Antidiarrhoeals and Laxatives

the same amounts over 30 min and 2.5 h respectively). If the intravenous route is unavailable, a nasogastric tube is also suitable for administering oral rehydration solution, at a rate of 20 ml/kg every h. If the child vomits, the rate of administration of the oral solution should be reduced.

Oral Rehydration Salts*

Indications Availability Dehydration from acute diarrhoea. GLUCOSE SALT SOLUTION 5 and 37.5g. Sodium chloride Sodium citrate Potassium chloride 2.6 g/litre of water 2.9 g/litre of water 1.5 g/litre of water

Glucose (anhydrous) 13.5 g/litre of water When glucose and sodium citrate are not available, they may be replaced by Sucrose (common sugar) 27 g/litre of water Sodium bicarbonate 2.5 g/litre of water In cases of cholera, oral rehydration salts containing a higher concentration of sodium may be required to prevent hyponatraemia. Note: The solution may be prepared either from prepackaged sugar/salt mixtures or from bulk substances and water. Solutions must be freshly prepared, preferably with recently boiled and cooled water. Accurate weighing and thorough mixing and dissolution of ingredients in the correct volume of clean water is important. Administration of more concentrated solutions can result in hypernatraemia. Dose Oral 5g (single use): dissolve in water and drink; 37.5g: to reconstitute it with 1 litre of clean water.
Adult- Fluid and electrolyte loss in acute diarrhoea; 200 to 400 ml solution after every loose motion.

Precautions Adverse Effects

Renal impairment.
Vomiting-

may indicate too rapid administration; hypernatraemia and hyperkalaemia may result from overdose in renal impairment or administration of too concentrated a solution.

NFI-2011

78

Solutions Correcting Water, Electrolyte and Acid Base Disturbances

Dose

Initial dose- 4 ml/kg at a rate of 15 min can be given in case of impending herniation. Continuous infusion of 3% NaCl ranging between 0.1 and 1.0 ml/kg/hour (Administered on a sliding scale if ICP monitoring available to maintain ICP <20).

Precautions

If serum osmalarity >320 -mannitol of little use may be harmful, given along with mannitol if no response in 3-6 hours, monitor serum sodium levels. Hyperchloremic metabolic acidosis; acute renal failure; subarachnoid hemorrhage; central pontine myelinosis; coagulopathies disorder; pulmonary edema; congestive heart failure due to overload; hypokalemia; hemolysis; phlebitis; rebound cerebral edema.

Adverse Effects

Potassium Chloride*
Pregnancy Category-C Indications Availability Dose Electrolyte imbalance; hypokalaemia. INJECTION 10 ml ampoule (11.2%w/v). Slow Intravenous infusion Adult and Child- Electrolyte imbalance; depending on the deficit or the daily maintenance requirements. Contraindications Plasma-potassium concentrations above 5mmol/litre; chronic renal failure; systemic acidosis; acute dehydration; adrenal insufficiency. For intravenous infusion the concentration of solution should not usually exceed 3.2g (43 mmol)/litre; specialist advice and ECG monitoring (see notes above); renal impairment; interactions (Appendix 6d); pregnancy (Appendix 7c); acute alkalosis, paediatric use. Cardiac toxicity on rapid infusion; nausea, vomiting, flatulence, diarrhoea. Store in a single dose container at a temperature not exceeding 30C.

Precautions

Adverse Effects Storage

Sodium Bicarbonate*
Pregnancy Category-C Indications Metabolic acidosis; cardiopulmonary resuscitation; hyperkalaemia; muscle spasm.

597

NFI-2011

Appendix 2: Calculation of Electrolytes

Milliequivalents
The milliequivalent is related to the total number of ionic charges in solution and it takes note of the valency of the ions. In other words, it is a unit of measurement of the amount of chemical activity of an electrolyte. The total concentration of cations always equals the total concentration of anions. A milliequivalent (mEq) weight is 1/1000 of the equivalent weight. An equivalent weight of an element is the atomic weight expressed in grams, divided by its valency.
1mEq = atomic weight in mg valency 23 1 = 35.5 mg = 23 mg

