Normal intracranial pressure (ICP) and cerebral perfusion pressure (CPP) have been identified as favorable prognostic factors in the outcome of patients with traumatic brain injuries (TBIs). Osmotic diuretics and hypertonic saline (HTS) are commonly used to treat elevated ICP in patients with TBI; however, sustained effects of repeated high-concentration HTS boluses for severely refractory ICP elevation have not been studied. The authors' goal in this study was to determine whether repeated 14.6% HTS boluses were efficacious in treating severely refractory intracranial hypertension in patients with TBI.
In a prospective cohort study in a neurocritical care unit, adult TBI patients with sustained ICP > 30 mm Hg for more than 30 minutes after exhaustive medical and/or surgical therapy received repeated 15-minute boluses of 14.6% HTS over 12 hours through central venous access.
Response to treatment was evaluated in 11 patients. Within 5 minutes of bolus administration, mean ICP decreased from 40 to 33 mm Hg (30% reduction, p < 0.05). Intracranial pressure–lowering effects were sustained for 12 hours (41% reduction, p < 0.05) with multiple boluses (mean number of boluses 7 ± 5.5). The mean CPP increased 22% and 32% from baseline at 15 and 30 minutes, respectively (p < 0.05). The mean serum sodium level (SNa) at baseline was 155 ± 7.1 mEq/L, and after multiple boluses of 14.6% HTS, SNa at 12 hours was 154 ± 7.1 mEq/L. The mean heart rate, systolic blood pressure, blood urea nitrogen, and creatinine demonstrated no significant change throughout the study.
The subset of TBI patients with intracranial hypertension that is completely refractory to all other medical therapies can be treated effectively and safely with repeated boluses of 14.6% HTS rather than a one-time dose.
Address correspondence to: Robert E. Hoesch, M.D., Ph.D., Division of Neurocritical Care, Department of Neurology, University of Utah, 175 N. Medical Drive East, Salt Lake City, Utah 84132. email: email@example.com.
Please include this information when citing this paper: published online May 24, 2013; DOI: 10.3171/2013.4.JNS121541.
BattisonCAndrewsPJGrahamCPettyT: Randomized, controlled trial on the effect of a 20% mannitol solution and a 7.5% saline/6% dextran solution on increased intracranial pressure after brain injury. Crit Care Med33:196–2022005
BrattonSLChestnutRMGhajarJMcConnell HammondFFHarrisOAHartlR: Guidelines for the management of severe traumatic brain injury. II. Hyperosmolar therapy. J Neurotrauma24:Suppl 1S14–S202007. (Erratum in J Neurotrauma 25:276–278 2008)
CooperDJMylesPSMcDermottFTMurrayLJLaidlawJCooperG: Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury: a randomized controlled trial. JAMA291:1350–13572004
FarahvarAGerberLMChiuYLHärtlRFroelichMCarneyN: Response to intracranial hypertension treatment as a predictor of death in patients with severe traumatic brain injury. Clinical article. J Neurosurg114:1471–14782011. (Erratum in J Neurosurg 115:191 2011)
HarutjunyanLHolzCRiegerAMenzelMGrondSSoukupJ: Efficiency of 7.2% hypertonic saline hydroxyethyl starch 200/0.5 versus mannitol 15% in the treatment of increased intracranial pressure in neurosurgical patients—a randomized clinical trial [ISRCTN62699180]. Crit Care9:R530–R5402005
HornPMünchEVajkoczyPHerrmannPQuintelMSchillingL: Hypertonic saline solution for control of elevated intracranial pressure in patients with exhausted response to mannitol and barbiturates. Neurol Res21:758–7641999
IchaiCArmandoGOrbanJCBerthierFRamiLSamat-LongC: Sodium lactate versus mannitol in the treatment of intracranial hypertensive episodes in severe traumatic brain-injured patients. Intensive Care Med35:471–4792009
KerwinAJSchincoMATepasJJIIIRenfroWHVitarboEAMuehlbergerM: The use of 23.4% hypertonic saline for the management of elevated intracranial pressure in patients with severe traumatic brain injury: a pilot study. J Trauma67:277–2822009
KhannaSDavisDPetersonBFisherBTungHO'QuigleyJ: Use of hypertonic saline in the treatment of severe refractory posttraumatic intracranial hypertension in pediatric traumatic brain injury. Crit Care Med28:1144–11512000
MirskiAMDenchevIDSchnitzerSMHanleyFD: Comparison between hypertonic saline and mannitol in the reduction of elevated intracranial pressure in a rodent model of acute cerebral injury. J Neurosurg Anesthesiol12:334–3442000
OddoMLevineJMFrangosSCarreraEMaloney-WilenskyEPascualJL: Effect of mannitol and hypertonic saline on cerebral oxygenation in patients with severe traumatic brain injury and refractory intracranial hypertension. J Neurol Neurosurg Psychiatry80:916–9202009
Paredes-AndradeESolidCARockswoldSBOdlandRMRockswoldGL: Hypertonic saline reduces intracranial hypertension in the presence of high serum and cerebrospinal fluid osmolalities. Neurocrit Care17:204–2102012
QureshiAIWilsonDATraystmanRJ: Treatment of transtentorial herniation unresponsive to hyperventilation using hypertonic saline in dogs: effect on cerebral blood flow and metabolism. J Neurosurg Anesthesiol14:22–302002
RockswoldGLSolidCAParedes-AndradeERockswoldSBJancikJTQuickelRR: Hypertonic saline and its effect on intracranial pressure, cerebral perfusion pressure, and brain tissue oxygen. Neurosurgery65:1035–10422009
SaltariniMMassaruttiDBaldassarreMNardiGDe ColleCFabrisG: Determination of cerebral water content by magnetic resonance imaging after small volume infusion of 18% hypertonic saline solution in a patient with refractory intracranial hypertension. Eur J Emerg Med9:262–2652002
SimmaBBurgerRFalkMSacherPFanconiS: A prospective, randomized, and controlled study of fluid management in children with severe head injury: lactated Ringer's solution versus hypertonic saline. Crit Care Med26:1265–12701998
SoustielJFVlodavskyEZaaroorM: Relative effects of mannitol and hypertonic saline on calpain activity, apoptosis and polymorphonuclear infiltration in traumatic focal brain injury. Brain Res1101:136–1442006
SutherlandWDMcCayD: Observations on the inhibitory influence exerted by hypertonic saline solutions and calcium chloride solutions on the action of specific haemolysins, with suggestions as to the therapy of blackwater fever. Biochem J5:1–221911
VialetRAlbanèseJThomachotLAntoniniFBourgouinAAlliezB: Isovolume hypertonic solutes (sodium chloride or mannitol) in the treatment of refractory posttraumatic intracranial hypertension: 2 mL/kg 7.5% saline is more effective than 2 mL/kg 20% mannitol. Crit Care Med31:1683–16872003
WadeCEGradyJJKramerGCYounesRNGehlsenKHolcroftJW: Individual patient cohort analysis of the efficacy of hypertonic saline/dextran in patients with traumatic brain injury and hypotension. J Trauma42:5 SupplS61–S651997
WareMLNemaniVMMeekerMLeeCMorabitoDJManleyGT: Effects of 23.4% sodium chloride solution in reducing intracranial pressure in patients with traumatic brain injury: a preliminary study. Neurosurgery57:727–7362005
YilmazNDulgerHKiymazNYilmazCGuduBODemirI: Activity of mannitol and hypertonic saline therapy on the oxidant and antioxidant system during the acute term after traumatic brain injury in the rats. Brain Res1164:132–1352007