Management of Hypertonic Saline Infiltration in ICU Patients
Immediately discontinue the infusion, remove the peripheral IV catheter, and monitor the affected site closely—the evidence demonstrates that infiltration of hypertonic saline through peripheral access carries minimal risk of serious complications and typically requires only supportive care without specific medical intervention.
Immediate Actions
- Stop the infusion immediately and remove the infiltrated peripheral IV catheter 1, 2
- Assess the extent of infiltration by examining for erythema, edema, and tissue swelling at the site 3, 2
- Document the volume infiltrated and the concentration of hypertonic saline (typically 3% in ICU settings) 3, 4
Risk Stratification and Expected Outcomes
The evidence strongly supports that infiltration of hypertonic saline, while requiring attention, rarely causes serious harm:
- Infiltration rates are low: 0.9% for bolus administration and 7.6% for continuous infusions in pediatric ICU patients 1
- No extravasation injuries reported: A large retrospective study of 1,020 administrations found zero cases requiring wound care or plastic surgery intervention 1
- Adult data confirms safety: Meta-analysis of 1,200 patients showed overall infiltration rate of only 3.3% (95% CI: 1.8-5.1%) 4
- Serious complications are exceedingly rare: Only one case of venous thrombosis (preceded by infiltration) was documented across all reviewed studies 4
Monitoring Protocol
For the first 24 hours post-infiltration:
- Assess the site every 2-4 hours for progression of erythema, edema, or development of phlebitis 3, 2
- Monitor for signs of compartment syndrome (though not reported in the literature, this represents standard practice for any significant infiltration)
- Check distal neurovascular status if the infiltration is substantial 2
When to Escalate Care
While the evidence shows minimal morbidity, consider consultation if:
- Progressive tissue necrosis develops (not reported in any reviewed studies but would warrant plastic surgery evaluation) 1
- Signs of compartment syndrome appear (pain out of proportion, paresthesias, pallor)
- Extensive infiltration with significant tissue swelling that compromises circulation
Supportive Care Measures
- Elevate the affected extremity to reduce edema
- Apply warm or cool compresses based on patient comfort (no specific evidence-based protocol exists)
- Provide analgesia as needed for discomfort
- No specific antidote or treatment is required 1, 2
Prevention Strategies for Future Administration
The evidence suggests hypertonic saline can be safely administered peripherally when proper precautions are taken:
- Limit infusion rate to ≤50 mL/hour through peripheral access to minimize complications 3, 2
- Use 16-20 gauge catheters for peripheral administration 2
- Prefer bolus administration over continuous infusion when possible (0.9% vs 7.6% infiltration rate) 1
- Monitor infusion sites closely during administration 3
- Consider central access for prolonged infusions (>6 hours) or high rates (>83.3 mL/h) where infiltration risk increases 3
Important Clinical Context
The traditional prohibition against peripheral administration of 3% hypertonic saline may be overstated 2. While central venous access avoids peripheral complications, it carries its own serious risks including pneumothorax, arterial injury, large vessel thrombosis, and bloodstream infection 2. The evidence from multiple studies across 1,200+ patients demonstrates that peripheral infiltration of 3% HTS results in minor, self-limited complications that resolve without intervention 1, 2, 4.
Key Pitfall to Avoid
Do not delay treatment of the underlying condition (intracranial hypertension, severe hyponatremia) due to concerns about peripheral infiltration 5, 3. The morbidity and mortality from untreated intracranial hypertension or severe symptomatic hyponatremia far exceeds the minimal risk from peripheral HTS infiltration 5.