It is used to increase the circulating volume and restore protein levels in conditions such as burns, pancreatitis, and plasma loss through trauma. Patients with active coronary or cerebral vascular disease or ongoing hemorrhage require blood when hemoglobin is < 10 g/dL (100 g/L). Results: They are also known as volume expanders as they draw water out of the intracellular space, increasing extracellular fluid volume. It has an osmolality of 154 mOsm/L and contains 77 mEq/L sodium and chloride. A 0.9% sterile solution of sodium chloride in water. With hypotonic fluid (eg, 0.45% saline), even less remains in the vasculature, and, thus, this fluid is not used for resuscitation. If you want to give the patient some additional D5W, it's preferable to run two simultaneous infusions (one with D5W and another with true isotonic bicarbonate). When infused, isotonic solutions expand both the intracellular fluid and extracellular fluid spaces, equally. If you continue to use this site we will assume that you are happy with it. Numerous large high-quality RCTs have shown that it causes renal failure and may increase mortality in sepsis. Dextrose 5% in water is also given for nutritional support to patients who are unable to eat because of illness, injury, or other medical condition. There is no physiologic rationale for its use as a resuscitative fluid. The illustration above may appear a bit amusing, but this actually mirrors various practices that I've encountered during my training and career. Normal saline | definition of normal saline by Medical dictionary IV Fluids and Solutions Guide & Cheat Sheet - Nurseslabs (5) Hyperchloremia caused by normal saline may cause renal vasoconstriction, increasing the risk of kidney injury. Why is normal saline used for blood transfusions? Extracorporeal CO2 removal: Putting the cart ahead of the horse? For example, large volumes of intravenous (IV) fluids can overexpand the liquid or plasma component of peripheral blood, diluting the percentage of formed blood cell elements. Another hypertonic IV solution used commonly is Dextrose 50% in Water (D50W) which is used to treat severe hypoglycemia and is administered rapidly via IV bolus. such as D5 0.18% (fifth-normal saline), D5 0.3% (third-normal saline) or even D5 0.45% . Also a special thanks to my colleague who told me about this website today on the campus when I was in total doubt as to where to go to have a sophisticated guide for my assignment on a care plan and indeed when I entered this lab today I saw myself at the center of my solution. Normal saline for injection can cause inflammation or irritation at the injection site. Myburgh JA, Finfer S, Bellomo R, et al: Hydroxyethyl starch or saline for fluid resuscitation in intensive care. Red blood cells placed in a solution with a lower water concentration compared to their contents (eg 1.7 per cent salt solution) will lose water by osmosis and shrink. Normal saline is a hypertonic, acidotic fluid. This effect causes cells to shrink and may disrupt their function. TPN requires a chronic IV access for the solution to run through, and the most common complication is infection of this catheter. 0.33% Sodium Chloride Solution is used to allow kidneys to retain the needed amounts of water and is typically administered with dextrose to increase tonicity. Dextrose 10% in Water (D10W) is an hypertonic IV solution used in the treatment of ketosis of starvation and provides calories (380 kcal/L), free water, and no electrolytes. Of the various intravenous solutions, only isotonic saline (0.9%) is recommended for use with blood components. Copyright 2009-. When to use IV fluid and blood transfusion? o [ abdominal pain pediatric ] Federal government websites often end in .gov or .mil. Don't use hypertonic bicarbonate to treat hyperkalemia (proven not to work). Pharmacology Flash Cards #1 BEST SELLER!Test-yourself review cards put critical clinical information for nearly 400 of the top generic medications at your fingertips. Normal saline is a rational therapy for acute metabolic alkalosis, because it will reduce the serum bicarbonate level back towards normal. The nature and severity of abdominal injuries vary read more , extremity compartment syndrome). In vitro characteristics of RBCs coinfused with 0.9% saline or D10W were not adversely impacted. Patients with traumatic hemorrhage shock may require a slightly different approach. Thanks. Engaging learning features cultivate your clinical application, critical thinking and patient education capabilities. Which IV fluid is compatible with blood products? Depending on the patient's weight and baseline bicarbonate, this will generally involve administration of ~150-300 mEq sodium bicarbonate to target a serum bicarbonate level of ~30-35 