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Safety of Peripheral Administration of 3% Hypertonic Saline in Critically Ill

Patients: A Literature Review

Article in Critical Care Nurse · February 2021

DOI: 10.4037/ccn2021400

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 Feature

Safety of Peripheral
Administration of 3%
Hypertonic Saline in
Critically Ill Patients:
A Literature Review
Ahmed O. Alenazi, PharmD, BSc, CACP
Zahra M. Alhalimi, PharmD
Manar H. Almatar, PharmD
Taha A. Alhajji, BS Pharm

Background Hyponatremia and neurocritical injury are life-threatening conditions requiring immediate
management with consideration of the safety concerns related to peripheral intravenous administration
of hypertonic solutions. Although a central intravenous catheter is the preferred route of administration,
central intravenous catheters have many complications and can potentially delay medication administra-
tion in urgent situations.
Objective To evaluate the safety and efficacy of continuous infusion of 3% hypertonic saline via peripheral
intravenous administration in critically ill adult patients.
Methods Data were collected from PubMed and Web of Science from database inception to April 7, 2019.
Included studies involved adult patients with hyponatremia and/or neurocritical situations and compared
administration of 3% hypertonic saline via peripheral administration with standard supportive care (admin-
istration through a central intravenous catheter).
Results Of 502 articles identified, 7 were included in the review. Three articles were retrospective studies,
2 were prospective studies, 1 was a case series, and 1 was a case report. Infusion-related adverse events
and electrolyte abnormalities due to 3% hypertonic saline administration through a peripheral intravenous
catheter were minimal and were limited to phlebitis, erythema, edema, hyperchloremia, and hypokalemia
with administration at a high infusion rate (83.3 mL/h) and for a prolonged duration (≥ 6 hours). Infusion
rate, duration, catheter gauge, and catheter placement may have a role in infusion-related adverse events.
Conclusions Current recommendations to administer continuous infusions of 3% hypertonic saline
through a central intravenous catheter should be reassessed. Peripheral intravenous administration can
be used safely and effectively in patients in critical situations. (Critical Care Nurse. 2021;41[1]:25-31)

H
yponatremia, defined as a serum sodium concentration of less than 135 mEq/L, is one of
the most prevalent electrolyte abnormalities in clinical practice.1 Hyponatremia occurs in
15% to 30% of hospitalized patients.2 The incidence and prevalence vary because the sodium
level can be affected by factors such as patient population, laboratory methods, and diagnostic criteria.2
Hyponatremia can increase morbidity, mortality, and length of hospital stay for a variety of high-risk
disorders or diseases such as heart failure, liver cirrhosis, and critical illness.3,4

©2021 American Association of Critical-Care Nurses doi:https://doi.org/10.4037/ccn2021400

www.ccnonline.org CriticalCareNurse Vol 41, No. 1, FEBRUARY 2021 25

 Table 1 Classification and common disorders of hyponatremia according to volume status5-7
Hypovolemia
Gastrointestinal fluid loss (eg,
severe diarrhea or vomiting)
Third spacing of fluids (eg,
pancreatitis, severe
hypoalbuminemia)
Salt-wasting nephropathy
Cerebral salt-wasting syndrome
Mineralocorticoid deficiency
Euvolemia Hypervolemia
Medications (see Table 2) Acute kidney injury/chronic
Syndrome of inappropriate antidiuretic hormone resulting kidney disease
from malignancy, central nervous system disorders (eg, Congestive heart failure
subarachnoid hemorrhage, meningitis, encephalitis), Liver cirrhosis
pulmonary disease (eg, pneumonia), or idiopathic origin Nephrotic syndrome
High fluid intake
Intense/prolonged physical activity (eg, marathon running)
Primary polydipsia (also referred to as psychogenic polydipsia)

