1686 Electrolytes
tate Injection; Potassium Bicarbonate and Potassium Chloride Effervescent
Tablets for Oral Solution; Potassium Bicarbonate and Potassium Chloride
for Effervescent Oral Solution; Potassium Chloride Extended-release Capsules; Potassium Chloride Extended-release Tablets; Potassium Chloride for
Injection Concentrate; Potassium Chloride for Oral Solution; Potassium
Chloride in Dextrose and Sodium Chloride Injection; Potassium Chloride
in Dextrose Injection; Potassium Chloride in Lactated Ringer’s and Dextrose Injection; Potassium Chloride in Sodium Chloride Injection; Potassium
Chloride Oral Solution; Potassium Chloride, Potassium Bicarbonate, and
Potassium Citrate Effervescent Tablets for Oral Solution; Potassium Gluconate and Potassium Chloride for Oral Solution; Potassium Gluconate and
Potassium Chloride Oral Solution; Potassium Gluconate and Potassium Citrate Oral Solution; Potassium Gluconate Elixir; Potassium Gluconate Tablets; Potassium Gluconate, Potassium Citrate, and Ammonium Chloride
Oral Solution; Trikates Oral Solution.
Proprietary Preparations (details are given in Part 3)
Arg.: Co-Salt; Control K; Gluco-K; Kaon; Orakit; QBE Elixir†; Austral.: Celloids PC 73; Celloids PS 29; Chlorvescent; Duro-K; KSR†; Slow-K; Span-K;
Austria: KCl-retard; Micro-Kalium; Belg.: Chloropotassuril; Kali-Sterop†;
Kalium Durettes†; Steropotassium; Ultra-K; Braz.: Clotassio; Decorfen;
Canad.: Apo-K; K-10; K-Dur; K-Lor†; K-Lyte/Cl; Kaon†; Micro-K; Potassium-Rougier†; Proflavanol C; Roychlor†; Slow-K; Chile: Kaion Retard; Sal
Dietetica; Slow-K; Yonka; Cz.: Kaldyum; Kalnormin; Spofalyt-Kalium†;
Denm.: Kaleorid; Fin.: Durekal; Kalinorm; Kalisol; Kalisteril†; Fr.: Diffu-K;
Kaleorid; Nati-K; Ger.: Kalinor-retard P; Kalium-Duriles†; Kalium†; KCl-retard; Rekawan; Gr.: Sopa-K; Hong Kong: Addi-K†; Apo-K; Kalium†; KSR;
Slow-K; Span-K; Hung.: Kaldyum; Kalium Durules; Kalium-R; India: Diucontin-K; Keylyte; Potklor; Irl.: Kay-Cee-L; Slow-K; Israel: Slow-K; Ital.: K-Flebo; Kadalex; Lento-Kalium; Malaysia: Apo-K; Beacon K; KSR†; Slow-K;
Mex.: Ceposil; Clor-K-Zaf; Corpotasin GK; Corpotasin LP; K-Dur; Kaliolite;
Kasele†; Kelefusin; Potasoral; Neth.: Kalium Durettes†; Slow-K; Norw.: Kaleorid; NZ: Chlorvescent; K-SR†; Slow-K; Span-K; Philipp.: Ion-O-Trate;
Kalium; Pol.: Kaldyum; Kalimat; Kalipoz; S.Afr.: Micro-K; Plenish-K; Sandoz
K; Slow-K; Swiss-Kal SR†; Singapore: Addi-K†; Apo-K; KSR†; Spain: AP
Inyect Cloruro Potasico; Boi K; Boi K Aspartico; Boi K Gluconato; Potasion;
Potasion Solucion; Swed.: Kaleorid†; Kalitabs; Kalium Duretter†; Kalium Retard; Switz.: Kaliglutol; Plus Kalium retard; Thai.: Addi-K; Enpott; Kaliject;
Potassride; Turk.: Kadaleks; UK: Kay-Cee-L; Slow-K; USA: Cena-K; Gen-K;
K + 10; K + 8†; K-Dur; K-G Elixir; K-Lease†; K-Lor; K-Lyte/Cl; K-Norm†; KTab; Kaon; Kaon-Cl; Kay Ciel; Klor-Con; Klorvess; Klotrix; Micro-K; Potasalan;
Rum-K†; Slow-K†; Ten-K; Venez.: Kaon†; Konat†.
