Water, water, everywhere, but please
don't give IV
From the January 23, 2003 issue
The treatment of severe hypernatremia can be challenging,
especially in patients with preexisting conditions that may
seem to limit therapeutic options. Such a situation recently
resulted in an ill-conceived decision to give sterile water
for injection IV to an elderly patient who had been admitted
to an ICU with pneumonia, CHF, respiratory failure, and severe
hypernatremia. 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.
"Free water" refers to water not associated with
organic or inorganic ions. Because hypernatremia usually results
from a deficit of "free water," it's likely that
the physician intended to replace this loss when he wrote
the order. Water can be replaced orally, however, it should
never be given IV without additives to normalize tonicity,
or hemolysis may occur.
Just before writing the order, the physician had contacted
a pharmacist to ask if "large bags of sterile water for
injection" were available. The pharmacist checked the
computer and told the physician that sterile water for injection
(used for compounding parenteral nutrition solutions) was
available. When he received the order, he entered it into
the computer and a label printed for a 2,000 mL bag of the
solution. A pharmacy intern retrieved a bag from the sterile
compounding area, placed the label on the back of the bag,
and dispensed it to ICU.
The 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"
because the pharmacy label was on the opposite side of the
bag. Another nurse noticed the statement later and the infusion
was stopped, but not before 550 mL had infused. The patient
experienced a hemolytic reaction, acute renal failure, and
SAFE PRACTICE RECOMMENDATION: Alert practitioners
to the danger of infusing sterile water without appropriate
additives. 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. While it did
not help prevent the error cited above, use of sterile water
for injection in two-liter (or larger) containers for IV compounding
could alert staff to its intended use. The difference in size
also will reduce the risk of confusion with other one-liter
IV solutions. Finally, be sure to place labels on the front
of IV bags without obscuring important information.
The hospital involved in this error has asked manufacturers
of sterile water for injection to place a warning label on
both sides of the container. ISMP also found that current
labeling on sterile water products is inconsistent among the
various manufacturers. Some containers boldly state: "Pharmacy
bulk package. Not for direct infusion" within a red border,
while others simply state: "For drug diluent use only."
USP also requires a statement that these products are not
suitable for intravascular injection without first being made
approximately isotonic by addition of a suitable solute. However,
this warning blends in with other label text and is not seen
easily (see photo). We are aware of additional cases of direct
injection of sterile water, so we've asked FDA and manufacturers
to place stronger, more easily recognizable warnings on all
large volume parenteral containers of sterile water for injection.