e.g. 1 mEq Na+ = 35.5 1

1 mEq Cl- =

Thus, a solution containing 1 mEq of Sodium per litre contains 23 mg Sodium. A solution containing 1 mEq of Sodium Chloride contains 23 mg Na+ and 35.5 mg Cl-, i.e. 58.5 mg Sodium Chloride per litre. In a salt containing ions of different valencies, Weight of a salt Sum of the atomic weights (valency containing 1 mEq = of the specified ion) x no. of speciof specified ion fied ions in molecule e.g. Weight of magnesium chloride ( mgCl2.6H2O) required to prepare a solution containing 1 mEq of magnesium per litre.
= 101.7 mg mgCl2.6H2O 2x1 For the conversion of grams per 100 ml (percentage) of a solution to mEq/litre, the following formula may be used. mEq per litre = percentage strength x 10000 mg of salt containing 1 mEq of specified ions 24.3 + (2 x 35.5) + 6[(2 x 1) + 16]

e.g. Number of mEq of Na+ per litre contained in Sodium Chloride injection 0.9% (1mEq Sodium is contained in 58.5 mg Sodium Chloride) NFI-2011 628

Appendix 2
mEq per litre of Na in Sodium Chloride 0.9% solution =
+

0.9 x 10,000 58.5

= 154 approximately

mEq =

Wt (g) mEq weight (g)

e.g. mEq in 5g of Potassium Chloride (atomic weight of Potassium Chloride = 74.6, valency = 1)
mEq Wt = mEq = 74.6 1000 5 0.0746 = = 0.0746 1 67 approximately

To convert mg per 100 ml ( mg%) to mEq per litre, the following formula is used : mg. per 100 ml. x 10 x valency atomic weight = mEq. per litre

In the case of gases (i.e. carbon dioxide) the volume per cent of the gas is multiplied by 10 and divided by 22.4, the later figure being the volume in litres occupied by a molecular weight of a gas. The results are expressed in millimoles per litre. vol. percent x 10 22.4 = mM. per litre

To convert mg per 100 ml ( mg%) to milliosmoles: mg. per 100 ml x 10 molecular weight = mOsm per litre

Table 1: Atomic weight, Valency, and Normal Ranges of the Common Electrolytes Normal Ranges, Plasma or Serum Electrolyte Na NaCl K Ca (total) Ca (ionized)
2+

Atomic Weight 23 58.5 39 40 40 24

Valency 1 1 1 1 1 2

mg. per 100 ml 310-34 570-620 16-22 9.1-11.5 4.25-5.25 1.8-3.6

mEq. per litre 135-147 98-106 4.1-5.7 2.1-2.6 2.1-2.6 1.5-3.1

mg

629

NFI-2011

Appendix 2
(HCO3)(mM. Co2) Infants Use formula for gases. 55-70 45-60 (vol. percent) Cl NH4 Cl SO4235.5 1 350-375 Contains 66.28 per-cent of Cl. 96 2 0.5-2.5 0.3-1.5 25-31 20-2 (mM/L) 98-106

Table 2: mg of a salt containing 1 mEq of a specified ion Ion weight of mEq in mg 20.0 Salt mg of salt containing 1 mEq of the specified ion 147 224 154 74.5 108 123 136 131 84 58.5 98

Ca++

Calcium Chloride, CaCl2,2H2O Calcium Gluconate, C12H22CaO14,H2O Calcium Lactate, C6H10 CaO6,5H2O Potassium Chloride, KCI Potassium Citrate, C6H5K3O7,H2O Magnesium Sulphate, mgSO4,7H2O Sodium Acetate, C2H3NaO2,3H2O Sodium Acid Citrate, C6H6Na2O7,1H2O Sodium Bicarbonate, NaHCO3 Sodium Chloride, NaCI Sodium Citrate, C6H5Na3O7,2H2O Sodium Lactate* Calcium Chloride, CaCI2,2H2O Potassium Chloride, KCI Sodium Chloride, NaCI Sodium Acetate, C2H3NaO2,3H2O

K+

39.1

mg++ Na
+

12.5 23.0

CI

35.5

73.5 74.5 58.5 136

C2H3O2 (Acetate)

59.0

NFI-2011

630

Appendix 2
C3H5O3 (Lactate) HCO389.0 Calcium Lactate, C6H10CaO6,5H2O Sodium Lactate* Sodium Bicarbonate, NaHCO3 308.3

61.0

84

*Prepared in solution by neutralising lactic acid with sodium hydroxide: 1.0 ml of 1 M sodium contains the equivalent of 112 mg.

