Peripheral Catheter to Administer Saline Could Be More Beneficial Than Central Catheters

When it comes to using catheters solely to administer continuous sodium chloride infusions, where these catheters are inserted is particularly important. In fact, recent research suggests that a peripheral catheter may be more beneficial than a central catheter for delivering saline.

These findings come from a team of scientists from the Methodist University Hospital in Memphis, the University of Tennessee Health Sciences Center, the University of North Carolina Hospitals and Clinics, and University of Florida Health in Jacksonville who recently conducted a preliminary study that suggests peripheral locations for catheters administering saline could cut down on catheter-related health complications as well as healthcare costs.

In an interview with Contagion, Heidi Riha, PharmD, a pharmacy resident in the emergency medicine division of the Methodist University hospital and one of the study authors stated, “Central line placement is not benign and may cause many adverse events including development of a catheter-associated bloodstream infection, which can lead to increased morbidity, mortality, and elevated healthcare costs."

Currently, recommendations for infusions of 3% sodium chloride solution usually advocate a central catheter, but this placement can cause catheter-associated bloodstream infections, symptomatic thrombosis, and other complications. In fact, according to the Centers for Disease Control and Prevention (CDC), “central-line associated bloodstream infections (CLABIs) result in thousands of deaths each year and billions of dollars in added costs to the US healthcare system.” These types of infections are also a dominant cause of healthcare-associated infections in pediatric settings.

The study, which is the first of its kind, evaluated 213 neurocritical care patients receiving sodium chloride infusions via peripheral catheters in two large, urban, teaching hospitals—Methodist University Hospital and University of Florida Health—with dedicated neurocritical care teams. The study excluded patients younger than 18 years of age, older than 89 years of age, and women who were pregnant or lactating. Individuals with a history of end-stage renal disease, a syndrome of inappropriate antidiuretic hormone, and diabetes insipidus were also excluded in order to avoid issues with assessing electrolyte abnormalities. The researchers examined a total of 213 patients, most of whom were African American males admitted with intracerebral hemorrhages (37.1%) or acute ischemic stroke (36.2 %). Furthermore, 2.3% had kidney disease, and 7.5% had chronic heart failure. The researchers also reported that 53 patients (24.9%) died during admission, while those surviving had a median duration of hospitalization of 11.3 days with 6.3 days spent in neurocritical care.

In that 213-patient population, there were only 15 infusion-related reactions documented in the study; nine patients suffered phlebitis, and six suffered extravasation. There were no documented incidents of venous thrombosis, and eight of the 15 patients who suffered reactions resumed their infusion at an alternative peripheral site with no further documented reactions. Only five patients had the site of administration changed to a central catheter site because of an infusion-related reaction. Eight of the reactions occurred in catheters with 20-gauge needles and seven in catheters with an 18-gauge needle. The rate of infusion varied across all reactions, but most (10) occurred at rates of 30mL/hour or less.

The team assessed the incidence of electrolyte abnormalities associated with the continuous infusion at a peripheral location and determined that the most common electrolyte disturbance was hyperchloremia (49.3%). In most cases, this disturbance did not require an intervention to treat it. However, 46.9% of the patients did go on to develop hypokalemia, with nearly all (43.6 %) requiring an intervention to treat it. The research team noted that the inability to provide information on the clinical importance of the documented electrolyte abnormalities was a weakness in the study, but said that “further research on the clinical implications of marked electrolyte abnormalities is needed.”

Based on the low occurrence of infusion-related reactions in the patients in the study, the team stated, “Current recommendations suggesting that a central catheter is required for administration of continuous intravenous infusions of three-percent sodium chloride solution should be reevaluated.” They added, “Providers should consider a peripheral site when the sole reason for placement of a central catheter is infusion of a three-percent sodium chloride solution.”

Dr. Riha noted that at her institution, “We have implemented a policy where 3-percent HTS can be given peripherally at up to rates of 75mL/hr,” but added that in the event that an institution infuses at greater rates than this, “They should conduct a retrospective analysis of the associated infusion-related reactions to assess if it is necessary to place a central line for infusion at these higher rates.”