A recurring issue has come about in regards to the best vascular access delivery of 3% Sodium chloride. According to Infusion Nursing: An evidence- based approach 3rd edition -(Mary Alexander, Ann Corrigan, Lisa Gorski, Judy Hankins, Roxanne Perucca) the recommendation is to administer 3% sodium chloride in an ICU setting and through a central line.
However, our renal group of doctors feel that it is fine to administer a 4-6 hour infusion through a peripheral line to correct severe hyponatremia.
Our dilema is when this hypertonic solution infiltrates, the pain is tremendous and healing is slow. Getting renal doctors to realize this is difficult.
My question are: What is the practice at your institution in regards to 3% sodium chloride infusions? Have 3% sodium chloride infiltrations caused harm to the patient? Has your institution safely administered 3% sodium chloride peripherally?
I look forward to the discussion.
-Lois Long Rajcan, MSN, RN, CRNI - Chester County Hospital, West Chester PA
I have infused 3% Sodium Chloride through peripheral veins in the past. I would always require that the physician's order include a finite volume to be infused or the rate per hour and a specific number of hours. In other words, there should never be an order for 3% or 5% Sodium Chloride that indicates it is a continuous infusion without a designated stop time. 3% NaCL has an osmolarity of 1054 mEq per liter, 527 mEq of sodium & 527 mEq of chloride. This means that this fluid is extremely hypertonic since normal serum osmolarity is 280 to 300 and a solution greater than 350 is consider hypertonic. The Infusion Nursing Standards of Practice state that any fluid or medication with an osmolarity greater than 600 should not be infused through a peripheral catheter. "Should" is the key word here. It does not state a mandate for a CVAD. While there is a much greater risk of thrombophlebitis and tissue damage with extravasation, I can understand why the physicians would resist putting in a CVAD when this is the only fluid requiring a CVAD and the renal failure patients have such as risk for CVAD complications. I can also understand your concern about extravasations. I think you must focus on how to safely infuse this fluid through peripheral veins. This would include all aspects of the INS Standards of Practice including site selection (always avoid areas of joint flexion, meaning no AC, wrist or hand sites, ever!), catheter selection (smallest gauges always!), catheter stabilization with a manufactured stablization method, mandating a frequent site assessment which would include aspiration for a blood return, and stopping the infusion with any complaint from the patient or sign/symptoms of any problem. If you do have an extravasation injury, NEVER apply heat to this site. Cold is indicated, but not heat as heat will make it worse. Your facility needs an updated policy and procedure on managing infiltration and extravasation injuries and this should consider using injected antidotes. For this fluid it would be hyaluronidase. So it can be safely infused through peripheral veins with a highly skilled person to insert the peripheral catheter, and close monitoring of the site during infusion. See INS standards for much more detail. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Lynn:
I thank you for your response.
Your response has reaffirmed our path towards resolving the infusion of 3% sodium chloride through a peripheral vein.
I was not aware that heat would cause this type of extravasation to make the situation worse. Perhaps that is the reason the extravasations are extremely painful and healing is slow due to warm compresses being placed on the site of extravasation.
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Lois Long Rajcan, MSN, RN, CRNI- Chester County Hospital, West Chester PA
Osmotic shifting is occurring - fluid moving from inside cells (where the largest fluid volume resides) to the interstial space due to the osmotic differences. When you add heat, you increase blood flow, spreading the extravasated fluid to a larger amount of tissue. This is the most common cause of infusion therapy-related legal cases against nurses. You really must work toward preventing this from occurring with all fluids and medications. Good luck, Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861