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Khasiyev F, Hakoun A, Christopher K, Braun J, Wang F. Safety and Effect on Intracranial Pressure of 3% Hypertonic Saline Bolus Via Peripheral Intravenous Catheter for Neurological Emergencies. Neurocrit Care 2024; 41:202-207. [PMID: 38379103 DOI: 10.1007/s12028-024-01941-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 01/05/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND Elevated intracranial pressure (ICP) is a neurological emergency in patients with acute brain injuries. Such a state requires immediate and effective interventions to prevent potential neurological deterioration. Current clinical guidelines recommend hypertonic saline (HTS) and mannitol as first-line therapeutic agents. Notably, HTS is conventionally administered through central venous catheters (CVCs), which may introduce delays in treatment due to the complexities associated with CVC placement. These delays can critically affect patient outcomes, necessitating the exploration of more rapid therapeutic avenues. This study aimed to investigate the safety and effect on ICP of administering rapid boluses of 3% HTS via peripheral intravenous (PIV) catheters. METHODS A retrospective cohort study was performed on patients admitted to Sisters of Saint Mary Health Saint Louis University Hospital from March 2019 to September 2022 who received at least one 3% HTS bolus via PIV at a rate of 999 mL/hour for neurological emergencies. Outcomes assessed included complications related to 3% HTS bolus and its effect on ICP. RESULTS Of 216 3% HTS boluses administered in 124 patients, complications occurred in 8 administrations (3.7%). Pain at the injection site (4 administrations; 1.9%) and thrombophlebitis (3 administrations; 1.4%) were most common. The median ICP reduced by 6 mm Hg after 3% HTS bolus administration (p < 0.001). CONCLUSIONS Rapid bolus administration of 3% HTS via PIV catheters presents itself as a relatively safe approach to treat neurological emergencies. Its implementation could provide an invaluable alternative to the traditional CVC-based administration, potentially minimizing CVC-associated complications and expediting life-saving interventions for patients with neurological emergencies, especially in the field and emergency department settings.
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Affiliation(s)
- Farid Khasiyev
- Department of Neurology, Saint Louis University, St. Louis, MO, USA
| | - Abdullah Hakoun
- Department of Neurology, Saint Louis University, St. Louis, MO, USA
| | - Kara Christopher
- Department of Neurology, Saint Louis University, St. Louis, MO, USA
| | - James Braun
- Department of Pharmacy, Sisters of Saint Mary Health Saint Louis University Hospital, 1008 S. Spring Ave, St. Louis, MO, 63110, USA
| | - Fajun Wang
- Department of Neurology, Saint Louis University, St. Louis, MO, USA.
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2
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Madieh J, Hasan B, Khamayseh I, Hrizat A, Salah T, Nayfeh T, Gharaibeh K, Hamadah A. The Safety of Intravenous Peripheral Administration of 3% Hypertonic Saline: A Systematic Review and Meta-analysis. Am J Med Sci 2023:S0002-9629(23)01181-3. [PMID: 37192695 DOI: 10.1016/j.amjms.2023.04.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 01/24/2023] [Accepted: 04/11/2023] [Indexed: 05/18/2023]
Abstract
BACKGROUND AND OBJECTIVES Three percent hypertonic saline (3% HTS) is used to treat several critical conditions such as severe and symptomatic hyponatremia and increased intracranial pressure. It has been traditionally administered through a central venous catheter (CVC). The avoidance of peripheral intravenous infusion of 3% HTS stems theoretically from the concern about the ability of the peripheral veins to tolerate hyperosmolar infusions. The aim of this systematic review and meta-analysis is to assess the rate of complications associated with the infusion of 3% HTS using peripheral intravenous access. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted a systematic review and meta-analysis to assess the rate of complications related to the peripheral infusion of 3% HTS. We searched several databases for available studies that met the criteria until February 24th, 2022. We included ten studies conducted across three countries examining the incidence of infiltration, phlebitis, venous thrombosis, erythema, and edema. The overall event rate was calculated and transformed using the Freeman-Tukey arcsine method and pooled using the DerSimonian and Laird random-effects model. I 2 was used to evaluate heterogeneity. Selected items from Newcastle-Ottawa Scale 12 were used to assess the risk of bias in each included study. RESULTS A total of 1200 patients were reported to have received peripheral infusion of 3% HTS. The analysis showed that peripherally administered 3% HTS has a low rate of complications. The overall incidence of each of the complications was as follows: infiltration 3.3%, (95% C.I. = 1.8-5.1%), phlebitis 6.2% (95% C.I. = 1.1-14.3%), erythema 2.3% (95% C.I. = 0.3-5.4%) edema 1.8% (95% C.I. = 0.0-6.2%) and venous thrombosis 1% (95% C.I. = 0.0-4.8%). There was one incident of venous thrombosis preceded by infiltration resulting from peripheral infusion of 3% HTS. CONCLUSION Peripheral administration of 3% HTS is considered a safe and possibly preferred option as it carries a low risk of complications and is a less invasive procedure compared to CVC.
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Affiliation(s)
- Jomana Madieh
- Queen's medical centre, Nottingham University Hospitals NHS Trust, Nottingham, UK.
| | - Bashar Hasan
- Evidence-based practice Research Program, Mayo Clinic, Rochester, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.
| | | | - Alaa Hrizat
- Department of Pathology, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
| | - Tareq Salah
- Joslin Diabetes Center, Harvard Medical School, Boston, MA, USA.
| | - Tarek Nayfeh
- Evidence-based practice Research Program, Mayo Clinic, Rochester, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.
| | - Kamel Gharaibeh
- Department of Internal Medicine, Faculty of Medicine, Al-Quds University, Abu Dis, Palestine; Division of Pulmonary and Critical Care, University of Maryland, Baltimore, MD, USA.
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3
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Stefanos SS, Kiser TH, MacLaren R, Mueller SW, Reynolds PM. Management of noncytotoxic extravasation injuries: A focused update on medications, treatment strategies, and peripheral administration of vasopressors and hypertonic saline. Pharmacotherapy 2023; 43:321-337. [PMID: 36938775 DOI: 10.1002/phar.2794] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/03/2023] [Accepted: 02/05/2023] [Indexed: 03/21/2023]
Abstract
Extravasation is the leakage of intravenous solutions into surrounding tissues, which can be influenced by drug properties, infusion techniques, and patient-related risk factors. Although peripheral administration of vesicants may increase the risk of extravasation injuries, the time and resources required for central venous catheter placement may delay administration of time-sensitive therapies. Recent literature gathered from the growing use of peripheral vasopressors and hypertonic sodium suggests low risk of harm for initiating these emergent therapies peripherally, which may prevent delays and improve patient outcomes. Physiochemical causes of tissue injury include vasoconstriction, pH-mediated, osmolar-mediated, and cytotoxic mechanisms of extravasation injuries. Acidic agents, such as promethazine, amiodarone, and vancomycin, may cause edema, sloughing, and necrosis secondary to cellular desiccation. Alternatively, basic agents, such as phenytoin and acyclovir, may be more caustic due to deeper tissue penetration of the dissociated hydroxide ions. Osmotically active agents cause cellular damage as a result of osmotic shifts across cellular membranes in addition to agent-specific toxicities, such as calcium-induced vasoconstriction and calcifications or arginine-induced leakage of potassium causing apoptosis. A new category has been proposed to identify absorption-refractory mechanisms of injury in which agents such as propofol and lipids may persist in the extravasated space and cause necrosis or compartment syndrome. Pharmacological antidotes may be useful in select extravasations but requires prompt recognition and frequently complex administration strategies. Historically, intradermal phentolamine has been the preferred agent for vasopressor extravasations, but frequent supply shortages have led to the emergence of terbutaline, a β2 -agonist, as an acceptable alternative treatment option. For hyperosmolar and pH-related mechanisms of injuries, hyaluronidase is most commonly used to facilitate absorption and dispersion of injected agents. However, extravasation management is largely supportive and requires a protocolized multidisciplinary approach for early detection, treatment, and timely surgical referral when required to minimize adverse events.
