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Dextrose 4 3 And Sod Ium Chloride 0 18 Iv Soln

Dextrose 4.3% and Sodium Chloride 0.18% IV Solution: A Comprehensive Medical Guide

Introduction

Intravenous (IV) fluids are a cornerstone of modern medicine. From basic hydration in emergencies to providing necessary electrolytes and nutrients in post-operative and intensive care settings, IV fluids serve a wide array of clinical functions. Among the many formulations used in hospitals worldwide is Dextrose 4.3% and Sodium Chloride 0.18% IV solution, often known as Bart’s solution or Dextrose-Saline (DS 4.3/0.18).

Composition and Characteristics

Dextrose 4.3% and Sodium Chloride 0.18% solution is a hypotonic crystalloid solution. Each 100 mL typically contains:

  • Dextrose (Glucose) – 4.3 g

  • Sodium Chloride – 0.18 g

  • Water for Injection – q.s. to 100 mL

Electrolyte Content per Liter:

  • Sodium (Na⁺): ~30.8 mmol/L

  • Chloride (Cl⁻): ~30.8 mmol/L

  • Energy provided: ~170 kcal/L

When administered, dextrose is rapidly metabolized, leaving behind free water, effectively making this a hypotonic solution in vivo. The sodium and chloride concentrations are much lower than that found in normal plasma (~135–145 mmol/L for sodium).

Pharmacokinetics and Pharmacodynamics

Dextrose:

Upon infusion, dextrose is quickly metabolized via glycolysis and the Krebs cycle, providing energy. The metabolism of dextrose leaves free water behind, which distributes into intracellular and extracellular compartments.

Sodium and Chloride:

These ions remain largely in the extracellular compartment. However, due to the low concentration, this solution is not suitable for sodium replacement therapy in hyponatremic patients.

Clinical Indications

Despite being relatively low in sodium content, Dextrose 4.3% and Sodium Chloride 0.18% IV solution is used in specific clinical scenarios where a balance between glucose provision and mild sodium replacement is required.

1. Maintenance Fluid in Pediatric Patients

Historically, this solution was widely used as a maintenance fluid in children, due to the perceived need for lower sodium concentrations. It provides both hydration and caloric energy from dextrose.

Caution: Recent guidelines have moved away from hypotonic solutions for children due to the risk of hyponatremia, especially in acutely ill children.

2. Post-Operative Fluid Management

This solution is sometimes used in the postoperative setting, especially if the patient has a mild sodium deficit and requires energy.

3. Mild Hydration

In cases where patients are unable to take oral fluids, and only mild hydration is required, this solution can be used to avoid fluid overload while providing glucose.

4. Glycogen Repletion in Hypoglycemia

While dextrose 5% is typically preferred, this solution may be used in cases where mild hypoglycemia is present along with a minor sodium imbalance.

Contraindications

This IV solution is not universally safe and must be administered cautiously. It is contraindicated or should be used with extreme caution in the following cases:

  • Severe Hyponatremia: As it has insufficient sodium to correct the deficit.

  • Patients with SIADH (Syndrome of Inappropriate Antidiuretic Hormone Secretion).

  • Cerebral Edema or Brain Injuries: Hypotonic fluids can worsen cerebral swelling.

  • Uncontrolled Diabetes Mellitus: Risk of exacerbating hyperglycemia.

  • Renal Failure or Heart Failure: Risk of fluid overload.

Risks and Adverse Effects

1. Hyponatremia

Perhaps the most serious risk associated with this solution is hospital-acquired hyponatremia, especially in children and postoperative patients. Because the body metabolizes dextrose, the remaining water is hypotonic and can dilute serum sodium concentrations.

Severe hyponatremia can lead to seizures, cerebral edema, coma, and even death.

2. Hyperglycemia

The dextrose content can increase blood glucose, particularly in patients with impaired glucose tolerance, diabetes, or insulin resistance.

3. Fluid Overload

In susceptible populations—especially those with compromised cardiac or renal function—fluid overload may occur, leading to pulmonary edema, hypertension, or heart failure.

4. Electrolyte Imbalances

Prolonged administration may lead to imbalances in potassium, calcium, and magnesium if not properly monitored.

Monitoring Parameters

When administering this IV fluid, it is essential to regularly monitor:

  • Serum electrolytes (especially sodium)

  • Blood glucose levels

  • Fluid balance (input/output)

  • Signs of fluid overload

  • Renal function

Comparison with Other IV Solutions

Solution Tonicity Sodium (mmol/L) Glucose (%) Common Uses
Normal Saline (0.9%) Isotonic 154 0 Volume replacement
Dextrose 5% Isotonic (in bag) / Hypotonic (in vivo) 0 5 Hydration, glucose
Dextrose 4.3% + NaCl 0.18% Hypotonic (in vivo) ~30 4.3 Pediatric maintenance (historical), post-op hydration
Lactated Ringer’s Isotonic 130 (Na⁺), 4 (K⁺), 28 (lactate), 2.7 (Ca²⁺) 0 Surgery, burns

Recent Guidelines and Changing Practices

Modern clinical practice has moved away from hypotonic maintenance fluids in many populations due to adverse outcomes. For instance:

  • The National Institute for Health and Care Excellence (NICE) recommends isotonic solutions (e.g., 0.9% NaCl with 5% glucose) for maintenance therapy in children.

  • Studies such as Moritz and Ayus (2003) found increased rates of hyponatremia when hypotonic solutions were used.

"Isotonic solutions are now considered safer for most patients requiring maintenance fluids." – [NEJM Clinical Guidelines]

Storage and Stability

  • Store at room temperature (15–25°C)

  • Avoid freezing

  • Use aseptically

  • Once opened, should be used immediately to avoid contamination

Dosing and Administration

Adults: The typical maintenance requirement is approximately 25–30 mL/kg/day of water and 1 mmol/kg/day of sodium. This fluid can provide some of both, but supplementation may be necessary.

Pediatrics: Dose must be calculated carefully. Typically:

  • Fluids = 100 mL/kg/day for the first 10 kg

  • 50 mL/kg/day for next 10 kg

  • 20 mL/kg/day for each kg over 20 kg

Dextrose-saline should be administered under medical supervision, with regular reassessment of needs.

Clinical Case Example

Case Study: Post-operative Management in a 6-year-old Child

A 6-year-old child weighing 20 kg underwent an appendectomy. Postoperatively, he was unable to tolerate oral intake. The surgical team started Dextrose 4.3% + NaCl 0.18% at maintenance rate.

Within 24 hours, the child developed mild confusion and vomiting. Labs revealed hyponatremia (Na⁺ = 125 mmol/L).

This prompted a switch to isotonic fluids, with careful correction of sodium. The child recovered, but the event underscored the risks of hypotonic maintenance fluids in children, especially post-op.

Conclusion

Dextrose 4.3% and Sodium Chloride 0.18% IV solution remains a relevant but cautiously used fluid in modern medicine. Though once widely applied in both adults and pediatric settings, especially for maintenance hydration, its hypotonic nature poses significant risks, particularly of hyponatremia. As clinical guidelines evolve, isotonic alternatives are now favored in many settings. Nevertheless, this solution retains value in specific clinical indications when administered with careful monitoring.

Key Takeaways

  • Dextrose 4.3%/NaCl 0.18% is hypotonic in vivo.

  • Used for maintenance therapy, especially historically in children.

  • Hyponatremia is a significant risk; monitor electrolytes closely.

  • Newer guidelines favor isotonic maintenance fluids.

  • Best used under strict medical supervision with regular reassessment.