Sodium Chloride

Pharmacologic Category

Electrolyte Supplement, Parenteral; Genitourinary Irrigant; Irrigant; Lubricant, Ocular; Sodium Salt

Dosing: Adult

Bronchodilator diluent: Inhalation: 1 to 3 sprays (1 to 3 mL) to dilute bronchodilator solution in nebulizer before administration.

Cystic fibrosis (off-label use): Inhalation: 7% hypertonic saline: 4 mL two times daily (Castellani 2018; Elkins 2006; Elkins 2016). Note: If patients cannot tolerate 7% hypertonic saline, 3% inhaled solution may be used; refer to institutional protocols. Pretreatment with an inhaled bronchodilator is recommended to prevent potential bronchospasm (Castellani 2018; Elkins 2006; Robinson 1997).

Genitourinary irrigant: Irrigation: 1 to 3 L/day by intermittent irrigation.

Hyponatremia: To correct acute (<48 hours) or chronic (>48 hours or duration unknown). In general, a serum sodium concentration increase of 4 to 6 mEq/L within a 24-hour period is sufficient to improve most symptoms of hyponatremia. In chronic severe hyponatremia, overcorrection risks iatrogenic osmotic demyelination syndrome. Goal of initial therapy is to increase serum sodium concentration by 4 to 6 mEq/L within the first 24 hours (maximum rate: 8 mEq/L in any 24-hour period). If patient is symptomatic and acutely hyponatremic or severely symptomatic, this goal should be achieved within the first 6 hours; maintain serum sodium at a constant level for the remainder of the 24-hour period (Sterns 2019). Choice of fluid concentration for sodium correction is dependent upon the severity of the hyponatremia with more concentrated solutions (eg, 3% NaCl) for more severe cases; monitor serum sodium closely during therapy (Sterns 2013). The following recommendations are based on using 3% NaCl:

Acute hyponatremia (serum sodium <130 mEq/L):

Asymptomatic: IV: Hypertonic saline: 3% NaCl: 50 mL bolus over at least 5 minutes; monitor serum sodium every 1 to 2 hours to assess need for additional treatment. Note: Withhold if hyponatremia is autocorrecting due to water diuresis (Sterns 2019).

Symptomatic: IV: Hypertonic saline: 3% NaCl: 100 mL over 10 minutes; if symptoms persist, may repeat up to a total of 3 doses over a period of 30 minutes (Sterns 2019; Verbalis 2013). Alternatively, some experts recommend 150 mL over 20 minutes up to a total of 2 doses while measuring serum sodium between infusions (ESE/ESICM/ERAEDTA [Spasovski 2014]).

Chronic hyponatremia (serum sodium <130 mEq/L):

Asymptomatic or mild to moderate symptoms, moderate hyponatremia (serum sodium 120 to 129 mEq/L): IV: Administration of 3% NaCl is generally not indicated; identify reason for hyponatremia and treat as appropriate (Sterns 2019).

Asymptomatic, severe hyponatremia (serum sodium <120 mEq/L): IV: Hypertonic saline: 3% NaCl (continuous infusion): Initial: 15 to 30 mL/hour with frequent (eg, every 4 hours) serum sodium monitoring; consider combination therapy with desmopressin in select patients (eg, high risk of developing osmotic demyelination syndrome to prevent overcorrection) (Sood 2013; Sterns 2019).

Severe symptoms or known intracranial pathology: IV: Hypertonic saline: 3% NaCl: 100 mL over 10 minutes; if symptoms persist, may repeat up to a total of 3 doses over a period of 30 minutes (Sterns 2019). Alternatively, some experts recommend 150 mL over 20 minutes up to a total of 2 doses while measuring serum sodium between infusions (ESE/ESICM/ERAEDTA [Spasovski 2014]).

Intracranial hypertension (refractory) due to various etiologies (eg, subarachnoid hemorrhage, trauma, neoplasm), transtentorial herniation syndromes (off-label use):

IV (via central venous access only): Hypertonic saline: 23.4% NaCl: 15 to 60 mL administered over 2 to 20 minutes (Koenig 2008; Lewandowski-Belfer 2014; Suarez 1998; Ware 2005).

Intraosseous: Hypertonic saline: 23.4% NaCl: 30 mL administered over 3 to 5 minutes; remove intraosseous catheter after 24 hours due to the complication risk with prolonged use (Farrokh 2019; Wang 2019).

Intracranial hypertension (traumatic brain injury) (off-label use): Note: Optimal dose has not been established; due to insufficient evidence, the Brain Trauma Foundation guidelines do not make specific recommendations on the use of hypertonic saline for the treatment of traumatic intracranial hypertension (BTF [Carney 2017]). Clinical trials are small; few are prospective. Some concentrations may not be commercially available; protocols include:

Continuous infusion: IV: Hypertonic saline: 3% NaCl: Initial: 30 to 50 mL/hour; titrate to maintain serum sodium between 145 to 155 mEq/L (Maguigan 2017; Rajajee 2019). May administer 23.4% bolus infusions to treat acute intracranial pressure (ICP) elevations (Rajajee 2019).

Intermittent bolus dosing: Hypertonic saline:

IV (via central venous access only): 23.4% NaCl: 30 mL administered over 2 to 10 minutes as needed to treat acute ICP elevations (Kerwin 2009; Rajajee 2019; Ware 2005).

IV (via central venous access only): 7.5% NaCl: 2 mL/kg administered over 20 minutes when ICP values exceed 25 mm Hg (Vialet 2003).

Intraosseous: 23.4% NaCl: 30 mL administered over 3 to 5 minutes for <24 hours; may be administered prior to administering a 3% NaCl continuous infusion; remove intraosseous catheter after 24 hours due to the complication risk with prolonged use (Farrokh 2019; Wang 2019).

Nasal congestion: Intranasal: 2 to 3 sprays in each nostril as needed.

Ophthalmic:

Ointment: Apply once daily or more often.

Solution: Instill 1 to 2 drops into affected eye(s) every 3 to 4 hours.

Parenteral nutrition:

Chloride maintenance electrolyte requirement: IV: As needed to maintain acid-base balance with parenteral nutrition; use equal amounts of chloride and acetate to maintain balance and adjust ratio based on individual patient needs (Mirtallo 2004).

Sodium maintenance electrolyte requirement: IV: 1 to 2 mEq/kg/24 hours; customize amounts based on individual patient needs (Mirtallo 2004).

Sclerotherapy, lower-extremity venous disease (off-label use):

Note: May mix with local anesthetic to reduce pain during injection. The following concentrations have been recommended based upon size of affected vein (Dietzek 2007; Peterson 2012; Scovell 2019).

IV: Hypertonic saline:

11.7% to 15% NaCl:

Vessel diameter <0.5 mm: 0.25 mL per injection.

Vessel diameter 0.5 to 1 mm: 0.5 mL per injection.

15% to 23.4% NaCl:

Vessel diameter 1 to 3 mm: 0.5 to 1 mL per injection.

Septic shock or sepsis-induced hypoperfusion, fluid resuscitation (off-label use): IV: Normal saline (0.9% NaCl): Initial resuscitation: Minimum of 30 mL/kg to be given within the first 1 hour for hypotension or lactate ≥4 mmol/L. Administer vasopressors during or after fluid resuscitation to maintain a mean arterial pressure ≥65 mmHg; following initial resuscitation, additional fluid administration guided by frequent reassessment of hemodynamic status may be necessary (Levy 2018). Note: Some patients may require more rapid administration and/or greater amount of fluid for complete initial resuscitation (SCCM [Rhodes 2017]).

Subarachnoid hemorrhage with hyponatremia (ie, ≤133 mEq/L or a decrease by ≥6 mEq/L over 24 to 48 hours) (off-label use): IV: Hypertonic saline: 3% NaCl: Initial: 20 mL/hour; titrate by increasing rate by 10 to 20 mL/hour to maintain serum sodium between 136 to 140 mEq/L; may also administer concurrently with oral sodium chloride (Woo 2009).

Wound irrigation: Spray affected area.

* See Dosage and Administration in AHFS Essentials for additional information.

Dosing: Geriatric

Refer to adult dosing.

Dosing: Pediatric

Dosage depends upon clinical condition, fluid, electrolyte, and acid-base balance of patient; systemic hypertonic solutions (>0.9%) should only be used for the initial treatment of acute serious symptomatic hyponatremia or increased intracranial pressure.

