Safety and Efficacy of 23.4% Sodium Chloride Administered via Peripheral Venous Access for the Treatment of Cerebral Herniation and Intracranial Pressure Elevation

Abstract

Background: Sodium chloride (NaCl) 23.4% solution has been shown to reduce intracranial pressure (ICP) and reverse transtentorial herniation. A limitation of 23.4% NaCl is its high osmolarity (8008 mOsm/l) and the concern for tissue injury or necrosis following extravasation when administered via peripheral venous access. The use of this agent is therefore often limited to central venous or intraosseous routes of administration. Our objective was to evaluate the safety and efficacy of administration of 23.4% NaCl via peripheral venous access compared with administration via central venous access. Methods:We reviewed pharmacy records to identify all administrations of 23.4% NaCl at our institution between December 2017 and February 2020. Medical records were then reviewed to identify complications, such as extravasation, soft tissue injury or necrosis, hypotension (mean arterial pressure less than 65 mm Hg), pulmonary edema, hemolysis, and osmotic demyelination. We also compared the change in physiological variables, such as ICP, mean arterial pressure, cerebral perfusion pressure, and heart rate, as well as laboratory values, such as sodium, chloride, bicarbonate, creatinine, and hemoglobin, following administration of 23.4% NaCl via the peripheral and central venous routes. Results:We identified 299 administrations of 23.4% NaCl (242 central and 57 peripheral) in 141 patients during the study period. There was no documented occurrence of soft tissue injury or necrosis in any patient. One patient developed hypotension following central administration. Among the 38 patients with ICP monitoring at the time of drug administration, there was no significant difference in median ICP reduction (− 13 mm Hg [central] vs. − 24 mm Hg [peripheral], p = 0.21) or cerebral perfusion pressure augmentation (16 mm Hg [central] vs. 15 mm Hg [peripheral], p = 0.87) based on route of administration.Conclusions: Peripheral venous administration of 23.4% NaCl is safe and achieves a reduction in ICP equivalent to that achieved by administration via central venous access.

Management of noncytotoxic extravasation injuries: A focused update on medications, treatment strategies, and peripheral administration of vasopressors and hypertonic saline

“…Most recently, a prospective evaluation of hypertonic saline for the treatment of cerebral herniation and intracranial pressure elevation administered 23.4% sodium chloride as an intravenous push over 2–5 min with 14 of 32 patients receiving peripheral infusions 33 . There were no reported events of extravasation or tissue injury, and hypotension defined as a drop in systolic blood pressure by ≥20 mm Hg occurred in 16% patients, which is consistent with rates observed in infusions administered over 10 min 32,33 …”

“…The first study to evaluate the safety of peripheral 23.4% sodium chloride given as an intravenous push over 10 min showed no difference in safety outcomes between peripheral and central administration with only one reported extravasation event that did not result in visible tissue injury. 32 Additionally, rapid administration of hypertonic saline has been associated with hypotension and cardiovascular collapse; however, hypotension is an expected therapeutic effect and may indicate efficacy due to the reflexive drop in MAP as ICP decreases. 24 Limited access to intravenous syringe pumps and strains on nursing time has prompted evaluation of faster administration times.…”

“…Administration through a CVC is preferred due to its high osmolarity (8008 mOsm/L); however, access may be limited in emergent situations. The first study to evaluate the safety of peripheral 23.4% sodium chloride given as an intravenous push over 10 min showed no difference in safety outcomes between peripheral and central administration with only one reported extravasation event that did not result in visible tissue injury 32 . Additionally, rapid administration of hypertonic saline has been associated with hypotension and cardiovascular collapse; however, hypotension is an expected therapeutic effect and may indicate efficacy due to the reflexive drop in MAP as ICP decreases 24 .…”

“…33 There were no reported events of extravasation or tissue injury, and hypotension defined as a drop in systolic blood pressure by ≥20 mm Hg occurred in 16% patients, which is consistent with rates observed in infusions administered over 10 min. 32,33 Overall, recent literature has demonstrated the safety of peripheral administration of hypertonic saline. In cases of time-sensitive neurologic injuries where central venous access is not readily available, peripheral administration of continuous infusion or boluses of hypertonic saline have been associated with few low-grade incidences of extravasation.…”

Potential Use of Pharmacogenetics to Reduce Drug-Induced Syndrome of Inappropriate Antidiuretic Hormone (SIADH)

“…Once a diagnosis is confirmed, treatment of drug-induced SIADH varies according to the severity of the hyponatremia [37]. Many patients can simply be managed by removal of the offending agent and restriction of oral water intake.…”