Safety of Continuous Peripheral Infusion of 3% Sodium Chloride Solution in Neurocritical Care Patients

Abstract

Background Numerous drug information resources recommend that continuous intravenous 3% sodium chloride solution be administered via a central catheter. Objectives To evaluate the incidence of infusion-related reactions and electrolyte abnormalities in neurocritical care patients treated with continuous intravenous infusion of 3% sodium chloride solution via a peripheral catheter. Methods Data on patients treated with continuous intravenous infusion of 3% sodium chloride solution at 2 academic medical centers were evaluated retrospectively to determine the administration site. Electronic notes on catheter status were reviewed to determine the occurrence of infusion-related reactions. Prespecified thresholds were used to assess electrolyte abnormalities. Results Of 213 patients who had peripheral continuous intravenous infusions of 3% sodium chloride solution, 15 (7%) had infusion-related reactions. Administration was changed to a central catheter in 56 patients (26.3%), but only 5 changes were due to an infusion-related reaction. Most (157 patients, 73.7%) received their entire treatment peripherally, for a median duration of 44 hours, 3 minutes. The most common electrolyte abnormalities were hyperchloremia in 49.3% and hypokalemia in 46.9% of patients. Conclusion Current recommendations that a central catheter is required for continuous intravenous infusion of 3% sodium chloride solution should be reevaluated. Only a few patients who had peripheral infusions had infusion-related reactions. Electrolyte abnormalities occurred frequently with peripheral infusion, but the clinical importance of the abnormalities remains unclear.

Administration of 3% Sodium Chloride Through Peripheral Intravenous Access: Development and Implementation of a Protocol for Clinical Practice

“…In the context of predetermined guidelines for specific patient populations and with specific monitoring criteria, our results show a low rate of AEs. Our AE rate is lower than other published data (Dillon et al, 2018; Jones et al, 2017; Luu et al, 2011; Meng et al, 2018; Perez & Figueroa, 2017), and this may be related to the patient population studied or sequelae from implementing the protocol with stringent monitoring criteria.…”

“…In addition to creating a protocol, the team identified any potential barriers to implementing the protocol, which guided the next steps in the pre‐implementation phase of this project. First, a nursing policy and procedure was written to include 3% sodium chloride as a medication that can be administered peripherally for up to 48 hr (INS, 2016; Jones et al, 2017; Meng et al, 2018; Nagler et al, 2014; Reynolds et al, 2014). This encouraged broad acceptance for the practice change, as there was a tangible policy to support nursing practice.…”

“…The acute management of traumatic brain injury (TBI), cerebral edema, and severe hyponatremia related to catastrophic neurologic injury and illness can be challenging in neurocritical care. There are limited data available to guide the most appropriate route of administration of 3% sodium chloride (Jones, Bode, Riha, & Erdman, 2017). Commonly 3% sodium chloride, with an osmolality of 1,026 mOsm/L, is used to normalize or augment serum sodium level.…”

“…They can potentially delay medication therapy in time‐sensitive circumstances (Parienti et al, 2015). More recent research suggests that hypertonic solutions with osmolality higher than 900 mOsm/L could be administered peripherally (Dillon, Merchan, Altshuler, & Papadopoulos, 2018; Jones et al, 2017; Luu et al, 2011; Meng, Nguyen, Patel, Mlynash, & Caulfield, 2018; Perez & Figueroa, 2017).…”

Hyperchloremia Is Associated With Poorer Outcome in Critically Ill Stroke Patients

“…Because of the propensity to cause brain edema by hypo-osmolar balanced crystalloids, hypertonic saline or normal saline (0.9% saline solution) are more frequently used in brain-injured patients ( 3 ). However, concerns have been raised that both hypertonic saline ( 4 , 5 ) and large-volume infusion of normal saline ( 6 , 7 ) may raise the risk of hyperchloremia.…”