631

NFI-2011

594

9.2 Fluids and electrolytes

BNF 61
in this section. Oral preparations for removing excess potassium and preparations for oral rehydration therapy are also included here. Oral bicarbonate, for metabolic acidosis, is also described in this section. For reference to calcium, magnesium, and phosphate, see section 9.5.

9.2

Fluids and electrolytes

9.2.1 Oral preparations for uid and electrolyte imbalance 9.2.2 Parenteral preparations for uid and electrolyte imbalance The following tables give a selection of useful electrolyte values:

9.2.1.1 Oral potassium

Compensation for potassium loss is especially necessary: . in those taking digoxin or anti-arrhythmic drugs, where potassium depletion may induce arrhythmias; . in patients in whom secondary hyperaldosteronism occurs, e.g. renal artery stenosis, cirrhosis of the liver, the nephrotic syndrome, and severe heart failure; . in patients with excessive losses of potassium in the faeces, e.g. chronic diarrhoea associated with intestinal malabsorption or laxative abuse. Measures to compensate for potassium loss may also be required in the elderly since they frequently take inadequate amounts of potassium in the diet (but see below for warning on renal insufciency). Measures may also be required during long-term administration of drugs known to induce potassium loss (e.g. corticosteroids). Potassium supplements are seldom required with the small doses of diuretics given to treat hypertension; potassium-sparing diuretics (rather than potassium supplements) are recommended for prevention of hypokalaemia due to diuretics such as furosemide or the thiazides when these are given to eliminate oedema.

Electrolyte concentrationsintravenous uids

Millimoles per litre Intravenous infusion Normal plasma values Sodium Chloride 0.9% Compound Sodium Lactate (Hartmanns) Sodium Chloride 0.18% and Glucose 4% Potassium Chloride 0.3% and Glucose 5% Na+ K+ HCO3 Cl Ca2 2.5 2

142 4.5 150 131 30 5

26 103 150 29 111 30

150

40 40

40

9 Nutrition and blood

Potassium Chloride 0.3% and Sodium Chloride 0.9%

190

To correct metabolic acidosis Sodium Bicarbonate 1.26% 150 150 1000 167

Sodium Bicarbonate 1000 8.4% for cardiac arrest Sodium Lactate (m/6) 167

Dosage If potassium salts are used for the prevention

Electrolyte contentgastro-intestinal secretions

Type of uid Gastric Biliary Pancreatic Small bowel Millimoles per litre H+ 4060 Na+ 2080 K+ 520 HCO3 Cl 100150 80120 4080 90130

120140 515 3050 120140 515 70110 120140 515 2040

Faeces, vomit, or aspiration should be saved and analysed where possible if abnormal losses are suspected; where this is impracticable the approximations above may be helpful in planning replacement therapy

of hypokalaemia, then doses of potassium chloride 2 to 4 g (approx. 25 to 50 mmol) daily (in divided doses) by mouth are suitable in patients taking a normal diet. Smaller doses must be used if there is renal insufciency (common in the elderly) to reduce the risk of hyperkalaemia. Potassium salts cause nausea and vomiting and poor compliance is a major limitation to their effectiveness; when appropriate, potassium-sparing diuretics are preferable (see also above). Regular monitoring of plasma-potassium concentration is essential in those taking potassium supplements. When there is established potassium depletion larger doses may be necessary, the quantity depending on the severity of any continuing potassium loss (monitoring of plasma-potassium concentration and specialist advice would be required). Potassium depletion is frequently associated with chloride depletion and with metabolic alkalosis, and these disorders require correction.

9.2.1 Oral preparations for uid and electrolyte imbalance

9.2.1.1 Oral potassium 9.2.1.2 Oral sodium and water 9.2.1.3 Oral bicarbonate Sodium and potassium salts, which may be given by mouth to prevent deciencies or to treat established deciencies of mild or moderate degree, are discussed

Administration Potassium salts are preferably given

as a liquid (or effervescent) preparation, rather than modied-release tablets; they should be given as the chloride (the use of effervescent potassium tablets BPC 1968 should be restricted to hyperchloraemic states, section 9.2.1.3).
Salt substitutes A number of salt substitutes which contain signicant amounts of potassium chloride are readily available as health food products (e.g. LoSalt c and Ruthmol c ). These should not be used by patients with renal failure as potassium intoxication may result.