Normal daily requirements:

Infants and Children ≤50 kg: Oral, IV: 2 to 5 mEq/kg/day (Mirtallo 2004)

Children >50 kg and Adolescents: Oral, IV: 1 to 2 mEq/kg/day (Mirtallo 2004)

Bronchiolitis, viral (inpatient): Infants and Children 1 to 24 months: Inhalation: 3% solution: 4 mL inhaled every 2 hours for 3 doses followed by every 4 hours for 5 doses and continued every 6 hours until discharge (Kuzik 2007); pretreatment with a bronchodilator may be necessary to prevent potential bronchospasm

Bronchodilator diluent: Infants, Children, and Adolescents: Inhalation: 1 to 3 sprays (1 to 3 mL) to dilute bronchodilator solution in nebulizer before administration

Cystic fibrosis: Children ≥6 years and Adolescents: Inhalation: 7% solution: 4 mL inhaled twice daily. Note: Clinically, some CF centers use 3% or 3.5% inhaled solutions if patients cannot tolerate 7%; pretreatment with a bronchodilator is recommended to prevent potential bronchospasm

Dehydration: Infants, Children, and Adolescents: IV: 0.9% isotonic solution: Initial: 20 mL/kg/dose; maximum dose: 1,000 mL followed by remaining replacement using sodium chloride concentration appropriate for age over 24 hours for dehydration (Meyers 2009)

Hyponatremia: Infants, Children, and Adolescents: IV: Note: Use 0.9% isotonic solution or 3% hypertonic solution depending on clinical severity and etiology.

Dose (mEq sodium) = [desired serum sodium (mEq/L) - actual serum sodium (mEq/L)] x 0.6 x wt (kg)

Note: For acute correction, use 125 mEq/L as the "desired serum sodium"; acutely correct serum sodium by 5 mEq/L/dose increments (eg, from a serum concentration of 120 mEq/L to 125 mEq/L) using a serum correction rate of ≤2 mEq/L/hour for the first few hours followed by a serum correction rate of ≤0.5 mEq/L/hour; goal serum correction rate: ≤12 mEq/L/day; more gradual correction in increments of 10 mEq/L/day is indicated in the asymptomatic patient

Hypovolemic shock: Infants, Children, and Adolescents: IV: 0.9% isotonic solution: 20 mL/kg/dose; may repeat up to ≥60 mL/kg until capillary perfusion improves or signs of fluid overload occur (Ceneviva 1998; Parker 2004)

Increased intracranial pressure (ICP): Infants, Children, and Adolescents: IV: 3% hypertonic solution:

Bolus: Limited data available; dosing regimens variable:

Traumatic brain injury guidelines: 6.5 to 10 mL/kg/dose (Fisher 1992; Kochanek 2012)

Alternate dosing: 5 mL/kg/dose administered early in presentation (during critical care transport) was reported in a retrospective trial of 101 pediatric patients (age range: 2 months to 17 years) with suspected increased ICP (Luu 2011); some centers use 2 to 5 mL/kg/dose; boluses are typically infused over 30 minutes but are occasionally administered more rapidly depending on the clinical scenario (Abd-Allah 2012; Brenkert 2013; Kamat 2003)

Continuous IV infusion: 0.1 to 1 mL/kg/hour titrated to maintain ICP <20 mm Hg (Kochanek 2012); monitor serum sodium concentration closely; some centers utilize titration protocols with rate adjustments varying with serum sodium concentration; maintain serum osmolarity <360 mOsmol/L

Nasal dryness/congestion: Note: Consult product specific labeling for approved use in pediatric patients; available concentrations vary.

Infants: Intranasal: Intranasal solution: 2 to 6 drops per nostril as needed

Children and Adolescents: Intranasal: Intranasal solution: Use as often as needed

Ocular dryness: Infants, Children, and Adolescents:

Ophthalmic, ointment: Apply once daily or more often as needed

Ophthalmic, solution: Instill 1 to 2 drops into affected eye(s) every 3 to 4 hours

Use: Labeled Indications

Inhalation: Restores moisture to pulmonary system; loosens and thins congestion caused by colds or allergies; diluent for bronchodilator solutions that require dilution before inhalation

Intranasal: Restores moisture to nasal membranes

Irrigation: Wound cleansing, irrigation, and flushing

Ophthalmic: Reduces corneal edema

Parenteral: Restores sodium ion in patients with restricted oral intake (especially hyponatremia states or low salt syndrome).

Concentrated sodium chloride: Additive for parenteral fluid therapy

Hypertonic sodium chloride: For severe hyponatremia and hypochloremia

Hypotonic sodium chloride: Hydrating solution

Normal saline: Restores water/sodium losses

* See Uses in AHFS Essentials for additional information.

Use: Off-Label: Adult

Cystic fibrosisLevel of Evidence [B, G]

Data from a randomized, double-blind, placebo-controlled trial support the long-term use of nebulized hypertonic (7%) saline in the treatment of cystic fibrosis patients with stable lung disease to improve lung function (modestly), decrease pulmonary exacerbations (including decrease in number of days with antibiotic use), and improve quality of life ^Ref.

Based on the Cystic Fibrosis Foundation cystic fibrosis pulmonary guidelines: chronic medications for maintenance of lung health, chronic use of inhaled hypertonic saline is recommended to improve lung function, quality of life, and to reduce pulmonary exacerbations.

Refractory elevated intracranial pressureLevel of Evidence [C]

Hypertonic saline: Refractory elevated intracranial pressure (ICP) due to various etiologies (eg, neoplasm). Data from retrospective, single center study and case series single center study suggest that 23.4% saline may be administered via the intraosseous route for <24 hours, when central access is not available. Larger studies are needed to further assess safety ^Ref. Note: May be used in patients in whom mannitol may not be recommended (eg, renal failure).

Sclerotherapy, lower-extremity venous diseaseLevel of Evidence [B, G]

Data from randomized, double-blind trials support the use of hypertonic saline as a sclerotherapy agent for lower-extremity vein sclerosis (ie, telangiectasias, reticular veins, varicose veins) ^Ref.

Based on the Society for Vascular Surgery (SVS) and American Venous Forum (AVF) practice guidelines for the care of patients with varicose veins and associated chronic venous diseases, hypertonic saline may be considered in patients requiring sclerotherapy for telangiectasias, reticular veins, and varicose veins ^Ref.

Septic shock or sepsis-induced hypoperfusion, fluid resuscitationLevel of Evidence [G]

Based on the Surviving Sepsis Campaign International Guidelines for the Management of Severe Sepsis and Septic Shock, crystalloids (either normal saline [ie, an unbalanced crystalloid] or balanced crystalloids [eg, lactated Ringer's, Hartmann's solution, Plasma-Lyte]) are the fluid of choice for initial resuscitation and subsequent intravascular volume replacement in patients with sepsis or septic shock ^Ref. Fluid resuscitation should begin immediately (within first hour) after the identification of sepsis ^Ref.

Subarachnoid hemorrhageLevel of Evidence [C, G]

Hypertonic saline: Evidence-based guidelines suggest that hypertonic saline is useful for the prevention and treatment of hypovolemia and hyponatremia following subarachnoid hemorrhage (SAH) ^Ref. Noncontrolled trials provide evidence to support the use of hypertonic saline to increase cerebral blood flow (CBF) and brain tissue oxygenation after SAH; however, the concentration of hypertonic saline used for this purpose is not commercially available and would need to be compounded, adding potential safety concerns ^Ref. Larger, randomized, controlled trials are needed to determine the overall effectiveness of hypertonic saline to increase CBF and brain tissue oxygenation and to determine if there are adverse effects associated with IV hypertonic saline therapy following SAH.

Transtentorial herniation syndromeLevel of Evidence [B]

Hypertonic saline: Data from retrospective cohort studies support the use of hypertonic saline in the treatment of transtentorial herniation syndrome ^Ref.

Traumatic brain injury with elevated intracranial pressureLevel of Evidence [C]

Hypertonic saline: Data from a retrospective review in a limited number of patients suggest hypertonic saline may be beneficial for the treatment of increased ICP in patients with traumatic brain injury ^Ref. In a meta-analysis of available clinical trials comparing hypertonic saline to mannitol, there were no differences observed relating to mortality, neurologic outcomes, and ICP reduction; however, hypertonic saline appeared to result in fewer ICP treatment failures ^Ref.

