Effective treatment of refractory intracranial hypertension after traumatic brain injury with repeated boluses of 14.6% hypertonic saline

Clinical article

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Object

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.

Methods

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.

Results

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.

Conclusions

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.

Abbreviations used in this paper:CPP = cerebral perfusion pressure; GOS = Glasgow Outcome Scale; HR = heart rate; HTS = hypertonic saline; ICP = intracranial pressure; SNa = serum sodium level; SBP = systolic blood pressure; TBI = traumatic brain injury.

Article Information

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: robert.hoesch@hsc.utah.edu.

Please include this information when citing this paper: published online May 24, 2013; DOI: 10.3171/2013.4.JNS121541.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Graphs showing immediate response of ICP and CPP to administration of a bolus of 14.6% HTS (means ± standard deviations, 56 doses). Fifteen-minute bolus infusion started at Time 0. Upper: Statistically significant decrease in ICP from baseline was noted within 5 minutes of bolus initiation, which lasted through 60 minutes (†p < 0.05, ANOVA, compared with Time 0; *p < 0.05, ANOVA and Scheffé test, compared with Time 0). Lower: Statistically significant increase in CPP from baseline was noted within 5 minutes of bolus infusion, which lasted through 60 minutes (†p < 0.05, ANOVA, compared with Time 0; *p < 0.05, ANOVA and Scheffé test, compared with Time 0). No repeated boluses were given within 60 minutes of previous bolus.

  • View in gallery

    Graphs showing sustained response of ICP and CPP to repeated boluses of 14.6% HTS (means ± standard deviations). Upper: Although a slight rebound was noted after the 60-minute time point, repeated boluses of 14.6% HTS provided sustained ICP-lowering effects for the duration of the 12-hour experimental period (*p < 0.05, comparing each time point with Time 0). Lower: Similar results were seen in CPP improvement with repeated boluses of 14.6% HTS (*p < 0.05, comparing each time point with Time 0). Despite a slight rebound lowering of CPP after 60 minutes, sustained CPP averaged between 70 and 75 mm Hg for the 12-hour experimental period.

  • View in gallery

    Graph demonstrating hemodynamic status during repeated boluses of 14.6% HTS represented by HR (upper) and SBP (lower) over a 12-hour experimental period (means ± standard deviations). No statistically or clinically significant variation in SBP or HR was noted during repeated boluses.

  • View in gallery

    Graph showing SNa and serum osmolality levels over the 12-hour experimental period. Normal laboratory range is shown as a shaded region (plotted means ± standard deviation). Upper: Starting levels of SNa were always above normal range, but no significant increase from Time 0 was noted with repeated boluses of 14.6% HTS through the 12-hour experimental period. Lower: Similar trends were noted in serum osmolality, where starting values were significantly above normal laboratory range, but no significant increase was noted with repeated boluses.

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