Multi-ingredient: Arg.: Dialitica II; Potasio C; Water Pill c Potasio†; Austral.: Aspartatol; Cardioplegia A; Cardioplegia Concentrate; Digestaid; Duo
Celloids PCCP; Duo Celloids PCIP; Duo Celloids PCMP; Duo Celloids
PSMP; Duo Celloids PSPC; Duo Celloids SPPC; Duo Celloids SPPS; Duo
Celloids SSPC; Extralife Uri-Care; Iron Compound†; K-Mag†; Kali Mag†;
Mag-Oro; Potasi; Silicic Complex†; Austria: Centramin; Corozell; Elozell;
Elozell spezial; Gladixol; Maycardin K; Trommcardin; Braz.: Albicon; Furosemide Composto; Hidrion; Canad.: Uracyst Test Kit; Chile: Sal Lite; Sal
Liviana En Sodio; Cz.: Acidigen†; Aviril H†; Cardilan; Solutio Thomas cum
Procaino; Tromcardin; Denm.: Burinex med kaliumklorid; Centyl med Kaliumklorid; Fin.: Miral; Fr.: Decramp; Rhinodoron; Ger.: Ardeycordal N†;
Bascardial†; Cardio-Kreislauf-Longoral; Chinosol; Cordesin; Galacordin; Kalium-Magnesium†; Magium K; Movicard; Rhinodoron; Septacord; Tromcardin; Trophicard; Gr.: Cardioplegia; Hong Kong: Cardioplegia; Hung.: Acidigen†; Aspacardin†; Panangin; Tromcardin; India: Cotaryl; Indon.:
Cardioplegia; Totilac; Irl.: Burinex K†; Centyl K; Diumide-K Continus; Low
Centyl K; Israel: Lyteers; Ital.: Briovitase; Polase; Pomag; Potassion; Potassium MG†; Malaysia: Burinex K†; Cardioplegia; Pot-Citra; Mex.: Corpotasin CL; Forcremol; Kaposalt; Norw.: Burinex K; Centyl med Kaliumklorid;
Philipp.: Diumide-K; Pol.: Aspargin; Magne-Balans Plus; Magnokal; Sal Ems
Artificiale; Sal Ems Factitium; Port.: Miostenil; Polase; Safrux; Rus.: Panangin
(Панангин); Triresid K (Трирезид К); S.Afr.: Burinex K; Kloref; Lenurex-K;
Urirex-K; Singapore: Burinex K; Cardioplegia; Spain: Acetuber; Glucopotasico; Leberetic; Potasico; Salcedol; Suero Potassico Bieffe ME†; Swed.:
Centyl K; Salures-K; Thai.: Cardioplegia; Turk.: Kadeks; Sensodyne-F; UK:
Burinex K†; Centyl K; Kloref; Lasikal; Neo-NaClex-K; Sando-K; SensodyneF; USA: Chlor-3; K-Lyte/Cl; Klorvess; Slo-Salt-K†; Temp Tab; Tri-K; Twin-K†.
Sodium
Natrium; Sód; Sodio.
Na = 22.98976928.
Description. Sodium chloride is the principal sodium salt used
as a source of sodium ions. Sodium salts used chiefly as sources
of bicarbonate ions, such as the acetate, bicarbonate, citrate, and
lactate, are covered under Bicarbonate, p.1673. Phosphate salts
of sodium are covered under Phosphate, p.1682.
Sodium Chloride
Chlorid sodný; Chlorure de Sodium; Cloreto de Sódio; Natrii
chloridum; Natrio chloridas; Natriumklorid; Nátrium-klorid;
Natriumkloridi; Salt; Sodio, cloruro de; Sodium, chlorure de;
Sodu chlorek; Sodyum Klorür.
NaCl = 58.44.
C AS — 7647-14-5.
ATC — A12C A01; B05CB01; B05XA03.
ATC Vet — QA12C A01; QB05CB01; QB05XA03.
An aqueous solution of sodium chloride 0.9% is often
known as physiological saline.
SALINE is a code approved by the BP 2008 for use on single
unit doses of eye drops containing sodium chloride 0.9% where
the individual container may be too small to bear all the appropriate labelling information. HECL is a similar code approved
for hyetellose and sodium chloride eye drops.
Pharmacopoeias. In Chin., Eur. (see p.vii), Int., Jpn, US, and
Viet.
Ph. Eur. 6.2 (Sodium Chloride). A white or almost white, crystalline powder or colourless crystals or white or almost white
pearls. Freely soluble in water; practically insoluble in dehydrated alcohol.
USP 31 (Sodium Chloride). Colourless cubic crystals or white
crystalline powder. Soluble 1 in 2.8 of water, 1 in 2.7 of boiling
water, and 1 in 10 of glycerol; slightly soluble in alcohol.
NOTE.
Equivalence. Each g of sodium chloride represents about
17.1 mmol of sodium and of chloride. Sodium chloride 2.54 g is
equivalent to about 1 g of sodium.
Storage. Solutions of some sodium salts, including sodium
chloride, when stored, may cause separation of solid particles
from glass containers and solutions containing such particles
must not be used.
Adverse Effects
Adverse effects of sodium salts are attributable to electrolyte imbalances from excess sodium; there may also
be effects due to the specific anion.
Retention of excess sodium in the body usually occurs
when there is defective renal sodium excretion. This
leads to the accumulation of extracellular fluid to maintain normal plasma osmolality, which may result in
pulmonary and peripheral oedema and their consequent effects.
Hypernatraemia (a rise in plasma osmolality) is usually
associated with inadequate water intake, or excessive
water losses (see p.1670). It rarely occurs after therapeutic doses of sodium chloride, but has occurred with
the use of hypertonic saline for induction of emesis or
for gastric lavage and after errors in the formulation of
infant feeds. Hypernatraemia may also occur after
inappropriate intravenous use of hypertonic saline.
The most serious effect of hypernatraemia is dehydration of the brain which causes somnolence and confusion progressing to convulsions, coma, respiratory failure, and death. Other symptoms include thirst, reduced
salivation and lachrymation, fever, sweating, tachycardia, hypertension or hypotension, headache, dizziness,
restlessness, irritability, weakness, and muscular
twitching and rigidity.
Gastrointestinal effects associated with acute oral ingestion of hypertonic solutions or excessive amounts
of sodium chloride include nausea, vomiting, diarrhoea, and abdominal cramps.
Excessive use of chloride salts may cause a loss of bicarbonate with an acidifying effect.