Level of Evidence Definitions

Level of Evidence Scale

Clinical Practice Guidelines

Cystic fibrosis:

“Cystic Fibrosis Pulmonary Guidelines: Chronic Medications for Maintenance of Lung Health,” January 2013

“ECFS Best Practice Guidelines: the 2018 Revision,” March 2018

Hyponatremia:

"Diagnosis, Evaluation, and Treatment of Hyponatremia: Expert Panel Recommendations," October 2013

Sclerotherapy:

SVS/AVF, "Practice Guidelines for the Care of Patients with Varicose Veins and Associated Chronic Venous Diseases," May 2011

Sepsis:

“Clinical Practice Parameters for Hemodynamic Support of Pediatric and Neonatal Septic Shock,” February 2007

“Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016,” March 2017

“The Surviving Sepsis Campaign Bundle: 2018 Update,” June 2018

Stroke:

AHA/ASA, “Guidelines for the Management of Spontaneous Intracerebral Hemorrhage,” July 2016

Traumatic Brain Injury:

"Guidelines for Field Management of Combat-Related Head Trauma," 2005

"Guidelines for Pre-Hospital Management of Severe Traumatic Brain Injury," March 2007

“Guidelines for the Acute Medical Management of Severe Traumatic Brain Injury in Infants, Children, and Adolescents – 2nd Edition,” January 2012

“Guidelines for the Management of Severe Traumatic Brain Injury,” January 2017

Administration: IV

>2% solutions: Administration through a central venous line is recommended due to high osmolarity and tonicity (Mortimer 2006). In the absence of a central line and when urgent administration is necessary, 3% solutions may be safely administered through a peripheral venous line (Dillon 2018; Jones 2016; Meng 2018; Mesghali 2019; Perez 2017). Concentrations >3% should be administered via central venous line only (Mortimer 2006; Suarez 1998). Consult individual institutional policies and procedures.

3% solution: Osmolarity: 1027 mOsm/L; sodium content: 513 mEq/L.

Higher concentrations (>1%) are irritants (with vesicant-like properties at higher osmolarities); higher osmolarity is associated with a higher risk. Ensure proper needle or catheter placement prior to and during infusion; avoid extravasation.

Extravasation management: If extravasation occurs, stop infusion immediately and disconnect (leave cannula/needle in place); gently aspirate extravasated solution (do NOT flush the line); initiate hyaluronidase antidote (if indicated); remove needle/cannula; elevate extremity. Apply dry cold compresses (Reynolds 2014).

Hyaluronidase: Intradermal or SubQ: Inject a total of 1 to 1.7 mL (15 units/mL) as five separate 0.2 to 0.3 mL injections (using a 25-gauge needle) into area of extravasation at the leading edge in a clockwise manner (Reynolds 2014).

Administration: Topical

Irrigation solution: Do not warm >66°C (150°F); not for IV use. Wound Wash Saline: Before use, expel a short stream into air to clear nozzle.

Administration: Intraosseous

>2% solutions: Based on data in adult patients, intraosseous administration is a reasonable alternative when quick IV access is not feasible (Cadena 2017; Farrokh 2019; Wang 2019).

Administration: Pediatric

Inhalation: Nebulization; studies administering hypertonic saline utilized varying types of nebulizers, including jet and ultrasonic

Nasal: Spray into 1 nostril while gently occluding other

Ophthalmic: Apply to affected eye(s); avoid contact of bottle tip with eye or skin

Oral: Administer with full glass of water

Parenteral: Central-line administration is preferred for hypertonic saline (>0.9%) if available and/or if infusion is to be continued; peripheral administration may be necessary for initiation of treatment in critical patients; use of peripheral administration should be limited; intraosseous administration may be used if unable to obtain intravenous access (Luu 2011)

Rate of administration:

Bolus:

0.9% isotonic solution:

Hypotension, shock:

Neonates: Published data not available; consider slower administration to avoid IVH (Kattwinkel 2010)

Infants, Children, and Adolescents: Administer boluses over 5 minutes (Brierley 2009)

Dehydration: Bolus: Administer over 20 to 60 minutes

3% hypertonic solution: In pediatric patients, boluses are typically infused over 30 minutes (Abd-Allah 2012; Kamat 2003). Although data is limited, faster rates have been reported; in a retrospective trial (n=56), a median infusion time of 17 minutes (IQR: 10 to 30 minutes) was reported for a median dose of 4.1 mL/kg. In this same trial, a subset (n=15) received bolus doses over ≤10 minutes; four of these patients received 3 to 5 mL/kg over ~3 minutes in the emergency department (Brenkert 2013)

Continuous IV infusion: Maximum rate: 1 mEq/kg/hour

Vesicant at higher concentrations (>1%); ensure proper needle or catheter placement prior to and during infusion; avoid extravasation. If extravasation occurs, stop infusion immediately and disconnect (leave cannula/needle in place); gently aspirate extravasated solution (do NOT flush the line); initiate hyaluronidase antidote if indicated (see Management of Drug Extravasations for more details); remove needle/cannula; elevate extremity. Apply dry cold compresses (Reynolds 2014).

Vesicant/Extravasation Risk

Concentrations >1%: Irritant (with vesicant-like properties at higher osmolarities)

Storage/Stability

Store injection at room temperature; do not freeze. Protect from heat. Use only clear solutions.

Compatibility

See Trissel’s IV Compatibility Database

Open Trissel's IV Compatibility

Medication Patient Education with HCAHPS Considerations

What is this drug used for?

Injection and tablet:

• It is used to treat low sodium levels.

Injection:

• It is used to treat fluid loss.

• It is used to mix with a drug that is given as a shot.

Flush:

• It is used to flush IV sets and access devices.

Liquid for breathing in:

• It is used to thin mucus so it can be taken from the body by coughing.

• It is used to mix with other drugs for use in a special machine (nebulizer).

All nose Products:

• It is used to treat dry or irritated nose passages.

• It is used to thin fluid in the nose passages.

All skin products:

• It is used to clean wounds.

For use in the eye:

• It is used to lower swelling.

All products:

• It may be given to you for other reasons. Talk with the doctor.

Frequently reported side effects of this drug

• Burning

• Nausea

• Vomiting

Other side effects of this drug: Talk with your doctor right away if you have any of these signs of:

• Electrolyte problems like mood changes, confusion, muscle pain or weakness, abnormal heartbeat, seizures, lack of appetite, or severe nausea or vomiting.

• Severe dizziness

• Passing out

• Chills

• Tremors

• Chest pain

• Fast heartbeat

• Flushing

• Vision changes

• Eye pain

• Severe eye irritation

• Shortness of breath

• Excessive weight gain

• Swelling of arms or legs

• Severe nasal irritation

• Injection site burning, stinging, redness, pain, or irritation

• Signs of a significant reaction like wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat.

Note: This is not a comprehensive list of all side effects. Talk to your doctor if you have questions.

Consumer Information Use and Disclaimer: This information should not be used to decide whether or not to take this medicine or any other medicine. Only the healthcare provider has the knowledge and training to decide which medicines are right for a specific patient. This information does not endorse any medicine as safe, effective, or approved for treating any patient or health condition. This is only a brief summary of general information about this medicine. It does NOT include all information about the possible uses, directions, warnings, precautions, interactions, adverse effects, or risks that may apply to this medicine. This information is not specific medical advice and does not replace information you receive from the healthcare provider. You must talk with the healthcare provider for complete information about the risks and benefits of using this medicine.

Medication Safety Issues

Sound-alike/look-alike issues:

High alert medication:

Other safety concerns:

Contraindications

Hypersensitivity to sodium chloride or any component of the formulation; hypertonic uterus, hypernatremia, fluid retention

Warnings/Precautions

Concerns related to adverse effects:

• Extravasation: Concentrated solutions of IV sodium chloride (>1%) are irritants (with vesicant-like properties at higher osmolarities); depends on osmolarity; higher osmolarity is associated with a higher risk. Ensure proper needle or catheter placement prior to and during infusion. Avoid extravasation.

• Hemolysis: The use of hypotonic saline solutions (eg, sodium chloride 0.225%) may result in hemolysis if administered rapidly and for prolonged periods. If hypotonic saline solutions become necessary, administration as D5W/NaCl 0.2% or NaCl 0.45% is recommended for most patients (eg, those without hyperglycemia).

• Hyponatremia: Administration of low sodium or sodium-free IV solutions may result in significant hyponatremia or water intoxication; monitor serum sodium concentration closely. In the treatment of acute hypernatremia (ie, development over a couple of hours), serum sodium concentration should be corrected no faster than 1 to 2 mEq/L per hour. If patient has been chronically hypernatremic, correct serum sodium no faster than 0.5 mEq/L per hour and by no more than 8 mEq/L in a given 24-hour period; use extreme caution since rapid correction may result in cerebral edema, herniation, coma, and death (Adrogué 2000; Kraft 2005; Sterns 2019).