mEq/L. Dougherty, L., & Lamb, J. Most forms of metabolic alkalosis seen in the ICU are chronic (e.g. Study design and methods: Learn more about the Merck Manuals and our commitment to Global Medical Knowledge. The most common types of solutions include normal saline (NS) and D5W. Technically, electrolyte solutions are considered isotonic if the total electrolyte content is approximately 310 mEq/L. The PN formulation provides energy, fluid, and various medications via peripheral or central venous access. Enter search terms to find related medical topics, multimedia and more. The most common way to categorize IV fluids is based on their tonicity: IV solutions can also be classified based on their purpose: Crystalloid IV solutions contain small molecules that flow easily across semipermeable membranes. In practice, crystalloid is generally preferred because it is cheaper and more readily available. The saline priming of blood transfusion tubing is one such nursing practice that has long . Why normal saline is bad? Administering PRBC's -alone or with NS? - allnurses Thus, nonoxygen-carrying fluids (eg, crystalloid or colloid solutions) may be used to restore intravascular volume in mild to moderate blood loss. This website has become a lifesaver! With hypotonic fluid (eg, 0.45% saline), even less remains in the vasculature, and, thus, this fluid is not used for resuscitation. Hetastarch is a cheap, synthetic colloid. For more information, check out ourprivacy policy. Increase your test scores in pharmacology class. EMCrit is a trademark of Metasin LLC. RBCs incubated with D5W and D5W/0.2% saline had greater (p<0.05) hemolysis than RBCs alone after 180 minutes. Saline IVs have even found a place outside the hospital, as a trendy hangover remedy. Parenteral nutrition provides requisite nutrients to patients intravenously, thereby bypassing a nonfunctional GI tract. This may buy them some time for their kidneys to recover, potentially avoiding the need for dialysis. Thanks, if possible could you post a site where I can find that information. Interestingly, the SALT-ED trial showed benefit from balanced crystalloid, despite most patients' receiving relatively little fluid. Experts are tested by Chegg as specialists in their subject area. chronic compensatory metabolic alkalosis in response to chronic respiratory acidosis). Accessibility A sick or injured patient with a CVP < 3 mm Hg is presumed to be volume depleted and may be given fluids with relative safety. There are many potential problems related to saline. 2017 Jan;44(1):30-38. doi: 10.1159/000449039. 2002 Jan;16(1):46-60. doi: 10.1053/tmrv.2002.29404. D5W (dextrose 5% in water) is a crystalloid isotonic IV fluid with a serum osmolality of 252 mOsm/L. Compatibility of ADSOL-stored Red Cells With Intravenous Solutions Homeostasis read more for discussion of maintenance fluid requirements and see Dehydration and Fluid Therapy in Children Dehydration in Children Dehydration is significant depletion of body water and, to varying degrees, electrolytes. Lactated Ringers is generally an outstanding choice as it is inexpensive, widely available, and physiologically sound (the choice of lactate as an anion is arguably superior to gluconate/acetate). Dextrose 20% in Water (D20W) is hypertonic IV solution an osmotic diuretic that causes fluid shifts between various compartments to promote diuresis. Do NOT hang longer than 4 hours. Adequate end-organ perfusion is best indicated by urine output of > 0.5 to 1 mL/kg/hour. You'll get a detailed solution from a subject matter expert that helps you learn core concepts. Normal saline is the solution of choice over D2W when preparing to administer a blood transfusion because c. Normal saline is an isotonic solu, Normal Saline (NS) is the solution of choice over D5W when preparing to administer a blood transfusion because A Normal Saline is hypertonic and compatible with all blood products B Normal Saline is the most common primary IV solution Normal Saline is an isotonic solution and prevents cell hemolysis D The dextrose in D5W increases risk of infection with transfusions. Because the antigen-bearing red blood cell membrane is not present, these substances do not require cross-matching. HOW MUCH FLUID IS USED IN 24HR PERIOD? With a tabbed, alphabetical organization and a New Drugs section, NDH2023 makes it easy to check drug facts on the spot. Priming Blood Transfusion Tubing: A Critical Review of the Blood Sodium chloride 0.45% (1/2 NS), also known as half-strength normal saline, is a hypotonic IV solution used for replacing water in patients who have hypovolemia with hypernatremia. Question: Normal Saline (NS) is the solution of choice over D5W when preparing to administer a blood transfusion because A Normal Saline is hypertonic