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Please Pass the Salt: Rapid Access to Hypertonic Saline and Considerations During Shortage

By Currents Editor posted 29 days ago

  

Lindsey Coppiano, PharmD, BCCCP, Neurocritical Care Pharmacist Augusta University Medical Center; Augusta, Georgia

Jessica Ringler, PharmD, BCCCP, Neurocritical Care Pharmacist
Augusta University Medical Center; Augusta, Georgia

Hypertonic solutions are high risk yet life-saving medications which can make the difference between a good or poor outcome during a neurologic emergency. Unfortunately, quick and reliable access to these medications can be challenging. One of the challenges faced is storage, as safety concerns limit where these medications can be stocked. In most instances, concentrated electrolyte solutions are recommended to be stored and dispensed only from the pharmacy. Recent guidelines from the Institute for Safe Medication Practices (ISMP) suggest that despite the high risk, institutions may consider the addition of 3% sodium chloride infusions to automated dispensing cabinets (ADCs) in pre-specified critical care or emergency units to facilitate rapid access. Many institutions have implemented this practice. However, the ISMP continues to recommend against the addition of 23.4% sodium chloride to unit-based ADCs in favor of patient-specific, hand-delivered doses from the pharmacy.1,2 Despite this recommendation, some institutions have moved towards making 23.4% sodium chloride available in neurocritical care units (NCCU) given the urgency of treatment for cerebral herniation syndromes and the potential for therapy delays to exacerbate injury. With the safety concerns highlighted by ISMP, institutions have been challenged with developing guidelines for safely prescribing, dispensing, and administering 23.4% sodium chloride in the NCCU. 

At our institution, 3% sodium chloride is available in the NCCU, trauma intensive care unit, and emergency department ADCs. At the time of initial implementation, 30 mL vials of 23.4% sodium chloride were added only to the NCCU and trauma intensive care unit ADCs. Multiple safety measures were protocolized to ensure safe utilization of hypertonic saline dispensed via ADCs. Both concentrations of sodium chloride are stored in locked, lidded compartments within the ADC.  Access via override is not permitted for either concentration, meaning that an order must be placed and verified by the pharmacist before access within the ADC is granted. High alert labeling is affixed to 3% sodium chloride to prevent inadvertent administration or confusion with a non-concentrated product (Figure 1). An additional safeguard with the 23.4% sodium chloride concentration includes cautionary tamper tape on each vial (Figure 2). Prescribing of 23.4% sodium chloride is restricted to indication-specific order sets and two-nurse verification is required within the electronic health record at the time of administration. An institutional comparison of time to 23.4% sodium chloride administration in the 18 months following these process changes found a reduction in time to treatment when compared to historical data. Following the process change, 44.1% (15/34) of all 23.4% sodium chloride doses were administered within 15 minutes from the time ordered, compared to only 11.8% of doses (18/152) prior to this process change.  


Figure 1: High-alert labeling on 3% sodium chloride infusions 


Figure 2: Cautionary tamper tape on 23.4% sodium chloride vials 

The availability of hypertonic sodium chloride has also been a challenge, as 23.4% sodium chloride and other hypertonic solutions have been plagued by drug shortages. The increasing prevalence of drug shortages due to supply chain bottlenecks, increase in demand, and manufacturing delays complicates the delivery of optimal patient care.3 The frequent shortages of these concentrated solutions has necessitated the use of alternative agents for cerebral herniation syndromes. Hospital systems must balance finding alternative agents with quick and safe implementation of process changes to make them readily available. A comparison of alternative concentrated sodium solutions agents is provided in Table 1. Principles to consider for safely implementing therapeutic interchanges include minimizing the number of available concentrations (e.g., centralizing one concentration and completely converting to an alternative), utilizing high alert labeling, enabling automated alerts within the electronic health record and ADC systems, and strongly emphasizing provider and nursing education.  

In 2020, our institution implemented a tiered approach to mitigating 23.4% sodium chloride shortages. When clinically appropriate, prescribers were encouraged to utilize mannitol as an alternative agent to conserve supply. The 23.4% sodium chloride vials remained in the NCCU and trauma intensive care unit automated dispensing cabinets at lower than normal par levels to closely monitor supply. When the 30 mL vials of 23.4% sodium chloride reached a critical level hospital wide, the 100 mL vials were utilized to compound patient specific doses in the pharmacy. Prescribers were educated regarding this change in process to ensure clear communication of need for urgent doses. Prescribers were also encouraged to utilize equipotent doses of 3% sodium chloride or other concentrated sodium products when clinically appropriate. Providers were typically directed toward 3% sodium chloride as it is stocked and readily available within the NCCU. A pre-existing order set for 3% sodium chloride bolus dosing greatly assisted in implementing this process change. 

 

Table 1. Electrolyte composition of commercially available hypertonic saline solutions

Sodium (mEq/L)

Chloride (mEq/L)

Bicarbonate (mEq/L)

Acetate

(mmol/L)

Osmolarity (mOsmol/L)

Equipotent Dosing of 120 mEq Sodium (mL)

3% Sodium Chloride

513

513

0

0

1,027

230

5% Sodium Chloride

855

855

0

0

1,710

140

23.4% Sodium Chloride 

4004

4004

0

0

8,008

30

8.4% Sodium Bicarbonate 

1000

0

1000

0

2,000

120

16.4% Sodium Acetate

2002

0

0

2002

4,000

60

 

Conclusion 

One of the mainstays of neurocritical care management is the use of hypertonic solutions to treat elevated intracranial pressures; however, safety concerns and drug shortages continue to complicate the safe and timely delivery of therapy. Use of high alert labeling, locked and lidded compartments, and integrating independent double checks into the medication-use process can allow hospitals to balance rapid administration with the risks of inappropriate administration. Though hypertonic sodium chloride shortages pose a challenge to health systems, the use of alternative agents, various manufacturers, and different product sizes help mitigate the burden felt by those on the frontline. When standard therapies are unavailable, clinical informatics and the ADC, combined with hospital-wide education, can be utilized as a tool to ensure safe and efficient medication delivery by providing alternative agents. This allows NCCUs to safely expedite the administration of concentrated sodium chloride solutions even in times of shortage.  

References

  1. Institute of Safe Medication Practices (ISMP). 2021. Prevent Errors During Emergency Use of Hypertonic Sodium Chloride Solutions. [online] Available at: <https://www.ismp.org/resources/prevent-errors-during-emergency-use-hypertonic-sodium-chloride-solutions.\
  2. Erwin BL, Denaburg MA, Cortopassi JB, Curtis GM, Taylor JC, May CC. Improving the medication-use process for 23.4% sodium chloride. Am J Health Syst Pharm. 2019 Jan 1;76(1):50-56. doi: 10.1093/ajhp/zxy007. PMID: 31381099.
  3. Clark SL, Levasseur-Franklin K, Pajoumand M, Barra M, Armahizer M, Patel DV, Wyatt Chester K, Tully AP. Collaborative Management Strategies for Drug Shortages in Neurocritical Care. Neurocrit Care. 2020 Feb;32(1):226-237. doi: 10.1007/s12028-019-00730-7. PMID: 31077080.

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