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  • CLASSES

    All Other Anti-asthma and COPD Products, Inhalant
    Artificial Tears and Ocular Lubricants
    Emollients and Protectants, Other
    General Skin Cleansers
    Irrigation Solutions, Saline
    Mucolytics
    Other Topical Nasal Preparations
    Saline Rinse
    Sodium Chloride Solutions
    Sodium Supplements
    Vaginal Douches

    DEA CLASS

    Rx, OTC

    DESCRIPTION

    Sodium and chloride are the primary cation and anion, respectively, of extracellular fluid
    Used for many indications, including fluid resuscitation, hyponatremia, increased ICP; given via neb to improve mucus clearance in cystic fibrosis
    Potential complications of systemic therapy may result from rapid volume expansion, rapid correction of hyponatremia, and hypotonic fluid administration

    COMMON BRAND NAMES

    4-Way Saline, Adsorbonac, Altamist, Ayr Baby Saline, Ayr Saline Nasal, BD Posiflush Normal Saline, BD Posiflush Sterile Field Normal Saline, BD Posiflush SureScrub Normal Saline, Blairex Broncho Saline, Breathe Free Saline, Deep Sea, Entsol, Hyper-Sal, HyperSal, Hypertears, Little Remedies for Noses, Muro 128, NebuSal, Ocean, Rhinaris, Rhinaris Lubricating, Saljet, Saljet Rinse, SaltAire, Sea Soft, Wound Wash

    HOW SUPPLIED

    4-Way Saline/Altamist/Ayr Baby Saline/Ayr Saline Nasal/Breathe Free Saline/Deep Sea/Entsol/Ocean/SaltAire/Sea Soft/Sodium Chloride Nasal Sol: 0.65%, 2.1%, 3%
    Adsorbonac/Muro 128/Sodium Chloride Ophthalmic Sol: 2%, 5%
    Altamist/Ayr Baby Saline/Ayr Saline Nasal/Breathe Free Saline/Deep Sea/Little Remedies for Noses/Ocean/Ocean Complete/Rhinaris/Rhinaris Lubricating/Sea Soft/Sodium Chloride Nasal Spray: 0.2%, 0.65%
    Altamist/Ayr Baby Saline/Ayr Saline Nasal/Breathe Free Saline/Deep Sea/Ocean/Sea Soft/Sodium Chloride Nasal Spray Met: 0.65%
    BD Posiflush Normal Saline/BD Posiflush Sterile Field Normal Saline/BD Posiflush SureScrub Normal Saline/Sodium Chloride Intravenous Sol: 0.9%
    BD Posiflush Normal Saline/BD Posiflush Sterile Field Normal Saline/BD Posiflush SureScrub Normal Saline/Sodium Chloride/Sodium Chloride, Bacteriostatic Intramuscular Inj Sol: 0.9%
    BD Posiflush Normal Saline/BD Posiflush Sterile Field Normal Saline/BD Posiflush SureScrub Normal Saline/Sodium Chloride/Sodium Chloride, Bacteriostatic Intravenous Inj Sol: 0.45%, 0.9%, 3%, 5%, 23.4%
    BD Posiflush Normal Saline/BD Posiflush Sterile Field Normal Saline/BD Posiflush SureScrub Normal Saline/Sodium Chloride/Sodium Chloride, Bacteriostatic Subcutaneous Inj Sol: 0.9%
    Blairex Broncho Saline/HyperSal/Hyper-Sal/NebuSal/Sodium Chloride Respiratory (Inhalation) Sol: 0.9%, 3%, 3.5%, 6%, 7%, 10%
    Entsol Nasal Gel: 1.1%
    Hypertears/Muro 128/Sodium Chloride Ophthalmic Ointment: 5%
    Saljet/Saljet Rinse/Sodium Chloride/Wound Wash Topical Sol: 0.9%
    Sodium Chloride Extracorporeal Sol: 0.9%
    Sodium Chloride Intravenous Inj Sol Conc: 14.6%, 23.4%
    Sodium Chloride Intravesical Sol: 0.9%
    Sodium Chloride Irrigation Sol: 0.45%, 0.9%
    Sodium Chloride Oral Tab: 1g
    Sodium Chloride Topical Tab: 1g

    DOSAGE & INDICATIONS

    For the treatment of dehydration or hypovolemia, including during diabetic ketoacidosis, cardiopulmonary resuscitation, and shock (e.g., septic shock, anaphylactic shock, cardiogenic shock).
    Intravenous dosage (0.9% isotonic solution)
    Adults

    1,000 mL IV bolus at a maximum infusion rate (e.g., over 5 to 10 minutes). Titrate and repeat dosage until hemodynamic stability is achieved. Greater amounts of fluid and more rapid administration may be necessary in some patients. Cardiogenic shock without evidence of fluid overload may require smaller challenges given over a longer period, such as 250 mL given over 10 to 20 minutes. Sepsis clinical practice guidelines recommend at least 30 mL/kg IV within the first 3 hours of sepsis-induced hypoperfusion. After initial fluid resuscitation, guide additional fluid administration by frequent reassessment of hemodynamic status (e.g., heart rate, blood pressure, arterial oxygen saturation, respiratory rate, temperature, urine output). Crystalloids are recommended as the fluid of choice for the initial resuscitation and subsequent intravascular volume replacement in patients with sepsis and septic shock. Patients with diabetic ketoacidosis may receive 15 to 20 mL/kg (or 1 to 1.5 L) of 0.9% Sodium Chloride Injection during the first hour of treatment. Thereafter, therapy should be guided by hemodynamic status and serum electrolytes; patients with normal or elevated sodium concentrations may receive 0.45% Sodium Chloride Injection at 250 to 500 mL/hour, while patients with low sodium may receive 0.9% Sodium Chloride Injection at 250 to 500 mL/hour. Closely monitor clinical status and serum osmolality in patients with diabetic ketoacidosis who have cardiac or renal disease to avoid fluid overload. Patients with non-emergent dehydration may receive 1 L over 1 hour, followed by appropriate rehydration fluids over the next 24 to 48 hours.

    Infants, Children, and Adolescents (Dehydration, non-emergent)

    20 mL/kg IV bolus (Usual Max: 1,000 mL/bolus) over 1 hour, followed by appropriate rehydration fluids over the next 24 to 48 hours.

    Infants, Children, and Adolescents (Hypovolemic or distributive [e.g., septic, anaphylactic] shock)

    20 mL/kg IV bolus (Usual Max: 1,000 mL/bolus) over 5 to 20 minutes. Children with septic shock often have a large fluid deficit and may require 40 to 60 mL/kg during the first hour and 200 mL/kg or more during the first 8 hours of therapy. May repeat as needed to restore blood pressure and tissue perfusion.

    Infants, Children, and Adolescents (Cardiogenic shock or poisonings [e.g., calcium channel blocker, beta-blocker])

    5 to 10 mL/kg IV bolus over 10 to 20 minutes. Carefully monitor for signs of worsening respiratory status and pulmonary edema. May repeat as needed to restore blood pressure and tissue perfusion.