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Affiliation(s)
- Sylvia S Stefanos
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, USA
| | - Tyree H Kiser
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, USA
| | - Robert MacLaren
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, USA
| | - Scott W Mueller
- Department of Pharmacy, University of Colorado Health, Aurora, Colorado, USA
| | - Paul M Reynolds
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, USA
- Department of Pharmacy, Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA
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4
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Safety of peripherally administered 3% hypertonic saline. Am J Emerg Med 2023; 63:127-131. [PMID: 36371934 DOI: 10.1016/j.ajem.2022.10.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 10/26/2022] [Accepted: 10/31/2022] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Administration of 3% sodium chloride through a peripheral venous catheter is associated with risk of infusion-related adverse events (IRAE) due to its high osmolarity. Given this concern and the paucity of data regarding these events, many hospitals have policies that require central line administration of 3% sodium chloride. OBJECTIVE The objective of this analysis was to evaluate the incidence of IRAE associated with peripheral administration of 3% sodium chloride. METHODS This analysis included patients who received 3% sodium chloride via a peripheral venous catheter between May 2017 and August 2019. The major endpoint of this analysis was the overall incidence of IRAE, defined as the documentation of infiltration or phlebitis. A multivariable logistic regression was performed to identify potential risk factors (e.g., age, infusion rate, infusion duration, peripheral venous catheter location, and needle gauge) for development of IRAE. RESULTS A total of 706 administrations in 422 patients were included. Seventy-four (10.5%) administrations were associated with a documented event. Based on the Infusion Nurses grading scale for infiltration or phlebitis, 48% of the events in this analysis were grade 1 in severity. Duration of infusion of 3% sodium chloride was found to be associated with an increased odds of an IRAE (OR per 1 h 1.02, 95% CI 1.01-1.02) in the multivariable analysis. Age, infusion rate, peripheral venous catheter location, and needle gauge were not independently associated with an increased risk of an IRAE. CONCLUSION These data suggest that IRAE occurred more frequently when 3% sodium chloride was administered over a longer duration and the majority of events were mild with no permanent tissue injury. It may be reasonable to consider peripheral administration of 3% sodium chloride in the acute care setting for a short duration, although additional studies are needed to continue to evaluate its safety.
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Goddard C, Collopy KT, Powers Iv WF. Prehospital Hypertonic Saline Administration After Severe Traumatic Brain Injury. Air Med J 2022; 41:498-502. [PMID: 36153150 DOI: 10.1016/j.amj.2022.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 03/29/2022] [Accepted: 04/07/2022] [Indexed: 06/16/2023]
Abstract
A 25-year old male paient was critically injuried in a high speed motor vehicle collision over an hour from the nearest trauma center. Paramedics diagnosed the patient with a traumatic brain injury and increasing intracranial pressure and transported the patient to a predesignated landing zone for helicopter intercept. During transport paramedics initiated a severe traumatic brain injury protocol which included the adminisration of 3% hypertonic saline. The flight crew continued 3% hypertonic saline managment which was later transferred to the receiving trauma team. Upon trauma center arrival the patient was diagnosed with a skull fracture and subdural hematoma. The patient was transitioned to a 3% hypertonic saline infusion for the next 24 h. The need for integrating systems of care is particularly important when managing patients with severe traumatic brain injury. This case report describes a patient with a severe TBI who received prehospital 3% hypertonic saline based on an integrated protocol developed between multiple prehosptial systems and a tertiary care trauma center. Severe traumatic brain injuries (TBIs) are a potentially catastrophic event, and morbidity can rise precipitously without early interventions to prevent hypoxia and hypotension and control for rising intracranial pressure. In recent years, hypertonic saline (HTS) has shown efficacy in lowering intracranial pressures for patients experiencing TBIs, the leading cause of death and disability among children and young adults in the United States.1 Integrating care between health care providers across the acute care continuum, from prehospital systems to discharge, is paramount in providing the best patient outcomes possible, especially in health care system expansions such as air medical transport. The need for integrating systems of care is particularly important when managing patients with severe TBI. Statewide prehospital care protocols vary greatly; 78% provide ventilation guidance, 77.3% have targeted end-tidal carbon dioxide levels below < 35 mm Hg, and only 1 (of 38 reviewed) includes HTS (3%).2 One barrier to consistency in protocol development is the available literature. One trial demonstrated that a prehospital bolus of 7.5% HTS in severe TBI did not improve mortality.3 However, the Brain Foundation guidelines continue to recommend the prehospital use of hyperosmolar therapy for patients with severe TBI and evidence of impending herniation.4 Hyperosmolar therapy is also recommended as an inpatient strategy for lowering increased intracranial pressure (ICP).4 One reason for this apparent disconnect is because the ideal timing of HTS administration and its concentration have not been determined.4 A meta-analysis previously determined no one prehospital fluid is superior to another in improving the outcomes of patients with severe TBI.5 However, none of the reviewed research investigated the continued use of HTS across an integrated system of care. This case report describes a patient with a severe TBI who received 3% HTS initiated in the prehospital setting with the infusion continued upon arrival at the trauma center using a system-wide integrated protocol.