BNF 61

9.2.1 Oral preparations for uid and electrolyte imbalance

595

POTASSIUM CHLORIDE
Indications potassium depletion (see notes above) Cautions see notes above; cardiac disease; elderly; with modied-release preparations, intestinal stricture, history of peptic ulcer, hiatus hernia; interactions: Appendix 1 (potassium salts) Contra-indications plasma-potassium concentration above 5 mmol/litre Renal impairment close monitoring requiredrisk of hyperkalaemia; avoid in severe impairment Side-effects nausea, vomiting, abdominal pain, diarrhoea, atulence; with modied-release preparations, gastro-intestinal obstruction, ulceration and bleeding also reported Dose . See notes above
Note Do not confuse Effervescent Potassium Tablets BPC 1968 (section 9.2.1.3) with effervescent potassium chloride tablets. Effervescent Potassium Tablets BPC 1968 do not contain chloride ions and their use should be restricted to hyperchloraemic states (section 9.2.1.3).

Ion-exchange resins may be used to remove excess potassium in mild hyperkalaemia or in moderate hyperkalaemia when there are no ECG changes.

POLYSTYRENE SULPHONATE RESINS

Indications hyperkalaemia associated with anuria or severe oliguria, and in dialysis patients Cautions children (impaction of resin with excessive dosage or inadequate dilution); monitor for electrolyte disturbances (stop if plasma-potassium concentration below 5 mmol/litre); sodium-containing resin in congestive heart failure, hypertension, and oedema; interactions: Appendix 1 (polystyrene sulphonate resins) Contra-indications obstructive bowel disease; neonates with reduced gut motility; calcium-containing resin in hyperparathyroidism, multiple myeloma, sarcoidosis, or metastatic carcinoma Renal impairment use sodium-containing resin with caution Pregnancy manufacturers advise use only if potential benet outweighs riskno information available Breast-feeding manufacturers advise use only if potential benet outweighs riskno information available Side-effects faecal impaction following rectal administration, gastro-intestinal concretions following oral administration, intestinal necrosis reported with concomitant use of sorbitol, gastric irritation, anorexia, nausea, vomiting, constipation (discontinue treatmentavoid magnesium-containing laxatives), diarrhoea, hypomagnesaemia; gastro-intestinal obstruction, ulceration, necrosis, and ischaemic colitis also reported; with calcium-containing resin, hypercalcaemia (including in dialysed patients and occasionally in those with renal impairment); with sodiumcontaining resin, sodium retention, hypocalcaemia Dose . By mouth, 15 g 34 times daily in water (not fruit squash which has a high potassium content) or as a paste; CHILD 0.51 g/kg daily in divided doses . By rectum, as an enema, 30 g in methylcellulose solution, retained for 9 hours followed by irrigation to remove resin from colon; NEONATE and CHILD, 0.51 g/ kg daily Calcium Resonium c (Sano-Aventis) Powder, buff, calcium polystyrene sulphonate. Net price 300 g = 68.47. Label: 13 Resonium A c (Sano-Aventis) Powder, buff, sodium polystyrene sulphonate. Net price 454 g = 67.50. Label: 13

Kay-Cee-L c (Geistlich) Syrup, sugar-free, red, potassium chloride 7.5% (1 mmol/mL each of K+ and Cl ), net price 500 mL = 4.07. Label: 21 Sando-K c (HK Pharma) Tablets, effervescent, potassium bicarbonate and chloride equivalent to potassium 470 mg (12 mmol of K+) and chloride 285 mg (8 mmol of Cl ). Net price 20 = 1.53. Label: 13, 21 Modied-release preparations Avoid unless effervescent tablets or liquid preparations inappropriate Slow-K c (Alliance) U Tablets, m/r, orange, s/c, potassium chloride 600 mg (8 mmol each of K+ and Cl ), net price 100 = 2.14. Label: 25, 27, counselling, swallow whole with uid during meals while sitting or standing