    Infants, Children, and Adolescents (Diabetic ketoacidosis with compensated shock)

    10 to 20 mL/kg IV bolus (Usual Max: 1,000 mL/bolus) over 1 hour. Thereafter, therapy should be guided by hemodynamic status and serum electrolytes; subsequent fluid replacement should be completed with 0.45% or 0.9% Sodium Chloride Injection over the next 24 to 48 hours.

    Neonates

    10 mL/kg IV bolus. Administer over 5 to 10 minutes for near-term neonates; slower administration is recommended for neonates less than 30 weeks gestation because rapid administration has been associated with intraventricular hemorrhage. May repeat once if significant improvement does not occur; further volume should only be considered in cases of documented large blood loss.

    For the treatment of hyponatremia.
    NOTE: In general, initial correction of acute or symptomatic hyponatremia should be undertaken with hypertonic 3% Sodium Chloride Injection. Asymptomatic, chronic hyponatremia should be corrected with isotonic 0.9% Sodium Chloride Injection.
    Intravenous dosage (0.9% isotonic or 3% hypertonic solution)
    Adults

    Dose (mEq sodium) = [desired serum sodium (mEq/L) - actual serum sodium (mEq/L)] x total body water (TBW). Total body water = lean body weight (kg) x 0.6 (male younger than 70 years), 0.5 (male 70 years or older or female younger than 70 years), or 0.45 (female 70 years or older). Initially, correct hyponatremia to a desired serum sodium of 120 to 125 mEq/L, then correct more gradually. In severe hyponatremia, a brief infusion correcting the serum sodium by 1 to 2 mEq/L/hour for the first 2 to 4 hours may be utilized. Some experts recommend aiming for a correction of 8 mEq/L/day; serum sodium should not increase by more than 10 to 12 mEq/L in the first 24 hours and 18 mEq/L in the first 48 hours of therapy. Monitor serum sodium concentrations every 1 to 2 hours. In general, correction of acute, symptomatic hyponatremia should be undertaken with a hypertonic 3% solution. In chronic severe hyponatremia, avoid overcorrection, which may lead to osmotic demyelination syndrome.

    Infants, Children, and Adolescents

    Dose (mEq sodium) = [desired serum sodium (mEq/L) - actual serum sodium (mEq/L)] x 0.6 x weight (kg). The rate of sodium correction depends on how quickly the hyponatremia developed. Initially, correct hyponatremia to a safe serum sodium concentration of approximately 120 to 125 mEq/L, then slow the correction to a more gradual rate. In severe symptomatic hyponatremia (e.g., risk of seizures), a brief infusion correcting the serum sodium by 1 to 2 mEq/L/hour for the first 2 to 4 hours may be utilized; thereafter, the rate of correction should not exceed 0.5 mEq/L/hour. Some experts recommend aiming for an increase of 8 mEq/L/day; others state that serum sodium should not increase by more than 10 to 12 mEq/L in the first 24 hours and 18 mEq/L in the first 48 hours of therapy. Monitor serum sodium concentrations every 1 to 2 hours while infusing hypertonic sodium chloride and then as clinically appropriate.

    Neonates

    Dose (mEq sodium) = [desired serum sodium (mEq/L) - actual serum sodium (mEq/L)] x 0.6 x weight (kg). The rate of sodium correction depends on how quickly the hyponatremia developed. Initially, correct hyponatremia to a desired serum sodium of 120 to 125 mEq/L, then correct more gradually. The rate of serum sodium correction should not exceed 0.4 to 0.5 mEq/L/hour, and serum sodium should not increase by more than 8 to 10 mEq/L in the first 24 hours. Monitor serum sodium concentrations every 1 to 2 hours. If hyponatremia is chronic or serum sodium is 120 mEq/L or more, use a 0.9% isotonic solution to correct the sodium deficit; if serum sodium is less than 120 mEq/L acutely and the patient is experiencing symptoms of hyponatremia, consider correcting the deficit with a hypertonic 3% solution. Of note, some experts do not recommend the use of hypertonic saline in asymptomatic very low birth weight (VLBW) or extremely low birth weight (ELBW) infants with hyponatremia.

    For mucolysis and sputum induction in patients with cystic fibrosis.
    Oral inhalation dosage (7% nebulized solution)
    Adults

    4 mL/dose via oral inhalation twice daily. To prevent bronchospasm, administer after a bronchodilator (e.g., albuterol). Mucus clearance is dose-dependent for hypertonic saline concentrations up to 7%; lesser concentrations (e.g., 3%) may be considered for patients who do not tolerate the 7% solution.

    Children and Adolescents 6 to 17 years

    4 mL/dose via oral inhalation twice daily. To prevent bronchospasm, administer after a bronchodilator (e.g., albuterol). Mucus clearance is dose-dependent for hypertonic saline concentrations up to 7%; lesser concentrations (e.g., 3%) may be considered for patients who do not tolerate the 7% solution.

    For the treatment of nasal congestion and dryness.
    Intranasal dosage (0.65% nasal solution)
    Adults

    2 to 6 drops in each nostril as needed. For nasal sprays, 2 sprays in each nostril as needed.

    Infants, Children, and Adolescents

    2 to 6 drops in each nostril as needed. For nasal sprays, 2 sprays in each nostril as needed. Drops are recommended for infants.

    Neonates

    2 to 6 drops in each nostril as needed. Drops are recommended for neonates.

    For nutritional supplementation.
    Intravenous or Oral dosage
    Adults

    1 to 2 mEq/kg/day IV admixed in total parenteral nutrition (TPN) as a daily maintenance requirement. Alternatively, this dosage may be administered enterally in patients who are not receiving TPN and require sodium chloride supplementation. Adjust as needed based on serum sodium concentrations.

    Children and Adolescents weighing more than 50 kg

    1 to 2 mEq/kg/day IV admixed in total parenteral nutrition (TPN) as a daily maintenance requirement. Alternatively, this dosage may be administered enterally in patients who are not receiving TPN and require sodium chloride supplementation. Adjust as needed based on serum sodium concentrations.

    Infants, Children, and Adolescents weighing 50 kg or less

    2 to 5 mEq/kg/day IV admixed in total parenteral nutrition (TPN) as a daily maintenance requirement. Alternatively, this dosage may be administered enterally in patients who are not receiving TPN and require sodium chloride supplementation. Adjust as needed based on serum sodium concentrations.

    Neonates

    2 to 5 mEq/kg/day IV admixed in total parenteral nutrition (TPN) as a daily maintenance requirement. Alternatively, this dosage may be administered enterally in patients who are not receiving TPN and require sodium chloride supplementation. Premature neonates with a gestational age of 33 weeks or less may require a higher sodium intake (4 to 5 mEq/kg/day) during the first 2 weeks of life compared to those born near term. Monitor sodium serum concentrations carefully and adjust dosage as needed.

    For temporary relief of corneal edema (i.e., ocular inflammation).
    Ophthalmic dosage (ophthalmic solution)
    Adults

    Instill 1 to 2 drops onto the affected eye(s) every 3 to 4 hours. Instruct patients to discontinue use and seek medical advice if condition worsens or persists for more than 72 hours.

