In this episode, I’ll discuss an article about the storage and safety of hypertonic saline.
One of the oldest systems-based efforts to improve patient safety in hospitals has been to control the storage and administration of concentrated electrolytes. The greatest focus since the 1980s was on removing concentrated potassium chloride from patient care areas due to multiple fatal events from the IV bolus administration of concentrated potassium chloride. In the early 2000s The Joint Commission set a national patient safety goal that focused on:
Remove concentrated electrolytes (including, but not limited to, potassium chloride, potassium phosphate, sodium chloride > 0.9%) from patient care units.
While these efforts no doubt prevented countless unnecessary deaths from medical error, there is a distinct difference between concentrated potassium and concentrated sodium chloride. There is no therapeutic use case for concentrated potassium and any administration would be an accident and place a patient at high risk of death, whereas there is a legitimate use for the IV bolus administration of concentrated sodium chloride – to act as a hyperosmolar agent that reduces acute cerebral edema in scenarios like acute ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, and traumatic brain injury.
When concentrated sodium chloride is needed for any of these conditions it is an emergent need and storing it in central pharmacy may introduce a clinically significant delay in the ability to start hyperosmolar therapy.
In an effort to translate knowledge into practice regarding the safety, dosing, storage and administration of concentrated sodium chloride a group of authors published a review article in American Journal of Health System Pharmacy.
The review article provides evidence for a logical argument in favor of the storage of concentrated sodium chloride in areas that care for neurocritical patients. Specifically the authors outline that:
- A bolus of concentrated sodium chloride, even up to and including the stock vial concentration of 23.4% is an effective and accepted strategy to emergently lower elevated intracranial pressure.
- Adverse events related to IV boluses of sodium chloride are mild and not clinically significant – in stark contrast to those with other concentrated electrolytes such as potassium chloride or magnesium sulfate.
- Hypertonic sodium chloride may be given through a peripheral vein in certain clinical circumstances.
- Modern safeguards built into automated dispensing cabinets can allow for safe storage as well as timely access to concentrated sodium chloride.
Using the evidence summarized in this article, with the proper staff education, patient monitoring and institutional protocols, it should be possible to safely allow the immediate availability of concentrated sodium chloride in neurocritical patient care area. It will require a focused effort by pharmacists to overcome the blanket assumption that all concentrated electrolytes should be removed from all patient care areas and this article provides the perfect foundation for that effort.
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