Intra-amniotic injection of hypertonic solutions of sodium chloride, which has been used for termination of
pregnancy, has been associated with serious adverse
effects including disseminated intravascular coagulation, renal necrosis, cervical and uterine lesions, haemorrhage, pulmonary embolism, pneumonia, and death.
Pharmacokinetics
Sodium chloride is well absorbed from the gastrointestinal tract. Excess sodium is mainly excreted by the
kidney, and small amounts are lost in the faeces and
sweat.
Human Requirements
The body contains about 4 mol (92 g) of sodium of
which about one-third is found in the skeleton and
about half is present in the extracellular fluid.
The body can adapt to a wide range of intakes by adjustment of renal excretion through physical and hormonal factors. Loss through the skin is significant only
if excessive sweating occurs. Sodium requirements
may be increased with exercise or exposure to high
ambient temperatures in the short term, until the body
adjusts.
Sodium is widely available in foods and is also added
as salt during processing, cooking, and at the table. Dietary deficiency of sodium is therefore extremely rare
and more concern has been expressed that current intakes are excessive. Restriction of sodium intake, by
limiting the amount of culinary salt consumed, may be
a useful aid in the management of some patients with
hypertension (p.1171).
UK and US recommended dietary intake. In the UK dietary reference values (DRV—see Human Requirements, p.1925)1
have been published for sodium. The reference nutrient intake
(RNI) for adults is 1.6 g of sodium (70 mmol) daily, which is
about 4 g of sodium chloride. In the USA, it has been recommended that daily intakes of sodium be limited to 2.4 g (6 g of
sodium chloride) or less.2 Dietary intake is often in excess of
these recommendations, and may be a factor in essential hypertension,3 and osteoporosis.4
1. DoH. Dietary reference values for food energy and nutrients for
the United Kingdom: report of the panel on dietary reference values of the committee on medical aspects of food policy. Report
on health and social subjects 41. London: HMSO, 1991.
2. Subcommittee on the tenth edition of the RDAs, Food and Nutrition Board, Commission on Life Sciences, National Research
Council. Recommended dietary allowances. 10th ed. Washington, DC: National Academy Press, 1989. Also available at:
http://www.nap.edu/openbook.php?isbn=0309046335 (accessed
21/07/08)
3. Midgley JP, et al. Effect of reduced dietary sodium on blood
pressure: a meta-analysis of randomized controlled trials. JAMA
1996; 275: 1590–7.
4. Devine A, et al. A longitudinal study of the effect of sodium and
calcium intakes on regional bone density in postmenopausal
women. Am J Clin Nutr 1995; 62: 740–5.
◊ General references.
Uses and Administration
1. Moder KG, Hurley DL. Fatal hypernatremia from exogenous salt
intake: report of a case and review of the literature. Mayo Clin
Proc 1990; 65: 1587–94. Correction. ibid. 1991; 66: 439.
2. Martos Sánchez I, et al. Hipernatremia grave por administración
accidental de sal común. An Esp Pediatr 2000; 53: 495–8.
3. Adeleye O, et al. Hypernatremia in the elderly. J Natl Med Assoc
2002; 94: 701–5.
4. Coulthard MG, Haycock GB. Distinguishing between salt poisoning and hypernatraemic dehydration in children. BMJ 2003;
326: 157–60. Correction. ibid.; 497.
Sodium chloride is used in the management of deficiencies of sodium and chloride ions in salt-losing conditions (see Hyponatraemia, p.1670). Sodium chloride
solutions are used as a source of sodium chloride and
water for hydration.
A 0.9% solution in water is iso-osmotic, and thus in
most cases isotonic with serum and lachrymal secretions. Doses may be expressed in terms of mEq or
mmol of sodium, mass (mg) of sodium, or mass of sodium salt. For comparative purposes, see Table 4, below.
A typical oral replacement dose of sodium chloride in
chronic salt-losing conditions is about 2.4 to 4.8 g
(about 40 to 80 mmol of sodium) daily as a modifiedrelease preparation, accompanied by a suitable fluid intake; doses of up to 12 g daily may be necessary in
Treatment of Adverse Effects
In patients with mild sodium excess, drinking water
and restricting sodium intake is sufficient. However, in
the event of recent acute oral overdose of sodium chloride, gastric lavage should be carried out along with
general symptomatic and supportive treatment. Serumsodium concentrations should be measured, and if severe hypernatraemia is present this should be treated
(see p.1670).
Precautions
Sodium salts should be used with caution in patients
with hypertension, heart failure, peripheral or pulmonary oedema, renal impairment, pre-eclampsia, or other conditions associated with sodium retention.
When sodium supplements are given orally, adequate
water intake should be maintained. Sustained-release
tablets should not be given to patients with gastrointestinal disorders associated with strictures or diverticula
because of the risk of obstruction.
Sodium chloride solutions should not be used to induce
emesis; this practice is dangerous and deaths from resulting hypernatraemia have been reported.
Table 4. Some sodium salts and their sodium content.
Sodium content per g
Sodium salt
mg
mmol
mEq
Sodium acetate (anhydrous)
280
12.2
12.2
Sodium acetate (trihydrate)
169
7.3
7.3
Sodium acid citrate
175
7.6
7.6
Sodium bicarbonate
274
11.9
11.9
Sodium chloride
394
17.1
17.1
Sodium citrate (anhydrous)
267
11.6
11.6
Sodium citrate (dihydrate)
235
10.2
10.2
Sodium lactate
205
8.9
8.9
Sodium 1687
severe cases. Oral supplements are also used for the
prevention of muscle cramps during routine haemodialysis (p.1671); a suggested dose is about 6 to 10 g of a
modified-release preparation per dialysis session.
