Chemistry

PS: The 4 sources are already selected by me. The are attached with my rough draft. There are 3 articles and a website (Lexicomp).

page limit is 3 pages, including references***

Here is the rubric used for grading:

For citation (AMA style):

Here is my PICO: Use this in the literature summary (25% of the grade)

Step Item Response
Step 1: Original Question Can 3% sodium chloride (3% hypertonic saline) be safely administered through a peripheral IV line?
Step 2: Population Patient with elevated intracranial pressure. Patient with severe hyponatremia.
Intervention/Exposure A typical initial rate of infusion of 3% sodium chloride is approximately 15 to 80

mL/hr. (1mL/kg/hour) for 2 to 3 hours.

Comparator (if applicable) 0.9%NS, 0.45% NS administration through peripheral IV Line, 5% dextrose in normal saline, Lactated Ringer’s solution. Central line administration for hypertonic saline.
Outcome Adverse reactions of hypertonic saline through Peripheral line compared to Central line.
Step 3: Well-developed clinical question What are the risks when hypertonic saline (3% saline) is administered through a peripheral IV Line? (Feel free to change to a better

Clinical question if you like)

HERE IS MY DRAFT that I submitted for review

· Notice that I did not integrate my Pico in my Intro/background

Question:

Can 3% sodium chloride (3% hypertonic saline) be safely administered through a peripheral IV line?

Saline solutions are mixtures of Nacl and water. They are mainly classified into hypotonic 0.18-0.3%, isotonic or normal saline 0.9% and hypertonic saline 3% or more. Saline solutions are widely used in medicine from wound cleaning, rehydration to cosmetic. According to Lexicomp, 3% sodium chloride has an osmolality of 1025 mOsm/L which is higher than the 900 mOsm/L recommended for parenteral nutrition4. 3% Hypertonic saline is mostly used in clinical settings. They are used in intracranial hypertension management and hyponatremia2. Traditionally, Hypertonic saline are administered via central line due to risk of damages to small veins if given via peripheral central line. However, it is common to see 3% sodium chloride used in clinical settings due to central line association with risk of complications such as infections, thrombosis, pneumothorax and delay of therapy for a patient in need of a time-sensitive therapy2,3. Therefore, is it safe for patients to get 3% sodium chloride through a peripheral IV line?

In a retrospective review study conducted on 66 patients who received 3% sodium chloride via Peripheral Venous Catheters (PVC) in Intensive care unit, Infusion-related adverse events (IRAEs) were collected from patients for analysis1. Complications such as Hyponatremia (29%) and cerebral edema (29%) were common. 6.1 % (4 of 66 patients) of patients experienced an IRAEs were aged between 38-82 years old and resulted with no permanent tissue damage1. 50% of patients who experienced IRAEs had their infusion restarted peripherally at another location1. Minimal damage was shown when the location was a large vein (80%) and 20-22 gauge catheters were used1. The onset time of IRAEs ranged from 2 to 94 hours (the median was 19 hours) after the start of the 3% Nacl infusion at a rate of 30 mL/h ( median 32ml/h, IR 30-35). Serum sodium at the beginning was 124 1.4 mEq/L compared to 131 1.3 mEq/L ( P< .0001) at the end of the infusion which shows a rise in serum sodium1. Central line infusion is an invasive procedure that requires skills to perform but allows instant distribution and minimal vascular wall damages. PVC provides patients with acute symptomatic hyponatremia and elevated intracranial pressure rapid access and prompt distribution of the 3% Nacl1.This article shows that using PVC for hypertonic saline is not always dangerous. The risks of tissue damage and invasiveness of central line can be good arguments for the use of PVC.

In a retrospective cohort study that evaluated adult and pediatric patients who were given 3% NaCl or mannitol via Peripheral IV line in the emergency department to manage intracranial pressure elevations with a primary outcome of extravasation incidence (leakage around the site of injection)3. 192 patients were included in the study. 85 (44%) received 3% Nacl and 107 (56%) received mannitol with no extravasation in either group3. In hospital mortality was higher in the mannitol group (54.7% vs. 32.9%; p = 0.003)3. In conclusion, since neither group experienced an extravasation, it is safe to use 3% sodium chloride peripherally in patients with elevated intracranial pressure at the ED.

In another article, a prospective study of patients admitted to Parkland Hospital Surgical ICU and who were treated with 3% NaCl via the peripheral IV catheter was collected from October 2013 to May 2014. 28 patients and 34 peripheral lines were monitored2. Infusion rates ranged from 30 to 50 ml/L for all subjects. The duration of the infusion was 1 to 124 hours (mean 36 hours)2. 2 patients presented complications which included infiltration, with an incidence of 6%, and 1 patient with thrombophlebitis, with an incidence of 3% 2. The complications rate was 10.7% (n=3) among the patients and 11.7% (n=4) on assessed peripheral lines for 3 patients. According to the article, thrombophlebitis is the most common complications of Peripheral IV line2. Duration of catheterization is an important indicator for thrombophlebitis with most patients at risk after 5 days of IV therapy2. The study concluded that 3% hypertonic saline peripheral administration presented low risk and non-life threatening complications and that any concern and risk are therefore unfounded2.

In conclusion, according to current literature using hypertonic saline (3% NaCl) presents a low risk when administered via a peripheral IV line. Even though hypertonic saline is traditionally administered through a central line because of the osmolarity of 3% sodium chloride exceeds 900 mOsm/L and puts patient at risk of thrombophlebitis, tissue damage, and extravasation reactions, peripheral administration is preferred in emergencies and time sensitive therapies1,2,3,4. Peripheral administration requires less skill and is less invasive than the central line. However, all the studies present limitations that could be reduced by conducting a randomized control trial or a prospective cohort study. Without a control group, it is hard to definitely say that 3% sodium chloride is safer when administered via a peripheral IV line versus central line.

I appreciate this drug information question and will follow up within 72 hours with any further questions.

Please read those articles and make they are correctly referenced.

References

1. Dillon, R. C., Merchan, C., Altshuler, D., & Papadopoulos, J. (2018). Incidence of Adverse Events During Peripheral Administration of Sodium Chloride 3%. Journal of Intensive Care Medicine, 33(1), 48–53.

2. Perez, C., & Figueroa, S. (n.d.). Complication Rates of 3% Hypertonic Saline Infusion Through Peripheral Intravenous Access. Journal of Neuroscience Nursing, 49(3)(0888-0395), 191–195. doi: 10.1097/JNN.0000000000000286

3. Mesghali, E., Fitter, S., Bahjri, K., & Moussavi, K. (n.d.). Safety of Peripheral Line Administration of 3% Hypertonic Saline and Mannitol in the Emergency Department. The Journal of Emergency Medicine, 56(4), 431–436.

4. Lexicomp® AHFS Drug Information®. © Copyright, 1959-2020, Selected Revisions January 1, 2009, American Society of Health-System Pharmacists®, 4500 East-West Highway, Suite 900, Bethesda, Maryland 20814.

Example of a well written Drug Information question response:

· As long as my paper looks like this (format and answers all the rubric question I’m happy)

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