The different causes and comorbidities associated

with a low sodium level pose major challenges in the Table 2 Mechanisms of hyponatremia caused
by drugs6,7
management of hyponatremia. Hyponatremia is primar-
ily a water imbalance and is associated with a disturbance Medication Mechanism of hyponatremia
Desmopressin Vasopressin analogues; pro-
in the hormone vasopressin (antidiuretic hormone). The Oxytocin motes water reabsorption
causes of hyponatremia are classified according to reduced, in kidney and return of
normal, or increased extracellular fluid volume (Table 1).5-7 water to blood circulation
Antidepressants Stimulate release or potentiate
Drugs cause hyponatremia through various mechanisms Opioids the effects of vasopressin
(Table 2). The most frequent mechanism is an increase 3,4-Methylenedioxymetham
in vasopressin release, increasing the inhibition of sodium phetamine (ecstasy)
reabsorption at the kidneys. Diuretics prevent sodium Diuretics Impaired urine dilution
Carbamazepine Uncertain mechanism of
reabsorption in the kidney tubules, resulting in a higher Vincristine action
level of sodium elimination.8 Antipsychotics
Signs and symptoms of hyponatremia vary depending Cyclophosphamide
Nonsteroidal anti-
on the acuity and severity of the hyponatremia (Table 3).5-7 inflammatory drugs
Severe neurological symptoms occur when the hypona-
tremia develops acutely (usually in less than 48 hours)
because the brain cannot adapt to this rapid change in Table 3 Hyponatremia signs and symptoms5,7
the sodium level. Cerebral edema develops subsequent
Severe acute Severe headache, obtundation, frank
to the water shift in the brain cells. In mild to moderate symptoms ataxia, seizures, cerebral edema,
chronic hyponatremia, brain cells adapt to the change, brainstem herniation, coma, death
and the patient remains asymptomatic or has mild cog- Mild symptoms Nausea, mild headache, mild ataxia,
mild cognitive impairment
nitive signs.5-7

Hyponatremia classifications are not mutually

Authors
Ahmed O. Alenazi is a critical care clinical pharmacist, Al Imam
Abdulrahman Bin Faisal Hospital, Dammam, Saudi Arabia.
Zahra M. Alhalimi was a PharmD student at Al Imam Abdulrahman
Bin Faisal University, Dammam, at the time of writing this article.
Manar H. Almatar was a PharmD student at Al Imam Abdulrah-
man Bin Faisal University, at the time of writing this article.
Taha A. Alhajji is an inpatient pharmacist, Al Imam Abdulrahman
Bin Faisal Hospital.
Corresponding author: Ahmed O. Alenazi, PharmD, BSc, CACP, Al Imam Abdulrahman
Bin Faisal Hospital, Ministry of National Guard-Health Affairs, PO Box 4616,
Dammam, Saudi Arabia 31412 (email: alenaziah5@ngha.med.sa).
To purchase electronic or print reprints, contact the American Association of Critical-
Care Nurses, 27071 Aliso Creek Rd, Aliso Viejo, CA 92656. Phone, (800) 899-1712
or (949) 362-2050 (ext 532); fax, (949) 362-2049; email, reprints@aacn.org.
exclusive. Clinical correlation and the possibility of
multiple causes of hyponatremia should be considered.5
The different classifications are based on the serum
sodium concentration, symptoms, duration and rapid-
ity of development, serum osmolality, and body volume
status (Table 4).5-7
The management of hyponatremia depends on the
acuity and severity of the symptoms, volume status, and
underlying cause. Rapid correction in severely symptom-
atic patients is important to prevent serious neurological
sequelae. Evidence indicates that the therapeutic limit of
sodium correction with hypertonic saline (HTS) ranges
from 8 to 12 mEq/L in the first 24 hours.3,9 Too-rapid

26 CriticalCareNurse Vol 41, No. 1, FEBRUARY 2021 www.ccnonline.org

 Table 4 Classifications of hyponatremia criteria5,7
Criteria Classification
Serum sodium concentration Mild: serum sodium concentration of 130 to 135 mEq/L
Moderate: serum sodium concentration of 125 to 129 mEq/L
Severe: serum sodium concentration less than 125 mEq/L
Symptoms Symptomatic: mild, moderate, or severe symptoms
Asymptomatic
Onset Acute: duration less than 48 hours
Chronic: duration greater than 48 hours
Osmolality (tonicity) Hypotonic: low plasma osmolality less than 280 mOsm/kg H2O
Isotonic: plasma osmolality within reference range (280-295 mOsm/kg H2O)
Hypertonic: plasma osmolality greater than 295 mOsm/kg H2O
Volume status Hypovolumic: sodium depletion in excess of water depletion
Euvolumic: excess of total body water with no change in total body sodium
Hypervolumic: increase in both total body water and sodium but with a relatively greater
increase in total body water than in sodium