    Ophthalmic dosage (ophthalmic ointment)
    Adults

    Apply a small amount of ointment (approximately 1/4 inch) to the inside, lower eyelid of the affected eye(s) every 3 to 4 hours. Instruct patients to discontinue use and seek medical advice if condition worsens or persists for more than 72 hours.

    For the treatment of increased intracranial pressure†.
    Intermittent Intravenous dosage (3% hypertonic solution)
    Adults

    A serum sodium concentration of 145 to 150 mEq/L may be targeted as this typically coincides with the desired reduction in intracranial pressure. Dose (mEq sodium) = [desired serum sodium (mEq/L) - actual serum sodium (mEq/L)] x total body water (TBW). Total body water = lean body weight (kg) x 0.6 (male younger than 70 years), 0.5 (male aged 70 years or older or female younger than 70 years), or 0.45 (female aged 70 years or older). Dose may be given as a single infusion. A 300 mL IV bolus dose given over 20 minutes was found to be a safe alternative to mannitol when given for elevated ICP in patients with severe head injury. Monitor ICP, serum osmolarity, and sodium concentrations. Titrate subsequent infusions to keep ICP below 20 mmHg. The Brain Trauma Foundation does not make recommendations regarding the use of hypertonic saline for intracranial hypertension.

    Infants, Children, and Adolescents

    5 to 10 mL/kg/dose IV administered over 5 to 30 minutes; larger doses (e.g., 10 mL/kg/dose) may require the upper end of the infusion range. In a series of case reports of patients with diabetic ketoacidosis, cerebral edema, and apparent intracranial hypertension, doses (10 mL/kg/dose) were infused over 30 minutes, equaling a rate of approximately 10 mEq/kg/hour. Monitor ICP, serum sodium, and serum osmolarity closely. Some experts recommend 320 to 360 mOsm/L as the upper safety threshold for serum osmolarity; however, there is disagreement among clinicians about the ideal limit for pediatric patients.

    Intermittent Intravenous dosage (23.4% hypertonic solution)
    Adults

    NOTE: 23.4% sodium chloride must ONLY be administered via a central line, and in small (e.g., 30 mL) infusion aliquots. A serum sodium concentration of 145 to 150 mEq/L may be targeted as this typically coincides with the desired reduction in intracranial pressure. Dose (mEq sodium) = [desired serum sodium (mEq/L) - actual serum sodium (mEq/L)] x total body water (TBW). Total body water = lean body weight (kg) x 0.6 (male younger than 70 years), 0.5 (male aged 70 years or older or female younger than 70 years), or 0.45 (female aged 70 years or older). Dose may be given as a single infusion through a central venous catheter. A 23.4% IV bolus of 30 mL given over 2 minutes has been used to treat elevated ICP in traumatic brain injury patients who had become tolerant to mannitol. In another study that compared 23.4% saline to mannitol, a 30 mL bolus hypertonic saline was given over greater than 30 minutes. Monitor ICP, serum osmolarity, and sodium concentrations. Titrate subsequent infusions to keep ICP below 20 mmHg. The Brain Trauma Foundation does not make recommendations regarding the use of hypertonic saline for intracranial hypertension.

    Continuous IV Infusion dosage (3% hypertonic solution)
    Adults

    Administer hypertonic saline via a central line. A common initial rate is 30 mL/hour IV continuous infusion, with further rate adjustments based on close monitoring of ICP, serum sodium, serum osmolarity, neurologic, hemodynamic, and renal status. Titrate subsequent infusions to keep ICP below 20 mmHg. The Brain Trauma Foundation does not make recommendations regarding the use of hypertonic saline for intracranial hypertension.

    Infants, Children, and Adolescents

    0.1 to 1 mL/kg/hour continuous IV infusion. Titrate to maintain ICP less than 20 mmHg. Carefully monitor serum sodium and serum osmolarity. Consensus guidelines recommend serum osmolarity should be maintained less than 360 mOsm/L; however, some experts recommend maintenance of serum sodium less than 160 mEq/L and serum osmolarity less than 320 mOsm/L to prevent acute renal failure.

    For the inpatient management of viral bronchiolitis†.
    Oral inhalation dosage (3% nebulized solution)
    Infants and Children 1 to 2 years

    4 mL/dose via oral inhalation every 2 hours for 3 doses, then every 4 hours for 5 doses, and finally every 6 hours until discharge. To prevent bronchospasm, administer after a bronchodilator (e.g., albuterol). Of note, although the American Academy of Pediatrics states that nebulized hypertonic saline may be administered to children 1 to 23 months of age hospitalized for bronchiolitis, use in the emergency department is not recommended. Evidence suggests hypertonic saline is effective in improving symptoms of non-severe bronchiolitis after 24 hours of use and reducing hospital length of stay when the admission exceeds 3 days. Although data has been contradictory, meta-analysis suggests use in areas where the length of administration is brief (e.g., the emergency department) does not improve short-term outcomes or decrease hospitalization rates.

    Neonates

    4 mL/dose via oral inhalation every 2 hours for 3 doses, then every 4 hours for 5 doses, and finally every 6 hours until discharge. To prevent bronchospasm, administer after a bronchodilator (e.g., albuterol). Evidence suggests hypertonic saline is effective in improving symptoms of non-severe bronchiolitis after 24 hours of use and reducing hospital length of stay when the admission exceeds 3 days. Although data has been contradictory, meta-analysis suggests use in areas where the length of administration is brief (e.g., the emergency department) does not improve short-term outcomes or decrease hospitalization rates.

    †Indicates off-label use

    MAXIMUM DOSAGE

    Adults

    For hypovolemia, 1,000 mL/bolus of a 0.9% isotonic solution. For sodium replacement and management of ICP, dosage must be individualized based on serum sodium concentrations and patient requirements.

    Geriatric

    For hypovolemia, 1,000 mL/bolus of a 0.9% isotonic solution. For sodium replacement and management of ICP, dosage must be individualized based on serum sodium concentrations and patient requirements.

    Adolescents

    For hypovolemia, do not exceed 20 mL/kg IV per bolus (Usual Max: 1,000 mL/bolus) of a 0.9% isotonic solution. For sodium replacement and management of ICP, dosage must be individualized based on serum sodium concentrations and patient requirements. Do not exceed 1 mEq/kg/hour IV as a continuous infusion. For management of ICP, do not exceed 10 mL/kg/dose IV of a 3% hypertonic solution.

    Children

    For hypovolemia, do not exceed 20 mL/kg IV per bolus (Usual Max: 1,000 mL/bolus) of a 0.9% isotonic solution. For sodium replacement and management of ICP, dosage must be individualized based on serum sodium concentrations and patient requirements. Do not exceed 1 mEq/kg/hour IV as a continuous infusion. For management of ICP, do not exceed 10 mL/kg/dose IV of a 3% hypertonic solution.

