D5 water and Cerebral Edema

ckh23, BSN, RN · Nov 2, 2012

What is your opinion or reaction when pt's with CHI, cerebral edema, and ICP monitoring are ordered D5 water for hypernatremia?
I hate it when D5W is ordered to fix hypernatremia. We have all seen these pts (which are also receiving mannitol) get this order and the ICP starts climbing as the hours go by. People automatically assume, "He's probably herniating." But if I look on the chart and D5w is ordered, I feel it's adding to the problem and not all is lost. I think D5W should be viewed as a high-risk medication just like 3% NaCl. I would even go as far to say that D5W should only be permitted if the infusion specifically lists the number of hrs to infuse....like 3% NACL. I actually have an issue with all hypotonic fluids in neurological pts. Most neurosurgeons order hypertonic fluids to decrease the likelihood of increased cerebral edema. As soon as the Na level is elevated, that D5w order pops up. Personally, I think free H20 via a feeding tube is much more stable way of treating hypernatremia than continous intravenous infusion.
Your thoughts..... :)

I agree. In our surgical/trauma ICU, people with head injuries never received any IVF with dextrose and non of their IV meds were ever mixed with dextrose. We also wanted them some what hypernatremic to help prevent those fluid shifts.

What docs are ordering these fluids? I would think if someone has a head injury with ICP monitoring it would be neurosurgery or neurology running the show. Perhaps there needs to be more communication between the docs, if it's a specialty like renal or internal medicine recommending the hypotonic fluids.

nurseprnRN, BSN, RN · Nov 2, 2012

If you're hypernatremic it's very unlikely that you would have cerebral edema.

Hypotonic solutions, either D5W or .2 (1/4 normal) or .45 (1/2 normal) NS are exactly what you give for hypernatremia, so your not liking that confuses me.

There's often a balancing act-- you don't want your patient to be so hypernatremic that you risk intracerebral bleeds (from the shrunken brain pulling away from the pia mater, which then bleeds), nor so hyponatremic that you risk cerebral edema. Sometimes you are running labs and adjusting hypertonic/hypotonic solutions hourly. PIA, but assess, assess, assess, and deal with it.

KelRN215, BSN, RN · Nov 2, 2012

I have not ever seen straight D5 ordered for hypernatremia... when I worked in Neurosurgery, it was usually 1/2 Normal Saline that we used. But I agree with GrnTea- hypernatremia and cerebral edema are not typically pieces of the same puzzle as cerebral edema is usually associated with hyponatremia.

If the patient is hypernatremic with a brain injury, is something else going on? Like Diabetes Insipidus? That was what I typically saw with hypernatremia in Neurosurgery patients and that meant transfer to ICU and vasopressin drip, usually.

hodgieRN · Nov 3, 2012

I am referring to pt's with cerebral edema from closed head injuries (trauma) who go into DI and who are possibly receiving mannitol (sorry, I should have been more specific with the DI. I realized I didn't mention it). This is more along the lines of major head trauma with severe brain injury, not edema in pt's with say brain cancer or stoke. D5W is the treatment for hypernatremia in itself but what I'm asking is, in your ICUs, do you see any issues with climbing ICP's if a doc orders hypotonic fluids in brain injury pt's with cerebral edema, or does your facility have strict guidelines against hypotonic fluids in these pt's? We do all these different things to lower ICP and reduce edema (sedatives, narcotics, paralytics, hypertonic fluids, mannitol, hypocapnia) and sometimes, I receive an order for D5w just b/c the sodium level up (for any number of reasons like DI [which vasopressin is course used for treatment]). That is what I am not liking. I just have different opinions on treating one thing as opposed to the whole picture. I feel d5w will eventually start shifting fluid into the cells, adding to the edema.

To answer you question ckh23, it's usually some doc that's rounding and sees the elevated Na level, and then orders it. And, on one of our order sets for severe brain injury, the first line of orders is "Change to 0.45% NS and replace output. If Na level rises to > 155, change IVF to D5w." I'm just wondering if anyone else has seen this type of protocol for these pt's who have issues with ICP. I'm asking if you guys think this might make the situation worse, or do you ever feel like one doc wants one thing and another wants something else. I obviously communicate endlessly with the doc's... but the Neurosurgeon wants hypertonic fluids and another one wants D5 water b/c the Na level is up. (And this doesn't include brain death, just severe brain injury btw).

And I'm wondering people's opinion and/or knowledge if free water given via the gut is more suitable than IV fluids if you had to pick between the two. Is it possible that one lowers hypernatremia in a more effective way that doesn't put the pt at risk for increased cerebral edema?

Anna Flaxis, BSN, RN · Nov 3, 2012

I'm going to echo GrnTea's post and say that you should be checking labs frequently and making appropriate adjustments. It is a fine balancing act. We are often called upon to do things that seem counterintuitive, and that is one of the beautiful things about nursing, is that we are where the rubber meets the road.

Of course, if the gut works, use it. In that way, it is "better" to use the enteral route whenever possible. However, the IV route is most direct and allows for more rapid titration, which is especially important for the critically ill patient. Getting them off IV support and onto PO as soon as possible is, of course, important, but when the balancing act is that delicate, I'd rather be fussing with IV titration than dealing with all the variables that go along with enteral.

CPhT2RNstudent · Nov 3, 2012

Both of the trauma I Neuro ICU's I have worked at do not use D5W. We use H2O in the gut. Different facilities have different protocols, but the ones I have worked at view dextrose fluids in a negative light when it comes to neuro pt's.

cardiacrocks, BSN, RN · Nov 3, 2012

I am not an ICU nurse, I do work on a specialty cardiac floor. I was wondering and I know this isn't your question, but how often are you checking blood sugars when someone is on dextrose IV? I know DI is not DM, but what if the person has DM, even if they don't it can increase blood sugar then you have a whole new range of issues as well. I was just wondering.

Esme12, ASN, BSN, RN · Nov 3, 2012

For neuro patients I have only give free H2O via NGT......any neuro/surg would have a stroke that i have worked with.......cardiarocks....the glucose levels are usually checked q 2-4 hours especially if they are diabetic but not because the have D5W running....but because the steroid use, if being used, and the stress of the injury alone causes severe increases of glucose

Anna Flaxis, BSN, RN · Nov 3, 2012

I can see your dilemma, but even in CHI patients, you still want to treat hypernatremia once it reaches a certain point (>155 according to your facility's protocols). Water replacement using D5W is standard treatment for central DI. Yes, you can definitely give free H2O via the enteral route to do the same thing, but this is often reserved for patients who are hemodynamically/neurologically stable and with mild hypernatremia (though clearly, facility policies/practices vary). I'm not sure what differences there would be between enteral water replacement and IV water replacement as far as risk for cerebral edema. Once the water is absorbed, whether through the SI or after metabolism of the dextrose in the IV solution, it moves through the compartments the same way, or at least I would imagine so.

SummitRN, BSN, RN · Nov 3, 2012

Seems like a good solution is frequent enough lyte labs to titrate hypertonic drips to prevent "overshooting?"

nurseprnRN, BSN, RN · Nov 3, 2012

I am not an ICU nurse, I do work on a specialty cardiac floor. I was wondering and I know this isn't your question, but how often are you checking blood sugars when someone is on dextrose IV? I know DI is not DM, but what if the person has DM, even if they don't it can increase blood sugar then you have a whole new range of issues as well. I was just wondering.

One liter of D5W contains approximately 200 calories, less than a glass of whole milk. Does that help?