and compatible with all blood products B Normal Saline is the most common primary IV solution Normal Saline is an isotonic solution and prevents cell hemolysis D The I can not leave this site without confessing myself. Tonicity plays a role but a minor role as upposed to calcium. Blood products require a dedicated line for infusion, and filtered intravenous tubing. Do you have to prime blood tubing with saline? It is recommended to infuse slowly to increase circulating volume. Normal saline (NS) is the commonly used term for a solution of 0.9% w/v of NaCl, about 300 mOsm/L. Our mission is to Empower, Unite, and Advance every nurse, student, and educator. There is no medicolegal or evidence-based justification for using hetastarch. It could even function as an osmotic diuretic agent. White blood cells White Blood Cells help fight infection, bacteria and other substances that enter the body. Thank you so much for this website,this has helped me alot in my nursing career . Dextrose 5% in Water (D5W) Intravenous - Drugs.com It has high levels of sodium and chloride, levels that are higher than the blood. 1 Blood Bank and Transfusion Service, Los Angeles County-University of Southern California Medical Center 90033-1084. It should not be administered with blood products as it can cause hemolysis of red blood cells. They are categorized according to their relative tonicity in relation to plasma. http://traffic.libsyn.com/ibccpodcast/IBCC_Episode_42_Fluid_Selection__pH_guided_resuscitation_Final.mp3. HMWD used for patients with hypovolemia and hypotension. Would you like email updates of new search results? Colloid solutions (eg, hydroxyethyl starch, albumin, dextrans) are also effective for volume replacement during major hemorrhage. Cirrhosis or liver injury (unless the patient has frank hepatic failure, it will be able to metabolize lactate). Which intravenous (IV) prescription does the nurse anticipate for this patient? There are three types: isotonic, hypotonic, and hypertonic. Dextrose Water: This solution contains dextrose, a form of glucose. Nearly all available physiologic, animal, and clinical data suggests balanced crystalloids are superior. 4 Intravenous immunoglobulin (IVIG) is only compatible with D5W. Currently, no blood substitutes are commercially available for use. Transfus Med Rev. PMC This effect usually isn't a concern unless a person gets . Hypotonic sodium solutions are used to treat hypernatremia and other hyperosmolar conditions. document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() ); Matt Vera, a registered nurse since 2009, leverages his experiences as a former student struggling with complex nursing topics to help aspiring nurses as a full-time writer and editor for Nurseslabs, simplifying the learning process, breaking down complicated subjects, and finding innovative ways to assist students in reaching their full potential as future healthcare providers. However, this compensation is overwhelmed after major losses. Furthermore, Plasmalyte doesn't contain calcium, so it's compatible with a wider variety of drugs. Thank you! This explains the alkalinizing effect of IV bicarbonate. Oftentimes, a post surgery patient will receive a hypertonic solution to treat the tissue edema that accompanies the operation. This will happen even if the patient is on mechanical ventilation (administered pCO2 increases the. 8600 Rockville Pike They contain no electrolytes and are used to treat shock related to vascular volume loss (e.g., burns, hemorrhage, trauma, or surgery). The most commonly used forms of bicarbonate are hypertonic bicarbonate (undiluted ampules) and isotonic bicarbonate, as compared above. It should be used in caution for patients with heart failure and renal insufficiency. Other monitoring read more may be considered for diagnosis or for more precise titration of fluid therapy if there is no cardiovascular improvement after initial therapy. Bicarbonate deficit (in mEq) can be estimated. Hello Mj, yes, of course, youre free to download them. Blood Transfusion / methods* JAMA 313(5):471-482, 2015. doi:10.1001/jama.2015.12, 2. Symptoms and signs include thirst, lethargy, dry mucosa, decreased urine output, and, as the degree read more for discussion of mild dehydration. When combined with red cells, other frequently used . Occasionally, intubated patients who are encountered who are extremely difficult to ventilate (typically due to status asthmaticus or severe ARDS). and transmitted securely. Dismiss. We recommend this book if you want a comprehensive nursing pharmacology guide. They are contraindicated in patients with hemorrhagic shock. Therefore, D5W is used as the base solution because most hospitals don't have IV sterile water available. The blood brain barrier prevents