Administered over 10-60 minutes

    • May be given through peripheral (PIV) access while central access obtained

    Adverse Effects

    • Hypernatremia

    • Fluid or solute overload

    • Hypokalemia

    • Acidosis

    • Overcorrection of hyponatremia

    Monitoring

    • BMP (Na+, K+, Cl-)

    • Symptoms of hyponatremia

    • Serum osmolality

    • Volume status

    • Neurological exam

    Compatibility

    • Not compatible with blood products or drugs incompatible with normal saline

    Comments

    • Critical to establish IV access with largest bore at most proximal point

Evidence

    Author,

    year

    Design, sample

    size

    Intervention & Comparison

    Outcome

    Dillion, 2018

    Observational,

    N=66

    3% NaCl through PIV

    • Max rate= 50 mL/hr

    • Mean duration infusion= 14 hrs (IQR 4-

    • Infusion-related phlebitis= 3%

    Perez 2017

    Observational,

    N=28

    3% NaCl through PIV

    • Max rate= 50 mL/hr

    • Mean duration infusion= 36 hrs (range 1-

    • Infusion-related phlebitis= 3%

    Jones, 2016

    Observational,

    N=213

    3% NaCl through PIV

    • Max rate= 30 mL/hr

    • Mean duration infusion= 0.85 hr (IQR 0.4-

  • 3)

    • Infusion-related phlebitis= 4%

    Ayus, 2015

    Case Series,

    N=47

Conclusions

    • Jones GM, et al. Am J Crit Care. 2016 Dec;26(1):37-42. PMID: 27965228

    • Ayus JC, et al. Am J Kidney Dis. 2015 Mar;65(3):435-42. PMID: 25465163

    • Hew-Butler T, et al. Clin J Sport Med. 2015 Jul;25(4):303-20. PMID: 26102445

    • Spasovski G, et al. Nephrol Dial Transplant. 2014 Apr;29 Suppl 2:i1-i39. PMID: 24569496

    • Verbalis JG, et al. Am J Med. 2013 Oct;126(10 Suppl 1):S1-42. PMID: 24074529

References

    • Sodium chloride. Micromedex [Electronic version].Greenwood Village, CO: Truven Health Analytics. Retrieved December 21, 2019, from

    http://www.micromedexsolutions.com/

    • Rogers IR, et al. Clin J Sport Med. 2011 May;21(3):200-3. PMID: 21519296

    • Dillon RC, et al. J Intensive Care Med. 2018 Jan;33(1):48-53. PMID: 28372499

    • Perez CA, et al. J Neurosci Nurs. 2017 Jun;49(3):191-195. PMID: 28471928

    • Jones GM, et al. Am J Crit Care. 2016 Dec;26(1):37-42. PMID: 27965228

    • Ayus JC, et al. Am J Kidney Dis. 2015 Mar;65(3):435-42. PMID: 25465163

    • Hew-Butler T, et al. Clin J Sport Med. 2015 Jul;25(4):303-20. PMID: 26102445

    • Spasovski G, et al. Nephrol Dial Transplant. 2014 Apr;29 Suppl 2:i1-i39. PMID: 24569496

    • Verbalis JG, et al. Am J Med. 2013 Oct;126(10 Suppl 1):S1-42. PMID: 24074529

Tags:hyponatremia 3% Sodium Chloride sodium seizure

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