Glucose facilitates the absorption of sodium from the
gastrointestinal tract, and solutions containing sodium
chloride and glucose usually with additional electrolytes (see p.1672) are used for oral rehydration in acute
diarrhoea (p.1694).
The concentration and dosage of sodium chloride solutions for intravenous use is determined by several factors including the age, weight, and clinical condition of
the patient and in particular the patients’ hydration
state. Serum-electrolyte concentrations should be carefully monitored. In severe sodium depletion, 2 to 3
litres of sodium chloride 0.9% may be given over 2 to
3 hours and thereafter at a slower rate. If there is combined water and sodium depletion a 1 to 1 mixture of
sodium chloride 0.9% and glucose 5% may be appropriate. Although hypertonic sodium chloride solutions
may be used in certain patients with severe acute dilutional hyponatraemia, over-rapid correction may have
severe neurological adverse effects (see Hyponatraemia, p.1670). Solutions containing 1.8 to 5% are available.
In hypernatraemia with volume depletion (p.1670),
sodium chloride 0.9% may be used to maintain plasma-sodium concentrations with expanding fluid volume. Sodium chloride 0.9% (or rarely, in marked hypernatraemia, 0.45%) is used for fluid replacement in
diabetic ketoacidosis (see Diabetic Emergencies,
p.435).
Among its other uses, sodium chloride solution 0.9%,
being isotonic, is a useful fluid for sterile irrigations,
for example, of the eye or bladder, and general skin or
wound cleansing. The 0.9% concentration is also widely used as a vehicle or diluent for the parenteral administration of other drugs. Nasal drops of sodium chloride
0.9% are used to relieve nasal congestion. A mouthwash containing sodium chloride is also available for
oral hygiene.
Sodium chloride solutions should not be used to induce
emesis; this practice is dangerous and deaths from resulting hypernatraemia have been reported.
Sodium chloride is sometimes used as an excipient in
capsules and tablets.
Homoeopathy. Sodium chloride has been used in
homoeopathic medicines under the following names:
Natrium muriaticum; Nat. Mur.; Natrii chloridum; Natricum chloratum; Natrum muriaticum.
NOTE. Do not confuse Natricum chloratum with sodium chlorate (p.2389).
Catheters and cannulas. For reference to sodium chloride
0.9% being used to maintain the patency of catheters and cannulas, and to its equivalent efficacy to heparin, see Catheters and
Cannulas under Uses and Administration of Heparin, p.1304.
Cystic fibrosis. Inhalation of 4 mL of a hypertonic solution of
sodium chloride (7%) twice daily for 48 weeks in 82 patients
with stable cystic fibrosis (p.166) was associated with a moderate
but sustained improvement in lung function and a marked reduction in the number of exacerbations and need for antibiotics,
when compared with 80 placebo-treated patients.1 There was,
however, no difference in the rate of change of lung function.
Each inhalation was preceded by a bronchodilator to minimise
airway narrowing; adverse reactions to the active treatment were
nonetheless reported in 14 patients and included cough, chest
tightness or pharyngitis, sinusitis, haemoptysis, sneezing, and
vomiting. As a result, 6 patients withdrew from the study, but the
effects resolved in the remainder without the need for dose reduction or interruption. Hypertonic saline was considered to be
an inexpensive and safe adjunctive therapy in patients with cystic
fibrosis.
1. Elkins MR, et al. A controlled trial of long-term inhaled hypertonic saline in patients with cystic fibrosis. N Engl J Med 2006;
354: 229–40.
Termination of pregnancy. Trans-abdominal intra-amniotic
instillation of sodium chloride 20% (maximum volume 200 to
250 mL) has been used for the termination of second-trimester
pregnancy. However, serious adverse effects have occurred (see
above), and other methods are generally preferred (p.2004).
Preparations
BP 2008: Compound Sodium Chloride Mouthwash; Potassium Chloride
and Sodium Chloride Intravenous Infusion; Potassium Chloride, Sodium
Chloride and Glucose Intravenous Infusion; Sodium Chloride and Glucose
Intravenous Infusion; Sodium Chloride Eye Drops; Sodium Chloride Eye
Lotion; Sodium Chloride Intravenous Infusion; Sodium Chloride Irrigation
Solution; Sodium Chloride Oral Solution; Sodium Chloride Solution; Sodium Chloride Tablets;
USP 31: Bacteriostatic Sodium Chloride Injection; Dextrose and Sodium
Chloride Injection; Fructose and Sodium Chloride Injection; Half-strength
Lactated Ringer’s and Dextrose Injection; Inulin in Sodium Chloride Injection; Lactated Ringer’s and Dextrose Injection; Lactated Ringer’s Injection;
Mannitol in Sodium Chloride Injection; Potassium Chloride in Dextrose and
Sodium Chloride Injection; Potassium Chloride in Lactated Ringer’s and
Dextrose Injection; Potassium Chloride in Sodium Chloride Injection; Sodium Chloride and Dextrose Tablets; Sodium Chloride Inhalation Solution;
Sodium Chloride Injection; Sodium Chloride Irrigation; Sodium Chloride
Ophthalmic Ointment; Sodium Chloride Ophthalmic Solution; Sodium
Chloride Tablets; Sodium Chloride Tablets for Solution.