• Sodium toxicity: Rate of correction is dependent upon whether or not hyponatremia is acute or chronic. Sodium toxicity (eg, osmotic demyelination syndrome [ODS]) is almost exclusively related to how fast a sodium deficit is corrected; both rate and magnitude are extremely important. For patients with acute (<24 hours) or chronic (>48 hours), severe (<120 mEq/L) hyponatremia, a serum sodium concentration increase of 4 to 6 mEq/L within a 24-hour period is sufficient for most patients. In chronic severe hyponatremia, overcorrection risks iatrogenic ODS. For patients with severe symptoms or other need for urgent correction, may increase by 4 to 6 mEq/L within the first 6 hours and postpone any further correction until the next day at a correction rate of 4 to 6 mEq/L per day. Do not increase serum sodium by >8 mEq/L in any 24-hour period. Choice of infusate sodium concentration is dependent upon the severity of the hyponatremia with more concentrated solutions (eg, NaCl 3%) for more severe cases; monitor serum sodium closely during administration (Sterns 2013; Sterns 2019).

Disease-related concerns:

• Cirrhosis: Use with caution in patients with cirrhosis.

• Edema: Use with caution in patients with edema.

• Heart failure: Use with caution in patients with heart failure.

• Hypertension: Use with caution in patients with hypertension.

• Renal impairment: Use with caution in patients with renal impairment; may cause sodium retention.

Dosage form specific issues:

• Benzyl alcohol and derivatives: Bacteriostatic sodium chloride contains benzyl alcohol; large amounts of benzyl alcohol (≥99 mg/kg/day) have been associated with a potentially fatal toxicity (“gasping syndrome”) in neonates; the “gasping syndrome” consists of metabolic acidosis, respiratory distress, gasping respirations, CNS dysfunction (including convulsions, intracranial hemorrhage), hypotension, and cardiovascular collapse (AAP ["Inactive" 1997]; CDC 1982); some data suggests that benzoate displaces bilirubin from protein binding sites (Ahlfors 2001); avoid or use dosage forms containing benzyl alcohol with caution in neonates. See manufacturer's labeling.

• Irrigants: For external use only; not for parenteral use. Do not use during electrosurgical procedures. Irrigating fluids may be absorbed into systemic circulation; monitor for fluid or solute overload.

• Wound Wash Saline: For single-patient use only.

* See Cautions in AHFS Essentials for additional information.

Geriatric Considerations

Use sodium chloride ophthalmic ointments with caution due to the potential to cause blurred vision. Limit use to bedtime dosing, if possible.

Warnings: Additional Pediatric Considerations

In neonates, maximum serum concentration correction rate should generally not exceed 10 mEq/L/day; in infants, children, adolescents, and adults, do not exceed a maximum serum concentration correction rate of 12 mEq/L/day. Administration of low sodium or sodium free IV solutions may result in significant hyponatremia or water intoxication in pediatric patients; monitor serum sodium concentration.

Some dosage forms may contain propylene glycol; in neonates large amounts of propylene glycol delivered orally, intravenously (eg, >3,000 mg/day), or topically have been associated with potentially fatal toxicities which can include metabolic acidosis, seizures, renal failure, and CNS depression; toxicities have also been reported in children and adults including hyperosmolality, lactic acidosis, seizures, and respiratory depression; use caution (AAP 1997; Shehab 2009).

Pregnancy Risk Factor

C

Pregnancy Considerations

Animal reproduction studies have not been conducted. Sodium requirements do not change during pregnancy (IOM 2004). Nasal saline rinses may be used for the treatment of pregnancy rhinitis (Wallace 2008)

Breast-Feeding Considerations

Sodium is found in breast milk. Sodium requirements do not change during lactation (IOM 2004).

Adverse Reactions

Frequency not defined:

Cardiovascular: Hypotension, localized phlebitis, peripheral edema, venous thrombosis

Central nervous system: Chills

Dermatologic: Pruritus, skin rash, urticaria

Endocrine & metabolic: Acid-base imbalance, electrolyte disturbance (dilution of electrolytes), hyperchloremia, hyperchloremic metabolic acidosis, hypernatremia, hypervolemia, hyponatremia

Local: Injection site infection, infusion site reaction

Neuromuscular & skeletal: Tremor

Respiratory: Pulmonary edema

Miscellaneous: Fever

<1%, postmarketing, and/or case reports: Hypersensitivity reaction, infusion related reaction

* See Cautions in AHFS Essentials for additional information.

Metabolism/Transport Effects

None known.

Drug Interactions Open Interactions

Lithium: Sodium Chloride may increase the excretion of Lithium. Risk C: Monitor therapy

Tolvaptan: Sodium Chloride may enhance the adverse/toxic effect of Tolvaptan. Specifically, Hypertonic Saline may increase the risk for too rapid of an increase in serum sodium concentrations. Management: This interaction is specific to Hypertonic Saline. Avoid concurrent use of Hypertonic Saline with Tolvaptan. Risk X: Avoid combination

Monitoring Parameters

Serum sodium, potassium, chloride, bicarbonate concentrations, and osmolarity; intake and output, weight. Monitor infusion site (during IV administration of hypertonic solutions).

Reference Range

Serum/plasma sodium concentration:

Neonates:

Full-term: 133 to 142 mEq/L

Premature: 132 to 140 mEq/L

Children ≥2 months to Adults: 135 to 145 mEq/L

Dosage Forms Considerations

1 g sodium chloride = elemental sodium 393.3 mg = 17.1 mEq sodium = sodium 17.1 mmol

Dosage Forms: US

Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product

Aerosol Solution, Inhalation:

Broncho Saline: 0.9% (240 mL [DSC])

Aerosol Solution, Nasal:

Ocean Complete Sinus Rinse: (177 mL)

Aerosol Solution, Nasal [preservative free]:

Ocean Complete Sinus Rinse: (177 mL) [drug free]

Gel, Nasal:

Ayr Saline Nasal: (14.1 g) [contains aloe barbadensis, brilliant blue fcf (fd&c blue #1), methylparaben, propylparaben, soybean oil]

Ayr Saline Nasal No-Drip: (22 mL) [contains aloe barbadensis, benzalkonium chloride, benzyl alcohol, soybean oil]

Rhinaris: 0.2% (28.4 g [DSC]) [contains benzalkonium chloride, propylene glycol]

Kit, Intravenous:

Liquivida Hydration: 0.9%

Liquid, External:

Atrapro Dermal Spray: (236 mL)

DiaB Klenz: (240 mL)

Elta Dermal Wound Cleanser: (240 mL)

MicroKlenz Wound Cleanser: (240 mL)

RadiaKlenz: (240 mL)

Remedy 4-in-1 Body Cleanser: 0.5% (236 mL)

Sea-Clens Wound Cleanser: (178 mL [DSC], 355 mL [DSC])

Ultra-Klenz: (240 mL, 360 mL)

Nebulization Solution, Inhalation:

Generic: 0.9% (3 mL)

Nebulization Solution, Inhalation [preservative free]:

HyperSal: 3.5% (4 mL) [latex free]

HyperSal: 7% (4 mL)

Nebusal: 3% (4 mL); 6% (4 mL)

PulmoSal: 7% (4 mL)

Generic: 0.9% (3 mL, 5 mL, 15 mL); 3% (4 mL, 15 mL); 7% (4 mL); 10% (4 mL, 15 mL)

Ointment, Ophthalmic:

Altachlore: 5% (3.5 g)

Muro 128: 5% (3.5 g)

Generic: 5% (3.5 g)

Packet, Nasal [preservative free]:

Ayr Saline Nasal Neti Rinse: Sodium chloride and sodium bicarbonate (40 ea) [iodine free]

AYR Saline Nasal Rinse: Sodium chloride and sodium bicarbonate (50 ea, 51 ea, 100 ea) [iodine free]

Solution, External:

Saljet: 0.9% (30 mL)

Wound Wash Saline: 0.9% (210 mL)

Solution, External [preservative free]:

Safe Wash: 0.9% (210 mL) [drug free, latex free]

Saljet Rinse: 0.9% (30 mL)

Solution, Injection:

Generic: 0.9% (2 mL, 10 mL, 20 mL, 30 mL, 100 mL); 14.6% (20 mL [DSC], 40 mL)

Solution, Injection [preservative free]:

Generic: 0.9% (2 mL, 3 mL, 5 mL, 10 mL, 20 mL, 50 mL)

Solution, Intravenous:

SwabFlush Saline Flush: 0.9% (10 mL)

Generic: 0.45% (25 mL, 50 mL, 100 mL, 250 mL [DSC], 500 mL, 1000 mL); 0.9% (10 mL, 25 mL, 50 mL, 100 mL, 150 mL, 250 mL, 500 mL, 1000 mL); 3% (500 mL); 5% (500 mL); 23.4% (100 mL, 200 mL)

Solution, Intravenous [preservative free]:

