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Hsu TY, Ho MP. Administered 3% hypertonic saline for neurologic emergency. Am J Emerg Med 2024; 80:215. [PMID: 38627126 DOI: 10.1016/j.ajem.2024.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Accepted: 04/11/2024] [Indexed: 05/31/2024] Open
Affiliation(s)
- Tien-You Hsu
- Department of Emergency Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Min-Po Ho
- Department of Emergency Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan.
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Brown CS, Rabinstein AA, Zhao Y, Wieruszewski ED. Safety of peripheral 3% hypertonic saline bolus administration for neurologic emergency. Am J Emerg Med 2023; 69:83-86. [PMID: 37079938 DOI: 10.1016/j.ajem.2023.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 04/02/2023] [Accepted: 04/03/2023] [Indexed: 04/22/2023] Open
Abstract
BACKGROUND/OBJECTIVE Hypertonic sodium chloride (HTS) is used for emergent treatment of acute cerebral edema and other neurologic emergencies. Central access is not commonly available in emergent situations and 3% HTS is utilized peripherally. Many studies have shown the safety of its administration at rates up to 75 mL/h, but there is a lack of data to establish the safety of peripherally administered, rapid bolus dosing in emergent situations. The objective of this study is to describe the safety of rapid, peripherally administered (≥ 250 mL/h) 3% HTS for neurologic emergencies. METHODS This is a retrospective, cohort study including adult patients receiving 3% HTS via a peripheral IV site for elevated intracranial pressure, cerebral edema, or other neurological emergencies at a rate of at least 250 m/h between May 5, 2018 - September 30, 2021. Patients were excluded if they simultaneously received another hypertonic saline fluid. Baseline characteristics collected included HTS dose, rate and site of administration, indication for use and patient demographics. The primary safety outcome was incidence of extravasation and phlebitis within one hour of HTS administration. RESULTS There were 206 patients receiving 3% HTS who were screened, and 37 patients met inclusion criteria. The most common reason for exclusion was administration at a rate < 250 m/h. The median age was 60 (IQR 45, 72) with 51.4% being male. The most common indications for HTS were traumatic brain injury (45.9%) and intracranial hemorrhage (37.8%). The most common administration location was the emergency department (78.4%). The median IV-gauge (n = 29) was 18 (IQR 18, 20), with the most common placement site being antecubital (48.6%). The median dose of HTS was 250 mL (IQR 250, 350), with a median administration rate of 760 mL/h (IQR 500, 999). There were no episodes of extravasation or phlebitis noted. CONCLUSIONS Rapid, peripheral administration of 3% HTS boluses is a safe alternative for treatment of neurologic emergencies. Administration at rates up to 999 mL/h did not result in extravasation or phlebitis.
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Affiliation(s)
- Caitlin S Brown
- Mayo Clinic, Department of Pharmacy Services, Rochester, MN, USA
| | | | - Yanjun Zhao
- Mayo Clinic, Department of Pharmacy Services, Rochester, MN, USA
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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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Lovett ME, Daniel M, Keesari R, MacDonald J, Rodriguez V, Muszynski J, Sribnick EA, O'Brien NF, Ayad O. Catheter-associated deep vein thrombosis in children with severe traumatic brain injury: A single-center experience. Pediatr Blood Cancer 2023; 70:e30044. [PMID: 36250988 DOI: 10.1002/pbc.30044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 09/08/2022] [Accepted: 09/17/2022] [Indexed: 12/25/2022]
Abstract
BACKGROUND This study was performed to describe the single-center experience of deep vein thrombosis (DVT) in children with severe traumatic brain injury (sTBI) who were mechanically ventilated with a central line, and to identify potentially modifiable risk factors. It was hypothesized that children with DVT would have a longer duration of central venous line (CVL) and a higher use of hypertonic saline (HTS) compared to those without DVT. PROCEDURE/METHODS This was a retrospective study of children (0-18 years) with sTBI, who were intubated, had a CVL, and a minimum intensive care unit (ICU) stay of 3 days. Children were analyzed by the presence or absence of DVT. HTS use was evaluated using milliliter per kilogram (ml/kg) of 3% equivalents. Univariable and multivariable logistic regression models were used to determine which factors were associated with DVT. RESULTS Seventy-seven children met inclusion criteria, 23 (29.9%) had a DVT detected in an extremity. On univariable analysis, children with DVT identified in an extremity had prolonged CVL use (14 vs. 8.5 days, p = .021) and longer duration of mechanical ventilation (15 vs. 10 days, p = .013). HTS 3% equivalent ml/kg was not different between groups. On multivariable analysis, mechanical ventilation duration was associated with DVT detection in an extremity, whereas neither CVL duration nor HTS use had an association. CONCLUSIONS There was a high incidence of extremity DVT detected in children with sTBI who received invasive mechanical ventilation and had a CVL. HTS administration was not associated with DVT detection in an extremity.
