Crystalloids are solutes (e.g., electrolytes, dextrose) having the ability to form crystals. They easily mix and dissolve in a solvent, forming a solution in which the crystalloids cannot be distinguished from the resulting solution. Crystalloid solutions are capable of diffusing through semipermeable cell membranes due to small molecules. Crystalloid solutions are usually electrolyte solutions that are classified as isotonic, hypotonic, or hypertonic, as previously addressed. Types of crystalloid solutions include dextrose solutions, sodium chloride solutions, balanced electrolyte solutions, and alkalizing and acidifying solutions.
Key Elements of Crystalloid Fluids
The key elements included in crystalloid IV fluids include water, carbohydrates (glucose), protein, vitamins, and electrolytes.
Water
The human body is a contained-fluid environment of water and electrolytes. Water accounts for about 60% of the body weight of the adult and 80% of the full-term infant. Holliday and Segar (1957) established that, regardless of age, all healthy persons require approximately 100 mL of water per 100 calories metabolized, for dissolving and eliminating metabolic wastes. This means that a person who expends 1800 calories of energy requires approximately 1800 mL of water for metabolic purposes. These water needs are increased in patients with water losses (e.g., respiratory rate greater than 20 breaths/min, fever, diaphoresis, located in a low-humidity environment); in patients with decreased renal concentration ability; and in elderly people. Insensible loss is approximately 1000 mL per day (Capriotti, 2021).
NURSING FAST FACT!Three main physiological mechanisms assist in regulating fluid homeostasis: osmoreceptors, antidiuretic hormone (ADH), and thirst. High plasma osmolality stimulates osmoreceptors in the thirst center in the hypothalamus that stimulate thirst and also the release of ADH from the posterior pituitary gland (Capriotti, 2021). ADH stimulates water reabsorption from the kidneys by reducing the amount of water lost in urine, thus promoting reabsorption of water back into the circulation. In a healthy person, these mechanisms work together. |
NURSING FAST FACT!Thirst develops when there is as little as a 1% to 2% change in serum osmolality. Thirst is one of the earliest symptoms of hemorrhage and is often present before other signs of blood loss are apparent (Grossman & Porth, 2014). |
Carbohydrates (Glucose)
Glucose, a nutrient included in maintenance, restoration, and replacement therapies, is converted into glycogen by the liver. By supplying calories for energy, body protein is spared. Sources of carbohydrates include dextrose (glucose) and fructose. When glucose is supplied by infusion, all the IV glucose is bioavailable. The addition of 100 g of glucose per day minimizes starvation. Every 2 L of 5% dextrose in water contains 100 g of glucose.
Amino acids (protein) are the body-building nutrients whose major functions include tissue growth and repair, replacing body cells, healing wounds, and synthesizing vitamins and enzymes. Amino acids are provided in IV nutrition (PN) formulations as synthetic crystalline amino acids. They are available in concentrations of 3% to 20%, with and without electrolytes. There are also specialty amino acid formulations that may be used with certain disease states (refer to Chapter 12).
Vitamins
Vitamins may be added to IV solutions. For patients who require PN, multivitamins are required as part of the PN solution (refer to Chapter 12). Vitamins are necessary for growth and maintenance, as well as for multiple metabolic processes. Vitamins cannot be synthesized by the body and must be provided in the diet. Some disease conditions alter vitamin requirements. Vitamin B complex is important in the metabolism of carbohydrates and in the maintenance of GI function, which is especially important in postoperative patients. Vitamin C promotes wound healing.
Electrolytes are the major additives to IV fluids. Correction, as well as prevention, of electrolyte imbalances is important in preventing the serious complications associated with excess or deficit of electrolytes. There are seven major electrolytes in normal body fluids, and the same seven major elements are supplied in manufactured IV solutions (refer to Chapter 3 to review electrolyte functions and the consequences of low/elevated electrolyte levels). The electrolytes of major importance in IV therapy are potassium, sodium, chloride, magnesium, phosphorus, calcium, and bicarbonate or acetate ion (important for acid-base balance).
