3% NS

Excuse my ignorance, I work in a specialty where all of my patients have at least 8 channels worth of pumps, but what is a dial-a-flo, and how's it different from a pump?

It's an in-line rate limiter:

It's more accurate and easier to use than a roller clamp, but obviously less accurate than a pump.

My book says that it can cause intravascular overload or hyperchloremic acidosis and pulmonary edema.. Must be infused slowly and with extreme caution which means you need a pump to monitor how many cc's you are giving.

I agree 100%. The increase in intravascular volume can also cause heart failure. Also, like Gila said, there's a condition called central pontine myelinolysis where the myelin sheath of nerve cells in the brainstem become damaged from too rapid of a correction in serum sodium in patients who are hyponatremic and receiving 3% NS

I would have freaked out too if I saw this drip on a dial-a-flow!!

A couple of years ago, I saw a list of the ten most dangerous drugs. Hypertonic saline was on the list.

It is. Any saline solutions above 0.9% is on Institute for Safe Medication Practices list of "high alert" drugs, that Joint Commision uses to set guidelines, such as using a pump and having two signatures, etc. etc. http://www.ismp.org/Tools/highalertmedications.pdf

For the most part, yes. If you are in a situation where you are giving 3% saline (hypertonic saline), you have a critical patient. In many cases, this concentration is used in patients who are severely hyponatremic with serious neurological signs and symptoms. Remember, the brain is very sensitive to sodium changes, while the heart is very sensitive to potassium changes. With severe hyponatremia, cerebral edema is a primary concern. Hypertonic saline is used to rapidly increase the sodium by around 4-5 Me q/L over the first couple of hours. We only correct enough to treat the serious neurological symptoms. Then, look at switching to another solution and slowly correct from there.

Obviously, we also want to correct the underlying cause of the hyponatremia. Another concept to consider is the fact that correcting sodium too fast can be met with devastating consequences. Osmotic demyelination syndrome being one of those devastating consequences. This is one medication that must be on a pump. The nurse was correct to be upset over only having a dial a flow up with this specific medication.

Excellent reply. What's amazing is when you have those patients come in with what you would consider extremely low sodiums...I'm talking in the 119 range and have no neuro symptoms whatsoever...amazing. Then I"ve got someone who's say 125 and they are symptomatic all over the place.

The kicker is, I remember when I was in nursing school, my instructor at the time (who hadn't worked the floor in decades) said I'd never see anyone with hyponatremia since salt was such a big part of the american diet. I see it all the time in the ICU and we work to correct it. Amazing, isn't it?

So if I had a patient with a sodium of I think 117 on an inpatient psych floor--asymptomatic, believe it or not--should that have been considered unstable enough to infuse IV and to transfer the patient--until stable--to another floor, a medical one.?????????????????????/

So if I had a patient with a sodium of I think 117 on an inpatient psych floor--asymptomatic, believe it or not--should that have been considered unstable enough to infuse IV and to transfer the patient--until stable--to another floor, a medical one.?????????????????????/

Thinking about the contents of the skull - you have brain, csf and intravascular fluid, basically. When serum sodium decreases, cerebral edema results. If the decrease in serum sodium is very gradual, the brain has time to compensate by moving solutes and fluid to the extracellular space, decreasing vascular volume. This would happen over many days or weeks. So the body is able to tolerate and adapt to decreases in sodium and symptoms may be very mild.

It's when the sodium gets very low very fast..say in 24-48hrs...that severe cerebral edema can result in changes in mentation, seizures, and even herniation and death.

Nonetheless, I would still consider hyponatremia of this nature to be serious and correction would be needed...however, treatment really depends on the severity of symptoms, fluid volume status and the severity of the metabolite imbalance. Treatment can range from limiting free water, medications, to 3% NS...a lot really depends on the pathophysiology of the hyponatremia.

I would have freaked out too if I saw this drip on a dial-a-flow!!

I would have too.

Last night I had a patient with Na 125. The MD ordered 3% NS to go in at 30ml/h.

I just re-read this and is it just me or is 3% NS for Na of 125 pretty aggressive? I've only ever seen them start 3% NS with Na results in the 110s. Usually if it's in the 120s I'd expect the docs to treat the cause and limit free water...

I just re-read this and is it just me or is 3% NS for Na of 125 pretty aggressive? I've only ever seen them start 3% NS with Na results in the 110s. Usually if it's in the 120s I'd expect the docs to treat the cause and limit free water...

If the patient is symptomatic you can't wait for it to fix itself through diuresis and water restriction.

the patient was pretty asymptomatic, i guess that is why no red flags went up...

okay...GilaRN, you sound like you know a lot about this stuff...not my area of expertise, but since mental health patients do have medical problems it's nice to try to stay somewhat knowledgable about medical stuff....so let me try to understand......the low Na+ levels effect more of the neuro/brain symptoms and not the heart? So tele isn't needed? correct? Is there any monitoring that should be done during the running? (obviously other then just keeping an eye on the patient)-- electronic monitoring I guess I am wondering about.....

I am curious as in psych we now and then see patients with signigicantly low Na+ levels related to water toxicity.....they will drink gallon after gallon and lower the level by diluting the blood with all the water..... I have had a patient or two with this and we limited water, locked the bathroom, and put the patient on sodium tablets....didn't end up with the need for IV but could I suppose so it would be nice to know how to handle it and know if the patient should go to medicine for treatment or if we could do it with the proper monitoring. .........

Close monitoring to include tele and seizure precautions is warranted on these patients. Especially patients with neurological effects and an acute cause for the hyponatremia. Sodium can effect cardiac conduction; however, the brain is especially sensitive to sudden changes in sodium levels. Remember, if you have sodium, water will follow. The brain is surrounded in a case of bone. So, when cerebral edema occurs, the tissue has nowhere to go. This is part of what makes managing elevated ICP difficult. If you want to know more, research the Monroe-Kellie hypothesis of volumes and cerebral compensatory mechanisms.

In addition, cardiac function is closely related to most other body systems and processes. For example, the hyponatremic patient has a seizure. During the seizure, hypoxemia develops causing cardiac irritability. You note ventricular ectopy on the monitor because of the hypoxemia and tissue hypoxia. You see, all the body systems are connected and related. This is why any "critical" patient should be on tele or some type of continuous cardiac monitoring.

Regarding "water toxicity." Hyponatremia and the neurological effects are of primary concern with these patients.