    Infants

    For hypovolemia, do not exceed 20 mL/kg IV per bolus of a 0.9% isotonic solution. For sodium replacement and management of ICP, dosage must be individualized based on serum sodium concentrations and patient requirements. Do not exceed 1 mEq/kg/hour IV as a continuous infusion. For management of ICP, do not exceed 10 mL/kg/dose IV of a 3% hypertonic solution.

    Neonates

    For hypovolemia, do not exceed 10 mL/kg IV per bolus of a 0.9% isotonic solution. For sodium replacement, dosage must be individualized based on serum sodium concentrations and patient requirements.

    DOSING CONSIDERATIONS

    Hepatic Impairment

    Specific guidelines for dosage adjustments in hepatic impairment are not available. Carefully consider fluid status in patients with hepatic impairment and hyponatremia.

    Renal Impairment

    Dosage should be modified based on clinical response, but no quantitative recommendations are available. For systemic therapy, monitor serum sodium concentrations and renal function carefully to avoid sodium retention.

    ADMINISTRATION

    Oral Administration

    May administer without regard to meals.

    Oral Liquid Formulations

    Sodium chloride injection solution may be administered enterally if necessary.
    In general, hypertonic solutions should be utilized to minimize volume. If a 23.4% solution is used, dilute in feedings or water prior to administration.

    Injectable Administration

    Visually inspect parenteral products for particulate matter and discoloration prior to administration whenever solution and container permit. Use of a final filter is recommended during administration of all parenteral solutions when possible.
    When administering sodium chloride from flexible plastic containers, do not connect in series, pressurize without fully evacuating the container's residual air, or use a vented intravenous administration set with the vent in the open position. Such use could result in air embolism.

    Intravenous Administration

    Central line administration is preferred for hypertonic sodium chloride solutions > 0.9%; however peripheral administration is acceptable in critically ill patients who require immediate therapy. Central access should be obtained for continued use. Monitor peripheral administration of hypertonic solutions carefully for potential extravasation and local tissue damage.
    0.45% Sodium Chloride Injection (without additional additives) is the most hypotonic sodium chloride solution that can be safely administered without risking cell lysis. Additional solutes such as dextrose or other electrolytes (e.g., potassium chloride) can be added to hypotonic sodium chloride solutions to increase their tonicity and make intravenous administration feasible without causing cell lysis.
    Do not mix or administer hypotonic or hypertonic sodium chloride injection solutions through the same administration set with whole blood or cellular blood components.
     
    IV Push
    0.9% Isotonic Solution (for emergent fluid resuscitation [e.g., severe hypovolemia or shock])
    Administer bolus over 5 to 10 minutes for most patients; however, some patients require slower administration:
    Patients with cardiogenic shock or cardiac dysfunction (e.g., calcium channel blocker or beta-blocker overdose): administer over 10 to 20 minutes.
    Premature neonates < 30 weeks gestational age: Avoid rapid administration; some evidence suggests that rapid administration may increase the risk of intracranial hemorrhage.
     
    Intermittent IV Infusion
    0.9% Isotonic Solution (for urgent fluid replacement [e.g., dehydration or diabetic ketoacidosis with compensated shock])
    Administer bolus over 1 hour.
    3% Hypertonic Solution (for increased ICP)
    Administer over 5 to 30 minutes; larger doses may require the upper end of the infusion range. A 300 mL IV bolus dose given over 20 minutes was found to be a safe alternative to mannitol when given for elevated ICP in patients with severe head injury.
    23.4% Hypertonic Solution (for increased ICP)
    Administer via central line ONLY; give in small (e.g., 30 mL) infusion aliquots over 2 to 30 minutes.
     
    Continuous IV Infusion
    3% Hypertonic Solution (for increased ICP)
    Rates can vary from 75 to 150 mL/hour (1 to 2 mL/kg/hour).

    Other Injectable Administration

    Intraosseous Administration
    For emergent fluid resuscitation, 0.9% Sodium Chloride Injection may be given via the intraosseous route when IV access is not available.

    Inhalation Administration
    Oral Inhalation Administration

    Inhalation Solution for Nebulization
    To minimize or prevent bronchospasm, administer a bronchodilator (e.g., albuterol) 15 to 60 minutes prior to inhalation of hypertonic sodium chloride.
    Inhaled hypertonic sodium chloride has been administered via jet and ultrasonic nebulization.

    Intranasal Inhalation Administration

    Hold bottle upright. Give short, firm squeezes into each nostril. Do not aspirate nasal contents back into bottle.
    Small Children and Infants: Use drops. Put drops in each nostril and have the child remain on their back for 1 to 2 minutes.
    Rinse bottle tip with hot water and wipe with a clean towel after each administration.
    To avoid contamination and prevent the spread of infection, do not use the bottle dispenser for more than 1 person to prevent the spread of infection.

    Ophthalmic Administration

    Ophthalmic solution
    Do not use if solution changes color or becomes cloudy.
    Apply to affected eye and replace cap after use.
    To avoid contamination, do not touch the tip of the dispenser to any surface (e.g., eye, fingertips, countertop); do not use the bottle dispenser for more than 1 person.
    Ophthalmic ointment
    Do not use if ointment is difficult to dispense or if particles are visible in the product.
    Pull down the lower lid of the affected eye
    Apply small amount of ointment (approximately 1/4th inch) to the inside of the eyelid.

    STORAGE

    Generic:
    - Discard product if it contains particulate matter, is cloudy, or discolored
    - Store at room temperature (between 59 to 86 degrees F)
    4-Way Saline:
    - Store at room temperature (between 59 to 86 degrees F)
    Adsorbonac:
    - Store at controlled room temperature (between 68 and 77 degrees F)
    Altamist:
    - Storage information not available
    Ayr Baby Saline:
    - Storage information not available
    Ayr Saline Nasal:
    - Storage information not available
    BD Posiflush Normal Saline:
    - Discard product if it contains particulate matter, is cloudy, or discolored
    - Discard unused portion. Do not store for later use.
    - Store at room temperature (between 59 to 86 degrees F)
    - Store in original unopened pouch
    BD Posiflush Sterile Field Normal Saline:
    - Discard product if it contains particulate matter, is cloudy, or discolored
    - Discard unused portion. Do not store for later use.
    - Store at room temperature (between 59 to 86 degrees F)
    - Store in original unopened pouch
    BD Posiflush SureScrub Normal Saline:
    - Discard product if it contains particulate matter, is cloudy, or discolored
    - Discard unused portion. Do not store for later use.
    - Store at room temperature (between 59 to 86 degrees F)
    - Store in original unopened pouch
    Blairex Broncho Saline:
    - Store at room temperature (between 59 to 86 degrees F)
    Breathe Free Saline:
    - Storage information not available
    Deep Sea :
    - Storage information not available
    Entsol:
    - Protect from direct sunlight
    - Store at room temperature (between 59 to 86 degrees F)
    HyperSal:
    - Avoid exposure to heat
    - Discard unused portion. Do not store for later use.
    - Protect from freezing
    - Store at room temperature (between 59 to 86 degrees F)
    Hyper-Sal:
    - Avoid exposure to heat
    - Discard unused portion. Do not store for later use.
    - Protect from freezing
    - Store at room temperature (between 59 to 86 degrees F)
    Hypertears:
    - Discard product if it contains particulate matter, is cloudy, or discolored
    - Do not freeze
    - Store between 59 to 77 degrees F
    Little Remedies for Noses:
    - Avoid excessive heat (above 104 degrees F)
    - Avoid exposure to heat
    - Store between 68 to 77 degrees F
    Monoject Prefill Advanced Heparin Lock Flush:
    - Protect from freezing
    - Store between 68 to 77 degrees F, excursions permitted 59 to 86 degrees F
    Muro 128:
    - Store at controlled room temperature (between 68 and 77 degrees F)
    NebuSal :
    - Avoid excessive heat (above 104 degrees F)
    - Discard unused portion. Do not store for later use.
    - Protect from freezing
    - Store at room temperature not exceeding 86 degrees F
    Ocean:
    - Storage information not available
    Ocean Complete:
    - Do Not Store at Temperatures Above 120 degrees F (49 degrees C)
    - Store at controlled room temperature (between 68 and 77 degrees F)
    - Store away from excessive heat and cold
    Rhinaris:
    - Protect from freezing
    Rhinaris Lubricating:
    - Storage information not listed
    Saljet :
    - Discard product if it contains particulate matter, is cloudy, or discolored
    - Discard unused portion. Do not store for later use.
    Saljet Rinse:
    - Discard product if it contains particulate matter, is cloudy, or discolored
    - Discard unused portion. Do not store for later use.
    SaltAire:
    - Storage information not listed
    Sea Soft:
    - Storage information not available
    Wound Wash:
    - Avoid excessive heat (above 104 degrees F)
    - Do Not Store at Temperatures Above 120 degrees F (49 degrees C)