rapid movement of solutes out of or into the brain. Saline solution: A bag of saline. Intravascular volume deficiency is acutely compensated for by vasoconstriction, followed over hours by migration of fluid from the extravascular compartment to the intravascular compartment, maintaining circulating volume at the expense of total body water. What are the advantages of parenteral nutrition? Red blood cell hemolysis during processing. However, dextrose is quickly metabolized and only the isotonic solution remains. Normal saline is the isotonic solution of choice for expanding the extracellular fluid (ECF) volume because it does not enter the intracellular fluid (ICF). What should I monitor with parenteral nutrition? An additional component, white cells, is often removed from donated blood before transfusion. Transfusion. Why is normal saline used for blood transfusions? Both 0.9% saline and Ringer's lactate are equally effective; Ringer's lactate may be preferred in hemorrhagic shock because it somewhat minimizes acidosis and will not cause hyperchloremia. Use to remove results with certain terms Q: Should blood tubing be primed with or without normal saline before administration of blood products?A: Christine Kessler, RN, MN, CNS, ANP, BC-ADM, replies:Many hospital transfusion protocols and related nursing practices have been based more on tradition and assumptions than on scientific evidence. Effects of various arterial infusion solutions on red blood cells in (4) In animal models, normal saline causes significant harm compared to balanced crystalloid (e.g. In patients with severe hypovolemia or hypovolemic . Quality of red blood cells washed using an automated cell processor with and without irradiation. Not understanding how to use various forms of bicarbonate. "Normal" saline is a hypertonic, acidotic fluid. Lactated Ringers contains 1.5 mM of calcium. It is the most physiologically adaptable fluid because its electrolyte content is most closely related to the composition of the bodys blood serum and plasma. . Background: It should also be avoided to be used in clients at risk for increased intracranial pressure as it can cause cerebral edema. However, this parameter is not measured directly. A 30 cc/kg bolus of Lactated Ringers might possibly raise the lactate level by ~0.5 mM. Epub 2016 Nov 4. It can also be used in fluid losses due to burns, fistula drainage, and trauma. Epub 2013 Nov 14. Subscribe online and gain access to the entire archive. The optimal rate of alkalinization is unknown, and likely varies depending on the individual patient scenario. These solutions are derived from starch and are used to increase intravascular fluid but can interfere with normal coagulation. Fluids can be warmed via fluid warmer, rapid infuser, or in-line warmer. The main reason you cannot utilize LR because the calcium in the LR will bind to the citrate in the blood and cause clumping of the RBCs this is also why you give 1gram of calcium after every 4 transfusions, becuase the citrate that is infused will bind to calcium in the body. However, there are few studies either evaluating or quantifying increased coagulation during rapid infusion of LR and blood. doi: 10.1111/j.1537-2995.2010.02960.x. This study guide will help you focus your time on what's most important. They need to be infused at a very low rate to avoid the risk of overload and pulmonary edema. It may also be used to treat metabolic acidosis in cases other than those caused by lactic acidosis 3. Always refer to your agency policy for guidelines for preparing, initiating, and monitoring blood and blood product transfusions. At how many gtts/min will you regulate the IV?, The physician has ordered 1500 ml of LR to infuse in 12 hours. How many gtt/min will the patient receive?, The patient is to receive 3000ml of D5W at 125 ml/hr. Doctors use IV saline to replenish lost fluids, flush wounds, deliver medications, and sustain patients through surgery, dialysis, and chemotherapy. Saline solution is administered intravenously (IV drips) and increases both intravascular and interstitial volume. Med Surg Ch 10 Infusion Therapies Flashcards | Quizlet It is the choice for first-line fluid resuscitation for certain patients. Blood substitutes are oxygen-carrying fluids that can be hemoglobin-based or perfluorocarbons. Plasma Protein Fraction is a solution that is also prepared from plasma, and like albumin, is heated before infusion. Get to know the different types of intravenous solutions or IV fluids in this guide and cheat sheet. Does dextrose increase risk of infection with blood transfusion? Because of compensatory vasoconstriction, mean arterial pressure (MAP) is only a rough guideline; organ hypoperfusion may be present despite apparently normal