Can hypertonic saline be administered without a central line (central venous line)?

From the Guidelines

Hypertonic saline can be administered without a central line, but with important limitations, specifically for concentrations up to 3% for short-term use. The administration of hypertonic saline without a central line is feasible, but it requires careful consideration of the concentration and the potential risks associated with peripheral intravenous administration. For concentrations up to 3% hypertonic saline, peripheral intravenous (IV) administration is generally considered safe for short-term use, as indicated by studies such as 1. However, higher concentrations (>3%) should ideally be given through a central line due to the risk of peripheral vein irritation, phlebitis, and potential tissue damage if extravasation occurs.

When administering 3% hypertonic saline peripherally, it is crucial to:

• Use a large vein to minimize the risk of irritation and phlebitis
• Ensure proper catheter placement to reduce the risk of infiltration or extravasation
• Monitor the IV site frequently for signs of infiltration or inflammation, as suggested by the principles outlined in 1
• Infusion rates should typically be slower when using peripheral access, generally 0.5-1 mL/kg/hour for 3% solutions, to mitigate the risk of adverse effects

The osmotic effect of hypertonic saline draws water from the intracellular to the extracellular space, which helps reduce cerebral edema and intracranial pressure, making it valuable in neurological emergencies, as discussed in 1. However, this same mechanism can cause significant fluid shifts and electrolyte disturbances, so close monitoring of serum sodium levels and neurological status is essential regardless of administration route, as emphasized in 1 and 1.

Key considerations for the administration of hypertonic saline without a central line include:

• Concentration: Up to 3% for short-term use
• Monitoring: Frequent checks for signs of infiltration, inflammation, and electrolyte imbalances
• Administration rate: Slower rates for peripheral access
• Patient selection: Careful consideration of the risks and benefits for each patient, particularly in critical care settings as reviewed in 1

From the Research

Administration of Hypertonic Saline

• Hypertonic saline can be administered without a central line, as several studies have shown that peripheral administration is safe and effective 2, 3, 4, 5.
• The risk of complications associated with peripheral administration of 3% hypertonic saline is low, with reported rates of infiltration, phlebitis, erythema, edema, and venous thrombosis ranging from 1-6% 2, 3.
• Peripheral administration of 3% hypertonic saline has been shown to be safe at infusion rates up to 50 mL/h 3 and even at higher rates of up to 999 mL/h for bolus administration 4.
• The use of peripheral intravenous administration of 3% hypertonic saline can be considered a safe alternative to central venous catheter administration, especially in urgent situations where central access is not available 5.

Considerations for Administration

• The gauge and placement of the peripheral intravenous catheter may play a role in infusion-related adverse events, with larger gauge catheters and antecubital placement potentially reducing the risk of complications 4.
• The infusion rate and duration of 3% hypertonic saline administration may also impact the risk of adverse events, with higher rates and longer durations potentially increasing the risk of phlebitis, erythema, and edema 5.
• Intraosseous administration of hypertonic saline may be considered in cases where intravenous access is difficult to obtain, although this is typically used for more concentrated solutions such as 23.4% saline 6.