    CONTRAINDICATIONS / PRECAUTIONS

    Cardiac disease, diabetic ketoacidosis, edema, heart failure, hyperaldosteronism, hyperchloremia, hypernatremia, hypertension, hypervolemia, metabolic acidosis, renal artery stenosis, renal disease, renal failure, renal impairment

    Use sodium chloride with great caution in patients with pre-existing hypernatremia, hyperchloremia, metabolic acidosis, or risk factors for such conditions. Intravenous solutions should be used with particular care in patients at risk for hypervolemia or other conditions that may cause sodium retention and fluid overload such as patients with primary or secondary hyperaldosteronism. In patients with cardiac disease sodium chloride administration and subsequent sodium retention may exacerbate hypertension, edema, and heart failure. In addition, because sodium chloride is primarily excreted by the kidney, administration to patients with renal disease, including renal artery stenosis, nephrosclerosis, renal impairment, or renal failure may result in significant sodium and chloride retention. During fluid resuscitation, rapid infusion of a large volume of fluid in patients with hypoxia and/or compromised cardiac or renal function may result in decreased cardiac output and pulmonary edema. Additionally, patients with diabetic ketoacidosis may be at risk for cerebral edema after rapid administration of a crystalloid (e.g., normal saline). In such incidences, smaller fluid boluses and/or longer administration times are appropriate. It is recommended to avoid routine volume expansion in newborns without evidence of acute blood loss. Monitor fluid balance, electrolyte concentrations, and acid base balance during prolonged therapy or whenever the patient or dosage and/or rate of administration warrants such evaluation. In patients with organ dysfunction, monitor respiratory status and tissue perfusion, as well as changes in clinical condition.

    Alcoholism, females, hyponatremia, hypoxemia, malnutrition

    To avoid sodium and/or water toxicity, it is essential to correct hyponatremia at an appropriate rate. In addition, central pontine myelinolysis (CPM), a noninflammatory demyelinating condition, can occur when hyponatremia is corrected too quickly. In general, serum sodium should not increase by more than 10—12 mEq/L in the first 24 hours and 18 mEq/L in the first 48 hours; an even slower rate of correction may be appropriate for the neonatal population. Patients with severe malnutrition, alcoholism, or advanced liver disease may be more susceptible to CPM and sodium replacement therapy should be tailored to stay well below established limits. In addition, administration of hypotonic sodium chloride solutions in pediatric patients, particularly in the presence of dehydration or in the post-operative or critical care setting, may result in significant dilutional hyponatremia, encephalopathy, and death. Risk for developing hyponatremia is also increased in females, those with psychogenic polydipsia, and those who are receiving concurrent medications that increase the risk of low serum sodium. Patients with hypoxemia and those with underlying central nervous system disease are at risk for developing hyponatremic encephalopathy. Women (particularly pre-menopausal) are also at higher risk. Monitor daily weights, fluid balance, and serum sodium concentrations closely in patients receiving parenteral fluid therapy.

    Hepatic disease

    Carefully consider fluid status in hyponatremic patients with hepatic disease (e.g., cirrhosis) before using sodium chloride supplementation. Water retention and dilutional hyponatremia are common in patients with advanced disease and should be treated with sodium and fluid restriction, as well as diuretics. Sodium supplementation may aggravate edema. In addition, patients with advanced liver disease may be more susceptible to central pontine myelinolysis (CPM); sodium replacement therapy should be tailored to stay well below established limits.

    Hemolysis

    Hemolysis of red blood cells can occur during the infusion of hypotonic solutions. In the presence of a hypotonic fluid, water enters the red blood cells across a diffusion gradient, causing the cells to swell and burst. After lysis, the intracellular contents of the cells (e.g., potassium, phosphate) are released into the extracellular space, resulting in hyperkalemia and potentially cardiac arrhythmias and death. Because of this phenomenon, isotonic or near-isotonic solutions are preferred for fluid administration. For intravenous fluids, isotonicity is defined as a solution that has equal osmotic pressure to that of the serum (285—295 mOsm/L). Normal saline (0.9% sodium chloride) contains 308 mOsm/L and is considered isotonic. In contrast, 0.45% sodium chloride (154 mOsm/L) and 0.225% sodium chloride (77 mOsm/L) are hypotonic. Hypotonic solutions should never be used for fluid resuscitation or rehydration; however, they are sometimes used in patients with high serum osmolarity (e.g., hypernatremia, diabetic ketoacidosis) in carefully monitored clinical settings. Additionally, hypotonic saline solutions offer a maintenance infusion option with less sodium content, which may be desirable in specific circumstances (e.g., in the neonatal population). However, the most hypotonic fluid that can be safely administered is 0.45% sodium chloride (154 mOsm/L); solutions with an osmolarity less than this are not recommended. The risk of hemolysis increases as the tonicity decreases ; of the commercially available saline products, 0.225% sodium chloride carries the greatest risk of hemolysis with infusion. Mixing hypotonic saline solutions with dextrose increases their tonicity and makes the overall solution approach isotonicity, making it feasible to administer an intravenous infusion with a lower sodium content. For example, 0.225% sodium chloride with dextrose 5% has an osmolarity of 329 mOsm/L. Because hemolysis is accentuated by an increased ratio of hypotonic solution to blood and prolonged cell contact time with the solution, it has been suggested that administering hypotonic solutions at a slower rate or through a central line may decrease the risk of cell lysis; however, hemolysis can still occur with such precautionary measures and use of any hypotonic solution in patients should be used with extreme caution.
     