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Affiliation(s)
- Chris Goddard
- Edward Via College of Osteopathic Medicine, Blacksburg, VA, United States
| | - Kevin T Collopy
- Novant Health New Hanover Regional Medical Center, AirLink/VitaLink Critical Care Transport, 2131 South 17th Street, Wilmington, NC 28401, United States.
| | - William F Powers Iv
- Novant Health New Hanover Regional Medical Center, AirLink/VitaLink Critical Care Transport, 2131 South 17th Street, Wilmington, NC 28401, United States; Novant Health New Hanover Regional Medical Center, Division of Acute Care Surgery, Wilmington, NC, United States
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Administration of 3% Sodium Chloride and Local Infusion Reactions. CHILDREN 2022; 9:children9081245. [PMID: 36010135 PMCID: PMC9406999 DOI: 10.3390/children9081245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 08/06/2022] [Accepted: 08/06/2022] [Indexed: 12/03/2022]
Abstract
Three-percent sodium chloride (3% NaCl) is a hyperosmolar agent used to treat hyponatremic encephalopathy or other cases of increased intracranial pressure. A barrier to the use of 3% NaCl is the perceived risk of local infusion reactions when administered through a peripheral vein. We sought to evaluate reports of local infusion reactions associated with 3% NaCl over a 10-year period throughout a large healthcare system. A query was conducted through the Risk Master database to determine if there were any local infusion reactions associated with peripheral 3% NaCl administration throughout the entire UPMC health system, which consists of 40 hospitals with 8400 licensed beds, over a 10-year time period from 14 May 2010 to 14 May 2020. Search terms included infiltrations, extravasations, phlebitis, IV site issues, and IV solutions. There were 23,714 non-chemotherapeutic and non-contrast-associated intravenous events, of which 4678 (19.7%) were at UPMC Children’s Hospital. A total of 2306 patients received 3% NaCl, of whom 836 (35.8%) were at UPMC Children’s Hospital. There were no reported local infusion reactions with 3% NaCl. There were no reported local infusion reaction events associated with 3% NaCl in a large healthcare system over a 10-year period. This suggests that 3% NaCl can be safely administered through a peripheral IV or central venous catheter.
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7
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Pohl CE, Harvey H, Foley J, Lee E, Xu R, O'Brien NF, Coufal NG. Peripheral IV Administration of Hypertonic Saline: Single-Center Retrospective PICU Study. Pediatr Crit Care Med 2022; 23:277-285. [PMID: 35180199 PMCID: PMC9743976 DOI: 10.1097/pcc.0000000000002903] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To determine the frequency and characteristics of complications of peripherally administered hypertonic saline (HTS) through assessment of infiltration and extravasation. DESIGN Retrospective cross-sectional study. SETTING Freestanding tertiary care pediatric hospital. PATIENTS Children who received HTS through a peripheral IV catheter (PIVC). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We conducted a single-center retrospective review from January 2012 to 2019. A total of 526 patients with 1,020 unique administrations of HTS through a PIVC met inclusion criteria. The primary endpoint was PIVC failure due to infiltration or extravasation. The indication for the administration of HTS infusion was collected. Catheter data was captured, including the setting of catheter placement, anatomical location on the patient, gauge size, length of time from catheter insertion to HTS infusion, in situ duration of catheter lifespan, and removal rationale. The administration data for HTS was reviewed and included volume of administration, bolus versus continuous infusion, infusion rate, infusion duration, and vesicant medications administered through the PIVC. There were 843 bolus infusions of HTS and 172 continuous infusions. Of the bolus administrations, there were eight infiltrations (0.9%). The continuous infusion group had 13 infiltrations (7.6%). There were no extravasations in either group, and no patients required medical therapy or intervention by the wound care or plastic surgery teams. There was no significant morbidity attributed to HTS administration in either group. CONCLUSIONS HTS administered through a PIVC infrequently infiltrates in critically ill pediatric patients. The infiltration rate was low when HTS is administered as a bolus but higher when given as a continuous infusion. However, no patient suffered an extravasation injury or long-term morbidity from any infiltration.
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Affiliation(s)
- Charles E Pohl
- Division of Pediatric Critical Care, Rady Children's Hospital, San Diego, CA
- Department of Pediatrics, University of California at San Diego, La Jolla, CA
| | - Helen Harvey
- Division of Pediatric Critical Care, Rady Children's Hospital, San Diego, CA
| | - Jennifer Foley
- Division of Pediatric Critical Care, Rady Children's Hospital, San Diego, CA
| | - Euyhyun Lee
- Altman Clinical and Translational Research Institute, University of California at San Diego, La Jolla, CA
| | - Ronghui Xu
- Division of Critical Care Medicine, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - Nicole F O'Brien
- Division of Critical Care Medicine, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - Nicole G Coufal
- Division of Pediatric Critical Care, Rady Children's Hospital, San Diego, CA
- Department of Pediatrics, University of California at San Diego, La Jolla, CA
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Gilbert BW, Dingman JS, Reeder JA, Paola SD. A teaspoon of sugar and a pinch of salt: Reviewing hyperosmolar therapy. JAAPA 2022; 35:43-47. [PMID: 35192554 DOI: 10.1097/01.jaa.0000819556.37543.70] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT The traditional hyperosmolar agents used to treat patients with elevated intracranial pressure are mannitol and hypertonic sodium chloride solution. This article focuses on some of the pros and cons of these treatments for managing cerebral edema.
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Affiliation(s)
- Brian W Gilbert
- At Wesley Medical Center in Wichita, Kan., Brian W. Gilbert is a clinical pharmacist in emergency medicine, J. Spencer Dingman is a clinical pharmacist in neurocritical care, Jacob A. Reeder is a clinical pharmacist in critical care, and Sean Di Paola practices in emergency medicine and trauma. The authors have disclosed no potential conflicts of interest, financial or otherwise
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9
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Hypertonic Saline Treatment in Traumatic Brain Injury: A Systematic Review. World Neurosurg 2022; 162:98-110. [DOI: 10.1016/j.wneu.2022.03.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 03/13/2022] [Accepted: 03/14/2022] [Indexed: 11/17/2022]
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10
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Influence of 3% Hypertonic Saline Versus 0.9% Saline on Intraoperative Maintenance Fluid Requirements in Adult Patients Undergoing Major Open Abdominal Surgeries: Randomized Controlled Study. World J Surg 2022; 46:1344-1350. [PMID: 35192016 DOI: 10.1007/s00268-022-06484-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND Three percent hypertonic saline (3% HTS) acts like an osmotic buffer and draws fluid from the extracellular space into the intravascular compartment. Primary objective was to evaluate whether use of 3% HTS resulted in a difference in intraoperative maintenance fluid requirement versus 0.9% saline (NS). Secondary objectives were to evaluate differences in 24 h fluid requirements and safety of 3% HTS. METHODS Adult patients of either sex, 18-65 years, undergoing elective major open abdominal surgeries were randomized to receive infusions of 3% HTS or NS at 1 ml/kg/hr through large bore peripheral i.v cannulas, or central venous catheters after anesthesia induction. Intraoperative maintenance fluids were administered to maintain mean arterial pressure (≥70 mmHg), urine output (≥0.5 ml/kg/hr) and central venous pressure of 8-10 cm H2O. RESULTS Ninety-three patients completed the study (46 in 3% HTS and 47 in NS group). No difference was seen in the volume of intraoperative maintenance fluids (3% HTS vs NS; 2243.9 ± 896.7 ml vs 2093.6 ± 868.7 ml; P = 0.34). Similarly, the 24 h postoperative fluid requirement was not different (3% HTS vs NS; 2006.6 ± 398.6 ml vs 2018.3 ± 389.3 ml; P = 0.94). Patients in 3% HTS group had statistically but not clinically significant higher serum sodium values at postoperative 12th and 24 h. No complication like thrombophlebitis or tissue ischemia was reported due to administration of 3% HTS through peripheral lines. CONCLUSION Administration of 3% HTS did not reduce intraoperative maintenance fluid requirements in patients undergoing major open abdominal surgeries. TRIAL REGISTRATION CTRI/2019/09/021032.
