Is it safe to administer hypertonic saline through a peripheral intravenous (IV) line?

From the Guidelines

Hypertonic saline can be safely administered through a peripheral IV line, but with important limitations, specifically concentrations up to 3% are generally considered safe. For peripheral IV access, concentrations up to 3% hypertonic saline are generally considered safe, while higher concentrations (>3%) should be administered through a central venous catheter due to the risk of vein irritation, phlebitis, and tissue damage if extravasation occurs 1. When administering through a peripheral line, use a large vein, ensure proper catheter placement, and monitor the IV site frequently for signs of infiltration or inflammation. The infusion rate should be controlled, typically starting at 0.5-1 mL/kg/hour for 3% solutions, and adjusted based on serum sodium monitoring and clinical response. Hypertonic saline works by creating an osmotic gradient that draws water from tissues into the bloodstream, which is why it requires careful administration. Patients receiving hypertonic saline should have regular monitoring of serum sodium levels, with a target rate of sodium correction not exceeding 8-10 mEq/L in 24 hours to prevent osmotic demyelination syndrome, especially in patients with chronic hyponatremia.

Some key considerations for the administration of hypertonic saline include:

• The use of large veins for peripheral IV access to minimize the risk of complications
• Close monitoring of the IV site for signs of infiltration or inflammation
• Controlled infusion rates to prevent rapid changes in serum sodium levels
• Regular monitoring of serum sodium levels to prevent osmotic demyelination syndrome
• The potential need for central venous catheter administration for concentrations greater than 3% due to the increased risk of complications 1.

It is essential to weigh the benefits of hypertonic saline administration against the potential risks and to carefully consider the individual patient's needs and clinical context when making decisions about its use.

From the FDA Drug Label

WARNINGS: ... Sodium Chloride Injection, USP, 23. 4% is hypertonic and must be diluted prior to administration. Inadvertent direct injection or absorption of concentrated sodium chloride solution may give rise to sudden hypernatremia and such complications as cardiovascular shock, central nervous system disorders, extensive hemolysis and cortical necrosis of the kidneys.

• Administration through a peripheral line is not explicitly recommended or warned against in the provided drug label.
• However, the label does state that hypertonic saline must be diluted prior to administration, implying that undiluted hypertonic saline can cause severe complications.
• Given the potential risks, it is not safe to administer undiluted hypertonic saline through any IV line, including a peripheral line, without proper dilution.
• The decision to administer hypertonic saline through a peripheral line should be made with caution, considering the potential risks of hypernatremia and other complications, and ensuring proper dilution is used 2.

From the Research

Administration of Hypertonic Saline through Peripheral IV Line

• The administration of hypertonic saline through a peripheral intravenous (IV) line has been a topic of discussion due to concerns about the potential complications associated with it 3, 4, 5.
• Studies have shown that the use of 3% hypertonic saline administered peripherally has a low rate of complications, including infiltration, phlebitis, erythema, edema, and venous thrombosis 3, 4.
• A systematic review and meta-analysis found that the overall incidence of complications was low, with infiltration occurring in 3.3% of cases, phlebitis in 6.2%, erythema in 2.3%, edema in 1.8%, and venous thrombosis in 1% of cases 3.
• Another study found that the rate of complications observed was 10.7% among all subjects, with documented complications including infiltration and thrombophlebitis 4.
• The use of peripheral administration of 3% hypertonic saline has been shown to be safe and effective in critically ill patients, with minimal infusion-related adverse events and electrolyte abnormalities 5.

Comparison with Central Venous Catheter Administration

• Central venous catheters are often used to administer hypertonic saline, but they may be associated with serious complications such as large vessel thrombosis, bloodstream infection, pneumothorax, and arterial injury 6, 4.
• In contrast, peripheral administration of 3% hypertonic saline may be a safer and less invasive option, with a lower risk of complications 3, 4, 5.
• However, the decision to use peripheral or central venous catheter administration should be made on a case-by-case basis, taking into account the individual patient's needs and medical history 6, 5.

Considerations for Administration

• The infusion rate, duration, catheter gauge, and catheter placement may have a role in infusion-related adverse events 5.
• Current recommendations to administer continuous infusions of 3% hypertonic saline through a central intravenous catheter should be reassessed, and peripheral intravenous administration can be used safely and effectively in patients in critical situations 5.
• Further studies are needed to fully understand the safety and efficacy of peripheral administration of 3% hypertonic saline in different patient populations and clinical settings 3, 4, 5.