Bolus administration of HTS has become favored due to its rapid effect and more transient increase in serum sodium levels compared to mannitol. Traditionally a central venous catheter has been the preferred route of administration of 3% HTS due to its high osmolarity (1026mOsm/L). CVC placement is not a benign procedure and time to placement can delay administration of life-saving medications.
Paper: Khasiyev, Farid et al. Safety and Effect on Intracranial Pressure of 3% Hypertonic Saline Bolus Via Peripheral Intravenous Catheter for Neurologic Emergencies. Neurocrit Care. Feb 2024. PMID: 38379103
Clinical Question: What is the safety and effect on ICP of administering rapid boluses of hypertonic 3% saline via peripheral intravenous catheters in patients with neurological emergencies?
What They Did:
- Retrospective, single-center, descriptive cohort study
- Patients admitted to Saint Mary Health Saint Louis University Hospital between March 2019 to Sept 2022
- Adult patients receiving at least one 3% HTS bolus via a 18 or 20g PIV at a rate of 999mL/hr for neurological emergencies
Outcomes:
- Complications related to 3% HTS bolus
- 3% HTS bolus effect on ICP
Inclusion:
- Admitted between March 2019 to Sept 2022
- Age ≥18 years
- Received at least one 3% HTS bolus via a PIV catheter at a rate of 999mL/hr for neurological emergencies
Exclusion:
- Presence of a CVC during the period of 3% HTS administration
- Continuous infusion of 3% HTS at a rate other than 999mL/hr
- Administration of 3% HTS for indications other than neurological emergencies
Results:
- 216 3% HTS peripheral boluses administered in 124 patients
- ICH: 37.9%
- AIS: 29.0%
- TBI: 27.4%
- EVD: 37.1%
- Decompressive Surgery: 21.8%
- Median quantity fo each bolus was 250mL
- 9% of patients also received mannitol in addition to 3% HTS
- Complications
- 8 administrations (3.7%)
- Pain at the injection site (4 administrations – 1.9%)
- Thrombophlebitis (3 administrations – 1.4%)
- Vein thrombosis (2 administrations – 0.9%)
- Extravasation (1 administration – 0.5%)
- Median ICP reduction: 6mmHg
- Median ICP Before 3% HTS: 18.4mmHg
- Median ICP After 3% HTS: 13.8mmHg
- Median ICP reduction in Patients Not Receiving Mannitol
- Median ICP Before 3% HTS: 17.5mmHg
- Median ICP After 3% HTS: 11.5mmHg
- No severe complications (Hypotension)
- 8 administrations (3.7%)
Strengths:
- Asks a clinically important question
- Complication rate of this study aligns with the complication risk reported in the existing literature
- Study evaluated safety and effect of 3% HTS via peripheral IV in neurologic emergencies
Limitations:
- Single-center, retrospective, noncomparative study which could limit generalizability to other institutions
- Study relied heavily on documentation of adverse events in EMR (complications may have been underreported)
- No comparison arm (i.e. could 3% HTS via a CVC lower ICP faster or more effectively?)
- Other medications were given through IVs that 3% HTS was given which could confound the complication analysis
- Lacked ICP data for every single patient and therefore many patients were excluded for this outcome
- No discussion of chart review methodology (No review of best practices for data extraction including abstractor training, standardized forms for abstraction, blinding to hypothesis of abstractors, or inter-rater reliability)
- Too small a study to comment on safety as events will be uncommon and without comparison (i.e. safe compared to what?)
Discussion:
- Most of the literature reporting patients receiving 3% HTS via PIV catheters are typically at lower infusion rates (<100mL/hr) with prolonged infusion time (>6hr) and infusion related complication rates ranging from 2.9% to 10.7% [2]
- IF YOU ARE GOING TO GIVE 3% HTS, GIVE IT AS A BOLUS NOT AN INFUSION:
- Daley M et al [3]:
- Single center, retrospective, cohort study that compared the efficacy and safety of 3% HTS bolus vs continuous infusion to achieve goal sodium amongst patients with TBI
- 90 patients were included
- Patients receiving bolus 3% HTS achieved goal sodium quicker than patients who received continuous infusion (2.55hrs vs 14.67hrs)
- Patients in the bolus 3% HTS received less volume of 3% HTS at 72hrs compared to continuous infusion (750mL vs 2493mL)
- Percentage of sodium levels at goal at 72hours was not statistically significant but there was a numeric trend favoring bolus 3% HTS (83.3% vs 56%)
- Additionally, there was no difference in mortality at 72 hours (20% vs 24.4%)
Author Conclusion: “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-associate complications and expediting life-saving interventions for patients with neurological emergencies, especially in the field and emergency department settings.”
Clinical Take Home Point: 3% HTS boluses via peripheral IVs has a low risk of complications and successfully lowers ICP in patients with neurologic emergencies.
References:
- Khasiyev, Farid et al. Safety and Effect on Intracranial Pressure of 3% Hypertonic Saline Bolus Via Peripheral Intravenous Catheter for Neurologic Emergencies. Neurocrit Care. Feb 2024. PMID: 38379103
- Madieh J et al. The Safety of Intravenous Peripheral Administration of 3% Hypertonic Saline and Mannitol in the Emergency Department. J Emerg Med 2019. PMID: 30745195
- Daley M et al. Getting Salty: Infusion vs Bolus Dosing of Hypertonic Saline in Patients With Traumatic Brain Injury. Crit Care Med Jan 2024. [Link is HERE]
Post Peer Reviewed By: Anand Swaminathan, MD (Twitter/X: @EMSwami)
