normal saline 1/2, 1/4 or 0.9%? - drsanmyt

[ArchivalUser]

how do you decide which normal saline you are going to use?

[ArchivalUser]

why are you using normal saline?

[ArchivalUser]

me too confused by it , in any case of pediatric which one we should give ?
somebody reply plz .

[ArchivalUser]

another great question drsanmyt. Credit for my understanding of this topic goes completely to dr.red's great lecture on water/ electrolyte balance. He made this complicated thing look so simple.

It is very simple :
A) first check if your patient is hypovolemic or not. Signs of hypovolemia are hypotension, orthostatic hypotension, dizziness , signs of dehydration. If you see these in the case, always choose 0.9% N.S whether you deal with hypernatremia or hyponatremia or hyperosmolar coma or any other case. NEVER GIVE HYPOTONIC SOLUTION LIKE 0.45% saline here, that will not improve the blood pressure. ALWAYS CORRECT VOLUME PROBLEM FIRST AND THEN TAKE CARE OSMOLAR PROBLEM.
Actually, this is common sense since we always knew ABC - airway, breathing, circulation comes first. So, if some one is hypovolemic, hypovolemia should be corrected first and the isotonic saline 0.9% is the only saline that can exapnd volume and correct blood pressure.

B) If your patient is not hypovolemic, focus on osmolar problem. Now, it depends on which electrolyte issue you are dealing with.
If hypernatremia , no hypovolemia but CNS signs ( confusion, seizures), give D5W IV ( this means you are giving free water IV with NO sodium at all as this is emergency and you should low Na+ in serum very fast. ) Dont choose NS or 0.45% NS here.
If hypernatremia, but no hypovolemia and no CNS signs, give FREE WATER orally. It can be corrected slowly no need to rush with IV hypotonic fluids here.

If hyponatremia , no hypovolemia but CNS signs ( confusion, seizures), give 3%NS IV ( this means you are lot of sodium IV as this is emergency and you should increase Na+ in serum very fast. ) Dont choose NS or 0.45% NS here.
If hyponatremia, but no hypovolemia and no CNS signs, do FREE WATER RESTRICTION. It can be corrected slowly no need to rush with IV hypertonic fluids here.

conclusion : first check hypovolemia. If hypovolemia, give NS always!. Then check for CNS signs and choose appropriate fluid as above to correct electrolyte disturbance fast here in view of CNS signs. If no CNS signs or no hypovolemia, no need to rush - use slow correction measures like I outlined above.

[ArchivalUser]

thanks thyrogen , what iv fluid we should use in pediatric patient?
is it always 1/4 ??
if yes till what age .

thanx

[ArchivalUser]

The rule for fluid replacement is first to know whether the patient is hypovolemic or not.
Again in pediatrics, people get confused. There is no rule that small kids get smaller sodium. Even in pediatric population, the tonicity is 0.9%. So, if they are Hypovolemic , they always get normal saline

In volume-depleted children, for example, after severe burns, patients improve and mortality rates decline with the rapid expansion of ECF. The total amount of fluid given in the first 6-12 hours is often approximately 100 mL/kg of an ECF-type ( isotonic) fluid, such as normal saline or lactated Ringer solution.

In children with moderate dehydration who cannot tolerate oral rehydration, ECF should be rapidly restored by administering lactated Ringer solution at a dosage of 40 mL/kg in 1-2 hours; oral rehydration should be started after the intravenous (IV) infusion is completed.

In patients with severe dehydration, ECF should be rapidly restored by administering 0.9% NaCl (ie, isotonic NaCl solution, normal saline), ringers lactate or both at a rate of 40 mL/kg over 1-2 hours. If skin turgor, alertness, or pulse rate do not return to normal by the end of the infusion, an additional dose of 20-40 mL/kg should be infused over 1-2 hours.

[ArchivalUser]

thanks thyogen....

[ArchivalUser]

though i agree with thyrogen's fluid management for adults, the fluid management in children is different.
children are not miniature adults, their physiology is different. for example, a neonate's kidney cant process the extra sodium load if you give him NS!!!! HE'LL PROBABLY DROWN IN FLUIDS.!!
the fluid of choice for treating dehydration in children is ringer lactate.once you are sure there is no oliguria and the child passes urine (r/o ARF) YOU CAN START REPLACING SODIUM. THE FLUID DEPENDS ON THE AGE OF THE CHILD
neonates to 10 you can give NS.
i cannot quote any book for the above understanding, just what i learnt in pediatrics rotation.
try researching the net if you are keen.

[ArchivalUser]

sorry! some problem in post. what i meant was-
neonates to 1 year- N/4 saline
1 to 4 yr- N/3 saline
5- 10 yr- N/2 saline
>10 you can give NS

[ArchivalUser]

in pediatric patient , it is given as NS or NS + 5% dextrose or NS/2 + 5% dextrose