    Pregnancy

    According to the manufacturer, it is not known whether sodium chloride can cause fetal harm or affect reproduction capacity; only administer sodium chloride during pregnancy if it is clearly needed. However, normal saline (0.9% NaCl) has been used for dehydration reversal during pregnancy and are not expected to cause harm when used in the usual manner. Saline nasal preparations and topical solutions are safe for use during pregnancy.

    Breast-feeding

    According to the manufacturer, it is not known whether sodium chloride is excreted in human milk. Because 0.9% sodium chloride has equal osmotic pressure to that of the serum, osmosis across cellular membranes is minimal, and the risk of adverse effects during breast-feeding is small with the use of this isotonic solution. Use caution when using sodium chloride bacteriostatic injection, as the benzyl alcohol preservative is associated with the development of metabolic acidosis, kernicterus, and intraventricular hemorrhage in the neonatal population; bacteriostatic injection is contraindicated for direct use in the neonatal population. Consider the benefits of breast-feeding, the risk of potential infant drug exposure, and the risk of an untreated or inadequately treated condition. If a breast-feeding infant experiences an adverse effect related to a maternally ingested drug, healthcare providers are encouraged to report the adverse effect to the FDA.

    Neonates, premature neonates

    Maintaining appropriate fluid and sodium balance can be very challenging for some neonates, especially those born prematurely. Aggressive fluid resuscitation in neonates, particularly premature neonates, may cause rapid volume expansion and has been associated with intraventricular hemorrhage. Premature neonates less than 30 weeks gestational age should receive fluid resuscitation with 0.9% sodium chloride over a longer duration of time. Bacteriostatic sodium chloride products contain benzyl alcohol and are contraindicated in neonates; if a sodium chloride solution is required for preparing medications or intravascular flush, only preservative-free injection should be used.

    Requires an experienced clinician

    Rapid correction of hypo- or hypernatremia requires an experienced clinician. Due to the risk of serious neurologic complications, dosage, rate, and duration of administration should be determined by a physician experienced in intravenous fluid therapy.

    Visual impairment

    Sodium chloride ophthalmic formulations (i.e., 2% and 5% ophthalmic solution and 5% ophthalmic ointment) have been associated with temporary ocular irritation and burning; however if ocular redness and irritation continue or if recipients experience ocular pain or changes in vision (i.e., visual impairment), use of the drugs should be discontinued.

    Geriatric

    There are no data to determine if geriatric patients respond differently to sodium chloride compared to younger patients. However, sodium chloride is excreted by the kidney, and elderly patients are more likely to have decreased renal function. In general, dose selection for the elderly should be cautious and start at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, and cardiac function as well as concomitant disease or drug therapy. Monitor renal function in the elderly when receiving sodium chloride.

    ADVERSE REACTIONS

    Severe

    coma / Early / 0-1.0
    seizures / Delayed / 0-1.0
    central pontine myelinolysis / Delayed / 0-1.0
    bronchospasm / Rapid / Incidence not known
    increased intracranial pressure / Early / Incidence not known
    renal failure (unspecified) / Delayed / Incidence not known
    intraventricular hemorrhage / Delayed / Incidence not known
    pulmonary edema / Early / Incidence not known
    oliguria / Early / Incidence not known
    heart failure / Delayed / Incidence not known
    thrombosis / Delayed / Incidence not known
    visual impairment / Early / Incidence not known

    Moderate

    hemolysis / Early / Incidence not known
    hemoptysis / Delayed / Incidence not known
    hyperchloremic acidosis / Delayed / Incidence not known
    hyponatremia / Delayed / Incidence not known
    encephalopathy / Delayed / Incidence not known
    sodium retention / Delayed / Incidence not known
    hypernatremia / Delayed / Incidence not known
    edema / Delayed / Incidence not known
    hypokalemia / Delayed / Incidence not known
    dehydration / Delayed / Incidence not known
    hepatomegaly / Delayed / Incidence not known
    hypertension / Early / Incidence not known
    erythema / Early / Incidence not known
    phlebitis / Rapid / Incidence not known
    dyspnea / Early / Incidence not known
    hypotension / Rapid / Incidence not known
    sinus tachycardia / Rapid / Incidence not known
    chest pain (unspecified) / Early / Incidence not known
    infusion-related reactions / Rapid / Incidence not known

    Mild

    pharyngitis / Delayed / Incidence not known
    sneezing / Early / Incidence not known
    sinusitis / Delayed / Incidence not known
    cough / Delayed / Incidence not known
    hoarseness / Early / Incidence not known
    nausea / Early / Incidence not known
    anorexia / Delayed / Incidence not known
    weakness / Early / Incidence not known
    urticaria / Rapid / Incidence not known
    injection site reaction / Rapid / Incidence not known
    fever / Early / Incidence not known
    infection / Delayed / Incidence not known
    rash / Early / Incidence not known
    tremor / Early / Incidence not known
    chills / Rapid / Incidence not known
    pruritus / Rapid / Incidence not known
    flushing / Rapid / Incidence not known
    ocular irritation / Rapid / Incidence not known
    ocular pain / Early / Incidence not known