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Raees M, Hooli S, von Saint André-von Arnim AO, Laeke T, Otupiri E, Fabio A, Rudd KE, Kumar R, Wilson PT, Aklilu AT, Tuyisenge L, Wang C, Tasker RC, Angus DC, Kochanek PM, Fink EL, Bacha T. An exploratory assessment of the management of pediatric traumatic brain injury in three centers in Africa. Front Pediatr 2022; 10:936150. [PMID: 36061402 PMCID: PMC9428450 DOI: 10.3389/fped.2022.936150] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 07/22/2022] [Indexed: 11/17/2022] Open
Abstract
PURPOSE Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in low- and middle-income countries (LMICs). Hospital care practices of pediatric TBI patients in LMICs are unknown. Our objective was to report on hospital management and outcomes of children with TBI in three centers in LMICs. METHODS We completed a secondary analysis of a prospective observational study in children (<18 years) over a 4-week period. Outcome was determined by Pediatric Cerebral Performance Category (PCPC) score; an unfavorable score was defined as PCPC > 2 or an increase of two points from baseline. Data were compared using Chi-square and Wilcoxon rank sum tests. RESULTS Fifty-six children presented with TBI (age 0-17 y), most commonly due to falls (43%, n = 24). Emergency department Glasgow Coma Scale scores were ≤ 8 in 21% (n = 12). Head computed tomography was performed in 79% (n = 44) of patients. Forty (71%) children were admitted to the hospital, 25 (63%) of whom were treated for suspected intracranial hypertension. Intracranial pressure monitoring was unavailable. Five (9%, n = 5) children died and 10 (28%, n = 36) inpatient survivors had a newly diagnosed unfavorable outcome on discharge. CONCLUSION Inpatient management and monitoring capability of pediatric TBI patients in 3 LMIC-based tertiary hospitals was varied. Results support the need for prospective studies to inform development of evidence-based TBI management guidelines tailored to the unique needs and resources in LMICs.
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Affiliation(s)
- Madiha Raees
- Division of Critical Care Medicine, Department of Anesthesia and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, United States.,Department of Critical Care Medicine, University of Pittsburgh Medical Center (UPMC) Children's Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Shubhada Hooli
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States
| | - Amélie O von Saint André-von Arnim
- Division of Pediatric Critical Care, Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, WA, United States.,Department of Global Health, University of Washington, Seattle, WA, United States
| | - Tsegazeab Laeke
- Division of Neurosurgery, Department of Surgery, College of Health Science, Addis Ababa University, Addis Ababa, Ethiopia.,Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway.,National Institute for Health Care and Research (NIHR) Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
| | - Easmon Otupiri
- School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Anthony Fabio
- Epidemiology Data Center, University of Pittsburgh, Pittsburgh, PA, United States
| | - Kristina E Rudd
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States.,Clinical Research, Investigation, and Systems Modeling of Acute Illness Center (CRISMA), University of Pittsburgh, Pittsburgh, PA, United States
| | - Rashmi Kumar
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Patrick T Wilson
- Department of Pediatrics, Columbia University Medical Center, New York, NY, United States
| | - Abenezer Tirsit Aklilu
- Division of Neurosurgery, Department of Surgery, College of Health Science, Addis Ababa University, Addis Ababa, Ethiopia.,Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway.,National Institute for Health Care and Research (NIHR) Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
| | - Lisine Tuyisenge
- Department of Paediatrics, University Teaching Hospital of Kigali, Kigali, Rwanda
| | - Chunyan Wang
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States
| | - Robert C Tasker
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, United States
| | - Derek C Angus
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States.,Clinical Research, Investigation, and Systems Modeling of Acute Illness Center (CRISMA), University of Pittsburgh, Pittsburgh, PA, United States
| | - Patrick M Kochanek
- Department of Critical Care Medicine, University of Pittsburgh Medical Center (UPMC) Children's Hospital of Pittsburgh, Pittsburgh, PA, United States.,Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA, United States
| | - Ericka L Fink
- Department of Critical Care Medicine, University of Pittsburgh Medical Center (UPMC) Children's Hospital of Pittsburgh, Pittsburgh, PA, United States.,Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA, United States
| | - Tigist Bacha
- Department of Pediatrics and Child Health, St. Paul Millennium Medical College, Addis Ababa, Ethiopia
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12
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Barik AK, Agrawal S, Gupta P, Kumari R. Evaluation of equiosmolar 20% mannitol, 3% hypertonic saline and 8.4% sodium bicarbonate on intraoperative brain relaxation and hemodynamic parameters in patients undergoing craniotomy for supratentorial tumors: a prospective randomized study. Minerva Anestesiol 2021; 87:997-1005. [PMID: 34612617 DOI: 10.23736/s0375-9393.21.15448-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Research comparing 20% mannitol, 3% hypertonic saline and 8.4% sodium bicarbonate for intraoperative hyperosmolar therapy during supratentorial tumor excision is sparse. With the hypothesis that equiosmolar concentration of these agents will produce equivalent effects, this study was conducted to compare the effects on intraoperative brain relaxation and hemodynamics. METHODS The prospective study was conducted over a period of one year. Ninety patients, aged 18-60 years, American Society of Anesthesiologists class Ι and ΙΙ with supratentorial tumor and scheduled for surgery were randomized into three groups to receive equiosmolar 20% mannitol (group 1), 3% hypertonic saline (group 2) and 8.4% sodium bicarbonate (group 3). Primary outcome assessed was the effect on intraoperative brain relaxation score while hemodynamic parameters, changes in arterial blood gas parameters, serum electrolytes, serum osmolarity, urine output, fluid intake, post-operative course, hospital stay were the secondary outcomes. RESULTS Demographic characteristics, surgical and anesthetic variables, were comparable between the three groups. Brain relaxation scores were significantly better in group 3 compared to group 2 and group 1 respectively. Patients in group 1 had lower mean blood pressure and central venous pressure values, higher urine output, fluid intake compared to other groups. Patients of group 3 had significantly higher pH, bicarbonate, partial pressure of carbon dioxide, serum sodium and serum osmolarity values compared to groups 1 and 2. CONCLUSIONS Eight point four percent sodium bicarbonate solution infusion is associated with superior intraoperative brain relaxation scores and improved haemodynamic stability compared to equiosmolar 3% hypertonic saline solution and 20% mannitol.