Crystalloid Physiological Initial and Therapeutic Responses
Therapeutic Response/Systemic Effects
The therapeutic response to crystalloid administration occurs as the fluid disperses through the ECF and ICF. The therapeutic response is predictable and is the reason for the choice of one fluid over another. The therapeutic response to isotonic solutions administered by the IV route is that the tonicity of the plasma remains unchanged. The 0.9% sodium chloride and lactated Ringer's solutions remain isotonic even after they disperse into the interstitial spaces; therefore, the tonicity of the interstitial space is unchanged.
Dextrose in water is an electrolyte-free solution. The solution of 5% dextrose in water is isotonic in the initial response, but because the dextrose is rapidly metabolized, what is left is free water that dilutes the ECF. The cells suddenly are suspended in a hypotonic environment, and osmosis will occur, with the cells absorbing the fluid until the two compartments are isotonic.
Many crystalloid solutions are made up of a combination of dextrose and electrolyte solutions, most of which are hypertonic initially. The therapeutic response to these fluids can be predicted based on the tonicity of the solution. Once the cells use the dextrose, the remaining sodium chloride and electrolytes will be dispersed as isotonic electrolyte solution, hydrating only the ECF. The dispersion of the solution to ECF and ICF will be dependent on the osmolarity of the solution. Remember that 5% dextrose when added to other solutions rapidly is absorbed into the cells to be used for energy. The remaining electrolyte solution is dispersed between the ECF and ICF. The only true hypertonic crystalloid solutions are 3% and 5% sodium chloride. These remain consistently hypertonic and can cause severe cellular dehydration.
NURSING FAST FACT!The ICF compartment contains approximately 60% to 65% of the body's fluid or 40% of the body's weight. The ECF compartment, including interstitial and intravascular fluids, accounts for 35% to 40% of the body's fluid or 20% of the body's weight. (Pierce et al., 2016; Capriotti, 2020) |
Carbohydrates can be administered by the IV route as dextrose, fructose, or invert sugar. Dextrose is the most commonly administered carbohydrate. The percentages of the solutions express the number of grams of solute per 100 g of solvent. Thus, a 5% dextrose in water (D5W) infusion contains 5 g of dextrose in 100 mL of water.
NURSING FAST FACT!One milliliter of water weighs 1 g, and 1 mL is 1% of 100 mL. Milliliters, grams, and percentages can be used interchangeably when calculating solution strength. Thus, 5% dextrose in water equals 5 g of dextrose in 100 mL, and 1 L of 5% dextrose in water contains 50 g of dextrose (example: 250 mL of 20% dextrose in water solution contains 50 g of dextrose). |
When carbohydrate needs are inadequate, the body will use its own fat to supply calories. Dextrose fluids are used to provide calories for energy, reduce catabolism of protein, and reduce protein breakdown of glucose to help prevent a negative nitrogen balance.
The monohydrate form of dextrose used in IV solutions provides 3.4 kcal per gram. It is difficult to administer enough calories with 5% dextrose in water, which provides only 170 calories per liter. One would have to administer 9 L to meet calorie requirements, and patients cannot tolerate 9000 mL of fluid in 24 hours! Concentrated solutions of carbohydrates in 20% to 70% dextrose are useful for supplying calories. These solutions, which contain high percentages of dextrose, must be administered slowly for adequate absorption and utilization by the cells.
Dextrose is a nonelectrolyte, and the total number of particles in a dextrose solution does not depend on ionization. Dextrose is thought to be the closest to the ideal carbohydrate available because it is well metabolized by all tissues. The tonicity of dextrose solutions depends on the particles of sugar in the solution. Dextrose 5% is rapidly metabolized and has no osmotically active particles after it is in the plasma. The osmolarity of a dextrose solution is determined differently from that of an electrolyte solution. Dextrose is distributed inside and outside the cells, with 8% remaining in the circulation to increase blood volume.
