themadmedic
03-29-03, 19:10
ISMP Alert: Danger of infusing plain sterile water IV
The treatment of severe hypernatremia can be challenging, especially in patients with preexisting conditions that may seem to limit therapeutic options. Such situations occasionally result in an ill-conceived decision to give sterile water for injection IV. In one recent case, an elderly patient who had been admitted to an ICU with pneumonia, CHF, respiratory failure, and severe hypernatremia received plain sterile water. The physician did not want the patient to receive any further infusions containing sodium. But the patient also was severely hyperglycemic. The physician's concern with giving sodium or dextrose to a patient with CHF and a high blood sugar led to an order to change the patient's peripheral IV to "free water" at 100 mL/hr.
Sterile water for injection was obtained from the pharmacy and a nurse began the infusion without question because she was aware of the patient's hypernatremia and overheard the physician ask the pharmacist if bags of sterile water were available. She failed to see a red statement on the bag stating "Pharmacy Bulk Package, Not For Direct Infusion." The patient eventually experienced a hemolytic reaction, acute renal failure, and died.
Clinicians should have a clear understanding of the physiology behind infusing hypotonic, isotonic and hypertonic solutions in context of the patient's blood electrolyte levels. They also should recognize that treatment of severe hypernatremia generally consists of infusions that contain sodium to reduce blood levels slowly. Too rapid correction of hypernatremia may lead to cerebral edema, seizures and possibly death. Develop protocols to guide safe and effective treatment of hypernatremia. If there are concerns about using dextrose solutions, elevated blood sugars can be treated with insulin. If there are concerns about fluid volume, patients can be given diuretics. If an order for sterile water is received, it should trigger an immediate call to the physician and referral to the facility's peer review process.
In the pharmacy, never allow IV compounding products to leave the sterile compounding area. Segregate these solutions and store them with warnings that they should never leave the pharmacy. The pharmacy computer should flash an alert, "Use Only as a Diluent," when these products are entered, and sterile water for injection should never appear as a choice in prescriber order entry systems.
ISMP is working with FDA and IV solution manufacturers to improve label warnings on sterile water products.
This alert has been provided by the ISMP. For additional information about medication errors and their prevention, please visit www.ismp.org. Please report recognized medication errors, near misses and hazardous conditions in confidence to the USP-ISMP alert service.
The treatment of severe hypernatremia can be challenging, especially in patients with preexisting conditions that may seem to limit therapeutic options. Such situations occasionally result in an ill-conceived decision to give sterile water for injection IV. In one recent case, an elderly patient who had been admitted to an ICU with pneumonia, CHF, respiratory failure, and severe hypernatremia received plain sterile water. The physician did not want the patient to receive any further infusions containing sodium. But the patient also was severely hyperglycemic. The physician's concern with giving sodium or dextrose to a patient with CHF and a high blood sugar led to an order to change the patient's peripheral IV to "free water" at 100 mL/hr.
Sterile water for injection was obtained from the pharmacy and a nurse began the infusion without question because she was aware of the patient's hypernatremia and overheard the physician ask the pharmacist if bags of sterile water were available. She failed to see a red statement on the bag stating "Pharmacy Bulk Package, Not For Direct Infusion." The patient eventually experienced a hemolytic reaction, acute renal failure, and died.
Clinicians should have a clear understanding of the physiology behind infusing hypotonic, isotonic and hypertonic solutions in context of the patient's blood electrolyte levels. They also should recognize that treatment of severe hypernatremia generally consists of infusions that contain sodium to reduce blood levels slowly. Too rapid correction of hypernatremia may lead to cerebral edema, seizures and possibly death. Develop protocols to guide safe and effective treatment of hypernatremia. If there are concerns about using dextrose solutions, elevated blood sugars can be treated with insulin. If there are concerns about fluid volume, patients can be given diuretics. If an order for sterile water is received, it should trigger an immediate call to the physician and referral to the facility's peer review process.
In the pharmacy, never allow IV compounding products to leave the sterile compounding area. Segregate these solutions and store them with warnings that they should never leave the pharmacy. The pharmacy computer should flash an alert, "Use Only as a Diluent," when these products are entered, and sterile water for injection should never appear as a choice in prescriber order entry systems.
ISMP is working with FDA and IV solution manufacturers to improve label warnings on sterile water products.
This alert has been provided by the ISMP. For additional information about medication errors and their prevention, please visit www.ismp.org. Please report recognized medication errors, near misses and hazardous conditions in confidence to the USP-ISMP alert service.