Table 5 Comparison of US and European guidelines for treatment of acute or symptomatic hyponatremia6
Symptoms US guidelines European guidelines
Severe Bolus of 100 mL of 3% sodium chloride over Bolus of 150 mL of 3% sodium chloride over
10 minutes, 3 times as needed 20 minutes, 2 to 3 times as needed
Moderate Continuous infusion of 3% sodium chloride at 0.5-2 mL/kg/h Bolus of 150 mL of 3% sodium chloride over 20 minutes once

correction increases the risk of osmotic demyelination Methods

syndrome,6 which is characterized by extensive demye-
lination in the brain and poor outcomes.10
To regulate and improve hyponatremia management,
professional organizations have developed 2 sets of guide-
lines.3,7 Both guidelines support the administration of a
bolus of 3% HTS for patients with acute or severely symp-
tomatic hyponatremia. However, the US guideline recom-
mends a continuous infusion of 3% HTS for moderately
symptomatic patients with hyponatremia, whereas the
European guideline endorses a bolus dose only (Table 5).
Hypertonic saline 3% has a high sodium level
(513 mEq/L) and a high osmolarity (1026 mOsm/L)
that exceeds the accepted limit for peripheral paren-
teral nutrition recommended by the American Soci-
ety for Parenteral and Enteral Nutrition guideline (900
mOsm/L).9 A central intravenous catheter (CIVC) is
the preferred route of administration.9,11 However, insert-
ing a CIVC is not risk free. The risks include arterial
puncture, pneumothorax, infection, thrombosis, and
potential delay in medication administration in time-
sensitive situations.9,11 Phlebitis and extravasation
injuries are the main safety concerns with peripheral
administration of 3% HTS.9,11 This review article evalu-
ates the safety and efficacy of continuous infusion of
3% HTS via peripheral intravenous administration in
critically ill adult patients.
Study Design and Search Strategy
We conducted this review by searching PubMed and
Web of Science database entries from the inception of
each database to April 7, 2019. We searched the terms
hypertonic saline, 3% hypertonic saline, 3% sodium chloride,
hyperosmolar, peripheral administration, infusion, peripheral
catheterization, critically ill, cerebral edema, hyponatremia,
neurocritical, and intensive care unit alone or in combina-
tion. We screened titles and abstracts to determine whether
the publications met the eligibility criteria. To maximize
the search for relevant publications, we reviewed refer-
ence lists of the selected publications. English language
was the only restriction.
Eligibility Criteria
Eligible studies met the inclusion criteria if the popu-
lation of interest was adults (age ≥ 18 years) with hypo-
natremia and/or a neurocritical situation. In included
studies, the intervention was administration of 3% HTS
through a peripheral intravenous catheter (PIVC) com-
pared with standard supportive care (administration of
3% HTS through a CIVC). Studies were excluded if they
were conducted in a pediatric population, if the interven-
tion included HTS solutions other than 3% HTS, or if 3%
HTS was administered through any route other than a
central or peripheral catheter.