Dextrose in water is available in various concentrations, including 2.5% (25 g/L), 5% (50 g/L), 10% (100 g/L), 20% (200 g/L), 30% (300 g/L), 38.5% (385 g/L), 40% (400 g/L), 50% (500 g/L), 60% (600 g/L), and 70% (700 g/L). Dextrose is also available in combination with other types of solutions. Concentrations higher than 10% are given through central vascular access devices (CVADs) due to their high osmolarity (Gorski et al., 2021). A general exception is the administration of limited amounts of 50% dextrose given slowly through a peripheral vein for emergency treatment of hypoglycemia.
- A diluent for administration of IV medications
- Provides calories and fluid replacement in concentrations of 10% or less
- Provides calories as part of PN formulas (≥10%)
- Adjunctive treatment of hyperkalemia (using high concentrations of dextrose)
- Emergency treatment of hypoglycemia (25% or 50%)
Risks
- Vein irritation, vein damage, and thrombosis may result when hypertonic dextrose solutions are administered in a peripheral vein. They are vesicants at concentrations greater 10% (Gorski et al., 2017).
- Solutions of 20% to 70% dextrose, when infused too rapidly, act as an osmotic diuretic and can pull interstitial fluid into plasma, causing severe cellular dehydration. Any solution of dextrose infused rapidly can place the patient at risk for dehydration. To prevent this adverse reaction, infuse the dextrose solution at the prescribed rate using an electronic infusion pump.
- Rapid infusion of 20% to 70% dextrose can also lead to transient hyperinsulinism reaction, in which the pancreas secretes extra insulin to metabolize the infused dextrose. Sudden discontinuation of any hypertonic dextrose solution may leave a temporary excess of insulin. Reduce the rate of administration gradually.
- Dextrose solutions cannot replace or correct electrolyte deficits, and continuous infusion of 5% dextrose in water places patients at risk for deficits in sodium, potassium, and chloride.
- Dextrose is never mixed with blood components because it causes hemolysis (pseudoagglutination; i.e., agglomeration) of the cells.
NOTE: Before adding any medication to a dextrose solution, check the compatibility information and/or consult with the pharmacist. Dextrose may also affect the stability of admixtures.
NURSING FAST FACT!Do not “play catch-up” if the solution infusion is behind schedule. Make sure that the IV solution does not “run away” and that it does not infuse rapidly into the patient. |
Sodium Chloride Solutions
Sodium chloride solutions are available as hypotonic—0.45% (1/2 sodium chloride), isotonic—0.9% (0.9% sodium chloride), and hypertonic—3% and 5% concentrations. Bacteriostatic isotonic 0.9% sodium chloride, which contains benzyl alcohol as a preservative, is also available and may be used in mixing and diluting certain medications. Sodium chloride 0.9% sodium chloride solution, commonly referred to as normal saline, has 154 mEq of both sodium and chloride, which is about 9% higher than normal plasma levels of sodium and chloride ions without other plasma electrolytes. Sodium chloride has a pH of 4.5 to 7 (Gahart et al., 2021).
Sodium chloride solutions are used cautiously in patients with heart failure, edema, or hypernatremia because it replaces ECF and can lead to fluid overload.
Indications
- Provides ECF replacement when chloride loss is greater than or equal to sodium losses (e.g., a patient undergoing nasogastric suctioning)
- Treats patients with metabolic alkalosis in the presence of fluid loss (the 154 mEq of chloride helps compensate for the increase in bicarbonate ions)
- Treats patients with sodium depletion
- Initiates or terminates a blood transfusion (0.9% NaCl is the only solution to be used with any blood product); the AABB allows exception to 0.9% NaCl if a solution is approved by the U.S. Food and Drug Administration (FDA) and is safe (refer to Chapter 11).
- Used to assess patency of vascular access devices (VADs) and to lock VADs to prevent catheter occlusion (0.9% NaCl in prefilled syringes)
Risks
- Provides more sodium and chloride than patients need, causing hypernatremia. The adult dietary sodium requirements are 90 to 250 mEq daily. More than 1 L may cause hypernatremia (Gahart et al., 2021). To prevent this overload of electrolytes, assess for signs and symptoms of sodium retention.