Proprietary Preparations (details are given in Part 3)
Arg.: Aqua Lent Limpia Cristales; Hypersol; Larmabak; Muro 128; Nasomicina Salina†; Oftalook; Relente; Salfis†; Xylisol; Yusin Tears I; Austral.:
Bausch & Lomb Sensitive Eyes Saline; Fess; Hypergel; Lens Plus; Mucolyt†;
Narium; Otrivin Saline Baby; Slow-Sodium; Austria: Ery-Set; SmartDose;
Uro-Pract†; Belg.: Lyomer Plus; Naaprep†; Natriclo†; Physiologica; Physiorhine; Braz.: Afrin Natural; Alive; Fluimare; Fluimucil Solucao Nasal; Max-
The symbol † denotes a preparation no longer actively marketed
idrate; Multisoro; Narisoro; Nasolac†; Nazosoro†; Novo Rino-S; Rino-Ped†;
Rinoben; Rinoflux; Rinosoro; Salsep; Sinustrat Solucao Natural; Snif; Sorine;
Sorine Pediatrico; Soro Nasal†; Soroliv; Soroneo; Sterimar†; Canad.: Certified Nasal; Hypergel; Lens Plus Buffered Saline Solution†; Mesalt; Muro
128†; Nasal Physiologic Solution; Normigel; Rhinaris Saline; Safeway Nasal;
Salinex; Softwear; Chile: Fisiolimp; Fludrop†; Larmabak; Pediasea; Printan;
Respirex; Rinodan; Rinokid; Rinosteryl; Sinus; Sterimar; Suero Fisiologico†;
Denm.: Viskose ojendraber; Fin.: Natrosteril; Fr.: Erjean; Hypergel; Irriclens; L’Oceane; Larmabak; Larmes Artificielles†; Normlgel; Physiologica;
Physiomer; Physiosoin; Polyrinse; Selgine; Serophta; Sinomarin; Sterimar;
Tonimer Baby; Versol†; Vesirig†; Ger.: Adsorbonac; Freka-Drainjet; Isogutt
akut; Isotone Kochsalz; Isotonische Kochsalzlosung; Olynth salin; Otrisal†;
Rhinomer; Rhinospray Atlantik; Rhinoton plus†; Sterimar†; Tetrisal; Gr.: Babynose†; Clinofar†; Larmabak†; Otrisalin†; Phy-O; Rhinodose†; Selva N†;
Hong Kong: Atomic Enema; Larmabak; Nasal Physiological Solution; Sinomarin; Sterimar; Unison Enema; Hung.: Rins-Sal; Salsol A; Unilarm†; Indon.: Otsu-NS; Wida NSI; Irl.: Sterimar; Israel: Baby AF; Clean-AF; Drossanose; Normasol; Ocean Spray; Otrivini; Sterimar; Tinok AF; Tipotaf; UroTainer†; Ital.: Adsorbonac; Hydrabak; Libenar; Narhinel; Naribel†; Otrivin
Baby; Physiodose; Physiomer; Rinowash; Serophta†; Sterimar; Malaysia:
Sterimar; Mex.: Alcacat†; Corni Limp; Hiperton; Muro 128; Sterimar;
Mon.: Unilarm; NZ: Narium; Philipp.: Larmabak; Physiomer; Salinase; Snif;
Pol.: Solnasin; Port.: Libenar†; Lyomer†; Rhinomer†; Sterimar†; Tonimer†;
Rus.: Salin (Салин); S.Afr.: Polyrinse; Vicks Vapomist; Singapore: Adsorbonac†; Larmabak; Sterimar; Spain: Antiedema; Apir Clorurado; Fisiologica; Fisiologico; Fisiologico Bieffe M; Fisiologico Braun; Fisiologico Farmacelsia; Fisiologico Isoton†; Fisiologico Mein; Fisiologico Serra Pamies;
Fisiologico Vitulia; Flebobag Fisio; Fleboflex Salina Fisio; Fleboplast Fisio;
Freeflex Cloruro Sodico; Irrigacion CLNA†; Meinvenil Fisiologico; Plast
Apyr Fisiologico; Solucion Fisio; Suero Fisiologico; Suero Fisiologico Isoton;
Suero Fisiologico†; Swed.: SmartDose†; Switz.: Drossa-Nose; Fluimare;
Naaprep; nasmer; Nose Fresh†; Physiologic; Physiosoin; Rhinomer; Serophy; Siccoral; Sterimar†; Tracheo Fresh†; Triomer; Thai.: U-Enema; Turk.:
Berko-Fiz; Fizyolen; Fizyosol; Lyomer; Otrisalin; Physiodose; Physiologica Gifrer; Rhinomer; Ser Damla; Serum Fizyolojik; Sinomarin; Sterimar; Tonimer;
UAE: Normaline; UK: Askina; Equaleze; Irriclens; Irripod; Miniversol; Normasol; Slow-Sodium; Stericlens; Sterimar; Steripod; Tubilux; Uriflex S; UroTainer M; Versol; USA: Adsorbonac; Afrin Moisturizing Saline Mist; Ak-NaCl; Ayr Saline; Breathe Free; Broncho Saline; Dristan Saline Spray; HuMist
Nasal Mist; Marlin Salt System; Muro 128; Muroptic; NaSal; Nasal Moist;
Normaline; Ocean; Pretz; Salinex; SeaMist; Your Choice; Venez.: Larmabak;
Nafavine.