Saline Flush ZR: 0.9% (2.5 mL, 5 mL, 10 mL) [latex free]

Generic: 0.45% (50 mL, 100 mL, 250 mL, 500 mL, 1000 mL); 0.9% (1 mL, 2 mL, 2.5 mL, 3 mL, 5 mL, 10 mL, 50 mL, 100 mL, 125 mL, 150 mL, 250 mL, 500 mL, 1000 mL); 3% (500 mL); 23.4% (30 mL)

Solution, Irrigation:

Generic: 0.9% (100 mL, 120 mL, 250 mL, 500 mL, 1000 mL, 1500 mL, 2000 mL, 3000 mL, 4000 mL, 5000 mL)

Solution, Nasal:

4-Way Saline: (29.6 mL)

Afrin Saline Nasal Mist: 0.65% (30 mL, 45 mL)

Altamist Spray: 0.65% (45 mL, 60 mL)

Ayr: 0.65% (50 mL)

Ayr Nasal Mist Allergy/Sinus: 2.65% (50 mL) [contains benzalkonium chloride]

Ayr Saline Nasal Drops: 0.65% (50 mL)

Baby Ayr Saline: 0.65% (30 mL)

Deep Sea Nasal Spray: 0.65% (44 mL) [contains benzalkonium chloride]

Humist: 0.65% (45 mL [DSC])

Na-Zone: 0.65% (59 mL [DSC])

Nasal Moist: 0.65% (15 mL, 45 mL) [contains benzyl alcohol]

Ocean for Kids: 0.65% (37.5 mL) [alcohol free, drug free; contains benzalkonium chloride]

Ocean for Kids: 0.65% (37.5 mL) [drug free; contains benzalkonium chloride]

Ocean Nasal Spray: 0.65% (44 mL, 45 mL, 66 mL, 104 mL, 480 mL) [contains benzalkonium chloride]

Pretz: (50 mL, 946 mL)

Pretz Irrigation: (237 mL)

Rhinaris: 0.2% (30 mL) [contains benzalkonium chloride, propylene glycol]

Saline Mist Spray: 0.65% (44 mL) [contains benzalkonium chloride]

Sea Soft Nasal Mist: 0.65% (45 mL [DSC])

Generic: 0.65% (44 mL, 88 mL)

Solution, Nasal [preservative free]:

Entsol Nasal: 3% (100 mL) [drug free]

Ocean Ultra Saline Mist: (90 mL) [drug free]

Pretz Natur Moist Nasal Spray: (20 mL) [cfc free]

Solution, Ophthalmic:

Altachlore: 5% (15 mL, 30 mL)

Muro 128: 2% (15 mL); 5% (15 mL, 30 mL)

Sochlor: 5% (15 mL)

Generic: 5% (15 mL)

Solution, Oral:

Generic: 4 mEq/mL (23.4%) (473 mL)

Swab, Nasal:

Ayr Saline Nasal Gel: (20 ea) [contains methylparaben, propylparaben, soybean oil, trolamine (triethanolamine)]

Tablet, Oral:

Generic: 1 g

Dosage Forms: Canada

Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product

Nebulization Solution, Inhalation:

Addipak Sodium Chloride: 0.9% (3 mL, 5 mL, 15 mL)

Aquapak: 0.9% (150 mL, 760 mL, 1070 mL, 2200 mL)

Generic: 0.9% (15 mL)

Solution, Injection:

Generic: 0.9% (2 mL, 10 mL, 20 mL, 30 mL, 50 mL, 100 mL, 250 mL, 500 mL, 1000 mL); 14.6% ([DSC])

Solution, Intravenous:

Generic: 0.45% (500 mL, 1000 mL); 0.9% (10 mL, 20 mL, 25 mL, 50 mL, 100 mL, 150 mL, 250 mL, 500 mL, 1000 mL); 3% (250 mL, 500 mL); 5% (500 mL); 23.4% (5 mL, 30 mL, 50 mL, 100 mL, 200 mL)

Solution, Irrigation:

Generic: 0.9% (500 mL, 1000 mL, 2000 mL, 3000 mL, 4000 mL)

Anatomic Therapeutic Chemical (ATC) Classification

• A12CA01
• B05CB01
• B05XA03

Generic Available (US)

May be product dependent

Pricing: US

Kit (Liquivida Hydration Intravenous)

0.9% (per each): $649.52

Liquid (Remedy 4-in-1 Body Cleanser External)

0.5% (per mL): $0.03

Nebulization (HyperSal Inhalation)

3.5% (per mL): $0.22

7% (per mL): $0.22

Nebulization (Nebusal Inhalation)

3% (per mL): $0.19

6% (per mL): $0.20

Nebulization (PulmoSal Inhalation)

7% (per mL): $0.20

Nebulization (Sodium Chloride Inhalation)

0.9% (per mL): $0.04 - $0.14

3% (per mL): $0.10

7% (per mL): $0.08 - $0.19

10% (per mL): $0.10

Ointment (Altachlore Ophthalmic)

5% (per gram): $3.89

Ointment (Muro 128 Ophthalmic)

5% (per gram): $4.22

Ointment (Sodium Chloride (Hypertonic) Ophthalmic)

5% (per gram): $3.09 - $4.26

Pack (Ayr Saline Nasal Neti Rinse Nasal)

1.57 g (per each): $0.19

Pack (AYR Saline Nasal Rinse Nasal)

1.57 g (per each): $0.08

Solution (Afrin Saline Nasal Mist Nasal)

0.65% (per mL): $0.09

Solution (Altachlore Ophthalmic)

5% (per mL): $1.16

Solution (Ayr Nasal)

0.65% (per mL): $0.05

Solution (Ayr Nasal Mist Allergy/Sinus Nasal)

2.65% (per mL): $0.07

Solution (Ayr Saline Nasal Drops Nasal)

0.65% (per mL): $0.05

Solution (Baby Ayr Saline Nasal)

0.65% (per mL): $0.08

Solution (Entsol Nasal Nasal)

3% (per mL): $0.33

Solution (Muro 128 Ophthalmic)

2% (per mL): $1.21

5% (per mL): $1.28

Solution (Nasal Moist Nasal)

0.65% (per mL): $0.16

Solution (Ocean for Kids Nasal)

0.65% (per mL): $0.08

Solution (Ocean Nasal Spray Nasal)

0.65% (per mL): $0.07

Solution (Rhinaris Nasal)

0.2% (per mL): $0.35

Solution (Safe Wash External)

0.9% (per mL): $0.03

Solution (Saline Flush ZR Intravenous)

0.9% (per mL): $0.67

Solution (Saline Nasal Spray Nasal)

0.65% (per mL): $0.03 - $0.06

Solution (Saljet External)

0.9% (per mL): $0.02

Solution (Saljet Rinse External)

0.9% (per mL): $0.02

Solution (Sodium Chloride (Hypertonic) Ophthalmic)

5% (per mL): $0.70 - $0.81

Solution (Sodium Chloride (PF) Injection)

0.9% (per mL): $0.09 - $0.40

Solution (Sodium Chloride Flush Intravenous)

0.9% (per mL): $0.04 - $0.36

Solution (Sodium Chloride Injection)

2.5 mEq/mL (per mL): $0.04 - $0.17

Solution (Sodium Chloride Intravenous)

0.45% (per mL): $0.02 - $0.04

0.9% (per mL): $0.02 - $0.08

3% (per mL): $0.01

4 mEq/mL (per mL): $0.04 - $0.14

5% (per mL): $0.01 - $0.02

Solution (Sodium Chloride Irrigation)

0.9% (per mL): $0.00 - $0.11

Solution (Sodium Chloride Oral)

4 mEq/mL (per mL): $0.12

Solution (SwabFlush Saline Flush Intravenous)

0.9% (per mL): $0.13

Solution (Wound Wash Saline External)

0.9% (per mL): $0.02

Tablets (Sodium Chloride Oral)

1 g (per each): $0.08 - $0.17

Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.

Mechanism of Action

Principal extracellular cation; functions in fluid and electrolyte balance, osmotic pressure control, and water distribution

Pharmacodynamics/Kinetics

Absorption: Oral: Rapid

Distribution: Widely distributed

Excretion: Primarily urine; also sweat, tears, saliva

Local Anesthetic/Vasoconstrictor Precautions

No information available to require special precautions

Effects on Dental Treatment

No significant effects or complications reported

Effects on Bleeding

No information available to require special precautions

Related Information

• Management of Drug Extravasations

Pharmacotherapy Pearls

Normal saline (0.9%) = 154 mEq/L; NaCl 3% = 513 mEq/L; NaCl 5% = 856 mEq/L; NaCl 23.4% = 4,000 mEq/L

Tablet 1 g = 17.1 mEq

Index Terms

0.9% Sodium Chloride; Crystalloid Solution (Normal Saline); Hypertonic Saline; NaCl; Normal Saline; Saline; Salt

FDA Approval Date

May 17, 1985

References

Abd-Allah, S. Personal communication. February 2012.