www.ccnonline.org CriticalCareNurse Vol 41, No. 1, FEBRUARY 2021 27


502 Articles were identified through database searches
483 Articles excluded because of topic:
Pharmacokinetics: 19
Pharmacology/pathology: 282
Diagnosis: 10
Other unrelated: 172
19 Articles
10 articles excluded because of duplication
2 articles excluded because of pediatric
population
7 Articles were included in the study
Figure Summary of article selection.
The primary outcome was identification of the
infusion-related adverse events (IRAEs) and electrolyte
disturbances most frequently reported with peripheral
administration of 3% HTS. Secondary outcomes were
the rate and duration of the infusion, catheter gauge,
anatomical site of catheter insertion, occurrence of
cerebral demyelination, rate of hyponatremia correction,
and overall mortality rate. Infusion-related adverse events
included phlebitis, extravasation, and venous thrombus.
According to published studies, frequently occurring
electrolyte abnormalities include hypokalemia, hyper-
chloremia, hypernatremia, and hypobicarbonatemia.
Results
The initial search identified 502 publications. We
excluded 483 irrelevant publications after reviewing the
titles and abstracts, 10 publications because of duplica-
tion, and 2 publications because the population of inter-
est did not meet inclusion criteria. Seven publications
were eligible. Of these, 3 were retrospective studies,11-13 2
were prospective studies,14,15 1 was a case series,16 and 1
was a case report.17 The population sizes ranged from 28
to 213 patients in all studies except 1 case report that
included 1 patient. Only 1 of the studies included was a
multicenter study; all other studies were single-center
studies (see Figure).
Four studies11-14 reported IRAEs and 2 studies12,15
reported electrolyte abnormalities due to 3% HTS admin-
istered through a PIVC. Dillon et al14 conducted a retro-
spective study to investigate the incidence of IRAEs
during peripheral administration of 3% HTS. The study
recruited 66 patients in an intensive care unit (ICU) or a
28 CriticalCareNurse Vol 41, No. 1, FEBRUARY 2021
medical step-down setting who had hyponatremia (64%)
or cerebral edema (29%). Hypertonic saline 3% was adminis-
tered for 14 hours, with a median infusion rate of 32 mL/h.
Infusion-related adverse events classified as grade 1 in
severity were reported in 4 patients. According to the
Infusion Nurses Society infiltration scale, which was used
in the study, grade 1 is defined as blanched skin, edema
less than 1 inch in any direction, skin cool to the touch,
and pain present or not present. In 2 patients (50%), the
IRAEs were managed by removing the PIVC and replac-
ing the infusion at a different peripheral anatomical site.
Phlebitis accounted for 50% of the IRAEs; 2 patients had
erythema and edema less than 1 inch in diameter.14 In
2015, Ayus et al16 reported a case series of 64 patients.
The patients had 71 hyponatremic episodes due to inap-
propriate antidiuretic hormone syndrome (61%), thiazide
diuretics (34%), or hypothyroidism (5%). The patients
received 500 mL of 3% HTS over 6 hours (83.3 mL/h)
for the management of hyponatremia in the emergency
department per the hospital protocol, and no infusion-
related reactions were reported.16
The duration and rate of infusion of 3% HTS prescribed
for PIVC administration may play a role in the develop-
ment of IRAEs. In 2016, Jones et al12 conducted a large
retrospective cohort study of the safety of a continuous
peripheral infusion of 3% HTS. The study recruited 213
neurocritical care patients in the ICU or medical ward.
Of these, 157 patients (73.7%) received 3% HTS via a
PIVC with an infusion rate of 30 to 75 mL/h and a median
duration of 44 hours, 43 minutes. Fifteen IRAEs were
reported, including 9 cases of phlebitis and 6 cases of
extravasation with no venous thrombus in any of the
patients.12 In a prospective study, Perez and Figueroa11
assessed the complication rate of 3% HTS infusion
through a PIVC. The sample was 28 patients with
neurocritical illness who received 3% HTS peripherally
for the management of cerebral hemorrhage, stroke,
and tumors in different ICU settings. A 3% HTS solu-
tion was infused at a rate of 30 to 50 mL/h for a mean
duration of 36 hours. Local extravasation occurred in 2
patients, with no major complications except for throm-
bophlebitis in 1 of the patients.11 Similarly, a prospective
study published by Meng et al13 in 2018 investigated the
association of phlebitis with continuous PIVC infusion
of 3% HTS in 60 adult patients. Most patients (78%)
received 3% HTS for the management of neurological
injuries. Infusion rates ranged from 15 to 100 mL/h (mean
infusion rate, 42 mL/h) and the mean infusion duration
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was 74.4 hours, or 3.1 days. Phlebitis was reported in 19
patients whose infusion rates were 30 mL/h or less and
in 13 patients whose infusion rates were greater than
30 mL/h; this difference was not significant (P = .38).13
Catheter gauge and anatomical site of administration
may also affect the incidence of IRAEs. Four studies men-
tioned the needle or catheter gauge, which ranged from
16 to 24 gauge.11-14 Two studies associated the develop-
ment of phlebitis with the gauge. Jones et al12 reported 8
events in patients whose catheters had 20-gauge needles
and 7 events in patients whose catheters had 18-gauge
needles. According to the study by Meng et al,13 phlebi-
tis was observed in 9 of 26 patients who received 16- to
18-gauge catheters and 23 of 80 patients who received
20- to 24-gauge catheters. In terms of the anatomical
site used to administer 3% HTS, Meng et al13 mentioned
using a flexion site (including the antecubital fossa or
wrist) in 32% of patients and a nonflexion site (such as
foot, hand, forearm, or arm) in 30% of patients. However,
the association between catheter gauge or anatomical
site and the development of phlebitis was not significant
(P > .05).13 Other studies also mentioned the use of dif-
ferent sites of administration.11,12,14
Electrolyte abnormalities were discussed in studies
by Jones et al12 and Mesghali et al.15 Hyperchloremia
(49.3% and 38.8%, respectively), hypokalemia (46.9%
and 24.7%, respectively), and hypernatremia (22.1% and
8.2%, respectively) were the electrolyte abnormalities
most frequently reported with 3% HTS infusion. Hypobi-
carbonatemia was also mentioned in a small proportion
of patients (8.9%) in the study by Jones et al.12 Almost
half of the patients with a hypokalemia-related abnor-
