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Note: Ammonium chloride is an alternative treatment and should be used only after sodium and potassium chloride supplementation has been optimized. The following equations represent different methods of chloride or alkalosis correction utilizing either the serum Cl - , the serum HCO 3 - , or the base excess. These equations will yield different requirements of ammonium chloride. Initially, administer 1 / 2 to 2 / 3 of the calculated dose, and then re-evaluate. Dosing of mEq NH 4 Cl via the chloride-deficit method (hypochloremia): mEq NH 4 Cl = 0.2 L/kg x wt in kg x [103 - serum Cl - ] mEq/L Dosing of mEq NH 4 Cl via the bicarbonate-excess method (refractory hypochloremic metabolic alkalosis): mEq NH 4 Cl = 0.5 L/kg x wt in kg x [serum HCO 3 - - 24] mEq/L Dosing of mEq NH 4 Cl via the base excess method: mEq NH 4 Cl = 0.3 L/kg x wt in kg x base excess (mEq/L)

Metabolic alkalosis: The following equations represent different methods of correction utilizing either the serum HCO 3 - , the serum chloride, or the base excess; administer 50% of dose over 12 hours, then re-evaluate: Dosing of mEq NH 4 Cl via the chloride-deficit method (hypochloremia): Dose of mEq NH 4 Cl = [0.2 L/kg x body weight (kg)] x [103 - observed serum chloride;

Note: 0.2 L/kg is the estimated chloride volume of distribution and 103 is the average normal serum chloride concentration (mEq/L) Dosing of mEq NH 4 Cl via the bicarbonate-excess method (refractory hypochloremic metabolic alkalosis): Dose of NH 4 Cl = [0.5 L/kg x body weight (kg)] x (observed serum HCO 3 - - 24);

Note: 0.5 L/kg is the estimated bicarbonate volume of distribution and 24 is the average normal serum bicarbonate concentration (mEq/L) These equations will yield different requirements of ammonium chloride. Dosage Forms: U.S. Excipient information presented when available (limited, particularly for generics); consult specific product labeling. Injection, solution: Ammonium 5 mEq/mL and chloride 5 mEq/mL (20 mL) [equivalent to ammonium chloride 267.5 mg/mL] Generic Equivalent Available: U.S. Yes Administration Parenteral: Dilute to 0.2 mEq/mL and infuse I.V. over 3 hours; maximum concentration: 0.4 mEq/mL; maximum rate of infusion: 1 mEq/kg/hour Compatibility Stable in dextran 6% in D 5 W, dextran 6% in NS, D 5 LR, D 5 NS, D 5 1 / 2 NS, D 5 1 / 4 NS, D 5 W, D 10 W, LR, 1 / 2 NS, NS.

Y-site administration: Variable (consult detailed reference): Warfarin. Stability Store intact vials at 20°C to 25°C (68°F to 77°F). Use Diuretic or systemic and urinary acidifying agent; treatment of hypochloremia Adverse Reactions Central nervous system: Coma, drowsiness, EEG abnormalities, headache, mental confusion, seizure Dermatologic: Rash Endocrine & metabolic: Calcium-deficient tetany, hyperchloremia, hypokalemia, metabolic acidosis, potassium may be decreased, sodium may be decreased Gastrointestinal: Abdominal pain, gastric irritation, nausea, vomiting Hepatic: Ammonia may be increased Local: Pain at site of injection Neuromuscular & skeletal: Twitching Respiratory: Hyperventilation Contraindications Hypersensitivity to ammonium chloride or any component; severe hepatic and renal dysfunction; patients with primary respiratory acidosis Precautions Use with caution in patients with primary respiratory acidosis or pulmonary insufficiency. Warnings Monitor closely for signs and symptoms of ammonia toxicity, including diaphoresis, altered breathing, bradycardia, arrhythmias, retching, twitching, and coma. Metabolism/Transport Effects None known. Drug Interactions (For additional information: Launch Lexi-Interact™ Drug Interactions Program ) Amphetamines: Ammonium Chloride may decrease the serum concentration of Amphetamines. This effect is likely due to an enhanced excretion of amphetamines in the urine. Risk C: Monitor therapy Analgesics (Opioid): Ammonium Chloride may increase the excretion of Analgesics (Opioid). Risk C: Monitor therapy Potassium-Sparing Diuretics: May enhance the adverse/toxic effect of Ammonium Chloride. Specifically the risk of systemic acidosis. Risk D: Consider therapy modification Salicylates: Ammonium Chloride may increase the serum concentration of Salicylates. Risk C: Monitor therapy Pregnancy Risk Factor C ( show table ) Pregnancy Implications Reproduction studies have not been conducted. Monitoring Parameters Serum electrolytes, serum ammonia Mechanism of Action Its dissociation to ammonium and chloride ions increases acidity by increasing free hydrogen ion concentration which combines with bicarbonate ion to form CO 2 and water; the net result is the replacement of bicarbonate ions by chloride ions Pharmacokinetics (Adult data unless noted) Metabolism: In the liver Elimination: In urine Use of UpToDate is subject to the Subscription and License Agreement .

Mechanism of Action Its dissociation to ammonium and chloride ions increases acidity by increasing free hydrogen ion concentration which combines with bicarbonate ion to form CO 2 and water; the net result is the replacement of bicarbonate ions by chloride ions Pharmacokinetics (Adult data unless noted) Metabolism: In the liver Elimination: In urine Use of UpToDate is subject to the Subscription and License Agreement . Topic 12619 Version 33.0 © 2013 UpToDate, Inc. All rights reserved. | Subscription and License Agreement | Release: 21.3 - C21.34 Licensed to: Morehouse School of Medicine | Support Tag: [1104-41.196.66.12-562CF1C545-S473950.14]