Achinger SG, Ayus JC. Treatment of hyponatremic encephalopathy in the critically ill. Crit Care Med. 2017;45(10):1762-1771. doi: 10.1097/CCM.0000000000002595.[PubMed 28704229]

Adelson PD, Bratton SL, Carney NA, et al, “Guidelines for the Acute Medical Management of Severe Traumatic Brain Injury in Infants, Children, and Adolescents. Chapter 11. Use of Hyperosmolar Therapy in the Management of Severe Pediatric Traumatic Brain Injury,” Pediatr Crit Care Med, 2003, 4(3 Suppl):40-4.[PubMed 12847347]

Adrogué HJ, Madias NE. Hypernatremia. N Engl J Med. 2000;342(20):1493-1499. doi: 10.1056/NEJM200005183422006.[PubMed 10816188]

Adrogué HJ and Madias NE, “The Challenge of Hyponatremia,” J Am Soc Nephrol, 2012, 23(7):1140-8.[PubMed 22626822]

Ahlfors CE. Benzyl alcohol, kernicterus, and unbound bilirubin. J Pediatr. 2001;139(2):317-319.[PubMed 11487763]

Al-Dahhan J, Jannoun L, and Haycock GB, "Effect of Salt Supplementation of Newborn Premature Infants on Neurodevelopmental Outcome at 10-13 Years of Age," Arch Dis Child Fetal Neonatal Ed, 2002, 86(2):F120-3.[PubMed 11882555]

Al-Rawi PG, Tseng MY, Richards HK, et al. Hypertonic saline in patients with poor-grade subarachnoid hemorrhage improves cerebral blood flow, brain tissue oxygen, and pH. Stroke. 2010;41(1):122-128. doi: 10.1161/STROKEAHA.109.560698.[PubMed 19910550]

Badjatia N, Carney N, Crocco TJ, et al, “Guideline for Prehospital Management of Traumatic Brain Injury 2nd Edition,” Prehosp Emerg Care, 2008, 12(Suppl 1):1-52.[PubMed 18203044]

Barer J, Hill LL, Hill RM, et al, “Fatal Poisoning From Salt Used as an Emetic,” Am J Dis Child, 1973, 125(6):889-90.[PubMed 4708280]

Bhardwaj A and Ulatowski JA, “Hypertonic Saline Solutions in Brain Injury,” Curr Opin Crit Care, 2004, 10(2):126-31.[PubMed 15075723]

Brain Trauma Foundation, American Association of Neurological Surgeons, Congress of Neurological Surgeons, “Guidelines for the Management of Severe Traumatic Brain Injury,” J Neurotrauma, 2007, 24(Suppl 1):1-106.[PubMed 17511534]

Brain Trauma Foundation, "Guidelines for the Field Management of Combat-Related Head Trauma," 2005. Available at http://www.braintrauma.org

Brenkert TE, Estrada CM, McMorrow SP, Abramo TJ. Intravenous hypertonic saline use in the pediatric emergency department. Pediatr Emerg Care. 2013;29(1):71-73.[PubMed 23283268 ]

Brierley J, Carcillo JA, Choong K, et al, “Clinical Practice Parameters for Hemodynamic Support of Pediatric and Neonatal Septic Shock: 2007 Update from the American College of Critical Care Medicine,” Crit Care Med, 2009, 37(2):666-88.[PubMed 19325359]

Bukhari RH, Lohr JM, Paget DS, Hearn AT, Cranley RD. Evaluation of lidocaine as an analgesic when added to hypertonic saline for sclerotherapy. J Vasc Surg. 1999;29(3):479-483. doi: 10.1016/s0741-5214(99)70276-4.[PubMed 10069912]

Burgess S, Abu-Laban RB, Slavik RS, Vu EN, Zed PJ. A systematic review of randomized controlled trials comparing hypertonic sodium solutions and mannitol for traumatic brain injury: implications for emergency department management. Ann Pharmacother. 2016;50(4):291-300.[PubMed 26825644]

Cadena R, Shoykhet M, Ratcliff JJ. Emergency neurological life support: intracranial hypertension and herniation. Neurocrit Care. 2017;27(suppl 1):S82-S88. doi: 10.1007/s12028-017-0454-z.[PubMed 28913634]

Carney N, Totten AM, O'Reilly C, et al. Guidelines for the management of severe traumatic brain injury. Neurosurgery. 2017;80(1):6-15. doi: 10.1227/NEU.0000000000001432.[PubMed 27654000]

Castellani C, Duff AJA, Bell SC, et al. ECFS best practice guidelines: the 2018 revision. J Cyst Fibros. 2018;17(2):153-178. doi: 10.1016/j.jcf.2018.02.006.[PubMed 29506920]

Ceneviva G, Paschall JA, Maffei F, Carcillo JA. Hemodynamic support in fluid-refractory pediatric septic shock. Pediatrics. 1998;102(2):e19.[PubMed 9685464]

Centers for Disease Control (CDC). Neonatal deaths associated with use of benzyl alcohol—United States. MMWR Morb Mortal Wkly Rep. 1982;31(22):290-291. http://www.cdc.gov/mmwr/preview/mmwrhtml/00001109.htm[PubMed 6810084]

Connolly ES Jr, Rabinstein AA, Carhuapoma JR, et al; American Heart Association Stroke Council; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; Council on Cardiovascular Surgery and Anesthesia; Council on Clinical Cardiology. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2012;43(6):1711-1737.[PubMed 22556195]

Dietzek CL. Sclerotherapy: introduction to solutions and techniques. Perspect Vasc Surg Endovasc Ther. 2007;19(3):317-324. doi: 10.1177/1531003507305884.[PubMed 17966153]

Diringer MN, Bleck TP, Hemphill JC 3rd, et al; Neurocritical Care Society. Critical care management of patients following aneurysmal subarachnoid hemorrhage: recommendations from the Neurocritical Care Society's Multidisciplinary Consensus Conference. Neurocrit Care. 2011;15(2):211-240.[PubMed 21773873]

Dellinger RP, Levy MM, Rhodes A, et al, “Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock, 2012,” Crit Care Med, 2013, 41(2):580-637.[PubMed 23353941]

Dellon EP, Donaldson SH, Johnson R, et al, "Safety and Tolerability of Inhaled Hypertonic Saline in Young Children With Cystic Fibrosis," Pediatr Pulmonol, 2008, 43(11):1100-6.[PubMed 18828160]

Dillon RC, Merchan C, Altshuler D, Papadopoulos J. Incidence of adverse events during peripheral administration of sodium chloride 3. J Intensive Care Med. 2018;33(1):48-53. doi: 10.1177/0885066617702590.[PubMed 28372499]

Elkins M, Dentice R. Timing of hypertonic saline inhalation for cystic fibrosis. Cochrane Database Syst Rev. 2016;12:CD008816. doi: 10.1002/14651858.CD008816.pub3.[PubMed 28146603]

Elkins MR, Robinson M, Rose BR, et al; National Hypertonic Saline in Cystic Fibrosis (NHSCF) study group. A controlled trial of long-term inhaled hypertonic saline in patients with cystic fibrosis. N Engl J Med. 2006;354(3):229-240. doi: 10.1056/NEJMoa043900.[PubMed 16421364]

Farrokh S, Cho SM, Lefebvre AT, Zink EK, Schiavi A, Puttgen HA. Use of intraosseous hypertonic saline in critically ill patients. J Vasc Access. 2019;20(4):427-432. doi: 10.1177/1129729818805958.[PubMed 30328363]

Finfer S, Bellomo R, Boyce N, et al, “A Comparison of Albumin and Saline for Fluid Resuscitation in the Intensive Care Unit. SAFE Study Investigators,” N Engl J Med, 2004, 350(22):2247-56.[PubMed 15163774]

Fisher B, Thomas D, and Peterson B, "Hypertonic Saline Lowers Raised Intracranial Pressure in Children After Head Trauma," J Neurosurg Anesthesiol, 1992, 4(1):4-10.[PubMed 15815431]

Forsyth LL, Liu-DeRyke X, Parker D, et al, “Role of Hypertonic Saline for the Management of Intracranial Hypertension After Stroke and Traumatic Brain Injury,” Pharmacotherapy, 2008, 28(4):469-84.[PubMed 18363531]