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Affiliation(s)
- Amiya K Barik
- Department of Anesthesiology, All India Institute of Medical Sciences, Rishikesh, India
| | - Sanjay Agrawal
- Department of Anesthesiology, All India Institute of Medical Sciences, Rishikesh, India -
| | - Priyanka Gupta
- Department of Anesthesiology, All India Institute of Medical Sciences, Rishikesh, India
| | - Ranjeeta Kumari
- Department of Anesthesiology, All India Institute of Medical Sciences, Rishikesh, India
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Safety and Efficacy of 23.4% Sodium Chloride Administered via Peripheral Venous Access for the Treatment of Cerebral Herniation and Intracranial Pressure Elevation. Neurocrit Care 2021; 35:845-852. [PMID: 34173156 DOI: 10.1007/s12028-021-01248-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 04/03/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Sodium chloride (NaCl) 23.4% solution has been shown to reduce intracranial pressure (ICP) and reverse transtentorial herniation. A limitation of 23.4% NaCl is its high osmolarity (8008 mOsm/l) and the concern for tissue injury or necrosis following extravasation when administered via peripheral venous access. The use of this agent is therefore often limited to central venous or intraosseous routes of administration. Our objective was to evaluate the safety and efficacy of administration of 23.4% NaCl via peripheral venous access compared with administration via central venous access. METHODS We reviewed pharmacy records to identify all administrations of 23.4% NaCl at our institution between December 2017 and February 2020. Medical records were then reviewed to identify complications, such as extravasation, soft tissue injury or necrosis, hypotension (mean arterial pressure less than 65 mm Hg), pulmonary edema, hemolysis, and osmotic demyelination. We also compared the change in physiological variables, such as ICP, mean arterial pressure, cerebral perfusion pressure, and heart rate, as well as laboratory values, such as sodium, chloride, bicarbonate, creatinine, and hemoglobin, following administration of 23.4% NaCl via the peripheral and central venous routes. RESULTS We identified 299 administrations of 23.4% NaCl (242 central and 57 peripheral) in 141 patients during the study period. There was no documented occurrence of soft tissue injury or necrosis in any patient. One patient developed hypotension following central administration. Among the 38 patients with ICP monitoring at the time of drug administration, there was no significant difference in median ICP reduction (- 13 mm Hg [central] vs. - 24 mm Hg [peripheral], p = 0.21) or cerebral perfusion pressure augmentation (16 mm Hg [central] vs. 15 mm Hg [peripheral], p = 0.87) based on route of administration. CONCLUSIONS Peripheral venous administration of 23.4% NaCl is safe and achieves a reduction in ICP equivalent to that achieved by administration via central venous access.
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Ong J, Van Gerpen R. Recommendations for Management of Noncytotoxic Vesicant Extravasations. JOURNAL OF INFUSION NURSING 2021; 43:319-343. [PMID: 33141794 DOI: 10.1097/nan.0000000000000392] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
To prepare clinicians to treat extravasation of noncytotoxic vesicants with antidotes and thermal compresses, a literature review was performed to identify noncytotoxic vesicants and to create evidence and consensus-based recommendations. The stage of injury and vesicant's mechanism of tissue injury dictate treatment. For a vasopressor extravasation, warm compresses and administration of a vasodilator are recommended. For osmolarity, pH, absorption refractory, and cytotoxic concentration-dependent vesicants, warm compresses and administration of hyaluronidase are recommended. Compared with potentially catastrophic costs of undertreatment, the cost of overtreatment is minimal.
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Affiliation(s)
- Jennie Ong
- Bryan Medical Center, Lincoln, Nebraska (Dr Ong and Ms Van Gerpen).,Jennie Ong, PharmD, is a clinical pharmacist at Bryan Medical Center in Lincoln, Nebraska, with 10 years of hospital pharmacy experience. Her specialties include formulary management and patient safety-oriented process improvements.,Ruth Van Gerpen MS, RN-BC, APRN-CNS, AOCNS®, is a clinical nurse specialist at Bryan Medical Center in Lincoln, Nebraska, with 36 years of oncology experience. Her subspecialties include pain management and infusion therapy
| | - Ruth Van Gerpen
- Bryan Medical Center, Lincoln, Nebraska (Dr Ong and Ms Van Gerpen).,Jennie Ong, PharmD, is a clinical pharmacist at Bryan Medical Center in Lincoln, Nebraska, with 10 years of hospital pharmacy experience. Her specialties include formulary management and patient safety-oriented process improvements.,Ruth Van Gerpen MS, RN-BC, APRN-CNS, AOCNS®, is a clinical nurse specialist at Bryan Medical Center in Lincoln, Nebraska, with 36 years of oncology experience. Her subspecialties include pain management and infusion therapy
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Jannotta GE, Gulek BG, Dempsey JS, Blissitt PA, Sullivan HC, Tran K, Joffe A, Lele AV. Administration of 3% Sodium Chloride Through Peripheral Intravenous Access: Development and Implementation of a Protocol for Clinical Practice. Worldviews Evid Based Nurs 2021; 18:147-153. [PMID: 33783949 DOI: 10.1111/wvn.12501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Patients with traumatic brain injury, cerebral edema, and severe hyponatremia require rapid augmentation of serum sodium levels. Three percent sodium chloride is commonly used to normalize or augment serum sodium level, yet there are limited data available concerning the most appropriate route of administration. Traditionally, 3% sodium chloride is administered through a central venous catheter (CVC) due to the attributed theoretical risk of phlebitis and extravasation injuries when hyperosmolar solution is administered peripherally. CVCs are associated with numerous complications, including arterial puncture, pneumothorax, infection, thrombosis, and air embolus. Peripherally infused 3% sodium chloride may bypass these concerns. AIMS To explore the evidence for peripherally infused 3% sodium chloride and to implement the findings. METHODS The Iowa Model of Evidence-Based Practice (EBP) was used to guide the project. A multidisciplinary team was established, and they developed an evidence-based protocol for the administration of 3% sodium chloride using peripheral intravenous catheters (PIVs), identified potential barriers to implementation, and developed targeted education to implement this practice change in a large academic medical center. RESULTS Of the 103 patients in this project, only three (2.9%) identified adverse events. Two were associated with continuous infusions, and one was associated with a bolus infusion. LINKING ACTION TO EVIDENCE This is the first study to describe a multidisciplinary protocol development and implementation process for the administration of 3% sodium chloride peripherally. Utilizing a multidisciplinary team is critical to the success of an EBP project. Implementing an evidence-based PIV protocol with stringent monitoring criteria for the administration of 3% sodium chloride has the potential to reduce adverse events related to CVC injury.
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Affiliation(s)
- Gemi E Jannotta
- Neurocritical Care Service, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Bernice G Gulek
- Neurocritical Care Service, Harborview Medical Center, University of Washington, Seattle, WA, USA.,Graduate School, College of Nursing, Washington State University, Spokane, WA, USA
| | - John S Dempsey
- Department of Pharmacy, Harborview Medical Center, Seattle, WA, USA
| | - Patricia A Blissitt
- Professional Development and Nursing Excellence, Harborview Medical Center, Seattle, WA, USA.,Department of Biobehavioral Nursing and Health Informatics, University of Washington School of Nursing, Seattle, WA, USA
| | - Helen C Sullivan
- Professional Development and Nursing Excellence, Harborview Medical Center, Seattle, WA, USA
| | - Kim Tran
- Department of Pharmacy, Harborview Medical Center, Seattle, WA, USA
| | - Aaron Joffe
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Abhijit V Lele
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA
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Xu Y, Vagnerova K. Anesthetic Management of Asleep and Awake Craniotomy for Supratentorial Tumor Resection. Anesthesiol Clin 2021; 39:71-92. [PMID: 33563387 DOI: 10.1016/j.anclin.2020.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Understanding how anesthetics impact cerebral physiology, cerebral blood flow, brain metabolism, brain relaxation, and neurologic recovery is crucial for optimizing anesthesia during supratentorial craniotomies. Intraoperative goals for supratentorial tumor resection include maintaining cerebral perfusion pressure and cerebral autoregulation, optimizing surgical access and neuromonitoring, and facilitating rapid, cooperative emergence. Evidence-based studies increasingly expand the impact of anesthetic care beyond immediate perioperative care into both preoperative optimization and minimizing postoperative consequences. New evidence is needed for neuroanesthesia's role in neurooncology, in preventing conversion from acute to chronic pain, and in decreasing risk of intraoperative ischemia and postoperative delirium.