Multi-ingredient: Arg.: Dialitica II; Phylarm; Yusin Tears II; Austral.: Cardioplegia A; Minims Artificial Tears†; Austria: Gluco-Salzlosung; Osmofundin 10%; Belg.: Alcasol; Ocal; Physiologica; Braz.: Glicofisiologica†; Malvona†; Nasolin; Novo Rino; Rinotil†; Sinustrat; Sinustrat Vasoconstritor; Sorine
Adulto; Canad.: Sclerodex; Chile: Concentrado Basico; Nasivin; Sal Lite;
Sal Liviana En Sodio; Cz.: Acidigen†; Fr.: Amukine; Biolau; Cataridol†;
Ceruspray; Dacryoserum; Emoform Gencives; Kamillosan Ocean; Ophtaclair; Phylarm†; Potensium sel de table; Proceane Isotonique; Rhinodoron;
Selso; Serozinc; Ger.: Kochsalz mit Glucose; Mar Plus†; Nisita†; Nubral 4†;
Nubral Forte†; Rhinodoron; Tutofusin S†; Weleda-Rheumasalbe M; Gr.:
Eyesalt†; Hong Kong: Eye Wash; Hung.: Acidigen†; Nisita†; India: Andre;
Catarest; Cato-Bell; Cotaryl; Neotomic; Irl.: Minims Artificial Tears; Israel:
Lyteers; Snore-No-More; Ital.: Aquasalina†; AZ 15; IperClean; Kamillosan
Ocean; Sterimar Cu; Sterimar Mn; Troca Flu Spray Nasale; Vulnopur; Mex.:
Amuchina†; Nasalub; Neth.: Symbial; Norw.: Salidex; Philipp.: Soothing
Eye Wash; Pol.: Gargarin; Sal Ems Artificiale; Sal Ems Factitium; Sal Vichy
Factitium; Port.: Glucanet†; Glucosalino; S.Afr.: Mrs Johnsons American
Soothing Syrup; Singapore: ENTsol; Spain: Apir Glucosalino; Flebobag
Glucosalina; Fleboplast Glucosalina; Freeflex Glucosalina; Glucosalina; Glucosalino; Humectante; Meinvenil Glucosalina; Plast Apyr Glucosalino; Potasico; Solurrinol; Suero Glucosalino; Suero Potassico Bieffe ME†; Switz.:
Amuchina Med; Glucosalin; Glucosaline; Kemerhinose; Narifresh; Nose
Fresh au D-panthenol; Perfusion mixte; Pommade Nasale Radix†; Prorhinel;
Rhinocure; Rhinocure simplex; Siccalix; Thai.: Eye-Gene; Eye-Gene Soft;
Mano; Opsil†; Visotone; Turk.: Isodeksol; Izodeks; Kadeks; UK: Asonor;
Blink; Minims Artificial Tears; USA: Chlor-3; Clear Eyes CLR; Massengill; Nasal-Ease; Slo-Salt-K†; Summers Eve Post-Menstrual; Temp Tab; Trichotine;
Venez.: Dextro-Sal†; Fisiolin; Glucofisiologica†.
The symbol ⊗ denotes a substance whose use may be restricted in certain sports (see p.vii)
Gases
This chapter includes monographs on gases with medical or pharmaceutical uses and applications (such as
oxygen, carbon dioxide, helium, and nitrogen) as well
as those where the medical interest lies primarily in
management of their toxicity or adverse effects (such
as carbon monoxide or hydrogen sulfide). Also included are some compressed and liquefied gases used as
refrigerants and aerosol propellants. Nitric oxide gas is
used in bronchopulmonary disorders and is discussed
in Cardiovascular Drugs (p.1358). Other gases with
medical uses can be found in Disinfectants and Preservatives (p.1622) and General Anaesthetics
(p.1779).
Refrigerants and Aerosol Propellants
A number of compressed and liquefied gases are used
as refrigerants and as aerosol propellants; these include
nitrogen, nitrous oxide, carbon dioxide, propane, and
the butanes. Chlorofluorocarbons (CFCs) were widely
used but because of environmental hazards their general use has been severely restricted and they are being
phased out in medicine and pharmacy. Hydrogenated
chlorofluorocarbons (hydrochlorofluorocarbons) and
nonchlorinated fluorocarbons (hydrofluorocarbons)
are being developed as alternatives, although neither
are devoid of environmental effects.
The evaporation of halogenated hydrocarbon propellants produces an intense cold that numbs the tissues,
and they have been used as topical analgesics (see Rubefacients and Topical Analgesia, p.5).
Refrigerants and aerosol propellants have been subject
to deliberate abuse. Inhalation of high concentrations
of halogenated hydrocarbons for their euphoriant effect may result in CNS depression, cardiac arrhythmias, respiratory depression, and death. Propane and butane can act as simple asphyxiants. Heat can cause the
decomposition of halogenated hydrocarbons into irritant and toxic gases such as hydrogen chloride and
phosgene.
Toxicity. Reviews have covered the toxicity and adverse effects
that may occur as a consequence of the deliberate abuse of aerosol propellants1-4 as well as the hazards associated with occupational exposure.5 Further references relevant to the toxicity of individual agents are given in the monographs.
1. Volatile substance abuse—an overview. Hum Toxicol 1989; 8:
255–344.