Gloviczki P, Comerota AJ, Dalsing MC, et al; Society for Vascular Surgery; American Venous Forum. The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg. 2011;53(5 Suppl):2S-48S. doi: 10.1016/j.jvs.2011.01.079.[PubMed 21536172]

Gresham GS and Mashru MK, “Fatal Poisoning With Sodium Chloride,” Forensic Sci Int, 1982, 20:87-8.[PubMed 7095681]

Hadaway L. Infiltration and extravasation. Am J Nurs. 2007;107(8):64-72.[PubMed 17667395]

Huang SJ, Chang L, Han YY, et al, “Efficacy and Safety of Hypertonic Saline Solutions in the Treatment of Severe Head Injury,” Surg Neurol, 2006, 65(6):539-46.[PubMed 16720165]

"Inactive" ingredients in pharmaceutical products: update (subject review). American Academy of Pediatrics (AAP) Committee on Drugs. Pediatrics. 1997;99(2):268-278.[PubMed 9024461]

Institute for Safe Medication Practice, “Plain D₅W or Hypotonic Saline Solutions Post-Op Could Result in Acute Hyponatremia and Death in Healthy Children,” ISMP Medication Safety Alert, August 13, 2009. Available at http://www.ismp.org/Newsletters/acutecare/articles/20090813.asp

IOM (Institute of Medicine), Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate, Washington, DC: National Academy Press, 2004.

Joint Commission on Accreditation of Healthcare Organizations, “2005 National Patient Safety Goals.” Available at http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/05_npsgs.htm

Jones GM, Bode L, Riha H, Erdman MJ. Safety of continuous peripheral infusion of 3% sodium chloride solution in neurocritical care patients. Am J Crit Care. 2016;26(1):37-42.[PubMed 27965228]

Kamat P, Vats A, Gross M, et al. Use of hypertonic saline for the treatment of altered mental status associated with diabetic ketoacidosis. Pediatr Crit Care Med. 2003;4(2):239-242.[PubMed 12749659]

Kattwinkel J, Perlman JM, Aziz K, et al, "Part 15: Neonatal Resuscitation: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care," Circulation, 2010, 122(18 Suppl 3):909-19.[PubMed 20956231]

Kerwin AJ, Schinco MA, Tepas JJ 3rd, Renfro WH, Vitarbo EA, Muehlberger M. The use of 23.4% hypertonic saline for the management of elevated intracranial pressure in patients with severe traumatic brain injury: a pilot study. J Trauma. 2009;67(2):277-282. doi: 10.1097/TA.0b013e3181acc726.[PubMed 19667879]

Khanna S, Davis D, Peterson B, et al, "Use of Hypertonic Saline in the Treatment of Severe Refractory Posttraumatic Intracranial Hypertension in Pediatric Traumatic Brain Injury," Crit Care Med, 2000, 28(4):1144-51.[PubMed 10809296]

Kochanek PM, Carney N, Adelson PD, et al, “Guidelines for the Acute Medical Management of Severe Traumatic Brain Injury in Infants, Children, and Adolescents -- Second Edition,” Pediatr Crit Care Med, 2012, 13(Suppl 1):1-82.[PubMed 22217782]

Koenig MA, Bryan M, Lewin JL 3rd, Mirski MA, Geocadin RG, Stevens RD. Reversal of transtentorial herniation with hypertonic saline. Neurology. 2008;70(13):1023-1029. doi: 10.1212/01.wnl.0000304042.05557.60.[PubMed 18272864]

Kraft MD, Btaiche IF, Sacks GS, Kudsk KA. Treatment of electrolyte disorders in adult patients in the intensive care unit. Am J Health-Syst Pharm. 2005;62(16):1663-1682.[PubMed 16085929]

Kuzik BA, Al-Qadhi SA, Kent S, et al, "Nebulized Hypertonic Saline in the Treatment of Viral Bronchiolitis in Infants," J Pediatr, 2007, 151(3):266-70, 270.e1.[PubMed 17719935]

Levy MM, Evans LE, Rhodes A. The Surviving Sepsis Campaign Bundle: 2018 update. Crit Care Med. 2018;46(6):997-1000. doi: 10.1097/CCM.0000000000003119.[PubMed 29767636]

Lewandowski-Belfer JJ, Patel AV, Darracott RM, Jackson DA, Nordeen JD, Freeman WD. Safety and efficacy of repeated doses of 14.6 or 23.4 % hypertonic saline for refractory intracranial hypertension. Neurocrit Care. 2014;20(3):436-442. doi: 10.1007/s12028-013-9907-1.[PubMed 24026522]

Luu JL, Wendtland CL, Gross MF, et al, "Three-Percent Saline Administration During Pediatric Critical Care Transport," Pediatr Emerg Care, 2011, 27(12):1113-7.[PubMed 22134236]

Maguigan KL, Dennis BM, Hamblin SE, Guillamondegui OD. Method of hypertonic saline administration: effects on osmolality in traumatic brain injury patients. J Clin Neurosci. 2017;39:147-150. doi: 10.1016/j.jocn.2017.01.025.[PubMed 28215427]

Marcialis MA, Dessi A, Pintus MC, et al, "Neonatal Hyponatremia: Differential Diagnosis and Treatment," J Matern Fetal Neonatal Med, 2011, 24(Suppl 1):75-9.[PubMed 21942597]

McCoy S, Evans A, Spurrier N. Sclerotherapy for leg telangiectasia--a blinded comparative trial of polidocanol and hypertonic saline. Dermatol Surg. 1999;25(5):381-385; discussion 385-386. doi: 10.1046/j.1524-4725.1999.08263.x.[PubMed 10469077]

Meadow R, “Nonaccidental Salt Poisoning,” Arch Dis Child, 1993, 68(4):448-52.[PubMed 8503665]

Meng L, Nguyen CM, Patel S, Mlynash M, Caulfield AF. Association between continuous peripheral i.v. infusion of 3% sodium chloride injection and phlebitis in adults. Am J Health Syst Pharm. 2018;75(5):284-291. doi: 10.2146/ajhp161028.[PubMed 29472509]

Mesghali E, Fitter S, Bahjri K, Moussavi K. Safety of peripheral line administration of 3% hypertonic saline and Mannitol in the emergency department. J Emerg Med. 2019;56(4):431-436. doi: 10.1016/j.jemermed.2018.12.046.[PubMed 30745195]

Meyers R, "Pediatric Fluid and Electrolyte Therapy,” J Pediatr Pharmacol Ther, 2009, 14:204–11[PubMed 23055905]

Mirtallo J, Canada T, Johnson D, et al; Task Force for the Revision of Safe Practices for Parenteral Nutrition. Safe practices for parenteral nutrition [published correction appears in JPEN J Parenter Enteral Nutr. 2006;30(2):177]. JPEN J Parenter Enteral Nutr. 2004;28(6):S39-S70.[PubMed 15568296]

Moder KG and Hurley DL, “Fatal Hypernatremia From Exogenous Salt Intake: Report of a Case and Review of the Literature,” Mayo Clin Proc, 1990, 65(12):1587-94.[PubMed 2255221]

Mogayzel PJ Jr, Naureckas ET, Robinson KA, et al; Pulmonary Clinical Practice Guidelines Committee. Cystic fibrosis pulmonary guidelines. Chronic medications for maintenance of lung health. Am J Respir Crit Care Med. 2013;187(7):680-689.[PubMed 23540878]

Mortimer DS, Jancik J. Administering hypertonic saline to patients with severe traumatic brain injury. J Neurosci Nurs. 2006;38(3):142-146.[PubMed 16817665]

Munar F, Ferrer AM, de Nadal M, et al, “Cerebral Hemodynamic Effects of 7.2% Hypertonic Saline in Patients With Head Injury and Raised Intracranial Pressure,” J Neurotrauma, 2000, 17(1):41-51.[PubMed 10674757]

Parker MM, Hazelzet JA, Carcillo JA. Pediatric considerations. Crit Care Med. 2004;32(11)(suppl):S591-S594.[PubMed 15542968]

Perez CA, Figueroa SA. Complication rates of 3% hypertonic saline infusion through peripheral intravenous access. J Neurosci Nurs. 2017;49(3):191-195. doi: 10.1097/JNN.0000000000000286.[PubMed 28471928]

Peterson JD, Goldman MP, Weiss RA, et al. Treatment of reticular and telangiectatic leg veins: double-blind, prospective comparative trial of polidocanol and hypertonic saline. Dermatol Surg. 2012;38(8):1322-1330. doi: 10.1111/j.1524-4725.2012.02422.x.[PubMed 22620717]

Rajajee V. Management of acute severe traumatic brain injury. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed May 30, 2019.