mality (43.6%) required an intervention to correct the
potassium level, and a small proportion of patients with
hyperchloremia (16.9%) required an intervention.
Discussion
Hyponatremia, traumatic brain injury, intracerebral
hemorrhage, and acute ischemic stroke are life-threatening
conditions that should be managed rapidly and effectively
with consideration for the safety concerns related to hyper-
tonic solutions. Central venous catheters, although con-
sidered effective instruments in patient care, are associated
with complications that may increase the length of stay,
mortality rate, and cost of care.12,18 Any delay in HTS
preparation, delivery, or catheter insertion may increase
the patient’s likelihood of morbidity or mortality. Ayus
and Moritz19 reported the case of a 21-year-old patient
www.ccnonline.org
with hyponatremia (serum sodium level, 119 mEq/L)
who died 4 hours after admission to the hospital. The
patient died because of a delay in the administration of
HTS; the hospital protocol limited the use of 3% HTS
to ICU settings and CIVC administration only.19 Wide-
spread misconceptions without strong evidence about
the peripheral administration of 3% HTS and IRAEs
exist. Concern about peripheral administration might
be valid when using a hypertonic peripheral parenteral
nutrition solution for more than 5 days.17
The IRAEs of thrombophlebitis, infusion extravasa-
tion, and venous thrombus formation were minimally
reported with administration of 3% HTS through a
peripheral vein. No permanent tissue injuries were
reported even with peripheral administration of 3%
HTS with a prolonged duration and a high infusion
rate.14 One study provided evidence that the develop-
ment of thrombophlebitis with peripheral adminis-
tration of 3% HTS was insignificant compared with
peripheral administration of all other solutions used in
routine care (47% vs 43%, P = .19).13 In addition, several
studies did not report an increase in the rate of throm-
botic events (deep venous thrombosis and pulmonary
embolism) with 3% HTS administration.11,20
This review included 2 reports of venous thrombo-
sis. In the study by Meng et al,13 1 patient developed a
superficial thrombus in the cephalic vein but did not
require
interven- Common infusion-related adverse
tion. In the events include extravasation; blanched
study by skin, erythema, and edema; phlebitis;
Perez and venous thrombus; necrosis or ulceration;
Figueroa,11 and life-threatening consequences.
infiltration
was noted in 1 patient after infusion of 3% HTS in the
left hand. The infusion was relocated to the right arm
and the patient developed infiltration. Doppler ultra-
sound of both arms showed thrombus in only the right
brachial and basilic veins.
Many factors increase the risk for venous thrombosis
with administration of 3% HTS. Examples are longer
duration of catheterization, the catheter material used,
the type of infusion, and vascular comorbidities. Vascu-
lar comorbidities such as hypertension, diabetes, dyslip-
idemia, and coronary artery disease, reported in 57%
of the patients in the study by Meng et al,13 may play a
major role in venous thrombosis related to HTS. The
median catheter duration was also significantly longer
CriticalCareNurse Vol 41, No. 1, FEBRUARY 2021 29
in patients receiving 3% HTS (2.6 days) than in those
receiving routine-care solutions (2.1 days, P = .01). With
the available evidence, it is not possible to correlate
venous thrombosis and the administration of 3% HTS
in the presence of vascular comorbidities.
Neurological symptoms related to 3% HTS are usually
monitored closely in the ICU.19 Cerebral demyelination
is a major neurological complication caused by overcor-
rection of the sodium level by more than 12 mEq/d in
patients with chronic hyponatremia.16 In a study of 71
patients with hyponatremia (mean [SEM] baseline sodium
level, 114.1 [0.8] mEq/L) who received 3% HTS, mean
(SEM) sodium levels 3, 12, 24, and 48 hours after initia-
tion of 3% HTS infusion increased to 117.9 (1.3), 121.2
(1.2), 123.9 (1.0), and 128.3 (0.8) mEq/L, respectively.16
Clinical and neurological symptoms markedly improved,
with patients making a full recovery after 48 hours of 3%
HTS infusion. Five patients with a significant overcorrec-
tion of sodium (≥ 25 mEq/L over 48 hours) did not develop
any neurological symptoms associated with cerebral demy-
elination.16 No other studies discussed the relationship
between peripheral administration of 3% HTS and the
development of demyelination. More studies are required
to confirm the relationship between cerebral demyelin-
ation and the peripheral administration of 3% HTS.
In 1 study, 5% HTS was infused peripherally over
15 minutes to 11 patients with an elevated intracranial
pressure, and no IRAEs were documented.21 Electrolyte
abnormalities were frequently reported, but the clinical
importance is still not clear.
Conclusions
This review article demonstrates that 3% HTS can be
safely administered peripherally in acutely ill patients,
causing a minimum of IRAEs even at a high rate of infu-
sion (83.3 mL/h) for a prolonged duration (≥6 hours).
The most frequently reported IRAE was thrombophlebi-
tis (< 10% of patients), with an insignificant difference
between patients who received 3% HTS and patients
who received routine-care solutions. The current recom-
mendation to administer 3% HTS through CIVCs should
therefore be reevaluated. Peripheral intravenous cathe-
ters can be used safely and effectively for the administra-
tion of 3% HTS in patients in critical circumstances.
Additional studies are required to evaluate the effects of
peripheral administration of 3% HTS on length of stay,
mortality rate, and health care costs. CCN
30 CriticalCareNurse Vol 41, No. 1, FEBRUARY 2021
Acknowledgments
The authors listed in the byline are the only investigators responsible for this
review article. This review was performed through electronic medical search
engines at Al Imam Abdulrahman Bin Faisal Hospital. This review article has
been not presented at any conference or meeting.
Financial Disclosures
None reported.
See also
To learn more about patient safety in the critical care setting, read “Safety
of Continuous Peripheral Infusion of 3% Sodium Chloride Solution in
Neurocritical Care Patients” by Jones et al in the American Journal of
Critical Care, 2017;26(1):37-42. Available at www.ajcconline.org.
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 CCN Fast Facts CriticalCareNurse
The journal for high acuity, progressive, and critical care nursing