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Affiliation(s)
- Yifan Xu
- Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University, 3181 Southwest Sam Jackson Park Road, Mail Code UH2, Portland, OR 97239, USA.
| | - Kamila Vagnerova
- Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University, 3181 Southwest Sam Jackson Park Road, Mail Code UH2, Portland, OR 97239, USA
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Mohney N, Alkhatib O, Koch S, O'Phelan K, Merenda A. What is the Role of Hyperosmolar Therapy in Hemispheric Stroke Patients? Neurocrit Care 2021; 32:609-619. [PMID: 31342452 DOI: 10.1007/s12028-019-00782-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The role of hyperosmolar therapy (HT) in large hemispheric ischemic or hemorrhagic strokes remains a controversial issue. Past and current stroke guidelines state that it represents a reasonable therapeutic measure for patients with either neurological deterioration or intracranial pressure (ICP) elevations documented by ICP monitoring. However, the lack of evidence for a clear effect of this therapy on radiological tissue shifts and clinical outcomes produces uncertainty with respect to the appropriateness of its implementation and duration in the context of radiological mass effect without clinical correlates of neurological decline or documented elevated ICP. In addition, limited data suggest a theoretical potential for harm from the prophylactic and protracted use of HT in the setting of large hemispheric lesions. HT exerts effects on parenchymal volume, cerebral blood volume and cerebral perfusion pressure which may ameliorate global ICP elevation and cerebral blood flow; nevertheless, it also holds theoretical potential for aggravating tissue shifts promoted by significant interhemispheric ICP gradients that may arise in the setting of a large unilateral supratentorial mass lesion. The purpose of this article is to review the literature in order to shed light on the effects of HT on brain tissue shifts and clinical outcome in the context of large hemispheric strokes, as well as elucidate when HT should be initiated and when it should be avoided.
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Affiliation(s)
- Nathan Mohney
- Department of Neurology, University of Miami Health System, 1120 NW 14th Street, Miami, FL, 33136, USA
- Department of Neurosurgery, University of Miami Health System, 1120 NW 14th Street, Miami, FL, 33136, USA
| | - Omar Alkhatib
- Department of Neurology, University of Miami Health System, 1120 NW 14th Street, Miami, FL, 33136, USA
- Department of Neurosurgery, University of Miami Health System, 1120 NW 14th Street, Miami, FL, 33136, USA
| | - Sebastian Koch
- Department of Neurology, University of Miami Health System, 1120 NW 14th Street, Miami, FL, 33136, USA
- Department of Neurosurgery, University of Miami Health System, 1120 NW 14th Street, Miami, FL, 33136, USA
| | - Kristine O'Phelan
- Department of Neurology, University of Miami Health System, 1120 NW 14th Street, Miami, FL, 33136, USA
- Department of Neurosurgery, University of Miami Health System, 1120 NW 14th Street, Miami, FL, 33136, USA
| | - Amedeo Merenda
- Department of Neurology, University of Miami Health System, 1120 NW 14th Street, Miami, FL, 33136, USA.
- Department of Neurosurgery, University of Miami Health System, 1120 NW 14th Street, Miami, FL, 33136, USA.
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Alenazi AO, Alhalimi ZM, Almatar MH, Alhajji TA. Safety of Peripheral Administration of 3% Hypertonic Saline in Critically Ill Patients: A Literature Review. Crit Care Nurse 2021; 41:25-30. [PMID: 33560431 DOI: 10.4037/ccn2021400] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
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 administration 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 (administration 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.
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Affiliation(s)
- Ahmed O Alenazi
- Ahmed O. Alenazi is a critical care clinical pharmacist, Al Imam Abdulrahman Bin Faisal Hospital, Dammam, Saudi Arabia
| | - Zahra M Alhalimi
- 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
- Manar H. Almatar was a PharmD student at Al Imam Abdulrahman Bin Faisal University, at the time of writing this article
| | - Taha A Alhajji
- Taha A. Alhajji is an inpatient pharmacist, Al Imam Abdulrahman Bin Faisal Hospital
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20
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Workeneh BT, Jhaveri KD, Rondon-Berrios H. Hyponatremia in the cancer patient. Kidney Int 2020; 98:870-882. [DOI: 10.1016/j.kint.2020.05.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 04/28/2020] [Accepted: 05/11/2020] [Indexed: 02/08/2023]
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21
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Jacobi J. Call for pharmacists to join vascular safety teams. Am J Health Syst Pharm 2020; 77:1347-1353. [DOI: 10.1093/ajhp/zxaa169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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22
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Intraosseous Administration of Hypertonic Saline in Acute Brain-Injured Patients: A Prospective Case Series and Literature Review. Neurologist 2020; 24:176-179. [PMID: 31688708 DOI: 10.1097/nrl.0000000000000248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Central venous catheters are often used to administer hypertonic saline (HTS) but might be associated with serious complications. Intraosseous (IO) access is an alternative method of medication and fluid delivery which is not associated with life-threatening complications and can be inserted faster than CVCs. METHODS A prospective case series was conducted on critically ill neurological patients that did not have central venous access, and for whom 3% HTS was indicated. Nonverbal indicators of pain were measured using the critical care pain observation tool. The pain score and serum sodium levels were collected at baseline, at 2, 6, 12, 18, and 24 hours after administration of 3% HTS using IO access. The area surrounding the IO insertion site was monitored for needle placement, extravasation, and tissue damage. RESULTS Five patients were enrolled. Three had an IO placed in the proximal humerus and 2 in the proximal tibia. Most patients did not have nonverbal indicators of pain during insertion and initial bolus. Serum sodium levels increased appropriately, as determined by the care providers. There were no cases of device dislodgement, extravasation, infection, soft tissue injury, or other local complications. CONCLUSIONS In this prospective case series, IO administration of 3% HTS was feasible, well-tolerated on the basis of nonverbal indicators of pain in the majority of patients and resulted in an appropriate rise in serum sodium levels. IO fills a niche among vascular access options for HTS, in emergent neurological situations when central venous access is not readily available or peripheral intravenous access is difficult to obtain.
