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A nursing instructor agreed to be the "guinea pig" for a student who needed practice giving intradermal skin tests. The instructor suggested that they use 0.1 ml of sodium chloride injection. They found a fresh vial on the nursing unit, and the student flawlessly prepared and administered the intradermal injection. The instructor, though, felt an unusual burning at the injection site. She and the student rechecked the vial, but everything seemed to be in order.
Two days later, the instructor noticed sloughing and ulceration around the site. She found another vial with the same label and took it to the hospital pharmacist. He examined it and identified the solution as concentrated sodium chloride injection, 146 mg/ml (14.6%, 2.5 mEq/ml). She should have used 0.9% sodium chloride injection (normal saline).
Concentrated sodium chloride injection shouldn't be kept on a nursing unit. (The exception is a hemodialysis unit, where it's used to elevate blood volume and reverse hyponatremia.) Vials of the concentrated solution are used to prepare I.V. admixtures in the pharmacy.
The instructor and her student learned an important lesson about reading labels carefully and completely before giving any medication. If they had, they would have seen the warning label that's found on all vials of concentrated sodium chloride: "Must be diluted prior to I. V. administration."
Pharmacists should be careful to place stocks of concentrated sodium chloride injection in special storage areas. And they should consider adding warning labels over the caps of each vial.