2. Ashton CH. Solvent abuse. BMJ 1990; 300: 1356–6.
3. Anderson HR. Increase in deaths from deliberate inhalation of
fuel gases and pressurised aerosols. BMJ 1990; 301: 41.
4. Kurtzman TL, et al. Inhalant abuse by adolescents. J Adolesc
Health 2001; 28: 170–80.
5. Matthews G. Toxic gases. Postgrad Med J 1989; 65: 224–32.
Bromochlorodifluoromethane
Bromoclorodifluorometano.
CBrClF 2 = 165.4.
Profile
Bromochlorodifluoromethane has been used as a fire-extinguishing agent.
◊ Reports of toxicity after the misuse or abuse of fire extinguishers containing bromochlorodifluoromethane,1-3 and in persons
exposed in other ways.4,5
1. Steadman C, et al. Abuse of fire-extinguishing agent and sudden
death in adolescents. Med J Aust 1984; 141: 115–17.
2. Lerman Y, et al. Fatal accidental inhalation of bromochlorodifluoromethane (Halon 1211). Hum Exp Toxicol 1991; 10: 125–8.
3. Gerhardt RT. Acute Halon (bromochlorodifluoromethane) toxicity by accidental and recreational inhalation. Am J Emerg Med
1996; 14: 675–7.
4. Matrat M, et al. Reactive airways dysfunction syndrome caused
by bromochlorodifluoromethane from fire extinguishers. Occup
Environ Med 2004; 61: 712–14.
5. Lo SH, et al. Grand rounds: outbreak of hematologic abnormalities in a community of people exposed to leakage of fire extinguisher gas. Environ Health Perspect 2006; 114: 1713–17.
Solid carbon dioxide, or ‘dry ice’ has a temperature of −80° and
has been used to treat warts (p.1584) and naevi by cryotherapy.
Carbon dioxide may be used as the insufflating gas for laparoscopy and as a contrast agent in radiography (p.1474).
Butane
n-Butane; Butano; E943a.
C 4 H 10 = 58.12.
C AS — 106-97-8.
H 3C
CH3
Pharmacopoeias. In USNF.
USNF 26 (Butane). A colourless gas. It is highly flammable and
explosive. Store in airtight cylinders at a temperature not exceeding 40°.
Profile
Butane is used as an aerosol propellant (above). It is widely used
as a fuel.
Abuse. Reports of toxicity associated with the abuse of butane.1-9
1. Gunn J, et al. Butane sniffing causing ventricular fibrillation.
Lancet 1989; i: 617.
2. Siegel E, Wason S. Sudden death caused by inhalation of butane
and propane. N Engl J Med 1990; 323: 1638.
3. Roberts MJD, et al. Asystole following butane gas inhalation. Br
J Hosp Med 1990; 44: 294.
4. Williams DR, Cole SJ. Ventricular fibrillation following butane
gas inhalation. Resuscitation 1998; 37: 43–5.
5. Rieder-Scharinger J, et al. Multiorganversagen nach Butangasinhalation: ein Fallbericht. Wien Klin Wochenschr 2000; 112:
1049–52.
6. Wehner F, et al. Tödliche Inhalation von Butan-Propan-Gas.
Arch Kriminol 2002; 209: 164–8.
7. El-Menyar AA, et al. A teenager with angiographically normal
epicardial coronary arteries and acute myocardial infarction after
butane inhalation. Eur J Emerg Med 2005; 12: 137–41.
8. Harris D, Mirza Z. Butane encephalopathy. Emerg Med J 2005;
22: 676–7.
9. Doogue M, Barclay M. Death due to butane abuse—the clinical
pharmacology of inhalants. N Z Med J 2005; 118: U1732.
Preparations
Proprietary Preparations (details are given in Part 3)
Multi-ingredient: Arg.: Batistol†; Frionex; Fr.: Cliptol Sport†.
Carbon Dioxide
Anglies dioksidas; Carbone, dioxyde de; Carbonei dioxidum;
Carbonei Dioxydum; Carbonic Acid Gas; Carbonic Anhydride;
Dióxido de carbono; E290; Hiilidioksidi; Koldioxid; Oxid uhličitý;
Szén-dioxid; Węgla dwutlenek.
CO 2 = 44.01.
C AS — 124-38-9.
ATC — V03AN02.
ATC Vet — QV03AN02.
NOTE. Carbon dioxide is about 1 ⁄ times as heavy as air.
Pharmacopoeias. In Chin., Eur. (see p.vii), Jpn, and US.
Ph. Eur. 6.2 (Carbon Dioxide). A colourless gas. Soluble 1 in
about 1 of water by volume at 20° and at a pressure of 101 kpA.
Store liquefied under pressure in suitable containers.
The BP 2008 directs that carbon dioxide should be kept in approved metal cylinders which are painted grey and carry a label
stating ‘Carbon Dioxide’. In addition, ‘Carbon Dioxide’ or the
symbol ‘CO2’ should be stencilled in paint on the shoulder of the
cylinder.
USP 31 (Carbon Dioxide). A colourless, odourless gas. Its solutions are acid to litmus. One volume dissolves in about 1 volume
of water. Store in cylinders.
Adverse Effects
Above a concentration of 6%, carbon dioxide causes headache,
dizziness, confusion, palpitations, hypertension, dyspnoea, increased depth and rate of respiration, and CNS depression. Concentrations of about 20% and higher produce convulsions and
loss of consciousness; inhalation of 50% carbon dioxide is reported to produce central effects similar to anaesthetics. The inhalation of high concentrations may produce respiratory acidosis.