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23
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Javeri Y, Jagathkar G, Dixit S, Chaudhary D, Zirpe KG, Mehta Y, Govil D, Mishra RC, Samavedam S, Pandit RA, Savio RD, Clerk AM, Srinivasan S, Juneja D, Ray S, Sahoo TK, Jakkinaboina S, Jampala N, Jain R. Indian Society of Critical Care Medicine Position Statement for Central Venous Catheterization and Management 2020. Indian J Crit Care Med 2020; 24:S6-S30. [PMID: 32205954 PMCID: PMC7085816 DOI: 10.5005/jp-journals-10071-g23183] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background and Purpose Short-term central venous catheterization (CVC) is one of the commonly used invasive interventions in ICU and other patient-care areas. Practice and management of CVC is not standardized, varies widely, and need appropriate guidance. Purpose of this document is to provide a comprehensive, evidence-based and up-to-date, one document source for practice and management of central venous catheterization. These recommendations are intended to be used by critical care physicians and allied professionals involved in care of patients with central venous lines. Methods This position statement for central venous catheterization is framed by expert committee members under the aegis of Indian Society of Critical Care Medicine (ISCCM). Experts group exchanged and reviewed the relevant literature. During the final meeting of the experts held at the ISCCM Head Office, a consensus on all the topics was made and the recommendations for final document draft were prepared. The final document was reviewed and accepted by all expert committee members and after a process of peer-review this document is finally accepted as an official ISCCM position paper. Modified grade system was utilized to classify the quality of evidence and the strength of recommendations. The draft document thus formulated was reviewed by all committee members; further comments and suggestions were incorporated after discussion, and a final document was prepared. Results This document makes recommendations about various aspects of resource preparation, infection control, prevention of mechanical complication and surveillance related to short-term central venous catheterization. This document also provides four appendices for ready reference and use at institutional level. Conclusion In this document, committee is able to make 54 different recommendations for various aspects of care, out of which 40 are strong and 14 weak recommendations. Among all of them, 42 recommendations are backed by any level of evidence, however due to paucity of data on 12 clinical questions, a consensus was reached by working committee and practice recommendations given on these topics are based on vast clinical experience of the members of this committee, which makes a useful practice point. Committee recognizes the fact that in event of new emerging evidences this document will require update, and that shall be provided in due time. Abbreviations list ABHR: Alcohol-based hand rub; AICD: Automated implantable cardioverter defibrillator; BSI: Blood stream infection; C/SS: CHG/silver sulfadiazine; Cath Lab: Catheterization laboratory (Cardiac Cath Lab); CDC: Centers for Disease Control and Prevention; CFU: Colony forming unit; CHG: Chlorhexidine gluconate; CL: Central line; COMBUX: Comparison of Bedside Ultrasound with Chest X-ray (COMBUX study); CQI: Continuous quality improvement; CRBSI: Catheter-related blood stream infection; CUS: Chest ultrasonography; CVC: Central Venous Catheter; CXR: Chest X-ray; DTTP: Differential time to positivity; DVT: Deep venous thrombosis; ECG: Electrocardiography; ELVIS: Ethanol lock and risk of hemodialysis catheter infection in critically ill patients; ER: Emergency room; FDA: Food and Drug Administration; FV: Femoral vein; GWE: Guidewire exchange; HD catheter: Hemodialysis catheter; HTS: Hypertonic saline; ICP: Intracranial pressure; ICU: Intensive Care Unit; IDSA: Infectious Disease Society of America; IJV: Internal jugular vein; IPC: Indian penal code; IRR: Incidence rate ratio; ISCCM: Indian Society of Critical Care Medicine; IV: Intravenous; LCBI: Laboratory confirmed blood stream infection; M/R: Minocycline/rifampicin; MBI-LCBI: Mucosal barrier injury laboratory-confirmed bloodstream infection; MRSA: Methicillin-resistant Staphylococcus aureus; NHS: National Health Service (UK); NHSN: National Healthcare Safety Network (USA); OT: Operation Theater; PICC: Peripherally-inserted central catheter; PIV: Peripheral intravenous line; PL: Peripheral line; PVI: Povidone-iodine; RA: Right atrium; RCT: Randomized controlled trial; RR: Relative risk; SCV/SV: Subclavian vein; ScVO2: Central venous oxygen saturation; Sn: Sensitivity; SOP: Standard operating procedure; SVC: Superior vena cava; TEE: Transesophageal echocardiography; UPP: Useful Practice Points; USG: Ultrasonography; WHO: World Health Organization How to cite this article Javeri Y, Jagathkar G, Dixit S, Chaudhary D, Zirpe KG, Mehta Y, et al. Indian Society of Critical Care Medicine Position Statement for Central Venous Catheterization and Management 2020. Indian J Crit Care Med 2020;24(Suppl 1):S6–S30.
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Affiliation(s)
- Yash Javeri
- Department of Critical Care, Anesthesia and Emergency Medicine, Regency Health, Lucknow, Uttar Pradesh, India, , e-mail:
| | - Ganshyam Jagathkar
- Department of Critical Care Medicine, Medicover Hospital, Hyderabad, Telangana, India, e-mail:
| | - Subhal Dixit
- Department of Critical Care Medicine, Sanjeevan & MJM Hospital, Pune, Maharashtra, India, e-mail:
| | - Dhruva Chaudhary
- Department of Pulmonary and Critical Care, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India, , e-mail:
| | - Kapil Gangadhar Zirpe
- Department of Neuro Trauma Unit, Grant Medical Foundation, Pune, Maharashtra, India, , e-mail:
| | - Yatin Mehta
- Department of Critical Care and Anesthesiology, Medanta The Medicity, Sector-38, Gurgaon, Haryana, India, Extn. 3335, e-mail:
| | - Deepak Govil
- Department of Critical Care, Medanta Hospital, The Medicity, Gurugram, Haryana, India, , e-mail:
| | - Rajesh C Mishra
- Department of Critical Care, Saneejivini Hospital, Vastrapur, Ahmedabad, Gujarat, India, , e-mail:
| | - Srinivas Samavedam
- Department of Critical Care, Virinchi Hospital, Hyderabad, Telangana, India, , e-mail:
| | - Rahul Anil Pandit
- Department of Intensive Care Unit, Fortis Hospital, Mumbai, Maharashtra, India, , e-mail:
| | - Raymond Dominic Savio
- Department of Critical Care Medicine, Apollo Hospital, Chennai, Tamil Nadu, India, e-mail:
| | - Anuj M Clerk
- Department of Intensive Care, Services Sunshine Global Hospital, Surat, Gujarat, India, e-mail:
| | - Shrikanth Srinivasan
- Department of Critical Care Medicine, Manipal Hospital, New Delhi, India, , e-mail:
| | - Deven Juneja
- Department of Critical Care Medicine, Max Superspecialty Hospital, New Delhi, India, , e-mail:
| | - Sumit Ray
- Department of Critical Care, Artemis Hospital, Gurugram, Haryana, India, e-mail:
| | - Tapas Kumar Sahoo
- Department of Critical Care, Medanta Hospital, Ranchi, Jharkhand, India, , e-mail:
| | - Srinivas Jakkinaboina
- Department of Critical Care Medicine, Citizens Specialty Hospital, Hyderabad, Telangana, India, , e-mail:
| | - Nandhakishore Jampala
- Department of Critical Care, Medicover Hospital, Hyderabad, Telangana, India, , e-mail:
| | - Ravi Jain
- Department of Critical Care Medicine, Nayati Medicity, Mathura, Uttar Pradesh, India, , e-mail:
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Ayus JC, Moritz ML. Misconceptions and Barriers to the Use of Hypertonic Saline to Treat Hyponatremic Encephalopathy. Front Med (Lausanne) 2019; 6:47. [PMID: 30931308 PMCID: PMC6428704 DOI: 10.3389/fmed.2019.00047] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 02/20/2019] [Indexed: 12/11/2022] Open
Abstract
Hyponatremic encephalopathy is a potentially life-threatening condition with a high associated morbidity and mortality. It can be difficult to diagnose as the presenting symptoms can be non-specific and do not always correlate with the degree of hyponatremia. It can rapidly progress leading to death from transtentorial herniation. Hypertonic saline is the recommended treatment for hyponatremic encephalopathy, whether acute or chronic, yet it is infrequently used. We believe that the main barriers to its use is the perception that hypertonic saline is associated with a significant risk for cerebral demyelination, that it can't be administered through a peripheral IV and that it requires monitoring in the ICU. Two illustrative cases are presented followed by a discussion of how intermittent bolus's of 100−150 ml of 3% NaCl in rapid succession to acutely increase the plasma sodium by 4−6 mEq/L is a safe and effective way to treat hyponatremic encephalopathy, that can be administered through a peripheral IV in a non-ICU setting.
