Safety of Peripheral Line Administration of 3% Hypertonic Saline and Mannitol in the Emergency Department

Background: Hypertonic saline (HTS) and mannitol are frequently utilized in the emergency department (ED) to manage elevations in intracranial pressure (ICP). Objective: The objective of this study was to compare the incidence of extravasation injury when HTS or mannitol was administered via peripheral i.v. line (PIV). Methods: This retrospective cohort study evaluated adult and pediatric patients given either 3% HTS or mannitol via PIV while in the ED. The primary outcome was extravasation incidence. Results: One hundred and ninety-two patients were included, of which 85 (44%) received HTS and 107 (56%) received mannitol. Patients who received HTS were younger (27.5 ± 24.3 years vs. 53.9 ± 22.3 years; p < 0.001); 55.3% of patients given HTS received it for traumatic brain injury (TBI) versus 38.3% of patients given mannitol (p = 0.021); and 44.9% of patients given mannitol received it for intracerebral hemorrhage versus 21.2% of patients given HTS (p = 0.001). There was no incidence of extravasation in either group. Patients who received HTS had lower ICP measurement 24 h post admission (2.107 ± 5.5 mm Hg vs. 4.236 ± 8.1 mm Hg; p = 0.047) and higher Glasgow Coma Scale (GCS) score upon discharge (GCS 14; interquartile range [IQR] 3–15 vs. GCS 3; IQR 3–14.2; p = 0.004). In-hospital mortality was higher in the mannitol group (54.7% vs. 32.9%; p = 0.003). Duration of mechanical ventilation was shorter in those patients who received HTS (1 day; IQR 0–56 days vs. 2 days; IQR 0–56 days; p = 0.023). Conclusions: There were no incidences of extravasation among patients given 3% HTS or mannitol. Clinicians should reconsider recommendations to restrict HTS or mannitol to central lines.