Abrupt withdrawal of carbon dioxide after prolonged inhalation
commonly produces pallor, hypotension, dizziness, severe headache, and nausea or vomiting.
Skin contact with solid carbon dioxide may cause frostbite.
Uses and Administration
Carbon dioxide has been added to the oxygen in certain types of
pump oxygenators to maintain the carbon dioxide content of the
blood.
Although carbon dioxide stimulates respiration, it is seldom used
for this purpose. Treatment of carbon monoxide poisoning with
carbon dioxide/oxygen mixtures is discouraged due to the risk of
respiratory acidosis.
Inhalation of carbon dioxide has been tried for relief of intractable hiccup (p.976). Carbonated vehicles are useful for masking
the unpleasant taste of some medicinal preparations.
1688
Carbon Monoxide (USAN)
Anglies monoksidas; Carbone, monoxyde de; Carbonei monoxidum; Hiilimonoksidi; Karbon Monoksit; Kolmonoxid; Monóxido
de carbono; Węgla tlenek.
CO = 28.01.
C AS — 630-08-0.
Description. Carbon monoxide is a colourless, odourless,
tasteless, highly flammable gas.
Adverse Effects
Carbon monoxide is produced by incomplete combustion of organic materials and is highly toxic when inhaled; infants, small
children, and elderly people are particularly susceptible. Although the number of cases of poisoning in countries such as the
UK has fallen as the availability of coal gas has declined and as
changes have been made to motor vehicles to improve their exhaust fumes, carbon monoxide is still a major cause of poisoning.
Common sources of carbon monoxide include poorly maintained and ventilated heating systems and improperly burnt fuel
in domestic fires.
When inhaled, carbon monoxide combines with haemoglobin in
the blood to form carboxyhaemoglobin, which is unable to transport oxygen; the symptoms of carbon monoxide poisoning are
largely due to anoxia. The skin and tissues may turn a classic
cherry red in patients poisoned with carbon monoxide although
this is seen most often after death.
The symptoms of carbon monoxide poisoning are varied and depend on the degree and duration of exposure. Unconsciousness
may occur suddenly but is commonly preceded by headache,
dizziness, weakness, nausea, and vomiting, which may be misdiagnosed as a viral illness or food poisoning. Other symptoms
may include skin lesions, excessive sweating, pyrexia, increased
respiration, mental dullness and confusion, visual disturbances,
convulsions, hypotension, tachycardia or other cardiac arrhythmias, myocardial ischaemia, and possibly myocardial infarction.
Death may result from respiratory failure, pulmonary oedema,
cardiovascular failure, or cerebral damage. The lethal concentration of carboxyhaemoglobin in the blood is about 50% or more.
Concentrations over 1000 ppm of carbon monoxide in inspired
air may be fatal in 1 hour. Neurological and psychiatric sequelae
may develop some weeks later in the survivors of severe poisoning and therefore a prolonged follow-up of such patients is advised; symptoms include memory impairment, apathy, mutism,
irritability, personality change, gait disturbance, and urinary and
faecal incontinence. Chronic carbon monoxide exposure may
present as a non-specific illness with headache, nausea, and flulike symptoms.
◊ General references.
1. Meredith T, Vale A. Carbon monoxide poisoning. BMJ 1988;
296: 77–9.
2. Crawford R, et al. Carbon monoxide poisoning in the home: recognition and treatment. BMJ 1990; 301: 977–9.
3. Ernst A, Zibrak JD. Carbon monoxide poisoning. N Engl J Med
1998; 339: 1603–8.
4. WHO. Carbon Monoxide. Environmental Health Criteria 213.
Geneva: WHO, 1999. Available at: http://www.inchem.org/
documents/ehc/ehc/ehc213.htm (accessed 05/07/04)
5. Satran D, et al. Cardiovascular manifestations of moderate to severe carbon monoxide poisoning. J Am Coll Cardiol 2005; 45:
1513–16.
6. Prockop LD, Chichkova RI. Carbon monoxide intoxication: an
updated review. J Neurol Sci 2007; 262: 122–30.
Treatment of Adverse Effects
The patient should be removed from the contaminated atmosphere and an effective airway established. Oxygen (100%)
should be given until the blood carboxyhaemoglobin concentration has fallen below dangerous levels (usually 5%). Management is then usually symptomatic and supportive with attention
being given to the possible need to treat or correct any cardiovascular disorders, metabolic acidosis, or cerebral oedema. Hyperbaric oxygen therapy may be considered in pregnant patients or
in severe poisoning (if the patient is, or has been, unconscious; if
the carboxyhaemoglobin concentration exceeds 20%; or if there
are neurological symptoms or cardiac complications) but is of
unproven benefit (see below) and its use is controversial.
◊ References.
1. Anonymous. Treatment of carbon monoxide poisoning. Drug
Ther Bull 1988; 26: 77–9.
2. Ely EW, et al. Warehouse workers’ headache: emergency evaluation and management of 30 patients with carbon monoxide poisoning. Am J Med 1995; 98: 145–55.
Hyperbaric oxygen therapy. The use of hyperbaric oxygen
therapy in the management of carbon monoxide poisoning is
controversial.1 It is of theoretical benefit since it increases the
rate at which carboxyhaemoglobin dissociates, and beneficial