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Affiliation(s)
- Juan Carlos Ayus
- Renal Consultants of Houston, Houston, TX, United States.,Division of Nephrology, School of Medicine Irvine, University of California, Irvine, Irvine, CA, United States
| | - Michael L Moritz
- Division of Nephrology, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
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Safety of Peripheral Line Administration of 3% Hypertonic Saline and Mannitol in the Emergency Department. J Emerg Med 2019; 56:431-436. [PMID: 30745195 DOI: 10.1016/j.jemermed.2018.12.046] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 12/21/2018] [Accepted: 12/24/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Hypertonic saline (HTS) and mannitol are frequently utilized in the emergency department (ED) to manage elevations in intracranial pressure (ICP). OBJECTIVE The objective of this study was to compare the incidence of extravasation injury when HTS or mannitol was administered via peripheral i.v. line (PIV). METHODS This retrospective cohort study evaluated adult and pediatric patients given either 3% HTS or mannitol via PIV while in the ED. The primary outcome was extravasation incidence. RESULTS One hundred and ninety-two patients were included, of which 85 (44%) received HTS and 107 (56%) received mannitol. Patients who received HTS were younger (27.5 ± 24.3 years vs. 53.9 ± 22.3 years; p < 0.001); 55.3% of patients given HTS received it for traumatic brain injury (TBI) versus 38.3% of patients given mannitol (p = 0.021); and 44.9% of patients given mannitol received it for intracerebral hemorrhage versus 21.2% of patients given HTS (p = 0.001). There was no incidence of extravasation in either group. Patients who received HTS had lower ICP measurement 24 h post admission (2.107 ± 5.5 mm Hg vs. 4.236 ± 8.1 mm Hg; p = 0.047) and higher Glasgow Coma Scale (GCS) score upon discharge (GCS 14; interquartile range [IQR] 3-15 vs. GCS 3; IQR 3-14.2; p = 0.004). In-hospital mortality was higher in the mannitol group (54.7% vs. 32.9%; p = 0.003). Duration of mechanical ventilation was shorter in those patients who received HTS (1 day; IQR 0-56 days vs. 2 days; IQR 0-56 days; p = 0.023). CONCLUSIONS There were no incidences of extravasation among patients given 3% HTS or mannitol. Clinicians should reconsider recommendations to restrict HTS or mannitol to central lines.
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Freeman N, Welbourne J. Osmotherapy: science and evidence-based practice. BJA Educ 2018; 18:284-290. [DOI: 10.1016/j.bjae.2018.05.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2018] [Indexed: 11/28/2022] Open
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Jiang Z, Xu H, Wang M, Li Z, Su X, Li X, Li Z, Han X. Effect of infusion speed of 7.5% hypertonic saline on brain edema in patients with craniocerebral injury: An experimental study. Gene 2018; 665:201-207. [PMID: 29729380 DOI: 10.1016/j.gene.2018.05.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Revised: 04/27/2018] [Accepted: 05/02/2018] [Indexed: 10/17/2022]
Abstract
This study firstly used a rat traumatic brain injury model to compare the therapeutic effects of different intravenous infusion speed of 7.5% hypertonic saline (HS). Then the authors applied different delivery rate of 7.5% HS to two groups of patients to figure out the optimal infusion rates. A total of 100 rats were randomly divided into control group, group A (7.5% HS 6 mL/h), group B (7.5% HS 3 mL/h), and group C (7.5% HS 2 mL/h). All rats were established for the brain injury model. A total of 30 patients were selected and randomly divided into group A (250 mL/h) and group B (125 mL/h), with 15 cases in each group. Urine amount was recorded per hour; furthermore, blood was extracted from the patients to measure the levels of AQP4, NKCC1, tumour necrosis factor-α (TNF-a), interleukin-1β (IL-1β), and interleukin-6 (IL-6). Compared with other groups, the expression levels of NKCC1 and AQP4 mRNA in group A was the lowest (P < 0.05). NKCC1 and AQP4 protein expression levels were the lowest in all the groups (P < 0.05). On the aspect of patients, group A displayed more significant difference compared with B group in terms of AQP4, NKCC1, TNF-a, IL-1β, and IL-6 (P < 0.05). In the two groups, a significant difference was noted in the urine amount at 4 h after administration (P < 0.05). In our study, infusion of hypertonic saline (250 mL/h) at the optimal rate of 7.5% HS decreased the intracranial pressure, brain tissue edema, and inflammatory cytokine expression; moreover, it can promote brain tissue protection.
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Affiliation(s)
- Zhenzhen Jiang
- Department of Nursing, Binzhou Medical University, Yantai, China
| | - Hongmei Xu
- Department of Hospital Infections Office, Affiliated Hospital of Binzhou Medical University, Binzhou, China.
| | - Meilin Wang
- Department of Nursing Department, Affiliated Hospital of Binzhou Medical University, Binzhou, China
| | - Zefu Li
- Department of Neurosurgery Medicine, Affiliated Hospital of Binzhou Medical University, Binzhou, China
| | - Xinyang Su
- Department of Nursing Department, Affiliated Hospital of Binzhou Medical University, Binzhou, China
| | - Xiaoli Li
- Department of Neurosurgery Medicine, Affiliated Hospital of Binzhou Medical University, Binzhou, China
| | - Zhenzhu Li
- Department of Neurosurgery Medicine, Affiliated Hospital of Binzhou Medical University, Binzhou, China
| | - Xuexin Han
- Department of Neurosurgery Medicine, Affiliated Hospital of Binzhou Medical University, Binzhou, China
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