When should normal saline (NS) 0.18% and 4% glucose be used for patient hydration and calorie needs?

From the Guidelines

Normal saline 0.18% with 4% glucose should be used for maintenance hydration in pediatric patients, particularly infants and young children who have higher glucose requirements and lower sodium needs than adults. This solution provides both free water and modest amounts of sodium and glucose, making it suitable for maintaining hydration in children who are NPO (nothing by mouth) or unable to meet their fluid needs orally 1. The glucose component provides approximately 160 calories per liter, helping to prevent ketosis and protein catabolism during periods of fasting.

Key considerations for the use of this solution include:

• Maintenance hydration in pediatric patients, especially those with higher glucose requirements and lower sodium needs
• Providing free water and modest amounts of sodium and glucose
• Preventing ketosis and protein catabolism during periods of fasting
• Not suitable for resuscitation or replacement of significant fluid losses, where isotonic solutions like normal saline 0.9% would be preferred
• Not typically used in adults, who generally require higher sodium concentrations for maintenance fluids

It's essential to note that the optimal glucose administration should not exceed 5 mg/kg/min, as recommended by previous guidelines 1. Additionally, the use of diabetic-specific enteral formula in ICU patients suffering from Type 2 Diabetes Mellitus seems to improve the glucose profile and may have clinical and economic impact 1.

In terms of administration rates, the typical maintenance rate follows the Holliday-Segar formula: 100 mL/kg/day for the first 10 kg of body weight, plus 50 mL/kg/day for the next 10 kg, plus 20 mL/kg/day for each kg above 20 kg. This solution is a suitable choice for pediatric patients who require maintenance hydration and have higher glucose requirements, but it's crucial to monitor their glucose levels and adjust the administration rate accordingly 1.

From the FDA Drug Label

CLINICAL PHARMACOLOGY: When administered intravenously, these solutions provide a source of water and carbohydrate. INDICATIONS AND USAGE Dextrose Injection is indicated as a source of water and calories.

The normal saline 0.18% and 4% glucose should be used for patient hydration and calorie needs when:

• A source of water and carbohydrate is required
• Calories are needed
• Parenteral maintenance of water requirements is necessary when salt is not needed or should be avoided However, the provided drug labels do not explicitly mention normal saline 0.18% and 4% glucose, therefore the information provided is based on the properties of dextrose and glucose solutions in general 2, 3.

From the Research

Normal Saline 0.18% and 4% Glucose Usage

• Normal saline (NS) 0.18% and 4% glucose is used for patient hydration and calorie needs, particularly in cases where electrolyte balance and glucose supplementation are required.
• The composition of NS 0.18% and 4% glucose makes it suitable for maintaining hydration and providing calories, as it contains a balanced mix of sodium and glucose 4.
• In acute burn cases, the use of NS 0.18% and 4% glucose as a maintenance fluid, in addition to Ringer's lactate for resuscitation, has been shown to help maintain sodium levels and prevent hyponatremia 4.
• The addition of glucose to the fluid replacement solution is recommended for exercise events lasting more than 1 hour, as it helps maintain oxidation of carbohydrates and delays fatigue 5.
• However, the use of NS 0.18% and 4% glucose may not be suitable for all patients, and the decision to use it should be based on individual patient needs and medical conditions.

Patient Hydration and Calorie Needs

• Patient hydration and calorie needs can be met through the use of NS 0.18% and 4% glucose, particularly in cases where oral intake is not possible or is insufficient 4.
• The glucose content in NS 0.18% and 4% glucose helps provide calories, while the sodium content helps maintain electrolyte balance 5.
• In cases of severe dehydration, the use of balanced solutions such as Ringer's lactate or Plasma-Lyte may be more effective than 0.9% saline in reducing the time in hospital and preventing hypokalaemia 6.
• The choice of fluid replacement solution should be based on individual patient needs and medical conditions, and should take into account factors such as electrolyte balance, glucose requirements, and renal function.

Clinical Applications

• NS 0.18% and 4% glucose can be used in a variety of clinical settings, including acute burn care, exercise and sports medicine, and perioperative care 5, 4, 7.
• The use of NS 0.18% and 4% glucose should be guided by individual patient needs and medical conditions, and should be monitored closely to prevent complications such as hyponatremia or hyperglycemia 4, 8.
• Further research is needed to determine the optimal use of NS 0.18% and 4% glucose in different clinical settings, and to establish clear guidelines for its use in patient care 6, 7.