It’s an interesting dilemma when considering how exactly to safely integrate hyperosmolar sodium chloride products into the emergency department. Stocking vials of 23.4% sodium chloride in the ED, whether in a Pyxis/Omnicell or a locked cabinet, creates an unnecessary risk for significant medication errors. Though no specific threshold exists for what is considered a ‘concentrated sodium chloride’ product by the joint commission, the decision must be made by the hospital P&T committee. Lower concentrations (3% and 5% saline) will most likely still exceed the threshold. Knowing the osmolarity of sodium chloride vs sodium bicarbonate is essential pharmacist knowledge.

However, these products can be stocked on the patient unit if 1) they are in their most ready to administer form and 2) if their absence places patients at risk for delays in therapy.

Or, 8.4% sodium bicarbonate could be considered. In most EDs it’s already readily accessible from Pyxis/Omnicells.  It’s been theorized that administering an equiosmolar load of hyperosmolar treatment to TBI patients should achieve the same ICP reduction. And there is some evidence to suggest this may in fact be the case. (Bourdeaux CP, Brown JM. Randomized controlled trial comparing the effect of 8.4% sodium bicarbonate and 5% sodium chloride on raised intracranial pressure after traumatic brain injury. Neurocrit Care. 2011 Aug;15(1):42-5)

Not to suggest that one should replace the other, but in an emergent situation, if the pharmacy is not able to deliver the hypertonic sodium chloride in a timely fashion, an equiosmolar dose of sodium bicarbonate could be considered.

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