values. Patients in shock typically require and tolerate infusion at the maximum rate. Normal saline Patients with normal kidneys will eventually re-generate bicarbonate, but this takes time. Each 150 mEq of bicarbonate comes along with a liter of volume. They cause fluid shifts from the ECF into the ICF to achieve homeostasis, therefore, causing cells to swell and may even rupture. Normal saline is the only compatible solution to use with the blood or blood component. allnurses is a Nursing Career & Support site for Nurses and Students. Rare side effects of this solution related to receiving too much volume include: diarrhea; cramps; nausea; vomiting; increases in . Why is normal saline the only solution used for blood transfusions(PRBC's)? MeSH Updated drug content reflects the most recent FDA drug approvals, withdrawals, and therapeutic uses. Lactated Ringers Solution (also known as Ringers Lactate or Hartmann solution) is a crystalloid isotonic IV fluid designed to be the near-physiological solution of balanced electrolytes. Isotonic bicarbonate may improve the pH and help avoid dialysis. This isn't possible, because. Choosing a specialty can be a daunting task and we made it easier. 2 Specific blood administration tubing is required for all blood transfusions. For example, in a severely hypovolemic patient who needs fluid and bicarbonate, you may wish to run the isotonic bicarbonate at 250-1,000 ml/hr (to provide both volume and bicarbonate). If a patient comes to us two hours after dying you cant bring them back to life. What are the safety considerations for blood transfusions? Copyright 2023 Merck & Co., Inc., Rahway, NJ, USA and its affiliates. This may be problematic especially in patients who are severely acidotic to begin with (which isn't uncommon among critically ill patients). A ratio of 1 unit of plasma for each 1 unit of red blood cells and each 1 unit of platelets is currently recommended (1 Fluids references Almost all circulatory shock states require large-volume IV fluid replacement, as does severe intravascular volume depletion (eg, due to diarrhea or heatstroke). There are many potential problems related to saline. Several years ago, the ICU at Genius General Hospital transitioned from using normal saline to using mostly Lactated Ringers (spoiler alert: it was neither difficult nor dramatic). The gtt factor is 60. Normal saline solution (0.9% NaCl) or NSS, is a crystalloid isotonic IV fluid that contains water, sodium (154 mEq/L), and chloride (154 mEq/L). Most IV fluids are isotonic, meaning, they have the same concentration of solutes as blood plasma. 8.3 IV Fluids, IV Tubing, and Assessment of an IV System Conclusion: In vitro characteristics of RBCs coinfused with 0.9% saline or D10W were not adversely impacted. They decrease osmotic pressure by diluting the blood. Lehnes Pharmacology for Nursing Care(11th Edition)The Eleventh Edition of Lehnes Pharmacology for Nursing Care provides a thorough understanding of key drugs and their implications for nursing care. INDICATIONS From Development to Implementation: Adjusting the Hematocrit of Deglycerolized Red Cell Concentrates to Meet Regulatory Standards. Sodium gluconate appears to be cleared unchanged from the kidneys. For example, 5% dextrose in water will hemolyze red cells. Colloid solutions are generally not used. However, because read more ). When developing clinical studies in neonates, we recommend use of D10W and a transfusion apparatus that minimizes the contact volume of the coinfusate with the RBC. Another hypotonic IV solution commonly used is 2.5% dextrose in water (D2.5W). Lactate may function as a metabolic fuel for the heart, so if anything, lactate could be a good thing. This has been shown in a variety of studies, most recently the SALT-ED RCT. This is the perfect supplement to class materials, offering solid preparation for NCLEX as well as a handy refresher for experienced nurses. Hypertonic dextrose solutions are used to provide kilocalories for the patient in the short term. Dissolved CO2 will transiently increase the patient's pCO2. This risk may be minimized by using blood < 12 days old; such red blood cells are more plastic and less likely to cause sludging in the microvasculature. Don't use bicarbonate to treat lactic acidosis or ketoacidosis (this doesn't work and gives bicarbonate a bad reputation). We evaluated the impact of coinfusion with dextrose-containing fluids (DW) on markers of RBC quality. Holcomb JB, Tilley BC, Baraniuk S, et al: Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: The PROPPR randomized clinical trial. Micronutrient deficiencies (vitamin and minerals). greater acidosis, impaired cardiac function, coagulopathy, impaired renal function, and mortality). Despite theoretical support for