9 Nutrition and blood

Management of hyperkalaemia
Acute severe hyperkalaemia (plasma-potassium concentration above 6.5 mmol/L or in the presence of ECG changes) calls for urgent treatment with 10 20 mL of calcium gluconate 10% by slow intravenous injection, titrated and adjusted to ECG improvement, to temporarily protect against myocardial excitability. An intravenous injection of soluble insulin (510 units) with 50 mL glucose 50% given over 515 minutes, reduces serum-potassium concentration; this is repeated if necessary or a continuous infusion instituted. Salbutamol [unlicensed indication], by nebulisation or slow intravenous injection may also reduce plasma-potassium concentration; it should be used with caution in patients with cardiovascular disease. The correction of causal or compounding acidosis with sodium bicarbonate infusion (section 9.2.2) should be considered (important: preparations of sodium bicarbonate and calcium salts should not be administered in the same linerisk of precipitation). Drugs exacerbating hyperkalaemia should be reviewed and stopped as appropriate; occasionally haemodialysis is needed.

9.2.1.2 Oral sodium and water

Sodium chloride is indicated in states of sodium depletion and usually needs to be given intravenously (section 9.2.2). In chronic conditions associated with mild or moderate degrees of sodium depletion, e.g. in salt-losing bowel or renal disease, oral supplements of sodium chloride or sodium bicarbonate (section 9.2.1.3), according to the acid-base status of the patient, may be sufcient.

598

9.2.2 Parenteral preparations for uid and electrolyte imbalance

BNF 61

Cautions restrict intake in impaired renal function, cardiac failure, hypertension, peripheral and pulmonary oedema, toxaemia of pregnancy Side-effects administration of large doses may give rise to sodium accumulation, oedema, and hyperchloraemic acidosis Dose . See notes above Sodium Chloride Intravenous Infusion (Non-proprietary) A

istration of glucose solutions without electrolytes can lead to hyponatraemia and other electrolyte disturbances. Average water requirements in a healthy adult are 1.5 to 2.5 litres daily and this is needed to balance unavoidable losses of water through the skin and lungs and to provide sufcient for urinary excretion. Water depletion (dehydration) tends to occur when these losses are not matched by a comparable intake, as may occur in coma or dysphagia or in the elderly or apathetic who may not drink enough water on their own initiative. Excessive loss of water without loss of electrolytes is uncommon, occurring in fevers, hyperthyroidism, and in uncommon water-losing renal states such as diabetes insipidus or hypercalcaemia. The volume of glucose solution needed to replace decits varies with the severity of the disorder, but usually lies within the range of 2 to 6 litres. Glucose solutions are also used to correct and prevent hypoglycaemia and to provide a source of energy in those too ill to be fed adequately by mouth; glucose solutions are a key component of parenteral nutrition (section 9.3). Glucose solutions are given in regimens with calcium and insulin for the emergency management of hyperkalaemia (see p. 595). They are also given, after correction of hyperglycaemia, during treatment of diabetic ketoacidosis, when they must be accompanied by continuing insulin infusion.

Intravenous infusion, usual strength sodium chloride 0.9% (9 g, 150 mmol each of Na+ and Cl /litre), this strength being supplied when normal saline for injection is requested. Net price 2-mL amp = 32p; 5mL amp = 38p; 10-mL amp = 52p; 20-mL amp = 1.04; 50-mL amp = 3.63
In hospitals, 500- and 1000-mL packs, and sometimes other sizes, are available Note The term normal saline should not be used to describe sodium chloride intravenous infusion 0.9%; the term physiological saline is acceptable but it is preferable to give the composition (i.e. sodium chloride intravenous infusion 0.9%).

With other ingredients Sodium Chloride and Glucose Intravenous Infusion

(Non-proprietary) A

Intravenous infusion, sodium chloride 0.18% (Na+ and Cl each 30 mmol/litre), glucose 4%
In hospitals, usually 500-mL packs and sometimes other sizes are available

9 Nutrition and blood

Intravenous infusion, sodium chloride 0.45% (Na+ and Cl each 75 mmol/litre), glucose 2.5%
In hospitals, usually 500-mL packs and sometimes other sizes are available

GLUCOSE
(Dextrose Monohydrate)
Note Glucose BP is the monohydrate but Glucose Intravenous Infusion BP is a sterile solution of anhydrous glucose or glucose monohydrate, potency being expressed in terms of anhydrous glucose