- Continuous infusion of 0.9% sodium chloride is associated with increased risk of hyperchloremic acidosis because sodium chloride provides one-third more chloride than is present in ECF. The excess chloride leads to loss of bicarbonate ions, leading to an imbalance of acid.
- May cause low potassium levels (i.e., hypokalemia) because of the lack of other important electrolytes over a period of time.
- Can lead to circulatory overload. Isotonic fluids expand the ECF compartment, which can lead to overload of the cardiovascular compartments.
NURSING FAST FACT!During stress, the body retains sodium, which contributes to hypernatremia. |
Hypotonic saline (0.45%) can be used to supply normal daily salt and water requirements safely. Hypertonic saline solution (3% to 5%) is used to correct severe sodium depletion and water overload.
Hypertonic saline can be dangerous when administered incorrectly. Nurses should follow these steps to ensure safe administration of hyperosmolar sodium chloride (3% and 5%).
- Check serum sodium level before and during administration.
- Administer only in monitored care settings.
- Monitor for signs of pulmonary edema.
- Ensure patency of PIVC and monitor site frequently with peripheral administration as 3% and 5% sodium solutions are classified as vesicants (Gorski et al., 2017).
- Administer only small volumes of hyperosmolar fluids.
- Use an electronic infusion device.
EBP. Administration of 3% NaCl, a hypertonic solution, is critical to treatment of patients with severe hyponatremic encephalopathy, traumatic brain injury, and cerebral edema. Because this solution is a vesicant, organizations often require a central vascular access device (CVAD) for administration in order to reduce the risk for peripheral vein extravasation. In a systematic review of the literature focusing on infusion-related events, researchers identified that peripheral infusion reactions were not common. Based upon the literature review, the researchers concluded that in the absence of a CVAD, peripheral administration of 3% NaCl is supported for urgent treatment. For prolonged treatment or if a CVAD is present, central administration is preferred (Metheny & Moritz, 2021).
Ringer's Solution (Injection)
First developed in the 1800s, Ringer's injection is an isotonic fluid that is used rather than 0.9% sodium chloride for treating patients with dehydration after reduced water intake or water loss. Ringer's solution (injection) is similar to normal saline (i.e., 0.9% sodium chloride) but also includes potassium chloride and calcium chloride. Ringer's injection is preferred to normal saline for treating patients with dehydration after drastically reduced water intake or water loss (e.g., with vomiting, diarrhea, or fistula drainage). This solution has some incompatibilities with medications, so it is necessary to check drug compatibility literature for guidelines.
NURSING FAST FACT!Ringer's injection does not contain enough potassium or calcium to be used as a maintenance fluid or to correct a deficit of these electrolytes. |
- Treatment of any type of dehydration
- Restoration of fluid balance before and after surgery
- Replacement of fluids lost from dehydration, from GI losses, and fistula drainage
- Used instead of lactated Ringer's solution when the patient has hepatic disease and is unable to metabolize lactate
- May be used as blood replacement for a short period of time
Risks
- May exacerbate sodium retention, congestive heart failure, and renal insufficiency
- Contraindicated in renal failure
Dextrose Combined With Sodium Chloride
When sodium chloride is infused, the addition of 100 g of dextrose prevents the formation of ketone bodies. Dextrose prevents catabolism, which is the breakdown of chemical compounds by the body. Consequently, there is a loss of potassium and intracellular water.
Carbohydrates and sodium chloride fluid combinations are used in cases of excessive loss of fluid through sweating, vomiting, or gastric suctioning.
Hydrating Solutions (Combinations of Dextrose and Hypotonic Sodium Chloride)
Solutions that contain dextrose and hypotonic saline provide more water than is required for excretion of salt and are useful as hydrating fluids. Hydrating fluids are used to hydrate general medical-surgical patients, to promote diuresis, and to assess the status of the kidneys before the initiation of maintenance solutions with electrolyte replacement. The establishment of urinary flow indicates that the kidneys have begun to function; the hydrating solution may then be replaced with a specific electrolyte solution. Carbohydrates in hydrating solutions reduce the depletion of nitrogen and liver glycogen and are also useful in rehydrating cells.
