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Does Using Normal Saline Cause Hypervolemia When Suffering From COPD?

Posted on Fri, 24 Oct 2014

Question: This is a bit of a complex situation. Pt has COPD, chronic cardiac failure, renal impairment, some hepatic dysfunction, pleural effusion, pneumonia, sepsis & is hypotensivre and afebrile. The patient is also nil by mouth, so there is a risk of dehydration. However, the pt has been commenced on a normal saline 100 mls an hour (for a total of 1 litre) which is being administered IV, presumably in part to avoid dehydration. But the pt is hypernatremic (e.g. sodium was 146 mmol/L & is now 150 mmol/L). The patient cannot expel too much fluid because of the risk of dehydration which could also lower BP even more. On the other hand, the pt's pleural effusion is a problem. In these particular circumstances, would it appear to you that the use of NORMAL saline has the potential to cause hypervolemia even though the pt is on 120mg of Lasix (frusemide) BD?

Answered by Dr. Rakesh Madhyastha (7 minutes later)

Brief Answer:
Normal saline is a contraindication

Detailed Answer:
Hello

Thanks for the query

It is true that hypernatremia indicates dehydration, however normal saline is a contraindication to treat it as it contains sodium. I recommend that he is on 5%Dextrose ( which will help hepatic dysfunction as well).
Water deficit has to be calculated and it has to be corrected over the next two days. Continue Lasix as he is in chronic cardiac failure .
If you can tell me how much is the weight of the patient, I can get back to you with the calculated water deificit.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Rakesh Madhyastha (9 minutes later)

Thank you Dr. Madhyastha. Your expertise is greatly appreciated. I cannot tell you his exact weight at present. However, he has been extremely malnourished for quite a few weeks due to loss of appetite and dysphagia. There is also some muscle wastage. He is definitely very underweight. He is about 5 feet, 8 inches tall.

Answered by Dr. Rakesh Madhyastha (13 minutes later)

Brief Answer:
Follow up

Detailed Answer:
Hello

Thanks for getting back

It is extremely unfortunate, I understand that he is malnourished but if he is kept nil by mouth is he getting nutrition through total parenteral nutrition? How are they managing daily nutritional requirements?

Approximate weight will do, height is of no use to calculate the water deficit.

My next reply could be about 4 hours from now, I am going to the hospital for my daily rounds. In between if I find time I will reply to you

Regards

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Rakesh Madhyastha (3 hours later)

Thank you again Dr. Madhyastha. Unfortunately, I cannot easily estimate his weight. But he has been severely malnourished for weeks. At one stage consideration was given to NG feeding but his PLT count became dangerously low and it was thought to be too risky. His platelet count is now back to normal. I don't know why a NG tube isn't being used. Could it cause aspiration? He already has an on going pleural effusion and pneumonia. He is also somewhat delirious. Would delirium make it too difficult to do NG feeding?People obviously need nutrition. But although he has been malnourished for a long time, an attempt is being made to rehydrate him. Would the lack of a nutritional intake at this stage make much of a difference to the outcome?

Answered by Dr. Rakesh Madhyastha (24 minutes later)

Brief Answer:
Follow up

Detailed Answer:
Hello

Thanks for getting back

NG tube cannot be given in patients who are in altered sensorium as there is high risk of aspiration. Pleural effusion could be part of the pneumonia, known as synpneumonic effusion. I guess they will have to consider total parental nutrition soon for nutritional needs.

I wish him a speedy recovery

Regards

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Rakesh Madhyastha (7 minutes later)

Thank you for your continuing assessment and advice. Since he is on IV saline fluid, could total parental nutrition be given through an IV as well?

Answered by Dr. Rakesh Madhyastha (2 minutes later)

Brief Answer:
TPN

Detailed Answer:
Hello

TPN is given through intra venously. Please make sure that hypernatremia is corrected first as this again might increase his sodium levels.

Regards

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Rakesh Madhyastha (41 hours later)

Dear Dr. Madhyastha, I have needed to re-open the discussion because of the rapidly changing circumstance over the last 36-48 hours. The patient's sodium level has now gone up to 157 mmol/L. However, the person's BP has suddenly crashed to 86/59. Also, even though the patient has chronic cardiac failure, the use of the diuretic (Lasix) has ceased, presumably because of the low BP. However, despite the renal impairment (failure?) and hypernatremia, he was put on to 1 litre of NORMAL saline combined with 4% dextrose (80-125 mls per hour). Is there now a risk of hypervolemia? The situation seems to be very complex and I can only provide you with limited data. But on the basis of that information, what would you advise? I've found out that the patient's last recorded weight was 53.4 kg, but he would have lost weight since then.

Answered by Dr. Rakesh Madhyastha (5 hours later)

Brief Answer:
Rapd action required

Detailed Answer:
Hello

Thanks for getting back

THe condition seems to have deterirorated. Fluid management now is tricky and requires the following parameters to be monitored hourly

1. Hourly intake and output chart. Hourly intake of fluids and urine output
2. Central venous line to be placed and maintained at CVP 10cm of water, this will ensure that the patient is neither dehydrated or over hydrated ( in volume overload), this will also enable us to give Lasix which is required for the cardiac failure
3. Normal saline cannot be given in hypernatremia, there is no doubt about that
4. Blood pressure needs to be improved with the help of ionotroped. Kidney function deteriorates fast when there is hypotension
5. S creatinine, sodium, potassium must be sent every 12 hours
6. The water deficit is around 3 litres, I suggest 1.5 litres to be given today and the ramining tomorrow. Preferable replacement fluid being 5D however this might not be possible as it might push into volume overload hence a CVP line is very essential at this point

I hope I was of help, my reply might get delayed today by 3-5 hours as it is my OPD day today.

I wish the patient a speedy recovery

Regards

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Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar