CICM SAQ 2010.2 Q1

Questions

1.1 Briefly outline the rationale for the use of hypertonic saline in:

  • Hyponatremia
  • Traumatic brain injury

1.2 List the possible complications of hypertonic saline administration.


Answers

Answer and interpretation

1.1. 1) Briefly outline the rationale for the use of hypertonic saline in Hyponatremia

  • Severe hyponatremia (<120 mEq/L) can cause significant and permanent neurologic injury or death. In the event of seizures or acute collapse relatively rapid initial correction may be required.
  • There is evidence that the severity and duration of hyponatremia may be related to cerebropontine myelinolysis, normal saline and fluid restriction may be inadequate to increase sodium levels appropriately.
  • Some conditions such as cerebral salt wasting or large GIT losses may result in losses that may not be able to be replaced by other means.

1.1. 2) Briefly outline the rationale for the use of hypertonic saline in Traumatic brain injury

  • The rationale for hypertonic saline compared with normal saline
  • Better compensates for blood loss
  • Improved CPP
  • Reduces harmful inflammatory responses
  • May prevent cerebral edema.
  • Can be used as a continuous infusion
  • Obviates the need for osmolality testing

Previous animal studies and smaller clinical trials suggested better outcomes in patients with TBI after use of hypertonic saline solution. The safety profile has been good, and some evidence suggests a potential survival benefit when hypertonic saline is given. However The National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health (NIH) has stopped enrollment of patients with severe traumatic brain injury (TBI) into a Resuscitation Outcomes Consortium (ROC) trial testing the effects of hypertonic saline solutions given before arrival at the emergency department. as early as possible after TBI. 1073 patients 6 month analysis – no difference.

1.2 List the possible complications of hypertonic saline administration.

  • Hypernatremia
  • Hyperchloraemic acidaemia
  • Renal failure
  • CCF/Pulmonary Oedema
  • Neurological SAH
  • rebound intracranial H/T
  • Central Pontine Myelinolysis

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Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

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