Hydrating solutions are potassium free. Potassium is essential to the body but can be toxic if the kidneys are not functioning effectively and therefore are unable to excrete the extra potassium.
Indications
- Help assess the status of the kidneys before replacement therapy is started
- Hydrate patients in dehydrated states
- Promote diuresis in dehydrated patients
Risks
- Require cautious administration in edematous patients (e.g., patients with cardiac, renal, or hepatic disease)
Balanced Electrolyte Solutions
A variety of balanced electrolyte fluids are commercially available. Balanced fluids are available as hypotonic or isotonic maintenance and replacement solutions. Maintenance fluids approximate normal body electrolyte needs; replacement fluids contain one or more electrolytes in amounts higher than those found in normal body fluids. Balanced fluids limit acid-base alterations and saline-induced hyperchloremic acidosis (as associated with 0.9% sodium chloride) (Malbrain et al., 2020). Examples of balanced solutions include lactated/acetated Ringer's solution and Plasma-Lyte.
EBP. Administration of balanced crystalloid solutions rather than 0.9% saline may be associated with a reduction in morbidity and mortality in critically ill patients. Isotonic saline administration is associated with hyperchloremia metabolic acidosis (due to high concentration of chloride in 0.9% saline solution), inflammation, hypotension, acute kidney injury, and death. Use of balanced crystalloid solutions is associated with reduced risk. Research is ongoing in this area of clinical practice (Semler & Kellum, 2019).
Table 4-1 provides a reference list of isotonic, hypotonic, and hypertonic solutions, and Table 4-2 provides a summary of electrolyte solutions, including osmolarity, pH, and electrolyte content.
| Isotonic Solutions | Hypotonic Solutions | Hypertonic Solutions |
|---|---|---|
| 0.9% sodium chloride Dextrose 5% in water Lactated Ringer's solution Ringer's solution | 0.225% NaCl 0.33% NaCl 0.45% NaCl 2.5% dextrose in water | 3% NaCl 5% NaCl 5% dextrose in 0.225% NaCl 5% dextrose in 0.45% NaCl 5% dextrose in 0.9% NaCl 10% dextrose in water 20% dextrose in water 50% dextrose in water |
| Solution | Osmolarity | Dextrose, g/100 mL | pH | Cal/100 mL | mEq/L | ||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Na | Cl | K | Ca | Mg | Acetate | Lactate | |||||
| Dextrose in Water (D/W) | |||||||||||
| 5% D/W | Isotonic—252 | 5 | 4.8 | 17 | |||||||
| 10% D/W | Hypertonic—505 | 10 | 4.7 | 34 | |||||||
| 20% D/W | Hypertonic—1010 | 20 | 4.8 | 68 | |||||||
| 50% D/W | Hypertonic—2526 | 50 | 4.6 | 170 | |||||||
| 70% D/W | Hypertonic—3532 | 70 | 4.6 | 237 | |||||||
| Sodium Chloride (NaCl) | |||||||||||
| 0.225% NaCl (1/4 strength) | Hypotonic—77 | 4.5 | 34 | 34 | |||||||
| 0.45% NaCl (1/2 strength) | Hypotonic—154 | 5.6 | 77 | 77 | |||||||
| 0.9% NaCl (full strength) | Isotonic—308 | 6.0 | 154 | 154 | |||||||
| 3% NaCl | Hypertonic—1027 | 5.0 | 513 | 513 | |||||||
| 5% NaCl | Hypertonic—1711 | 5.0 | 855 | 855 | |||||||
| 0.25% D and 0.9% NaCl | Isotonic—321 | 2.5 | 4.5 | 8 | 154 | 154 | |||||
| Dextrose and Sodium Chloride (D/NaCl) | |||||||||||
| 5% D and 0.225% NaCl | Isotonic—321 | 5 | 4.6 | 17 | 34 | 34 | |||||
| 5% D and 0.45% NaCl | Hypertonic—406 | 5 | 4.6 | 17 | 77 | 77 | |||||
| 5% D and 0.9% NaCl | Hypertonic—560 | 5 | 4.4 | 17 | 154 | 154 | |||||
| Balanced Electrolyte Solutions | |||||||||||
| Lactated Ringer's solution | Isotonic—275 | 6.5 | 130 | 109 | 4 | 3 | 28 | ||||