albumin, there's no real evidentiary support. Our members represent more than 60 professional nursing specialties. Additionally, angiotensin-converting enzyme inhibitors should be withheld for at least 24 hours before administering albumin because of the risk of atypical reactions, such as hypotension and flushing. They decrease osmotic pressure by diluting the blood. Pharmacy. Normal saline is the isotonic solution of choice for expanding the extracellular fluid (ECF) volume because it does not enter the intracellular fluid (ICF). This serves the dual purpose of administering to the patient any residual blood left in the administration set (up to 40 mL), and it flushes the line for later use. Pulmonary Artery Catheter (PAC) Monitoring, Acute Hypoxemic Respiratory Failure (AHRF, ARDS), Recognizing complications of abdominal trauma, End Point and Monitoring of Fluid Resuscitation, Dehydration and Fluid Therapy in Children, Advocate Glucose SOS, BD Glucose, Dex4 Glucose, Glutol , Glutose 15 , Glutose 45 , Glutose 5. Alternatively, if the patient is resuscitated to a euvolemic state. Which fluid is used to flush IV line after blood transfusion? The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Hinkle, J. L., & Cheever, K. H. (2017). (WB, n = 25) and packed red blood cells (PRBC, n = 26) were rapidly admixed with normal saline (NS), Lactate solution and LR with 1 g (LR-1), 2 g (LR-2), and 5 g (LR-5) CaCl2/L solutions for assessment of infusion . 2011 Jan;51 Suppl 1:25S-33S. Used together with dextrose. The following are the general nursing interventions and considerations when administering isotonic solutions: Hypotonic IV solutions have a lower osmolality and contain fewer solutes than plasma. 10 Answers. Transfusion guidelines advise against coinfusing red blood cells (RBCs) with solutions other than 0.9% saline. On the other hand, water . The technique involves replacing all of a patients blood with a cold saline solution, which rapidly cools the body and stops almost all cellular activity. Intravascular volume deficiency read more ). The trusted provider of medical information since 1899, Last review/revision Jun 2022 | Modified Sep 2022. Isotonic IV fluids have a total osmolality close to that of the ECF and do not cause red blood cells to shrink or swell. 0.225% Sodium Chloride Solution is often used as a maintenance fluid for pediatric patients as it is the most hypotonic IV fluid available at 77 mOsm/L. HHS Vulnerability Disclosure, Help Exogenous bicarbonate has long been used by nephrologists in efforts to improve pH and avoid dialysis. Lactated Ringers solution and 5 per cent dextrose in 0.225 per cent saline should not be administered concurrently with blood. Left to their own devices, patients with ARDS or status asthmaticus will often eventually compensate for their respiratory acidosis by mounting a compensatory metabolic alkalosis. Thank you so much for your dedication, effort, and great work. This is the practice at my hospital, let me know if you have seen different and why. The nurse working in the emergency department (ED) is caring for a patient who experienced deep-thickness burns over 40% of the body and is in shock. Dextrans are polysaccharides that act as colloids. Our recommended nursing pharmacology resources and books: Disclosure:Included below are affiliate links from Amazon at no additional cost from you. 5% Albumin is a solution derived from plasma and is a commonly utilized colloid solution. The procedure is simple: fluids are restricted to normal saline and serum sodium levels, and it . A liter of D5W provides fewer than 200 kcal and contains 50g of glucose. Bicarbonate will persist longer, after the pCO2 has been exhaled. However, interpretation of the images is highly user dependent and can be complicated by the presence of valvular dysfunction and the use of positive pressure ventilation. Blood typically is given as packed red blood cells, which should be cross-matched, but in an urgent situation, 1 to 2 units of type O Rh-negative blood are an acceptable alternative. What are the side effects of normal saline? | Nutritive Agent Is lactated Ringers compatible with blood products? Effects of intravenous delivery systems on infused red blood cells. (2) Normal saline exacerbates acidosis. Search for other works by this author on: You do not currently have access to this content. Finally, for occasional patients with significant pre-existing hyperkalemia or metabolic acidosis, fluid choice may be extremely important. Overall, there is a subset of patients with acute kidney injury, uremic metabolic acidosis, and hyperkalemia who will respond very favorably to isotonic bicarbonate with resolution of their electrolytic problems.
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