View as “PDF version”
We
once described the unfortunate case of a 12-year-old juvenile diabetic who was
inadvertently given 500 ml of hypertonic saline intravenously (Young 1979). He developed hypernatremia,
hyperosmolality, metabolic acidosis, and hyperglycemia. Seizures and stupor
ensued, followed by coma and death. Computerized cranial tomography revealed
numerous small subcortical hemorrhages that were verified postmortem.
And
we have a friend who developed osmotic demyelination syndrome (formerly known
as central pontine myelinolysis) after overaggressive correction of
hyponatremia using hypertonic saline. The need for rapid correction of
hyponatremia (and the speed of such correction) needs to be balanced against
the risk of overcorrection leading to the osmotic demyelination syndrome.
ISMP
recently published an article on preventing errors during emergency use of
hypertonic sodium chloride solutions (ISMP 2021). Though the major focus of the ISMP article
was on very high concentrations of sodium chloride (eg.
23.4%) as used for emergency treatment of severe cerebral edema or other causes
of increased intracranial pressure where herniation is imminent, their
recommendations apply equally to use of any hypertonic sodium chloride
solution.
ISMP found errors in multiple aspects of managing
hypertonic sodium chloride solutions (storage, preparation, ordering,
administration, monitoring). In the pharmacy there were numerous errors in
which the wrong concentration of sodium chloride was used to manually compound
a solution, often associated with look-alike labeling and packaging of the
products. Sometimes, 500 ml. bags of 3% sodium chloride were stocked in various
areas instead of 0.9% sodium chloride. Retrieval of the wrong concentration
from ADC’s (automated dispensing cabinets) occasionally occurred. And intravenous
administration errors also occurred (eg. infusing 3% sodium chloride solution longer than prescribed or
administering the solution at 100 mL/hour instead of 25 mL/hour). There were
also programming errors in smart pump infusions.
We
refer you to the current ISMP article (ISMP 2021) itself for their full list of recommended risk-reduction
strategies, but here are some of the highlights:
We are concerned about that last recommendation regarding
monitoring. While that may be appropriate when using hypertonic sodium chloride
to reduce intracranial pressure, monitoring at 6-hour intervals if you are
using hypertonic sodium chloride to correct for severe symptomatic hyponatremia
is inadequate. In such cases the rate of sodium correction in 24 hours with
this regimen should not exceed 6 to 8 mEq/L in 24 hours or 12 to 14 mEq/L in 48
hours (based on case studies showing that there were no cases of central
pontine myelinolysis if correction rates were less than 10 mEq/L
over 24 hours). A 4- to 6-mmol/L increase in serum [Na+] is usually sufficient
to reverse the most serious manifestations of acute hyponatremia (Verbalis 2013).
So, in treating a patient with neurological symptoms (seizures, coma, etc.) from
acute hyponatremia, a bolus of 3% sodium chloride is often used and the serum
sodium should be checked in 20 minutes. It may be repeated if neurological
symptoms have not improved, but the serum sodium must again be checked to
ensure there is not overcorrection. A recent large series of treatment of
symptomatic hyponatremia with hypertonic sodium chloride (Chifu 2021)
noted that overcorrection was more likely when hypertonic sodium chloride was
used and in severely symptomatic patients. Though there are no firm guidelines
on the frequency at which serum sodium should be monitored, one recommendation
is that the best way to avoid overly rapid correction is to check serum sodium
every two hours and monitor urine output closely (Madeira
2014).
ISMP’s 2019 Guidelines for the Safe Use of Automated
Dispensing Cabinets (ISMP
2019) recommended avoiding
stocking vials/ampules of concentrated electrolytes, including sodium chloride
in concentrations greater than 0.9%, in ADC’s. ISMP recommended that vials of
23.4% sodium chloride should not be stocked in ADCs, suggesting that the
pharmacy should prepare, label with appropriate warnings, and hand-deliver any
IV push doses of 23.4% sodium chloride used in critical care or
emergency/urgent care units. But ISMP, in the current article (ISMP
2021), recognizes that the
23.4% sodium chloride may be needed so expediently that any delay waiting for
the pharmacy to manually prepare a dose would be dangerous.
References:
Young
RSK, Truax BT. Hypernatremic Hemorrhagic
Encephalopathy. Ann Neurol 1979; 5: 588-591
https://onlinelibrary.wiley.com/doi/abs/10.1002/ana.410050618?sid=nlm%3Apubmed
ISMP
(Institute for Safe Medication Practices). Prevent Errors During Emergency Use
of Hypertonic Sodium Chloride Solutions. ISMP Medication Safety Alert! Acute
Care Edition 2021; 26(22): November 4, 2021
Verbalis JG, Goldsmith SR, Greenberg A, et al. Diagnosis,
evaluation, and treatment of hyponatremia: expert panel recommendations. Am J
Med 2013; 126(10 Suppl 1) :S1-42
https://www.amjmed.com/article/S0002-9343(13)00605-0/fulltext
Chifu I, Gerstl A, Lengenfelder B, et al. Treatment of symptomatic
hyponatremia with hypertonic saline: a real-life observational study. Eur J
Endocrinol 2021;1 84(5): 647-655
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8052513/
Madeira
C, Chang D. How Should Hyponatremia Be Evaluated and Managed? The Hospitalist
2014; 2014(8)
ISMP
(Institute for Safe Medication Practices). Guidelines for the Safe Use of
Automated Dispensing Cabinets. ISMP 2019; February 7, 2019
https://www.ismp.org/resources/guidelines-safe-use-automated-dispensing-cabinets
Print
“PDF
version”
http://www.patientsafetysolutions.com/