In this episode, I’ll discuss peripheral IV administration of 3% sodium chloride solution.
Infusions of 3% sodium chloride are routinely recommended to be given through central, not peripheral IV lines. This recommendation is based on the theory that since the osmolarity of 3% sodium chloride exceeds 900 mOsm/L, it puts the patient at risk of thrombophlebitis, tissue necrosis, and extravasation reactions.
Some recent studies have illustrated that this theory may not be relevant and that 3% sodium chloride may be safe for administration in peripheral IV lines.
One single-center prospective study of 28 patients was published in 2017 in the Journal of Neuroscience Nursing. The study was done to evaluate the safety of a hospital policy change that allowed the administration of 3% sodium chloride via 16- to 20-gauge peripheral IVs to a maximum infusion rate of 50 mL/hr in patients without central venous access.
Patients were assessed for infiltration, erythema, swelling, phlebitis, thrombosis, and line infection. Overall, patients received 3% sodium chloride for a duration between 1 and 124 hours with infusion rates of 30 to 50 mL/hr. The rate of complications was 10.7%. Complications included infiltration (2 patients), with an incidence of 6%, and thrombophlebitis (1 patient), with an incidence of 3%.
The authors concluded:
There has been a long concern among healthcare providers, including nursing staff, in regard to pIV administration of prolonged 3% HTS infusion therapy. Our study indicates that peripheral administration of 3% HTS carries a low risk of minor, nonlimb, or life-threatening complications. Although central venous infusion may reduce the risk of these minor complications, it may increase the risk of more serious complications such as large vessel thrombosis, bloodstream infection, pneumothorax, and arterial injury. The concern regarding the risks of pIV administration of 3% HTS may be overstated and unfounded.
Another retrospective two-center study was also published in 2017, this time in the American Journal of Critical Care.
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. At one of the hospitals the maximum peripheral infusion rate was 30 mL/hr, and at the other hospital, it was 75 mL/hr.
The authors concluded
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.
Taken together, I think that these studies support the peripheral infusion of 3% sodium chloride in patients who do not already have central venous access.
The most important risks with 3% sodium chloride infusion, in my opinion, are still hypernatremia and overly rapid correction of hyponatremia. Frequent serum sodium and patient neurological monitoring is still required, regardless of what type of venous access a patient receiving 3% sodium chloride infusion has.
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