Understanding 3% NaCl Usage and Administration Guidelines in Children’s Hospitals

The use of 3% sodium chloride (NaCl) infusion is a well-documented and efficacious treatment modality for correcting hyponatremia. However, particularly in pediatric patients, its use via infusion through a peripheral line and its use outside the setting of an intensive care unit are often prohibited through hospital protocol or treating physician preferences. 

To better understand the methodologies, practices, and protocols around the use of 3% NaCl in children’s hospitals, a team of researchers led by senior author Michael L. Moritz, MD, clinical director of the Division of Pediatric Nephrology at UPMC Children’s Hospital of Pittsburgh conducted a survey of pediatric pharmacies and their practices around 3% NaCl in a cohort of children’s hospitals that are members of the Children’s Hospital Association network.

The study was published in January in the journal Children. Joining Dr. Moritz on the study was Juan C. Ayus, MD, from the University of California Irvine, and Siddharth A. Shah, MD, a former fellow in the Division of Pediatric Nephrology at UPMC Children’s, and now at Norton Children’s Hospital and the University of Louisville.

"The use of 3% NaCl for treating hyponatremia in pediatric patients often faces restrictions and prohibitions at the system or pharmacy level. Some of these restrictions, in our opinion, are not based on the best evidence currently available. In most instances and settings, 3% NaCl can be administered safely through a peripheral line and in settings outside the ICU," says Dr. Moritz. "With training and diligent patient monitoring, this highly effective therapeutic approach for correcting hyponatremia can and should benefit more patients.”

Study Highlights and Clinical Significance

The study conducted by Dr. Moritz et al. found that 93% of institutions who responded to the survey had restrictions in place for the use of 3% NaCl. More than half of hospitals either restricted or prohibited infusion of 3% NaCl through a peripheral vein or its use outside of the ICU.

"There is a persistent yet erroneous belief that infusion reactions are a common occurrence or likelihood if 3% sodium chloride is administered via a peripheral vein. While reactions have been noted for other types of electrolyte infusions when given through a peripheral vein, this is simply not supported by the evidence,” says Dr. Moritz.

While it is certainly possible that an overcorrection could lead to osmotic demyelination syndrome, there are approaches to using 3% NaCl to avoid this potential complication.

"Our prior work on the subject has shown that 3% NaCl, given in bolus form intermittently, can be easily controlled and greater reduce or eliminate the possibility of a serum overcorrection. This approach also can easily be adapted or used outside the ICU with the proper oversight and training,” says Dr. Moritz.

Further findings from the survey show a majority of institutions restrict the use of 3% NaCl in other ways. More than two-thirds of responding sites (68%) have limitations on infusion rates, and more than half of sites also limit the volume of infusions.

"I think it is clear from our research that there are likely widespread restrictive practices around 3% NaCl in children's hospitals for pediatric patients, and we suspect that many of the restrictions are based on outdated information. In practical terms, a generally safe and effective approach to combatting hyponatremia is going unused in many instances where it could be beneficial and simplify treatment for patients,” says Dr. Moritz. “We need to have a more evidence-based approach to 3% NaCl in our pediatric settings.”

To learn more about the survey and its findings and review some of the more current evidence for less restrictive approaches to 3% NaCL, please read the full paper and supporting references at the link below.

Reference

Shah SA, Ayus JC, Moritz ML. A Survey of Hospital Pharmacy Guidelines for the Administration of 3% Sodium Chloride in Children. Children. 2022; 9(1): 57.