Safety of Peripheral Administration of

3% Hypertonic Saline in Critically Ill
Patients: A Literature Review

H yponatremia and neurocritical injury are life-

threatening conditions requiring immediate
management with consideration of the safety
concerns related to peripheral intravenous administration
of hypertonic solutions. Although a central intravenous
catheter is the preferred route of administration, central
intravenous catheters have many complications and can
potentially delay medication administration in urgent sit-
uations. This review article evaluates the safety and effi-
cacy of continuous infusion of 3% hypertonic saline (HTS)
via peripheral intravenous administration in critically ill
adult patients.
• Neurological symptoms related to 3% HTS are usually
monitored closely by health care providers in the
intensive care unit. Cerebral demyelination is a major
neurological complication caused by overcorrection
of the sodium level by more than 12 mEq/d in
patients with chronic hyponatremia.
• In 1 study, 5% HTS was infused peripherally over 15
minutes to 11 patients with an elevated intracranial
pressure, and no IRAEs were documented. Electrolyte
abnormalities were frequently reported, but the clini-
cal importance is still not clear.

• Central venous catheters, although considered effec- • This review article demonstrates that 3% HTS can be
tive instruments in patient care, are associated with safely administered peripherally in acutely ill patients,
complications that may increase the length of stay, causing a minimum of IRAEs even at a high rate of infu-
mortality rate, and cost of care. sion (83.3 mL/h) for a prolonged duration (≥ 6 hours).

• Widespread misconceptions without strong evidence
about the peripheral administration of 3% HTS and
infusion-related adverse events (IRAEs) exist.
• The IRAEs of thrombophlebitis, infusion extravasa-
tion, and venous thrombus formation were minimally
reported with administration of 3% HTS through a
peripheral vein. No permanent tissue injuries were
reported even with peripheral administration of 3%
HTS with a prolonged duration and a high infusion rate.
• The most frequently reported IRAE was thrombophle-
bitis (< 10% of patients), with an insignificant difference
between patients who received 3% HTS and patients
who received routine-care solutions. The current rec-
ommendation to administer 3% HTS through central
intravenous catheters should therefore be reevaluated.
• Peripheral intravenous catheters can be used safely
and effectively for the administration of 3% HTS in
patients in critical circumstances. CCN

• Many factors increase the risk for venous thrombosis

with administration of 3% HTS. Examples are longer
duration of catheterization, the catheter material used,
the type of infusion, and vascular comorbidities. Vas-
cular comorbidities such as hypertension, diabetes,
dyslipidemia, and coronary artery disease may play a
major role in venous thrombosis related to HTS.

Alenazi AO, Alhalimi ZM, Almatar MH, Alhajji TA. Safety of peripheral administration of 3% hypertonic saline in critically ill patients: a literature review. Critical
Care Nurse. 2021;41(1):25-31.

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