Intravenous infusion, sodium chloride 0.45% (Na+ and Cl each 75 mmol/litre), glucose 5%
In hospitals, usually 500-mL packs and sometimes other sizes are available

Intravenous infusion, sodium chloride 0.9% (Na+ and Cl each 150 mmol/litre), glucose 5%
In hospitals, usually 500-mL packs and sometimes other sizes are available Note See above for warning on hyponatraemia especially in children and elderly

Ringers Solution for Injection A Calcium chloride (dihydrate) 322 micrograms, potassium chloride 300 micrograms, sodium chloride 8.6 mg/mL, providing the following ions (in mmol/ litre), Ca2 2.2, K+ 4, Na+ 147, Cl 156
In hospitals, 500- and 1000-mL packs, and sometimes other sizes, are available

Indications uid replacement (see notes above), provision of energy (section 9.3); hypoglycaemia (section 6.1.4) Side-effects glucose injections especially if hypertonic may have a low pH and may cause venous irritation and thrombophlebitis Dose . Water replacement, see notes above; energy source, 13 litres daily of 2050% solution Glucose Intravenous Infusion (Non-proprietary) A Intravenous infusion, glucose or anhydrous glucose (potency expressed in terms of anhydrous glucose), usual strength 5% (50 mg/mL), 10% (100 mg/mL), and 20% (200 mg/mL); 20% solution, net price 20-mL amp = 2.04; 50% solution,1 20-mL amp = 95p, 50-mL vial = 2.13
In hospitals, 500- and 1000-mL packs, and sometimes other sizes and strengths, are available; also available as Minijet c Glucose, 50% in 50-mL disposable syringe1

Sodium Lactate Intravenous Infusion, Compound

(Non-proprietary) A

(Hartmanns Solution for Injection; Ringer-Lactate Solution for Injection) Intravenous infusion, sodium chloride 0.6%, sodium lactate 0.32%, potassium chloride 0.04%, calcium chloride 0.027% (containing Na+ 131 mmol, K+ 5 mmol, Ca2 2 mmol, HCO3 (as lactate) 29 mmol, Cl 111 mmol/litre)
In hospitals, 500- and 1000-mL packs, and sometimes other sizes, are available

1. A restriction does not apply where administration is for saving life in emergency

Intravenous potassium
Potassium chloride and sodium chloride intravenous infusion is the initial treatment for the correction of severe hypokalaemia and when sufcient potassium cannot be taken by mouth. Ready-mixed infusion solutions should be used when possible; alternatively, potassium chloride concentrate, as ampoules containing 1.5 g

Intravenous glucose
Glucose solutions (5%) are used mainly to replace water decit and should not be given alone except when there is no signicant loss of electrolytes; prolonged admin-

BNF 61

9.2.2 Parenteral preparations for uid and electrolyte imbalance

599

(K+ 20 mmol) in 10 mL, is thoroughly mixed with 500 mL of sodium chloride 0.9% intravenous infusion and given slowly over 2 to 3 hours, with specialist advice and ECG monitoring in difcult cases. Higher concentrations of potassium chloride may be given in very severe depletion, but require specialist advice. Repeated measurement of plasma-potassium concentration is necessary to determine whether further infusions are required and to avoid the development of hyperkalaemia, which is especially likely in renal impairment. Initial potassium replacement therapy should not involve glucose infusions, because glucose may cause a further decrease in the plasma-potassium concentration.

Potassium Chloride Concentrate, Sterile (Non-proprietary) A

Sterile concentrate, potassium chloride 15% (150 mg, approximately 2 mmol each of K+ and Cl / mL). Net price 10-mL amp = 48p
Important Must be diluted with not less than 50 times its volume of sodium chloride intravenous infusion 0.9% or other suitable diluent and mixed well Solutions containing 10 and 20% of potassium chloride are also available in both 5- and 10-mL ampoules

