1 vial


Note: any sodium chloride solution in excess of 0.9% is considered ‘hypertonic’. In this monograph, ‘hypertonic’ refers only to 23.4% sodium chloride.

Hypertonic Saline, Concentrated Salt
  • Treatment of raised intracranial pressure (for example, in traumatic brain injury)
  • To increase serum sodium in the presence of symptomatic severe hyponatraemia (Na <110 mmol/l) only under the guidance of an ICU Specialist
23.4% (4.7g) sodium chloride in 20 ml clear solution in a glass ampoule (concentration of 4 mmol or 234 mg per ml)
Administer via central line only; if no central line is present & emergency administration for intracranial hypertension is required, consider use of mannitol instead
Store at room temperature
Drugs that are only compatible with normal saline may not be compatible with hypertonic sodium chloride. Transfusions of blood or blood products should not be given through the same line as lysis of red blood cells may occur.

20 mls 23.4% sodium chloride undiluted by infusion over 15-30 minutes

In an emergency it can be administered by direct IV injection over 30-60 seconds
In the setting of a persistently raised intracranial pressure, repeat dosing is usually indicated to achieve a serum sodium not higher than 155 mmol/l
23.4% sodium chloride should not be used in children
(For the treatment of raised intracranial pressure Starship Children’s Hospital guidelines recommend 3-5 mls/kg of 3% sodium chloride)

Dose in renal impairment

Should be used with caution as repeated administration will result in sodium and fluid retention. Administration may also cause renal injury or worsen pre-existing renal injury.



Dose in renal replacement therapy

use with caution
use with caution
dose as in normal renal function

In traumatic brain injury, 23.4% sodium chloride exerts an osmotic effect & so draws fluid out of oedematous cerebral tissues. By reducing the water content of an injured brain, mass effect and so intracranial pressure can be reduced. This may lead directly to a decrease in secondary brain injury. Onset of effect is rapid, peaking at 10 minutes and may last up to 1 hour. 23.4% Sodium chloride may also have an anti-inflammatory effect that decreases the incidence of multiple organ dysfunction syndrome (MODS).
  • Severe hypernatraemia

23.4% sodium chloride constitutes a significant chloride load that may cause a hyperchloraemic metabolic acidosis
Tissue necrosis occurs with extravasation
Central pontine myelinosis has been described if serum sodium is corrected too quickly in hyponatraemia
Rebound intracranial hypertension is possible on cessation if therapeutic hypernatraemia is used
Coagulopathies have been described following administration of 23.4% sodium chloride as it can affect platelet aggregation, APTT and INR

Ensure central line correctly positioned before administering

In Therapeutic hypernatraemia:
Co-administration with corticosteroids may precipitate congestive heart failure & acute pulmonary oedema in patients susceptible to heart failure
Serum sodium concentration >160 mmol/L are associated with a greatly increased risk of renal failure & seizures especially if maintained for >24 hours

Correction of severe hyponatraemia:
Serum sodium should not be raised by more than 10 mmol/L in 24 hours. Patients at greatest risk of osmotic demyelination syndrome (central pontine myelinolysis) are those who have had severe hyponatraemia for several days & in whom serum sodium is raised by more than 20 mmol/L in 24 hours or is over-corrected to above 140 mmol/L

Laboratory Tests
Serum sodium levels should be checked frequently in patients requiring administration of 23.4% sodium chloride

Drug/Laboratory Test Interactions
May alter APTT & INR

No safety data is available so should only be used if clearly needed

Nursing Mothers
No safety data is available so should only be used if clearly needed

Paediatric Use
May exacerbate pre-existing heart failure by increasing circulating volume
Seizures, encephalopathy, osmotic demyelination syndrome
Increased risk of renal injury or worsening of pre-existing renal failure
Severe tissue necrosis if extravasates
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Clinical responsibility for the choice, dose, route & frequency of any medication always remains with the prescribing doctor.
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