    DRUG INTERACTIONS

    Azelastine; Fluticasone: (Moderate) Concomitant use of systemic sodium chloride, especially at high doses, and corticosteroids may result in sodium and fluid retention. Assess sodium chloride intake from all sources, including intake from sodium-containing intravenous fluids and antibiotic admixtures. Carefully monitor sodium concentrations and fluid status if sodium-containing drugs and corticosteroids must be used together.
    Beclomethasone: (Moderate) Concomitant use of systemic sodium chloride, especially at high doses, and corticosteroids may result in sodium and fluid retention. Assess sodium chloride intake from all sources, including intake from sodium-containing intravenous fluids and antibiotic admixtures. Carefully monitor sodium concentrations and fluid status if sodium-containing drugs and corticosteroids must be used together.
    Benzalkonium Chloride: (Major) Sodium chloride (saline solutions) should not be used to dilute benzalkonium chloride as saline solutions may decrease the antibacterial potency of the antiseptic. Stored tap water should also not be used for dilution since it may contain microorganisms. Resin deionized water may also contain pathogens and it may inactivate benzalkonium chloride.
    Betamethasone: (Moderate) Concomitant use of systemic sodium chloride, especially at high doses, and corticosteroids may result in sodium and fluid retention. Assess sodium chloride intake from all sources, including intake from sodium-containing intravenous fluids and antibiotic admixtures. Carefully monitor sodium concentrations and fluid status if sodium-containing drugs and corticosteroids must be used together.
    Budesonide: (Moderate) Concomitant use of systemic sodium chloride, especially at high doses, and corticosteroids may result in sodium and fluid retention. Assess sodium chloride intake from all sources, including intake from sodium-containing intravenous fluids and antibiotic admixtures. Carefully monitor sodium concentrations and fluid status if sodium-containing drugs and corticosteroids must be used together.
    Budesonide; Formoterol: (Moderate) Concomitant use of systemic sodium chloride, especially at high doses, and corticosteroids may result in sodium and fluid retention. Assess sodium chloride intake from all sources, including intake from sodium-containing intravenous fluids and antibiotic admixtures. Carefully monitor sodium concentrations and fluid status if sodium-containing drugs and corticosteroids must be used together.
    Ciclesonide: (Moderate) Concomitant use of systemic sodium chloride, especially at high doses, and corticosteroids may result in sodium and fluid retention. Assess sodium chloride intake from all sources, including intake from sodium-containing intravenous fluids and antibiotic admixtures. Carefully monitor sodium concentrations and fluid status if sodium-containing drugs and corticosteroids must be used together.
    Corticosteroids: (Moderate) Concomitant use of systemic sodium chloride, especially at high doses, and corticosteroids may result in sodium and fluid retention. Assess sodium chloride intake from all sources, including intake from sodium-containing intravenous fluids and antibiotic admixtures. Carefully monitor sodium concentrations and fluid status if sodium-containing drugs and corticosteroids must be used together.
    Corticotropin, ACTH: (Moderate) Concomitant use of systemic sodium chloride, especially at high doses, and corticosteroids may result in sodium and fluid retention. Assess sodium chloride intake from all sources, including intake from sodium-containing intravenous fluids and antibiotic admixtures. Carefully monitor sodium concentrations and fluid status if sodium-containing drugs and corticosteroids must be used together.
    Cortisone: (Moderate) Concomitant use of systemic sodium chloride, especially at high doses, and corticosteroids may result in sodium and fluid retention. Assess sodium chloride intake from all sources, including intake from sodium-containing intravenous fluids and antibiotic admixtures. Carefully monitor sodium concentrations and fluid status if sodium-containing drugs and corticosteroids must be used together.
    Deflazacort: (Moderate) Concomitant use of systemic sodium chloride, especially at high doses, and corticosteroids may result in sodium and fluid retention. Assess sodium chloride intake from all sources, including intake from sodium-containing intravenous fluids and antibiotic admixtures. Carefully monitor sodium concentrations and fluid status if sodium-containing drugs and corticosteroids must be used together.
    Dexamethasone: (Moderate) Concomitant use of systemic sodium chloride, especially at high doses, and corticosteroids may result in sodium and fluid retention. Assess sodium chloride intake from all sources, including intake from sodium-containing intravenous fluids and antibiotic admixtures. Carefully monitor sodium concentrations and fluid status if sodium-containing drugs and corticosteroids must be used together.
    Fludrocortisone: (Moderate) Concomitant use of systemic sodium chloride, especially at high doses, and corticosteroids may result in sodium and fluid retention. Assess sodium chloride intake from all sources, including intake from sodium-containing intravenous fluids and antibiotic admixtures. Carefully monitor sodium concentrations and fluid status if sodium-containing drugs and corticosteroids must be used together.
    Flunisolide: (Moderate) Concomitant use of systemic sodium chloride, especially at high doses, and corticosteroids may result in sodium and fluid retention. Assess sodium chloride intake from all sources, including intake from sodium-containing intravenous fluids and antibiotic admixtures. Carefully monitor sodium concentrations and fluid status if sodium-containing drugs and corticosteroids must be used together.
    Fluticasone: (Moderate) Concomitant use of systemic sodium chloride, especially at high doses, and corticosteroids may result in sodium and fluid retention. Assess sodium chloride intake from all sources, including intake from sodium-containing intravenous fluids and antibiotic admixtures. Carefully monitor sodium concentrations and fluid status if sodium-containing drugs and corticosteroids must be used together.
    Fluticasone; Salmeterol: (Moderate) Concomitant use of systemic sodium chloride, especially at high doses, and corticosteroids may result in sodium and fluid retention. Assess sodium chloride intake from all sources, including intake from sodium-containing intravenous fluids and antibiotic admixtures. Carefully monitor sodium concentrations and fluid status if sodium-containing drugs and corticosteroids must be used together.
    Fluticasone; Umeclidinium; Vilanterol: (Moderate) Concomitant use of systemic sodium chloride, especially at high doses, and corticosteroids may result in sodium and fluid retention. Assess sodium chloride intake from all sources, including intake from sodium-containing intravenous fluids and antibiotic admixtures. Carefully monitor sodium concentrations and fluid status if sodium-containing drugs and corticosteroids must be used together.
    Fluticasone; Vilanterol: (Moderate) Concomitant use of systemic sodium chloride, especially at high doses, and corticosteroids may result in sodium and fluid retention. Assess sodium chloride intake from all sources, including intake from sodium-containing intravenous fluids and antibiotic admixtures. Carefully monitor sodium concentrations and fluid status if sodium-containing drugs and corticosteroids must be used together.
    Formoterol; Mometasone: (Moderate) Concomitant use of systemic sodium chloride, especially at high doses, and corticosteroids may result in sodium and fluid retention. Assess sodium chloride intake from all sources, including intake from sodium-containing intravenous fluids and antibiotic admixtures. Carefully monitor sodium concentrations and fluid status if sodium-containing drugs and corticosteroids must be used together.
    Hydrocortisone: (Moderate) Concomitant use of systemic sodium chloride, especially at high doses, and corticosteroids may result in sodium and fluid retention. Assess sodium chloride intake from all sources, including intake from sodium-containing intravenous fluids and antibiotic admixtures. Carefully monitor sodium concentrations and fluid status if sodium-containing drugs and corticosteroids must be used together.
    Lithium: (Moderate) Moderate to significant dietary sodium changes, or changes in sodium and fluid intake, may affect lithium excretion. Systemic sodium chloride administration may result in increased lithium excretion and therefore, decreased serum lithium concentrations. In addition, high fluid intake may increase lithium excretion. For patients receiving sodium-containing intravenous fluids, symptom control and lithium concentrations should be carefully monitored. It is recommended that patients taking lithium maintain consistent dietary sodium consumption and adequate fluid intake during the initial stabilization period and throughout lithium treatment. Supplemental oral sodium and fluid should be only be administered under careful medical supervision.
    Methylprednisolone: (Moderate) Concomitant use of systemic sodium chloride, especially at high doses, and corticosteroids may result in sodium and fluid retention. Assess sodium chloride intake from all sources, including intake from sodium-containing intravenous fluids and antibiotic admixtures. Carefully monitor sodium concentrations and fluid status if sodium-containing drugs and corticosteroids must be used together.
    Mometasone: (Moderate) Concomitant use of systemic sodium chloride, especially at high doses, and corticosteroids may result in sodium and fluid retention. Assess sodium chloride intake from all sources, including intake from sodium-containing intravenous fluids and antibiotic admixtures. Carefully monitor sodium concentrations and fluid status if sodium-containing drugs and corticosteroids must be used together.
    Prednisolone: (Moderate) Concomitant use of systemic sodium chloride, especially at high doses, and corticosteroids may result in sodium and fluid retention. Assess sodium chloride intake from all sources, including intake from sodium-containing intravenous fluids and antibiotic admixtures. Carefully monitor sodium concentrations and fluid status if sodium-containing drugs and corticosteroids must be used together.
    Prednisone: (Moderate) Concomitant use of systemic sodium chloride, especially at high doses, and corticosteroids may result in sodium and fluid retention. Assess sodium chloride intake from all sources, including intake from sodium-containing intravenous fluids and antibiotic admixtures. Carefully monitor sodium concentrations and fluid status if sodium-containing drugs and corticosteroids must be used together.
    Tolvaptan: (Moderate) Coadministration of tolvaptan and hypertonic saline (e.g., 3% NaCl injection solution) is not recommended. The use of hypertonic sodium chloride in combination with tolvaptan may result in a too rapid correction of hyponatremia and increase the risk of osmotic demyelination (i.e., central pontine myelinolysis).
    Triamcinolone: (Moderate) Concomitant use of systemic sodium chloride, especially at high doses, and corticosteroids may result in sodium and fluid retention. Assess sodium chloride intake from all sources, including intake from sodium-containing intravenous fluids and antibiotic admixtures. Carefully monitor sodium concentrations and fluid status if sodium-containing drugs and corticosteroids must be used together.