Reynolds PM, MacLaren R, Mueller SW, Fish DN, Kiser TH. Management of extravasation injuries: a focused evaluation of noncytotoxic medications. Pharmacotherapy. 2014;34(6):617-632. doi: 10.1002/phar.1396.[PubMed 24420913]

Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2016. Intensive Care Med. 2017;43(3):304-377. doi: 10.1007/s00134-017-4683-6.[PubMed 28101605]

Robinson M, Hemming AL, Regnis JA, et al. Effect of increasing doses of hypertonic saline on mucociliary clearance in patients with cystic fibrosis. Thorax. 1997;52(10):900-903. doi: 10.1136/thx.52.10.900.[PubMed 9404379]

Sadick NS. Sclerotherapy of varicose and telangiectatic leg veins. Minimal sclerosant concentration of hypertonic saline and its relationship to vessel diameter. J Dermatol Surg Oncol. 1991;17(1):65-70. doi: 10.1111/j.1524-4725.1991.tb01595.x.[PubMed 1991883]

Scovell S. Liquid, foam, and glue sclerotherapy techniques for the treatment of lower extremity veins. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed February 5, 2020.

Shehab N, Lewis CL, Streetman DD, Donn SM. Exposure to the pharmaceutical excipients benzyl alcohol and propylene glycol among critically ill neonates. Pediatr Crit Care Med. 2009;10(2):256-259.[PubMed 19188870]

Smith EJ, and Palevsky S, “Salt Poisoning in a Two-Year-Old Child,” Am J Emerg Med, 1990, 8:571-2.[PubMed 2222612]

Sodium chloride for oral use [prescribing information]. Tampa, FL: Westminster Pharmaceuticals, LLC; received May 2019.

Sodium chloride injection [prescribing information]. Lake Forest, IL: ICU Medical, Inc; August 2018.

Sood L, Sterns RH, Hix JK, Silver SM, Chen L. Hypertonic saline and desmopressin: a simple strategy for safe correction of severe hyponatremia. Am J Kidney Dis. 2013;61(4):571-578. doi: 10.1053/j.ajkd.2012.11.032.[PubMed 23266328]

Spasovski G, Vanholder R, Allolio B, et al; Hyponatraemia Guideline Development Group. Clinical practice guideline on diagnosis and treatment of hyponatraemia [published correction appears in Eur J Endocrinol. 2014;171(1):X1]. Eur J Endocrinol. 2014;170(3):G1-G47. doi: 10.1530/EJE-13-1020.[PubMed 24569125]

Sterns RH, Hix JK, Silver SM. Management of hyponatremia in the ICU. Chest. 2013;144(2):672-679.[PubMed 23918113]

Sterns RH. Overview of the treatment of hyponatremia in adults. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed May 30, 2019.

Suarez JI, Qureshi, AI, Bhardwaj A, et al. Treatment of refractory intracranial hypertension with 23.4% saline. Crit Care Med. 1998;26(6):1118-1122. doi: 10.1097/00003246-199806000-00038.[PubMed 9635664]

Suarez JI, Qureshi AI, Parekh PD, et al. Administration of hypertonic (3%) sodium chloride/acetate in hyponatremic patients with symptomatic vasospasm following subarachnoid hemorrhage. J Neurosurg Anesthesiol. 1999;11(3):178-184.[PubMed 10414672]

Subbarao P, Balkovec S, Solomon M, et al, "Pilot Study of Safety and Tolerability of Inhaled Hypertonic Saline in Infants With Cystic Fibrosis," Pediatr Pulmonol, 2007, 42(5):471-6.[PubMed 17436328]

Tseng MY, Al-Rawi PG, Pickard JD, Rasulo FA, Kirkpatrick PJ. Effect of hypertonic saline on cerebral blood flow in poor-grade patients with subarachnoid hemorrhage. Stroke. 2003;34(6):1389-1396. doi: 10.1161/01.STR.0000071526.45277.44.[PubMed 12730557]

Verbalis JG, Goldsmith SR, Greenberg A, et al. Diagnosis, evaluation, and treatment of hyponatremia: expert panel recommendations. Am J Med. 2013;126(10 Suppl 1):S1-42. doi: 10.1016/j.amjmed.2013.07.006.[PubMed 24074529]

Verbalis JG, Goldsmith SR, Greenberg A, et al, “Hyponatremia Treatment Guidelines 2007: Expert Panel Recommendations,” Am J Med, 2007, 120 (11 Suppl 1):1-21.[PubMed 17981159]

Vialet R, Albanese J, Thomachot L, et al. Isovolume hypertonic solutes (sodium chloride or mannitol) in the treatment of refractory posttraumatic intracranial hypertension: 2 mL/kg 7.5% saline is more effective than 2 mL/kg 20% mannitol. Crit Care Med. 2003;31(6):1683-1637. doi: 10.1097/01.CCM.0000063268.91710.DF.[PubMed 12794404]

Wallace DV, Dykewicz MS, Bernstein DI, et al, "The Diagnosis and Management of Rhinitis: An Updated Practice Parameter," J Allergy Clin Immunol, 2008, 122(2 Suppl):1-84.[PubMed 1866258]

Wang J, Fang Y, Ramesh S, et al. Intraosseous administration of 23.4% NaCl for treatment of intracranial hypertension. Neurocrit Care. 2019;30(2):364-371. doi: 10.1007/s12028-018-0637-2.[PubMed 30397844]

Ware ML, Nemani VM, Meeker M, Lee C, Morabito DJ, Manley GT. Effects of 23.4% sodium chloride solution in reducing intracranial pressure in patients with traumatic brain injury: a preliminary study. Neurosurgery. 2005;57(4):727-736.[PubMed 16239885]

Woo CH, Rao VA, Sheridan W, Flint AC. Performance characteristics of a sliding-scale hypertonic saline infusion protocol for the treatment of acute neurologic hyponatremia. Neurocrit Care. 2009;11(2):228-234. doi: 10.1007/s12028-009-9238-4.[PubMed 19533046]

Wyckoff MH, Perlman JM, and Laptook AR, "Use of Volume Expansion During Delivery Room Resuscitation in Near-Term and Term Infants," Pediatrics, 2005, 115(4):950-5.[PubMed 15805369]

Brand Names: International

Ai Na Duo (CN); Alive (BR); Alrin Baby (IL); Antiedema (ES); Apisal (AE, QA, SA); Aqua-Rinosol (RU); Breathy (ID); Chlorek Sodowy 24Na (PL); Clean-AF (IL); Descodrin (BR); Droser (TR); Earinse (HK); Fima NS (ID); Fisiolimp (CL); Fizyolen (TR); Hidrathea (ES); Hiperton (MX); HO-SOL (UA); Hydrabak (IT); Hynasal (IN); Hypersalt (PH); Hypersol (AR, BD, IN); Hytosol (IN); Infusol (MY); Inj. natrii chlorati isotonica (PL); Jellywash (FR); Kochsalz (AT); Larmabak (AR, FR, HK, SG, TR, VE); Libenar (IT); Maresis (BR); Maxidrate (BR); Miwana (PL); Muco Clear (GB); Muconase (PH); Muro 128 (KR); Naclin (AR); Nafavine (VE); Narium (AU, NZ); Nasakid (CL); Nasalt (IN); Nasoclear (IN, PH); Natriclo (BE); Natrii chloridum (EE); Natrii chloridum 0,9% solutio pro irrigatione (PL); Natrium chloratum (PL); Nazol Aqua (RU); Nebusal (GB); Neorino (BR); No-Sol (UA); Normaline (AE); Normasol (SG); Normlgel (FR); Norsalin (QA); Nosalen (UA); Ocean Spray (IL); Oftalook (AR); Oftarinol (PL); Olynth salin (DE); Omni-Sorb (DE); Ophth-hypertonic (PK); Ophth-lubric (PK); Osmogel (IN); Otrisalin (TR); Phylarm (MX); Physiodose (HK, IT, MY, PL); Physiologic (CH); Physiologicasol (BE); Physiorhine (BE); Polyrinse (ZA); Rinokid (CL); Rinolyuks (UA); Rinomist (QA); Rinowash (IT); Rizosin (RU); Salacyn (SG); Salimist (SA); Salinor (BD); Saloride (BD); Salsol (HU); Sensitive Eyes Saline Solution (PL); Serophy (CH); Sinus (CL); Snif (BR, PH); Sodisol (BD); Sodium Chloride (PL); Solnasin (PL); Tipotaf (IL); Totalatlas (AR); Urgo sterile (DE); Wida NS (ID); Xenosol (BD); Xylisol (AR)

Last Updated 2/27/20