| Plasma-Lyte A* | Isotonic—280-310 | 7.4 | 140 | 98 | 5 | 3 | 27 | ||||
| Normosol-R* | Isotonic—295 | 7.4 | 140 | 98 | 5 | 3 | 27 | ||||
| Specialty Solutions | |||||||||||
| 1/6 M Sodium | Isotonic—335 lactate | 6.5 | 167 | 167 | |||||||
| 10% Mannitol | Hypertonic—549 | 5.7 | |||||||||
| 20% Mannitol | Hypertonic—1098 | 5.7 | |||||||||
Ca = calcium; Cal = calories; Cl = chloride; K = potassium; Mg = magnesium; Na = sodium; NaCl = sodium chloride.
*Both Plasma-Lyte A and Normosol-R also contain 23 mEq of gluconate
Lactated Ringer's Solution
Lactated Ringer's solution is classified as a balanced isotonic solution because its fluid and electrolyte contents are similar to those of plasma. It is used to replace electrolytes at physiological levels in the ECF compartment and is a commonly used balanced solution. This solution is also called Hartmann's solution, named after the physician who added lactate to Ringer's injection for the purpose of treating acidosis in the 1930s. Lactated Ringer's solution is a commonly prescribed solution, with an electrolyte concentration closely resembling that of the ECF compartment. Notably, there is also a Ringer's acetate, which may be used in critically ill patients in whom there is concern about high levels of plasma lactate levels (Correa et al., 2015). The composition of lactated Ringer's and Ringer's acetate is almost identical with the exception of the added buffer (lactate or acetate).
NURSING FAST FACT!Lactated Ringer's solution has some incompatibilities with medications, so it is necessary to check drug compatibility literature for guidelines. |
Lactated Ringer's solution is used for the following situations.
Indications
- Rehydration in all types of dehydration
- Restoration of fluid volume deficits
- Replacement of fluid lost as a result of burns
- Treatment of mild metabolic acidosis
- Treatment of salicylate overdose
Risks
- Three liters of lactated Ringer's solution contains about 390 mEq of sodium, which can quickly elevate the sodium level in a patient who does not have a sodium deficit.
- Lactated Ringer's solution should not be used in patients with impaired lactate metabolism, such as those with hepatic disease, Addison's disease, severe metabolic acidosis or alkalosis, profound hypovolemia, or profound shock or cardiac failure. In these conditions, serum lactate levels may already be elevated.
Normosol R and Plasma-Lyte A
Both Normosol R (Hospira) (National Library of Medicine, n.d.a) and Plasma-Lyte A (Baxter) (National Library of Medicine, n.d.b) are balanced electrolyte solutions similar to lactated Ringer's solution in concentrations of sodium, chloride, and potassium. Instead of lactate as the buffer agent, these solutions use acetate and gluconate. Their osmolarity is similar to that of isotonic saline but with a much lower chloride content, and they also contain potassium and magnesium. They may be used for initial fluid resuscitation but not for patients with chloride-sensitive metabolic alkalosis or hyperkalemia (Tinawi, 2021).
Mannitol
Mannitol is a crystalloid sugar alcohol substance that is available in various concentrations. Classified as an osmotic diuretic, mannitol is distributed to the extracellular space, causing the movement of water to the extracellular and vascular spaces. Depending upon the concentration, the osmolarity ranges from 275 to 1375 mOsm/L. No further dilution of this product is necessary; however, any crystals present in the solution must be completely dissolved before administration (Gahart et al., 2021).