    PREGNANCY AND LACTATION

    Pregnancy

    According to the manufacturer, it is not known whether sodium chloride can cause fetal harm or affect reproduction capacity; only administer sodium chloride during pregnancy if it is clearly needed. However, normal saline (0.9% NaCl) has been used for dehydration reversal during pregnancy and are not expected to cause harm when used in the usual manner. Saline nasal preparations and topical solutions are safe for use during pregnancy.

    According to the manufacturer, it is not known whether sodium chloride is excreted in human milk. Because 0.9% sodium chloride has equal osmotic pressure to that of the serum, osmosis across cellular membranes is minimal, and the risk of adverse effects during breast-feeding is small with the use of this isotonic solution. Use caution when using sodium chloride bacteriostatic injection, as the benzyl alcohol preservative is associated with the development of metabolic acidosis, kernicterus, and intraventricular hemorrhage in the neonatal population; bacteriostatic injection is contraindicated for direct use in the neonatal population. Consider the benefits of breast-feeding, the risk of potential infant drug exposure, and the risk of an untreated or inadequately treated condition. If a breast-feeding infant experiences an adverse effect related to a maternally ingested drug, healthcare providers are encouraged to report the adverse effect to the FDA.

    MECHANISM OF ACTION

    Sodium is the principle cation of the extracellular fluid, while chloride is the principle anion. Both ions are physiologically important. Sodium functions as the primary osmotic determinant in extracellular fluid regulation and tissue hydration. Additionally, sodium regulates the membrane potential of cells and the active transport of molecules across cell membranes. Chloride is also responsible for maintaining fluid balance, but it is also essential in the maintenance of acid-base balance. Low plasma chloride levels cause an increase in bicarbonate, producing alkalosis. Sodium is a unique electrolyte because, in general, water balance is directly related to its concentration. High sodium concentrations and an increase is plasma osmolality stimulates mechanisms that increase the water content of the body, such as increased thirst and increased antidiuretic hormone (ADH) secretion, which leads to renal conservation of water. During hyponatremia, the decrease in plasma osmolality stops ADH secretion; therefore, renal water excretion leads to an increase in sodium concentration. Although sodium and water balance is usually regulated by osmolality, volume depletion also stimulates thirst and ADH secretion; ADH secretion is triggered even if the patient is hyponatremic.
     
    For use as IV fluids:
    Isotonic IV fluids have an osmotic pressure that is approximately equal to that of serum (285—295 mOsm/L). Normal saline (0.9% NaCl) has an osmolality of 308 mOsm/L and is considered isotonic. In contrast, 0.45% NaCl (154 mOsm/L) and 0.225% NaCl (77 mOsm/L) are hypotonic. The initial goal of treating dehydration and shock is to restore intravascular volume, which improves perfusion to critical organs. Because 0.9% NaCl is isotonic, administered fluid remains in the extracellular compartment (comprised of interstitial and intravascular spaces) where it helps restore blood volume and supports peripheral perfusion. Hypotonic solutions should not be used for initial fluid resuscitation because a significant portion of the administered fluid distributes outside the intravascular compartment. Hypotonic solutions are sometimes used in patients with high serum osmolarity (e.g., hypernatremia, diabetic ketoacidosis). In addition, hypotonic saline solutions offer a maintenance infusion option with less sodium content, which is desirable in certain patient populations. However, the most hypotonic fluid that can be safely administered without risking cell lysis is 0.45% NaCl (154 mOsm/L). Mixing hypotonic saline solutions with dextrose or other electrolytes increases their tonicity and makes the overall solution approach isotonicity, making it feasible to administer an intravenous infusion with a lower sodium content.
     
    For the reduction of increased intracranial pressure:
    In patients with head trauma, administration of intravenous hypertonic NaCl (e.g., 3% NaCl) reduces intracranial pressure by creating an osmotic gradient across the blood-brain barrier. Penetration of sodium across the blood-brain-barrier is low, which results in water passively diffusing into the intravascular space. This reduction of fluid with in the cerebral tissue decreases intracranial volume, cerebral edema, and intracranial pressure. Other theoretical benefits involved in the reduction of intracranial pressure include restoration of normal cellular resting membrane potential and cell volume, stimulation of arterial natriuretic peptide release, inhibition of inflammation, and enhancement of cardiac output.
     
    To increase hydration of viscous respiratory secretions:
    Local application of NaCl to the respiratory epithelium creates an osmotic gradient, allowing water to diffuse onto the airway surface and rehydrate the periciliary fluid. In patients with cystic fibrosis, orally inhaled hypertonic saline (e.g., 6—7% NaCl) has been proposed to increase the hydration of airway secretions, which enhances mucociliary clearance and improves sputum expectoration, reducing the risk of infection and progressive airway destruction. Though the exact mechanism is unknown, osmotic hydration, disruption of mucus strand cross-linking, and reduction of mucosal edema may facilitate such improvement.

    PHARMACOKINETICS

    Sodium chloride is administered orally, intravenously, via inhalation, intranasally, and topically to the eye. Sodium chloride distributes primarily to extracellular compartments, including plasma and interstitial fluid; sodium is maintained outside the cell via the Na+/K+-ATPase pump, which exchanges intracellular sodium for extracellular potassium. Penetration across the blood-brain barrier is low. Sodium chloride is excreted primarily in the urine, but it is also excreted in sweat and stool. In healthy patients at steady state with minimal sweat losses, sodium excreted in urine is roughly the same as dietary intake. Sweat sodium concentration is increased in children with cystic fibrosis, aldosterone deficiency, or pseudohypoaldosteronism.
     
    Affected cytochrome P450 isoenzymes: none

    Oral Route

    Approximately 98% of sodium chloride is absorbed in the small intestine. The presence of glucose enhances sodium absorption, providing rationale for including glucose and sodium in oral rehydration solutions.