Bicarbonate and lactate

Sodium bicarbonate is used to control severe metabolic acidosis (pH < 7.1) particularly that caused by loss of bicarbonate (as in renal tubular acidosis or from excessive gastro-intestinal losses). Mild metabolic acidosis associated with volume depletion should rst be managed by appropriate uid replacement because acidosis usually resolves as tissue and renal perfusion are restored. In more severe metabolic acidosis or when the acidosis remains unresponsive to correction of anoxia or hypovolaemia, sodium bicarbonate (1.26%) can be infused over 34 hours with plasma-pH and electrolyte monitoring. In severe shock (section 2.7.1), for example in cardiac arrest, metabolic acidosis can develop without sodium or volume depletion; in these circumstances sodium bicarbonate is best given as a small volume of hypertonic solution, such as 50 mL of 8.4% solution intravenously; plasma-pH and electrolytes should be monitored. Sodium lactate intravenous infusion is no longer used in metabolic acidosis because of the risk of producing lactic acidosis, particularly in seriously ill patients with poor tissue perfusion or impaired hepatic function. For chronic acidotic states, sodium bicarbonate can be given by mouth (section 9.2.1.3).

POTASSIUM CHLORIDE
Indications electrolyte imbalance; see also oral potassium supplements, section 9.2.1.1 Cautions for intravenous infusion the concentration of solution should not usually exceed 3 g (40 mmol)/ litre; specialist advice and ECG monitoring (see notes above); interactions: Appendix 1 (potassium salts) Contra-indications plasma-potassium concentration above 5 mmol/litre Renal impairment close monitoring requiredhigh risk of hyperkalaemia; avoid in severe impairment Side-effects rapid infusion toxic to heart Dose . By slow intravenous infusion, depending on the deficit or the daily maintenance requirements, see also notes above Potassium Chloride and Glucose Intravenous Infusion (Non-proprietary) A Intravenous infusion, usual strength potassium chloride 0.3% (3 g, 40 mmol each of K+ and Cl /litre) or 0.15% (1.5 g, 20 mmol each of K+ and Cl /litre) with 5% of anhydrous glucose
In hospitals, 500- and 1000-mL packs, and sometimes other sizes, are available

9 Nutrition and blood

SODIUM BICARBONATE
Indications metabolic acidosis, see also notes above Hepatic impairment section 1.1.1 Dose . By slow intravenous injection, a strong solution (up to 8.4%), or by continuous intravenous infusion, a weaker solution (usually 1.26%), an amount appropriate to the body base decit (see notes above) Sodium Bicarbonate Intravenous Infusion A Usual strength sodium bicarbonate 1.26% (12.6 g, 150 mmol each of Na+ and HCO3 /litre); various other strengths available
In hospitals, 500- and 1000-mL packs, and sometimes other sizes, are available

Potassium Chloride and Sodium Chloride Intravenous Infusion (Non-proprietary) A Intravenous infusion, usual strength potassium chloride 0.15% (1.5 g/litre) with sodium chloride 0.9% (9 g/litre), containing K+ 20 mmol, Na+ 150 mmol, and Cl 170 mmol/litre or potassium chloride 0.3% (3 g/litre) with sodium chloride 0.9% (9 g/litre), containing K+ 40 mmol, Na+ 150 mmol, and Cl 190 mmol/litre
In hospitals, 500- and 1000-mL packs, and sometimes other sizes, are available

Potassium Chloride, Sodium Chloride, and Glucose Intravenous Infusion (Non-proprietary) A Intravenous infusion, sodium chloride 0.45% (4.5 g, Na+ 75 mmol/litre) with 5% of anhydrous glucose and usually sufcient potassium chloride to provide K+ 1040 mmol/litre (to be specied by the prescriber)
In hospitals, 500- and 1000-mL packs, and sometimes other sizes, are available

Minijet c Sodium Bicarbonate (UCB Pharma) A Intravenous injection, sodium bicarbonate in disposable syringe, net price 4.2%, 10 mL = 11.03; 8.4%, 10 mL = 11.10, 50 mL = 12.15

SODIUM LACTATE U
Indications see notes above Sodium Lactate (Non-proprietary) A U Intravenous infusion, sodium lactate M/6, contains the following ions (in mmol/litre), Na+ 167, HCO3 (as lactate) 167

Intravenous infusion, sodium chloride 0.18% (1.8 g, Na+ 30 mmol/litre) with 4% of anhydrous glucose and usually sufcient potassium chloride to provide K+ 1040 mmol/litre (to be specied by the prescriber)
In hospitals, 500- and 1000-mL packs, and sometimes other sizes, are available