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Affiliation(s)
- Marlina E Lovett
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, The Ohio State University School of Medicine, Columbus, Ohio, USA
| | - Megan Daniel
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, The Ohio State University School of Medicine, Columbus, Ohio, USA
| | - Rohali Keesari
- Pediatric Biostatistics Core, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jennifer MacDonald
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, The Ohio State University School of Medicine, Columbus, Ohio, USA
| | - Vilmarie Rodriguez
- Department of Pediatrics, Division of Hematology and Oncology, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA
| | - Jennifer Muszynski
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, The Ohio State University School of Medicine, Columbus, Ohio, USA.,Center for Clinical and Translational Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Eric A Sribnick
- Center for Clinical and Translational Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Surgery, Division of Neurosurgery, Nationwide Children's Hospital, The Ohio State University School of Medicine, Columbus, Ohio, USA
| | - Nicole F O'Brien
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, The Ohio State University School of Medicine, Columbus, Ohio, USA
| | - Onsy Ayad
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, The Ohio State University School of Medicine, Columbus, Ohio, USA
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Neuropharmacology in the Intensive Care Unit. Crit Care Clin 2022; 39:171-213. [DOI: 10.1016/j.ccc.2022.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Ballesteros-Peña S, Fernández-Aedo I, Vallejo-De la Hoz G, Tønnesen J, Miguelez C. Identification of potentially irritating intravenous medications. ENFERMERIA INTENSIVA 2022; 33:132-140. [PMID: 35941074 DOI: 10.1016/j.enfie.2021.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 05/28/2021] [Indexed: 06/15/2023]
Abstract
AIMS To identify commonly used intravenous drugs that may produce endothelial damage. METHODS An experimental research study was performed using a sample of 62 intravenous drugs commonly used in emergency care, pH and osmolarity were measured. Subsequently, based on these values, the theoretical capacity to cause irritation or endovascular damage was determined and classified as high, moderate, and low. RESULTS Samples from 19 drugs for fluid therapy, 21 antibiotics and 22 drugs for intravenous use were studied. Glucose solutions, sodium bicarbonate 1M and mannitol 10% showed a high capacity to cause venous irritation. Vancomycin, ciprofloxacin, amiodarone, haloperidol, and labetalol solution presented a high capacity for irritation based on their acidic pH. The antibiotics, dexketoprofen, diazepam, digoxin, etomidate, phenytoin, levetiracetam and metamizole also showed high osmotic values in their reconstituted or undiluted presentations. Moreover, osmolarity of diazepam, digoxin and phenytoin remained high despite being diluted in 100 ml of saline. CONCLUSIONS Knowing the pH and osmolarity of intravenous drugs allows their capacity to cause endothelial damage to be assessed. The use of comprehensive tables based on the chemical properties of the drugs can be a useful tool to help prevent chemically-induced phlebitis.