- Reduction of intracranial pressure and cerebral edema
- Reduction of intraocular pressure
Risks
- Serious hypersensitivity reactions, including anaphylaxis
- Fluid and electrolyte imbalances are the most common and may be severe.
- May induce dehydration with hyperkalemia, hypokalemia, or hyponatremia.
- The 20% and 25% concentrations are considered vesicant solutions, capable of causing skin necrosis upon extravasation (Gorski et al., 2017).
NOTE: Mannitol solution requires cautious use in patients with an impaired cardiac or renal system. It is contraindicated in the presence of anuria, severe pulmonary and cardiac congestion, and intracranial bleeding (Gahart et al., 2021).
Alkalizing and Acidifying Solutions
Alkalizing Solutions
Metabolic acidosis, defined by a pH less than 7.35, occurs in situations in which GI losses (e.g., diarrhea), dehydration, shock, hepatic disease, starvation, or diabetes causes retention of chlorides, ketone bodies, or organic salts or in which too large an amount of bicarbonate is lost. An alkalizing solution is used for treatment in conjunction with treating the underlying cause of the metabolic acidosis. Treatment is usually indicated to raise and maintain the plasma pH to greater than 7.20 (Thomas & Hamawi, 2020). Sodium bicarbonate is the agent most commonly used to correct metabolic acidosis. It is available in various concentrations including 5%, 7.5%, and 8.4%). The 7.5% and 8.4% solutions should be diluted with an equal amount of water for injection or diluted with a compatible IV solution (Gahart et al., 2021). One ampule of 8.4% sodium bicarbonate contains 50 mEq each of sodium and bicarbonate and is hypertonic at 2000 mOsm/L.
NURSING FAST FACT!Sodium bicarbonate injection is a vesicant and can result in tissue necrosis, ulceration, and sloughing upon extravasation. VAD patency is always carefully assessed prior to administration. It is also incompatible with many medications; the VAD should be flushed thoroughly before and after administration (Gahart et al., 2021; Gorski et al., 2017). |
Acidifying Solutions
Metabolic alkalosis is a condition associated with an excess of bicarbonate and a deficit of chloride and is defined by a pH greater than 7.45. Examples of clinical conditions leading to metabolic alkalosis include loss of hydrogen ions through vomiting/nasogastric suction, renal losses in the presence of excess aldosterone, and excessive sodium bicarbonate administration. Management of this condition is dependent upon the etiology of the condition and may include interventions such as proton pump inhibitors or changes in diuretic drugs or doses (Thomas & Yaseen, 2020). Direct treatment of metabolic alkalosis with IV fluids is usually isotonic sodium chloride (0.9%). Ammonium chloride also may be used; it is administered upon dilution in isotonic sodium chloride injection (National Center for Biotechnology Information, 2021).
NURSING FAST FACT!Ammonium chloride is contraindicated in patients with hepatic disease or renal failure and is used with caution in patients with pulmonary insufficiency or cardiac related edema. |
CRYSTALLOID ADMINISTRATION
Nursing Assessment
Key Nursing Interventions 1. Administer IV fluids at room temperature. 2. Administer IV solutions/medications at prescribed rate and monitor for results. 3. Monitor a.Central venous pressure (CVP) and for evidence of fluid volume excess/deficit. b.Laboratory test result values (e.g., serum protein levels, electrolytes, hemoglobin, and hematocrit). d.Complications associated with vascular access devices (VADs) (phlebitis, erratic flow rates, infiltration). 4. Monitor VAD patency. Flush VAD before each infusion as part of the steps to assess catheter function and after each infusion to clear the infused medication from the catheter lumen to prevent contact between incompatible medications. Follow flushing and locking guidelines. 5. Replace fluid containers according to established organizational policies, procedures, and/or current practice guidelines. |
NURSING FAST FACT!Do not forget to include fluids used as drug diluents in the calculation of fluid intake! |