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Affiliation(s)
- S Ballesteros-Peña
- Osakidetza, Organización Sanitaria Integrada Bilbao-Basurto, Bilbao, Spain.
| | - I Fernández-Aedo
- Biocruces Bizkaia Health Research Institute, Barakaldo, Vizcaya, Spain; Universidad del País Vasco/Euskal Herriko Unibertsitatea (UPV/EHU), Leioa, Bizkaia, Spain
| | - G Vallejo-De la Hoz
- Biocruces Bizkaia Health Research Institute, Barakaldo, Vizcaya, Spain; Universidad del País Vasco/Euskal Herriko Unibertsitatea (UPV/EHU), Leioa, Bizkaia, Spain; Osakidetza, Organización Sanitaria Integrada Barrualde-Galdakao, Galdakao, Bizkaia, Spain
| | - J Tønnesen
- Universidad del País Vasco/Euskal Herriko Unibertsitatea (UPV/EHU), Leioa, Bizkaia, Spain; Achucarro Basque Center for Neuroscience, Leioa, Bizkaia, Spain
| | - C Miguelez
- Universidad del País Vasco/Euskal Herriko Unibertsitatea (UPV/EHU), Leioa, Bizkaia, Spain
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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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Alkazemi A, McLaughlin KC, Chan MG, Schontz MJ, Anger KE, Szumita PM. Safety of Intravenous Push Levetiracetam Compared to Intravenous Piggyback at a Tertiary Academic Medical Center: A Retrospective Analysis. Drug Saf 2021; 45:19-26. [PMID: 34716562 DOI: 10.1007/s40264-021-01122-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Medication administration via intravenous push presents multiple potential advantages; however, there may be an increased risk of adverse drug reactions. In 2020, Brigham and Women's Hospital changed levetiracetam intravenous administration to intravenous push (IVP). OBJECTIVE The purpose of this analysis was to compare the safety profile of IVP to intravenous piggyback (IVPB) levetiracetam administration. METHODS This institutional review board-approved, single-center, pre-post analysis was performed between 1 November, 2019 and 30 May, 2020. The electronic health record was used to identify all administrations of intravenous levetiracetam greater than 1000 mg in patients ≥ 18 years old. The major safety outcomes included hypotension, bradycardia, drug-induced sedation, and intravenous site reactions such as phlebitis and infiltration. The major efficiency outcome was the time from pharmacy order verification to first-dose administration. RESULTS A total of 498 administrations in 162 patients were included in the analysis: 252 administrations in 84 patients in the IVP group and 246 administrations in 78 patients in the IVPB group. The incidence of bradycardia was 7 vs 3 (3.2% vs 1.5%, p = 0.34); hypotension 10 vs 6 (5.2% vs 3.5%, p = 0.44); sedation 21 vs 36 (19.3% vs 27.9%, p = 0.12); and peripheral IV site reactions 0 vs 1 (0% vs 0.6%, p = 0.39) in the IVP vs IVPB groups, respectively. The median time between order verification and first-dose administration was significantly reduced in the IVP vs IVPB group (23.5 vs 55 min, p < 0.001). CONCLUSIONS Intravenous push levetiracetam administration of doses up to 4000 mg was associated with a similar incidence of cardiovascular, sedation, and infusion site-related adverse events compared to IVPB and resulted in a significant reduction in time to first-dose administration. Intravenous push levetiracetam in doses as high as 4000 mg may be considered safe with appropriate monitoring.
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Affiliation(s)
- Afrah Alkazemi
- Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115-6195, USA. .,Massachusetts College of Pharmacy and Health Sciences University, 179 Longwood Avenue, Boston, MA, 02215, USA.
| | - Kevin C McLaughlin
- Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115-6195, USA
| | - Michael G Chan
- Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115-6195, USA
| | - Michael J Schontz
- Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115-6195, USA
| | - Kevin E Anger
- Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115-6195, USA
| | - Paul M Szumita
- Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115-6195, USA
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Ballesteros-Peña S, Fernández-Aedo I, Vallejo-De la Hoz G, Tønnesen J, Miguelez C. Identificación de medicamentos intravenosos potencialmente irritantes. ENFERMERÍA INTENSIVA 2021. [DOI: 10.1016/j.enfi.2021.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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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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